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10467511-DS-11 | 10,467,511 | 26,380,722 | DS | 11 | 2158-04-27 00:00:00 | 2158-04-27 23:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with cerebral palsy and spastic quadraparesis presents
from her group home with SOB and also found to have fevers.
Patient reports that her arms were "shaking" which is why she
was brought to the hospital. Patient reports that she remembers
watching her arms shake. Per EMS report, pt was found in her
bathroom with difficulty breathing/pale, with significant amount
of mucus coming from her mouth/nose. She was placed on NRB and
brought to the ED. In the ED, initial vs were: 102.3 110 150/55
22 96% 10L Non-Rebreather.
On conversation with her nurse ___, patient has had upper
respiratory symptoms since ___, with increased
secretion/congestion and drooling, so she was taken to ___ ED
and diagnosed with bronchitis, given neb/prednisone and z-pack
(unclear if actually took these meds). The nurse states that the
pt has known dysphagia.
Labs were remarkable for WBC of 4.1 with neutrophil predominance
and 4% bands. Patient was given levofloxacin and flagyl for
?pneumonia. She was also given acetaminophen PR for fevers.
On the floor, VS were: T 97.5 BP 108/55 P 88 R 18 O2 sat 100%
RA. Patient also reports pain in L groin and her vagina, which
has been going on for a while (patient cannot specify). Also
reports cough that has been productive of white sputum. +fevers
today, which patients reports is new. Reports good PO
intake/good appetite, when asked about aspiration with eating,
patient does not appear sure.
Per records sent with the patient, she was recently treated for
UTI with macrobid x7 days (seen on ___, course to finish on
___, but unclear actually took these meds.
Past Medical History:
cerebral palsy
spastic quadraparesis
depression
osteoarthritis
total left hip replacement with multiple revisions, c/b chronic
osteomyelitis s/p Girdlestone resection and revision by Dr.
___ in ___
cataracts
dry macular degeneration
movement disorder/dystonia
atrophic vaginitis
Social History:
___
Family History:
mother passed away from heart attack, otherwise noncontributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T 97.5 BP 108/55 P 88 R 18 O2 sat 100% RA.
General: Alert, oriented to self/place/month/year, no acute
distress. patient with constant mouth movement/dystonia
HEENT: PERRL, Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated
Lungs: LLL crackles, otherwise clear without wheezes or rhonchi
CV: RRR, normal S1 + S2, II/VI systolic murmur, no rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. complaining of L groin pain.
Ext: Warm, well perfused with well healed surgical scars on
heels. 2+ pulses, no clubbing, cyanosis or edema
Genital: inside edges of labia minora at introitus, there is
erythema and tenderness to palpation. no discharge noted.
Neuro: able to follow commands and wriggle toes/squeeze hands,
but otherwise weak throughout. normal tone, low bulk noted.
DISCHARGE EXAM:
97.6 145/84 61 20 98%RA
Exam essentially unchanged.
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-4.1 RBC-3.88* Hgb-11.8* Hct-35.9*
MCV-92 MCH-30.5 MCHC-33.0 RDW-14.1 Plt ___
___ 11:00AM BLOOD Neuts-77* Bands-3 Lymphs-9* Monos-8 Eos-3
Baso-0 ___ Myelos-0
___ 11:00AM BLOOD Glucose-108* UreaN-15 Creat-0.5 Na-137
K-4.2 Cl-99 HCO3-29 AnGap-13
___ 11:00AM BLOOD ALT-47* AST-53* AlkPhos-53 TotBili-0.2
___ 06:05AM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.4#
Mg-2.0
RELEVANT LABS:
___ 11:31AM BLOOD Lactate-2.2*
___ 07:49PM BLOOD Lactate-1.8
___ 06:05AM BLOOD WBC-2.7* RBC-3.67* Hgb-10.9* Hct-34.1*
MCV-93 MCH-29.7 MCHC-32.0 RDW-13.8 Plt ___
___ 06:05AM BLOOD Neuts-38.1* ___ Monos-9.9
Eos-13.2* Baso-1.3
DISCHARGE LABS: none
MICROBIOLOGY:
BCx ___: negative to date
UCx ___: no growth
Rapid resp screen ___: negative for adeno, parainfluenza
___, influenza A/B and RSV
Respiratory Viral Culture (Pending):
UCx ___: no growth
Urine legionella antigen: negative
IMAGING:
___ CXR: Single portable view of the chest is compared to
previous exam from ___. Low lung volumes are again
seen. Streaky opacity at the left lung base suggestive of
atelectasis. The lungs are otherwise clear of consolidation or
large effusion. Cardiomediastinal silhouette is stable in
configuration noting mitral annular calcifications. Osseous and
soft tissue structures are unremarkable.
___ CT HEAD:
1. No intracranial hemorrhage or mass effect.
2. Pansinus disease.
___ CXR PA/LAT: In comparison with the study of ___, there
is little change. Bibasilar areas of opacification, more
prominent on the left, most likely represent atelectasis.
However, in the appropriate clinical setting, a developing
pneumonia cannot be definitely excluded.
___ PELVIC U/S: Limited study since no endovaginal component
was performed but the uterus is normal and no adnexal cysts or
solid masses were seen.
Brief Hospital Course:
TRANSITIONAL ISSUES:
[ ] Vaginal pain thought to be due to atrophic vaginitis, will
need further evaluation and possible treatment. (Per her nurse,
?starting premarin with PCP).
[ ] Repeat CBC in the future given one episode of leukopenia in
house.
[ ] Repeat LFTs in the future for monitoring of mild
transaminitis
___ yo F with PMH of cerebral palsy/quadriparesis and depression
p/w acute SOB and cough/fevers. CXR in ED with ?atelectasis, no
obvious consolidation, given levo and flagyl in ED for empiric
treatment of aspiration pneumonia. Patient was treated for CAP
with levofloxacin and defervesced. Other sources of infections
were ruled out.
# Community acquired pneumonia: patient with reported acute SOB
by EMS, placed on nonrebreather on scene but but weaned off very
quickly to RA on transfer to the floor and satting well. CXR
with streaky opacities in LLL concerning for pneumonia vs.
atelectasis. However, given the clinical history of
congestion/cough/?sputum production and fever, she was treated
empirically for community acquired pneumonia with levofloxacin.
Urine legionella and respiratory viral screen was negative. She
was evaluated by speech/swallow and cleared for soft solids and
thin liquids. She was maintained on 1:1 assistance with meals.
Other causes of infections were ruled out with negative UCx. BCx
are pending but no growth at the time of discharge (4 days).
# Leukopenia: patient with one episode of leukopenia in house,
thought to be due to acute infection. It was monitored and
resolved on its own.
# Atrophic vaginitis: patient complaining of vaginal pain,
thought to be due to her diagnosis of atrophic vaginitis. On
discussion with ___, her nurse, has had thoughts of starting
the patient on premarin for treatment. Will defer to outpatient
management. Patient was symptomatically treated with aloe vesta
barrier cream during this hospitalization.
# Movement disorder/?seizure disorder: patient with reported PMH
of movement disorder, with choreoathetic movement on exam. She
was continued on Divalproex (EXTended Release) and
Levetiracetam.
# Mild transaminitis: unclear etiology, no RUQ pain. Does not
appear obstructive on labs. The LFTs were monitored and trended
down.
# Constipation: patient was continued on scheduled colace/senna
and lactulose prn. However, patient did not have BM in house, so
her bowel regimen was increased to include miralax daily prn and
fleets enema daily prn with good effect.
CHRONIC ISSUES:
# Depression/Anxiety: continued on clonazepam, venlafaxine
# Allergies: continued on fexofenadine in house, will continue
loratadine daily as outpt
# Urinary incontinence: continued on oxybutynin
# GERD: continued on ranitidine daily
# Insomnia: continued on ambien prn
# Osteoarthritis: continued on codeine prn for pain
# CODE STATUS: Patient reported that she was DNR/DNI during this
hospitalization.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from medication list from The Arc.
1. Divalproex (EXTended Release) 1000 mg PO QHS
hold if sedated
2. Clonazepam 2 mg PO QHS
3. Calcium Carbonate 1250 mg PO DAILY
4. Loratadine *NF* 10 mg Oral daily
5. Oxybutynin 5 mg PO DAILY Start: In am
6. Ascorbic Acid ___ mg PO DAILY
7. Docusate Sodium 200 mg PO BID
8. LeVETiracetam 1500 mg PO BID
9. Ranitidine 150 mg PO DAILY Start: In am
10. Venlafaxine XR 150 mg PO DAILY Start: In am
11. Artificial Tears Preserv. Free 1 DROP BOTH EYES DAILY Start:
In am
12. Acetaminophen 1000 mg PO BID
13. Senna 1 TAB PO DAILY
14. Lactulose 15 mL PO BID:PRN constipation
15. Bismuth Subsalicylate 30 mL PO QID:PRN diarrhea
16. Simethicone 120 mg PO QID:PRN gas pain
17. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion
18. Carbamide Peroxide 6.5% ___ DROP AD QHS:PRN ear wax removal
Duration: 4 Days
19. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
20. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO BID
2. Artificial Tears Preserv. Free 1 DROP BOTH EYES DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Calcium Carbonate 1250 mg PO DAILY
5. Clonazepam 2 mg PO QHS
6. Divalproex (EXTended Release) 1000 mg PO QHS
hold if sedated
7. Docusate Sodium 200 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU BID congestion
9. Lactulose 15 mL PO BID:PRN constipation
10. LeVETiracetam 1500 mg PO BID
11. Loratadine *NF* 10 mg Oral daily
12. Oxybutynin 5 mg PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Senna 1 TAB PO DAILY
15. Simethicone 120 mg PO QID:PRN gas pain
16. Venlafaxine XR 150 mg PO DAILY
17. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
18. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 Capsule(s) by mouth every 8 hours Disp
#*15 Capsule Refills:*0
19. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
not to exceed 4 grams of acetaminophen per day
20. Bismuth Subsalicylate 30 mL PO QID:PRN diarrhea
21. Carbamide Peroxide 6.5% ___ DROP AD QHS:PRN ear wax removal
Duration: 4 Days
22. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 Tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
23. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
24. Fleet Enema ___AILY:PRN constipation
RX *Fleet Enema 19 gram-7 gram/118 mL 1 Enema(s) rectally daily
Disp #*10 Bottle Refills:*0
25. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation every 6 hours as needed shortness of
breath/wheezing
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
inhalation every 6 hours Disp #*30 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: community acquired pneumonia, constipation
Secondary Diagnosis: cerebral palsy, movement disorder, atrophic
vaginitis
Discharge Condition:
Mental Status: Clear, but difficult to understand speech at
baseline.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of your
cough/shortness of breath at home, you were found to have high
fevers and were treated for pneumonia. With antibiotics, your
fevers resolved. Please finish taking your antibiotics for
pneumonia.
You had complaints about pain with urination, but you did not
have urinary tract infection. It is likely from the excoriation
and irritation of your vagina. Please follow up with your
primary care physician and your ob/gyn for your atrophic
vaginitis.
Followup Instructions:
___
|
10467535-DS-10 | 10,467,535 | 23,818,786 | DS | 10 | 2119-08-18 00:00:00 | 2119-08-18 19:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
bloody diarrhea
PCP: ___ (___) ___
Major Surgical or Invasive Procedure:
Flex Sig ___
History of Present Illness:
___ woman whose PMH includes HTN, HL, DMII and UC diagnosed in
___, when she was hospitalized at ___
with bloody diarrhea and CT scan showed left-sided colitis. She
was treated with Cipro and Flagyl, which she took for a week but
had no improvement in her symptoms. Subsequent colonoscopy ___ showed "mod active colitis in cont and cicumferential
pattern consistent with uc or infectious colitis no polyps or
masses or deep ulcers, bxs of sigmoid colon taken, changes were
mucosal hemorrhaghes, granularity, friability. Per GI Dr ___
___, "start 5asa, will prob need steroids but would like to see
few more stool cultures to r/o salmonella, shigella,
campylobacter and ecoli 0157." Was on Asacol and uceris for
about 2 weeks with moderate control. The following month was
having ___ watery stools/day > ___ BM formed by ___. She has
been weaned off 5-ASA due to insurance reasons in early
___, and was on uceris QOD for 3 weeks. TOward end of 3
weeks (late ___) increasing loose stools with mucus, felt worse.
Started ___ effect, symptoms worsened, increased
uceris to daily, still worsened.
Now presents to ED with nausea and few heaves, some bloating and
worsening diarrhea up to 12 BMs/day over the last few days, now
with BRBPR. Initially with some left-sided cramps, then
resolves, no abdominal pain, F/C. Drinking Gatorade last few
days but not eating bc worsens sx. Also intermittent
lightheadedness, very tired. Denies urinary symptoms. Denies CP,
SOB, cough. Hasnt been checking glucose this week.
In the ED:
VITALS: Temp: 95.4 HR: 100 > 79 BP: 95/62 > nadir 77/46 >
110/50 Resp: 16 O(2)Sat: 100% RA
LABS notable for: WBC 12, Na 131, Mg 1.3, INR 1.8, lactate 1.9.
No radiology.
MEDS administered: NS 2L, LR 1L, MgSO4 2g
Admitted to Medicine for further mgmt. presumed UC flare with
borderline hypotension.
Currently reports headache, feels dehydrated. Remains without
abd pain or any pain. THis am was very lightheaded, better after
IVF in ED. No cough, SOB/DOE, CP. No URI sx, no dysuria. ROS
otherwise NC.
Past Medical History:
ulcerative colitis dx ___
Hypertension, essential
Hypercholesteremia
Diabetes type 2, uncontrolled
Reflux esophagitis
Headache, variant migraine
Ovarian cyst, bilateral
Obesity
Social History:
___
Family History:
Father with DM and HTN. No GI hx.
Physical Exam:
VITALS: 98 105/56 93 18 98% RA
GEN: alert, NAD, tired-appearing
HEENT: neck supple, dry MM
LUNGS: CTA
CV: RRR s1s2
ABD obese ND +BS soft NT
EXT no edema, no joint effusions; feet warm 2+ DP pulses
NEURO A&O x3, answers ques appropriately, follows commands,
normal gait
PSYCH appropriate, calm
FOLEY none
ACCESS PIV
DISCHARGE EXAM:
Vitals: 97.7, 126/70, 70, 16, 98%RA
Gen: NAD, sitting up in the bed, pleasant
Eyes: EOMI, sclera anicteric
ENT: MMM
Cardiovasc: RRR
Resp: CTAB
GI: soft, non-tender throughout, ND, BS+
EXT: NO ___ pitting edema
Skin: No visible rash
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
___ 09:45AM WBC-12.0* RBC-4.29 HGB-13.6 HCT-40.1 MCV-94
MCH-31.7 MCHC-33.9 RDW-12.4 RDWSD-42.6
___ 09:45AM NEUTS-62 BANDS-7* ___ MONOS-5 EOS-4
BASOS-0 ___ MYELOS-0 AbsNeut-8.28* AbsLymp-2.64
AbsMono-0.60 AbsEos-0.48 AbsBaso-0.00*
___ 09:45AM PLT SMR-HIGH PLT COUNT-411*
___ 09:45AM GLUCOSE-206* UREA N-6 CREAT-0.7 SODIUM-131*
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-23 ANION GAP-18
___ 09:45AM ALT(SGPT)-34 AST(SGOT)-26 ALK PHOS-67 TOT
BILI-0.5
___ 09:45AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.4
MAGNESIUM-1.3*
___ 09:57AM LACTATE-1.9
___ 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:15PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-5 TRANS EPI-1
___ 01:15PM URINE UCG-NEGATIVE
BASELINE LABS at ___:
Hb/Hct
13.___
14.___/44.6 ___
FLEX sig:
Impression: Diffuse, continuous erythema, edema/congestion,
superifical ulcerations, abnormal vascularity, friability and
spontaneous bleeding from the rectum to the distal sigmoid
colon,
consistent with patient's known diagnosis of Ulcerative colitis.
(biopsy)
Otherwise normal sigmoidoscopy to distal sigmoid
Recommendations: Follow-up biopsies.
Continue solumedrol 20mg IV q8hrs.
Avoid NSAIDs and narcotics.
Ok to advance to a low residue diet. ]
Please sent hepatitis b serologies, quant gold, and TPMT
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-7.5 RBC-3.41* Hgb-11.0* Hct-33.2*
MCV-97 MCH-32.3* MCHC-33.1 RDW-12.4 RDWSD-43.8 Plt ___
___ 07:05AM BLOOD Glucose-290* UreaN-12 Creat-0.7 Na-137
K-4.4 Cl-102 HCO3-26 AnGap-13
___ 06:50AM BLOOD Mg-1.8
___ 07:05AM BLOOD CRP-5.8*
Brief Hospital Course:
___ with UC flair after changing medications for insurance
reasons.
# ulcerative colitis flare, severe:
Refractory to mesalamine and oral steroids as outpt, hypotensive
with leukocytosis and bandemia on presentation. GI consulted and
patient underwent flex sig with significant colitis. C. diff
negative. CRP elevated to the ___. Stool cultures negative. She
was started on IV solumedrol x 3 days with follow up CRP that
was 5. SHe had substantial improvement in her symptoms. She was
discharged on a steroid taper and will follow up with her
outpatient GI provider to determine her controller medication.
Her steroid course was complicated by Hyperglycemia (see below).
Pending at time of discharge was a TPMT level. Quant gold was
intermediate and negative CXR. She was discharged on a PPI,
Vitamin D/Calcium and Bactrim for PPx.
# hypovolemia secondary to bloody diarrhea/ GI losses: Improved
with IVF and treatment above.
# coagulopathy: likely nutritional/ low vitamin K levels. Gave
5mg PO x1 on ___ and monitor INR. Came down from 1.8 to 1.6
with improved PO intake. COntinue to monitor as an outpatient.
# DMII: FSBS up to 300s on IV solumedrol. Her metformin was
restarted and she was placed on glargine 5units daily. This will
need to be adjusted as an outpatient when tapering the steroids.
# HTN: Held HCTZ. Restarted lisinopril at 5mg PO daily down from
home dose of 20mg PO daily. BP was stable on this regimen. She
will follow up as an outpatient for BP control.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ (mesalamine) 1.5 g oral DAILY
2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
3. Lisinopril 20 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Uceris (budesonide) 9 mg oral DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
3. Glargine 5 Units Lunch
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 5 Units before
LNCH; Disp #*2 Vial Refills:*1
RX *insulin syringe-needle U-100 30 gauge Use 1 ___ per day
Daily Disp #*100 Syringe Refills:*0
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. PredniSONE 40 mg PO DAILY
for 7 days then taper by 5mg every 7 days.
35mg PO daily x7d then
30mg PO x7d
25mg PO x7d ect...
Tapered dose - DOWN
RX *prednisone 10 mg 4 tablet(s) by mouth Daily Disp #*126
Tablet Refills:*0
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
RX *calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-200
unit 2 tablet(s) by mouth twice a day Disp #*120 Tablet
Refills:*1
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*1
8. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ulcerative colitis flair
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 a flair of your UC. You
underwent a procedure and lab testing that confirmed this. You
were started on IV steroids and you greatly improved. There is
currently testing pending to help determine what the medication
to use following the steroids. You were started on a series of
medications to help prevent complications from the steroids.
Your diabetes also is more active because of the steroids and
you were started on insulin to help control your blood sugar.
Please take your medications as directed and follow up as listed
below.
Followup Instructions:
___
|
10467577-DS-13 | 10,467,577 | 24,246,257 | DS | 13 | 2162-03-24 00:00:00 | 2162-03-31 18:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ivp dye
Attending: ___
Chief Complaint:
Right-sided face, arm, leg weakness and slurred speech.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ yo. RH WF w/PMH of well-controlled HIV on
HAART, HTN, dyslipidemia, DM, who presented to OSH with sudden
onset of right-sided facial droop and weakness, and was
transferred here for further care.
Ms. ___ was in her usual state of health until yesterday
evening, when at bingo, she suddenly developed a right facial
droop, and felt that her right arm was weaker; she also noticed
that she couldn't stand up and was slurring her speech. She had
no headache nor nausea/vomiting. Pt was then brought to ___
___, where her initial vitals were: BP 197/86 p74 RR 20
O2sat 97%. Her exam was described as R droop and RUE & RLE
weakness. Pt received labetalol 100 mg IV x 1 before transfer
here. Since coming here, pt thinks that her speech sounds less
dysarthric and that her arm movements have improved.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies muscle weakness. Denies loss of sensation.
Chronic bladder retention, pt self-catheterizes. Denies
difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain. Denies dysuria or hematuria. Denies myalgias, or rash.
Chronic arthralgias in both hands.
Past Medical History:
- HIV on HAART: acquired through sexual contact when pt was in
her ___. Well controlled for many years, w/undetectable viral
load and CD4 counts fluctuating 390s-500
- HTN
- Dyslipidemia and HAART-related lipodystrophy
- DM II, now insulin dependent
- Osteoarthritis
- Osteoporosis
- GERD
- Depression
- Urinary retention (patient intermittently self catheterizes)
Social History:
___
Family History:
Sister w/CVA. No apparent family history of skinny calves or
high arched feet.
Physical Exam:
=========================================
ADMISSION PHYSICAL EXAM: ___
=========================================
Vital Signs:
Time Temp HR BP RR Pox
01:21 98.4
01:38 71 162/90 16 99%
02:30 69 135/50 23 98%
04:31 70 142/68 20 99%
General: NAD, lying in bed comfortably.
Head: NC/AT but marked lipodystrophy noted w/facial atrophy and
buffalo hump, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no meningismus, no LAD or thyromegaly
Cardiovascular: No carotid or subclavian bruits; carotids wnl
volume & upstroke, no JVD, nl jugular waveforms w/ a>v, apex
nondisplaced & nonsustained, RRR, no M/R/G
Pulmonary: Respirations nonlabored; equal air entry bilaterally,
no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable dorsalis pedis pulses;
Heberden's & ___ nodes of fingers
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status: Awake, alert, oriented x 3. Recalls a coherent
history. Concentration easily maintained. Language fluent with
minimal dysarthria, but w/frequent phonemic parpahasic errors
and
disproportionately impaired repetition, intact verbal
comprehension. No paraphasic errors. Follows two-step commands,
midline and appendicular but gets confused with more complex
multistep and crossed-body commands. High- and low-frequency
naming intact. Normal reading. Normal prosody. Excellent recall
of recent events. No apraxia or visual neglect.
- Cranial Nerves: [II] PERRL 3->2 brisk. VF full to ___
counting. [III, IV, VI] EOM intact, no nystagmus. [V] V1-V3 with
subjectively decreased pinprick on right face. Pterygoids
contract normally. [VII] Mildly decreased activation of R corner
of mouth [VIII] Hearing grossly intact. [IX, X] Palate elevation
symmetric. [XI] SCM strength ___ bilaterally. [XII] Tongue
midline and moves facilely.
- Motor: Generalized cachectic muscle wasting. Prominent right
UE
pronator drift. L forearm orbits around lagging R. No tremor or
asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5-] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5-] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5]* [L 5]*
Finger Flexors [R 5]* [L 5]*
* Limited by hand arthritis
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
- Sensory: Mildly decreased to pinprick on R, or proprioception
bilaterally. Position sense poor in toes; vibration relatively
preserved.
- Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L 2 2 2 2 2
R 2+ 2+ 2+ 2 2
Plantar response flexor on left extensor on right.
- Coordination: Clumsy on rapid sequential & alternating
movements on R. No dysmetria on FNF dysproportionate to weakness
- Gait: Deferred as pt going for CT scan
=======================================
DISCHARGE PHYSICAL EXAM: ___
=======================================
Tmax: 98.6 Tc: 98.1 BP: 106/48 (90-140/30-60) 50-60 19 98% on RA
___: 106
General: NAD, lying in bed comfortably
Head: NC/AT but marked lipodystrophy noted w/facial atrophy and
buffalo hump, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no meningismus, no LAD or thyromegaly
Cardiovascular: No carotid or subclavian bruits; carotids wnl
volume & upstroke, no JVD, nl jugular waveforms w/ a>v, apex
nondisplaced & nonsustained, RRR, no M/R/G
Pulmonary: Respirations nonlabored; equal air entry bilaterally,
no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable dorsalis pedis pulses;
hammartoes on left>right, bilateral wasting of intrinsic feet
muscles and TA, band atrophy of upper and lower extremities
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status: Awake, alert, oriented x 3. Recalls a coherent
history. Concentration easily maintained. Language fluent with
minimal dysarthria, but w/frequent phonemic parpahasic errors
and disproportionately impaired repetition, intact verbal
comprehension. No paraphasic errors. Follows two-step commands,
midline and appendicular but gets confused with more complex
multistep and crossed-body commands. High- and low-frequency
naming intact. Normal reading. Normal prosody. Excellent recall
of recent events. No apraxia or visual neglect.
- Cranial Nerves: [II] PERRL 3->2 brisk. VF full to ___
counting. [III, IV, VI] EOM intact, no nystagmus. [V] V1-V3 with
subjectively decreased pinprick on right face. Pterygoids
contract normally. [VII] Mildly decreased activation of R corner
of mouth [VIII] Hearing grossly intact. [IX, X] Palate elevation
symmetric. [XI] SCM strength ___ bilaterally. [XII] Tongue
midline and moves facilely.
- Motor: Generalized cachectic muscle wasting, band atrophy in
all 4 extremities. No tremor or asterixis. Spasticity in left
leg
Direct Confrontational Strength Testing
Arm
Deltoids [R 5-] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5-] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5]* [L 5]*
Finger Flexors [R 5]* [L 5]*
* Limited by hand arthritis
Leg
Iliopsoas [R 5] [L 4+]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 4] [L 4]
Gastrocnemius [R 5] [L 5]
- Sensory: Mildly decreased to pinprick on R, or proprioception
bilaterally. Position sense poor in toes; vibration relatively
preserved.
- Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L 2 2 2 2+ 0
R 2+ 2+ 2+ 2 0
Plantar response flexor on left extensor on right.
- Coordination: Clumsy on rapid sequential & alternating
movements on R. No dysmetria on FNF dysproportionate to weakness
- Walks with assistance, significant foot-drop on left. Walks
with cane at home, seems safer with walker here.
Pertinent Results:
___ 08:37AM CK(CPK)-109
___ 08:37AM CK-MB-7 cTropnT-0.02*
___ 08:37AM CHOLEST-159
___ 08:37AM %HbA1c-6.1* eAG-128*
___ 08:37AM TRIGLYCER-393* HDL CHOL-23 CHOL/HDL-6.9
LDL(CALC)-57
___ 08:37AM TSH-2.0
___ 08:37AM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
___ 02:26AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 02:26AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
___ 02:26AM URINE RBC-2 WBC-98* BACTERIA-FEW YEAST-NONE
EPI-1
___ 02:26AM URINE WBCCLUMP-FEW MUCOUS-RARE
___ 01:40AM GLUCOSE-131* UREA N-29* CREAT-1.0 SODIUM-139
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15
___ 01:40AM estGFR-Using this
___ 01:40AM cTropnT-0.03*
___ 01:40AM CALCIUM-9.6 PHOSPHATE-4.2 MAGNESIUM-1.8
___ 01:40AM WBC-10.8 RBC-3.46* HGB-10.9* HCT-33.0* MCV-96
MCH-31.5 MCHC-33.0 RDW-14.6
___ 01:40AM NEUTS-77.6* LYMPHS-17.4* MONOS-3.6 EOS-1.2
BASOS-0.2
___ 01:40AM PLT COUNT-230
___ 01:40AM ___ PTT-28.5 ___
MRI HEAD WITH AND WITHOUT CONTRAST (___)
Stable left basal ganglionic hemorrhage without underlying mass
lesion seen.
CT HEAD WITHOUT CONTRAST (___)
1. Stable appearance of 2.5 x 1.3 cm hyperdense focus in the
putamen/ left external capsule, likely representing hypertensive
hemorrhage. No significant mass effect with no herniation.
2. Multiple occipital subcutaneous lipomas are noted.
MRA ___
COMPARISON: CT head from the same day.
FINDINGS: There is a stable hemorrhage in the left basal
ganglion without underlying enhancement or mass lesion noted.
There is surrounding edema and mass effect without midline
shift. There are small vessel ischemic changes in the white
matter. Intracranial flow voids are maintained.
MRA of the circle of ___ demonstrates no evidence for
aneurysm or high-grade stenosis within the limitations of the
examination. There is no evidence for acute ischemia.
IMPRESSION:
Stable left basal ganglionic hemorrhage without underlying mass
lesion seen.
EKG ___
Sinus rhythm. Slow R wave progression with non-specific ST-T
wave changes in leads V1-V3 and non-specific ST-T wave changes
elsewhere. Cannot exclude ischemia but these findings are not
diagnostic compared to tracing #1 no diagnostic change. Clinical
correlation is suggested.
TRACING #2
Rate PR QRS QT/QTc P QRS T
66 180 80 ___ 28 33 64
Brief Hospital Course:
Mrs. ___ is a ___ right-handed woman who presents
after the sudden onset of right hand clumsiness and weakness,
difficulty standing owing to right leg weakness and dysarthria,
in the context of well-controlled HIV complicated by
dyslipidemia, hypertension, peripheral neuropathy, diabetes.
She was taken to ___ and CT revealed a cerebral
hemorrhage in the region of the left putamen, dissecting the
posterior insular cortex from the internal capsule (1.5 x 2.6 x
4.0 cm). See was transferred to ___ for further management.
On arrival, examination was slightly improved, by Mrs. ___
subjective judgment, but clumsiness, mild upper motor neuron
weakness were noted, predominantly in the right arm, with trace
weakness of the right face and a very mild aphasia (naming and
repitition were only trace impaired). Pin-prick was reduced on
the right, but there is a baseline deficit of sensation
(moderate vibration, moderate pin and mild joint position
impairment) and marked weakness of foot dorsiflexion and the
intrinsic muscles of her feet, all of which are attributable to
her neuropathy.
On discharge, right facial droop was barely noticeable, there
was mild ataxia of the right arm with trace upper motor weakness
in the right arm. Findings attributed to her neuropathy above,
based on clearly chronic atrophy, were unchanged.
# Hemorrhage:
MRI reveals no vascular anomaly (MRA), but there is
hypointensity of the contralateral putamen/internal capsule on
the right on gradient echo that is consistent with a prior
hemorrhage that is symmetric to the hemorrhage described above -
this suggest that it seems more likely hypertensive than due to
a vascular anomaly (which is unlikely to be symmetric). This is
also consistent with her admitting blood pressure of 197
systolic. Medication compliance seems excellent, so this does
seem difficult to explain, but compliance was reenforced and we
are happy that monitoring can continue in rehabilitation. On
the day of discharge her blood pressure was nicely controlled
from the low 100s to 110s. We would recommend that heparin
subcutaneous prophylaxis can now resume, greater than 48 hours
after hemorrhage. Hemorrhage was stable on rescan at ___,
then on MRI. Her symptoms improved, so further scans at this
time seem needless.
# Neuropathy:
This was of a sensory motor character and the differential
diagnosis for this includes a sensorimotor neuropathy of HIV,
diabetes, or an inherited disorder of the
___ spectrum. For this we would
like to have her seen in ___ clinic. She would also
benefit from AFO's to prevent tripping - this was mentioned by
her and consistent with an impressive foot-drop, particularly on
the left, but she has fortunately as yet had no falls. She has
occasional pain at night of a burning quality in her feet. For
this she has been taking gabapentin 300 TID PO, with an
occasional extra dose at night, for ___ mg.
# HIV:
This has been very well controlled and affords strong evidence
that there is excellent medication compliance - her CD4 count
has been between 400-500 and her viral load undetectable for
many years. Complications include diabetes, dyslipidemia and
lipdystrophy, perhaps even the above neuropathy. Combined ART
(cART) consists of tenofovir (Viread) 30mg daily, abacavir
(Ziagen) 30mg bid, and efavirenz (Sustiva) 600mg.
# Dyslipidemia and Lipodystrophy:
This is manifest predominantly as a hypertriglycidemia that is
thought to be associated with her combined antiretroviral
therapy. LDL is presently 57 and triglycerides are 393. She
takes rosuvastatin 20mg QHS. "Lipomas" were noted on CT, but
this likely represented lipodystrophy.
# Hypertension:
This appears to be well controlled on her home regimen, but
should be followed while in rehab to see if any spikes are
noted. Lisinopril 10mg is taken at home and has been restarted.
She also takes metoprolol tartrate 50 mg BID.
# Urinary Retention:
She self-catheterizes at home given incomplete voiding in the
context of longer standing urgency incontinence. This could be
related to a ___ process, if one seeks a
unifying diagnosis. She has a questionable UTI and has been
started on Bactrim DS 1 tablet BID for 7 days, ending ___ (last doses that day). She will travel with a Foley, given
that a bed was found sooner than expected and we did not want to
remove this immediately prior to discharge. The patient can
help direct whether removal is appropriate, but we would suggest
that this could happen later today or early tomorrow.
# Diabetes:
This is thought to be a complication of cART, but aa a furhter
feature related to the differential diagnoses of peripheral
neuropathy and urinary difficulties could be considered.
Metfomin 850 mg BID and insulin 70/30, 17 units in am and 27
units QHS at home. While an inpatient, the fixed dose was
reduced and
# GERD:
She takes omeprazole 20mg BID at home.
# Anxiety/Depression:
At home she takes alprazolam 0.5mg QD, along with escitalopram
20mg QD and mirtazapine 7.5 mg QHS.
# Osteoporosis:
Another reason to work on her foot drop to prevent falls.
Calcium and vitamin D should be considered.
# Osteoarthritis:
Mostly affects the hands, seems to be a minor problem to her at
this time.
Medications on Admission:
- Omeprazole 20mg BID
- Lisinopril 10mg
- Metfomin 850mg BID
- Tenofovir (Viread) 30mg daily
- Alprazolam 0.5mg QD
- Escitalopram 20mg QD
- Rosuvastatin 20mg HS
- Abacavir (Ziagen) 30mg BID
- Metoprolol 50mg BID
- Insulin 70/30 ___ 17 u in am and 27 u qhs,
- Efavirenz (Sustiva) 600mg
- Mirtazapine 7.5mg
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. MetFORMIN (Glucophage) 850 mg PO BID
4. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
5. Escitalopram Oxalate 20 mg PO DAILY
6. Abacavir Sulfate 300 mg PO BID
7. Metoprolol Tartrate 50 mg PO BID
8. Efavirenz 600 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
First day = ___
Last day = ___
11. ALPRAZolam 0.5 mg PO TID:PRN anxiety
12. Gabapentin 300 mg PO TID
13. 70/30 13 Units Breakfast
70/30 18 Units Dinner
Insulin SC Sliding Scale using REG Insulin
14. Rosuvastatin Calcium 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISSUES:
1. Left putamen intraparenchymal hemorrhage, likely
hypertensive.
CHRONIC ISSUES:
1. Hypertension
2. Hyperlipidemia
3. Type 2 diabetes
4. Peripheral neuropathy (sensorimotor)
5. GERD
6. Anxiety and depression
7. Likely prior right putamen hemorrhage (see hospital course)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Able to walk with cane, but more safely with
walker.
Please see brief hospital course for a description of her
baseline examination.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were transferred
here from ___ because you were found to have a
hemorrhage in your brain. The most likely cause of this
hemorrhage was your high, or perhaps fluctuations in, blood
pressure.
In the hospital we also found that you have chronic weakness and
sensory loss in your feet, which may be due to a neuropathy
occurs in the presence, or perhaps combination, of diabetes and
HIV. We recommend special boots called "AFOs" to help you walk
which can be fitted while you are at rehab. We also made you an
appointment with the ___ clinic to further explore
this problem.
Please attend the outpatient follow-up appointments listed below
with Stroke Neurology (Dr. ___ and Neuromuscular Neurology
(Dr. ___ to follow up on this hospitalization.
We added the following medications for treatment of a urinary
tract infection. Please take this medication for a total 7-day
course. Your course will end ___.
- CONTINUE Bactrim (Sulfameth/Trimethoprim)
Please continue all of your home medications as prescribed.
Followup Instructions:
___
|
10467775-DS-14 | 10,467,775 | 20,827,456 | DS | 14 | 2130-04-23 00:00:00 | 2130-04-23 16:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sore throat
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y.o male with h.o HTN who presents with sore throat since
___. Pt reports he has baseline R.facial area/below the
R.mandible pain chronically. However, this began to worsen and
pt developed a sore throat on ___ that progressively worsened
and became up to a ___ "sharp". Currently, pain is ___. Pt
reports pain got so bad he couldn't sleep. He reports he took
one of his coworkers "pain pills" yesterday which helped. He
tried tylenol prior without relief and was taking advil with
improvement in symptoms. He reports slight odynophagia and
dysphagia secondary to pain. He reports feeling SOB due to
"swelling" sensation in his throat especially when attempting to
sleep. He denies SOB otherwise. He denies cough, rhinorrhea, CP,
palpitations, fever, chills, dizziness, headache, abdominal
pain, nausea, vomiting, diarrhea, constipation, melena, brbpr,
dysuria.
.
Other 10pt ROS Reviewed and otherwise negative.
In the ED, pt was given IV unasyn, dexamethasone 10mg and IVF.
VSS appeared stable.
.
Other 10 pt ros otherwise reviewed and negative.
Past Medical History:
HTN
CKD-III baseline 1.4-1.6
hyperlipidemia
Social History:
___
Family History:
father with throat cancer
Physical Exam:
GEN: well appearing
Vitals:T 98.7 BP 154/76 HR 81 RR 18 sat 100% on RA
HEENT: ncat eomi anicteric
neck: full ROM, non-tender
face: no obvious facial swelling, +tenderness just below
R.mandible.
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound
ext: no c/c/e 2+pulses
neuro: face symmetric, speech fluent
psych: calm, cooperative
Pertinent Results:
___ 01:43PM LACTATE-0.9
___ 08:40AM GLUCOSE-112* UREA N-18 CREAT-1.5* SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
___ 08:40AM estGFR-Using this
___ 08:40AM WBC-10.9 RBC-4.67 HGB-13.7* HCT-40.9 MCV-88
MCH-29.4 MCHC-33.5 RDW-14.3
___ 08:40AM NEUTS-63.9 ___ MONOS-7.0 EOS-2.2
BASOS-0.2
___ 08:40AM PLT COUNT-188
Xray neck:
IMPRESSION:
No evidence of prevertebral soft tissue swelling. If there is
high clinical suspicion for retropharyngeal abscess consider CT
examination.
.
CT neck:
IMPRESSION:
Hyper enhancing 2.5 x 1.7 cm density within the right tonsillar
region
suggestive of acute tonsillitis. Clinical correlation
recommended. No definite fluid collection or drainable abscess
is identified.
Prominent right cervical lymph nodes likely reactive in
etiology.
.
Blood cx: pending
throat cx: pending
Brief Hospital Course:
___ y.o male with h.o HTN who presented with sore throat and
found to have concern for tonsilitis.
.
#pharyngitis/tonsillitis with pharyngeal wall phlegmon
#sore throat with dyspnea, odynophagia
ENT consulted. Throat culture ordered but pending on discharge.
Pt was placed on IV unasyn during admission. He was also given 3
doses of IV decadron and placed on continuous 02 monitoring. CT
scan revealed concern for acute tonsillitis without any
drainable abscess. Pt's symptoms markedly improved on this
regimen. He did not have any further SOb, odynophagia and was
tolerating a regular diet without the need for any further pain
regimen. Therefore, pt was discharged with plans to complete a
10 day total course of augmentin therapy and to follow up with
ENT (___) in ___ days for further evaluation. Pt aware and
agrees to plan. Pt advised he could take low dose ibuprofen( for
2 days) or acetaminophen for pain relief. Pt instructed not to
drink ETOH when taking these medications.
.
#ETOH misuse-denies h.o withdrawal. Reported drinking ___ pint
and beer every other day. Placed on a CIWA scale but did not
have any evidence of withdrawal. He was given thiamine and
folate. Would recommend continued ongoing discussion about ETOH
misuse. He was unable to be seen by social work prior to
discharge.
.
#HTN, benign-continued home meds
.
#CKD III-baseline 1.4-1.6. Pt at baseline.
.
#FEN-regular, adat
#ppx-hep sc TID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 9 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 by mouth twice a
day Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
tonsillitis with phlegmom
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 sore throat and shortness of
breath. You were found to have an inflammation of your tonsils
with some fluid around the R.side. For this, you were given IV
antibiotics which were converted to by mouth antibiotics
(augmentin) which you will need to take for a total of 10 days.
You were also given steroids. You will need to be sure to follow
up with the ENT office, Dr. ___ in ___ days. Please call this
office on ___ to schedule a follow up.
.
You may take low dose tylenol ___ every 6 hours for pain or
ibuprofen 200mg every 8 hours for up to 2 more days. Take these
medications only as prescribed. Do not drink any alcohol with
these medications.
Followup Instructions:
___
|
10467775-DS-15 | 10,467,775 | 22,838,019 | DS | 15 | 2134-07-20 00:00:00 | 2134-07-20 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
myalgias
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with a history of HTN, CKD III,
and HLD, who presents with myalgias.
He describes developing a cough over the weekend 5 days ago, for
which he was drinking lots of tea, taking an occasional aspirin.
Two days ago, he started noticing some muscle aches, which he
thought were due to working hard to clean school over ___. He also noted his urine became darker, which he
attributed to drinking tea. The day prior to admission, he also
developed chills and ___ colored stools, prompting him to go to
urgent care. There, the patient had an elevated creatinine to
2.9
from baseline 1.3, AST elevated to 1091. They gave him 2 L IVF,
CK was pending so he was sent home. After leaving, his CK
returned at 269,771. He was called and asked to present to the
ED. He otherwise denied fevers, nausea/vomiting, chest pain,
shortness of breath, palpitations.
Of note, he has been taking atorvastatin 10 mg for the past ___
years. He also got his flu shot earlier in the year.
Past Medical History:
HTN
CKD stage III
HLD
Glaucoma
Social History:
___
Family History:
father with throat cancer
Physical Exam:
ADMISSION EXAM
VS: T 99.2, BP 147/75, HR 73, RR 18, O2 sat 98 % RA
GEN: In NAD.
HEENT: PERRL, moist mucous membranes, oropharynx clear without
exudates.
NECK: No JVD, no cervical lymphadenopathy.
CV: RRR, no murmurs/gallops/rubs.
PULM: CTAB, no wheezing/crackles/rhonchi.
ABD: Soft, non tender, non distended.
EXTREM: No ___ edema. Pulses +2 ___P, ___ bilaterally.
SKIN: No rashes.
NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly
intact.
Discharge Exam:
PHYSICAL EXAM:
___ 0735 Temp: 98.1 PO BP: 148/77 L Lying HR: 63 RR: 18 O2
sat: 98% O2 delivery: Ra
Last 24 hours Total cumulative -1270ml
IN: Total 3055ml, PO Amt 270ml, IV Amt Infused 2785ml
OUT: Total 4325ml, Urine Amt 4325ml
General: alert, oriented, no acute distress
HEENT: MMM, skin & sclerae anicteric
Neck: supple, no LAD
Resp: CTAB, no r/r/w
CV: RRR, normal S1/S2, no m/r/g
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no HSM,
MSK: Warm well perfused, no edema, no extremity tenderness, 2+
pulses in BUE/BLE
Neuro: ___ strength in bilateral UE
Pertinent Results:
ADMISSION LABS
===========================
___ 11:00AM BLOOD WBC-7.3 RBC-4.05* Hgb-12.1* Hct-36.5*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.2 RDWSD-46.5* Plt ___
___ 11:00AM BLOOD Neuts-56.7 ___ Monos-13.0 Eos-2.6
Baso-0.3 Im ___ AbsNeut-4.13 AbsLymp-1.97 AbsMono-0.95*
AbsEos-0.19 AbsBaso-0.02
___ 11:00AM BLOOD ___ PTT-27.6 ___
___ 11:00AM BLOOD Glucose-154* UreaN-46* Creat-2.8*# Na-139
K-5.7* Cl-104 HCO3-24 AnGap-11
___ 11:00AM BLOOD ALT-227* AST-1089* ___
AlkPhos-42 TotBili-0.5
___ 11:00AM BLOOD Albumin-3.8 Calcium-9.2 Phos-4.3 Mg-2.8*
___ 09:20PM BLOOD TSH-4.3*
___ 11:09AM BLOOD Lactate-2.3*
PERTINENT STUDIES
===========================
CXR ___
No acute cardiopulmonary abnormality.
CK Trend:
Peak:160,010
Level at discharge: 11,809
Cr trend:
Peak: 2.8
Level at discharge:1.5
Discharge Labs:
___ 06:49AM BLOOD WBC: 5.9 RBC: 3.50* Hgb: 10.4* Hct: 31.9*
MCV: 91 MCH: 29.7 MCHC: 32.6 RDW: 14.2 RDWSD: 47.4* Plt Ct: 253
___ 06:49AM BLOOD Glucose: 104* UreaN: 21* Creat: 1.5* Na:
144 K: 4.4 Cl: 112* HCO3: 21* AnGap: 11
___ 06:49AM BLOOD ALT: 128* AST: 221* CK(CPK): ___
AlkPhos: 37*
Brief Hospital Course:
___ with history of HTN, HLD, and CKD who was admitted for
rhabdomyolysis.
# RHABDOMYOLYSIS
Initially presented to ___ office for symptoms of myalgias and
tea colored urine. There was discovered to have serum CK 269,771
prompting referral to ED for rhabdomyolysis. Most likely
precipitated by atorvastatin use and/or recent viral illness. On
arrival was found to have down-trending CK to 160,010 with
evidence of acute kidney injury (serum Cr 2.8 at peak).
Evaluated by nephrology and admitted to medicine service for
further management. Received aggressive fluid resuscitation with
appropriate urine output with steady improvement in renal
function and CK. Patient was overall improving, IVF were
stopped, and CK continued to downtrend. At time of discharge, CK
was 11,809 (down from a peak of 160,010 on arrival to ___. Pt
was encouraged to maintain PO hydration after discharge.
# HYPERKALEMIA
# ACUTE KIDNEY INJURY: In setting of rhabdomyolysis as above.
Steadily improved with Lasix 20 mg IV boluses x2 and IVF.
- Discharge Cr: 1.5 (down from max 2.8)
TRANSITIONAL ISSUES
==========================
[ ] The patient needs a lab check (CMP, CPK) on ___ to
ensure ongoing improvement in labs with ongoing PO hydration.
[ ] Atorvastatin was stopped given concern that this caused his
rhabdomyolysis.
[ ] His HCTZ and losartan were held initially in the setting of
his ___. The losartan was restarted prior to discharge, but
please restart the HCTZ as able at first PCP follow up
appointment.
[ ] TSH mildly elevated. Recommend repeating following
resolution of acute illness.
# CONTACT: ___ (girlfriend: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Losartan Potassium 50 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Losartan Potassium 50 mg PO DAILY
RX *losartan [Cozaar] 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Vitamin D ___ UNIT PO DAILY
4. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until instructed to
do so by your PCP
___:
Home
Discharge Diagnosis:
Primary diagnosis:
==================
Rhabdomyolysis
Acute kidney injury
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for rhabdomyolysis, a condition where your
muscles get injured and start to break down
- You also had an injury to your kidneys, most likely caused by
the debris from muscle break-down in your bloodstream that
collected and concentrated in your kidneys and caused them
damage
- Your potassium was elevated because of your kidney injury
What was done for me while I was in the hospital?
- You were given lots of IV fluids to flush out all the debris
from muscle breakdown out of your system and out of your kidneys
- Your home blood pressure medications and lipid medication
(atorvastatin) were not given because they can sometimes worsen
the injury to your kidneys or muscles
- You were given Lasix, a medication that makes you pee and
helps get rid of excess potassium in your blood
What should I do when I leave the hospital?
- Please discuss with your PCP whether you should resume your
previous blood pressure medication (which was a combination of
losartan and hydrochlorothiazide ["HCTZ"] in a single pill). For
now, you were discharged on just losartan.
- Please go into your nearest ___ facility on ___ for a
lab check. We would like to ensure that your kidney function and
muscle enzymes (CPK) are continuing to improve. The orders for
these tests are already in the system at ___.
- Please take your medications as instructed.
- Please go to your follow up appointments as scheduled in the
discharge papers.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10468541-DS-18 | 10,468,541 | 24,150,912 | DS | 18 | 2177-04-06 00:00:00 | 2177-04-06 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gabapentin
Attending: ___
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with hypertension, hyperlipidemia, metastatic
prostate cancer s/p radical prostatectomy and radiation now on
leuprolid and denosumab, and spinal stenosis s/p epidural
steroid injection on ___, presenting with general weakness,
noted to have hyperglcyemia.
Patient went to heme-onc today in follow-up of metastatic
prostate cancer and was noted to be very weak. Labs drawn and
glucose >800. Patient has had ___ weeks of increased thirst and
increased frequency of urination. Recent dizziness. Endorses 8
lb weight loss. Denies recent fevers, chills, cough, dysuria,
abdominal pain, shortness of breath, chest pain, diarrhea,
nausea, vomiting. Has chronic back pain and received epidural
steroid injection to L5-S1 on ___ for spinal stenosis.
In the ED, initial vitals were: 98.3 86 167/82 20 96% ra
- Initial labs were significant for wbc 12.3, H/H 13.0/36.7, plt
178. Na 125 (corrected 136), K 4.6, Cl 90, Bicarb 18, BUN 42, Cr
1.6, glucose 817. Gap 28. AST/ALT 77/82, T bili 1.6. A1c 12.9.
Lactate 2. pH 7.38. UA with 1000 glucose, no ketons.
- Imaging revealed CXR with bibasilar opacit atelectasis without
definite acute cardiopulmonary process.
- The patient was given 4L NS, started on an insulin drip. Anion
gap closed to 12. Glucose down to 246, K 4.8. Insulin drip
stopped. Given 6U Insulin.
Vitals prior to transfer were: 97.5 60 109/60 18 97%; FSBG 230.
Upon arrival to the floor, vitals 97.9, 138/67, 59, 18, 100RA.
Lying in bed comfortably. Says he feels well, better now that
received IVF. Says that he is taking his meds at home.
Past Medical History:
6 MM R LUNG BASE NODULE ___
ALLERGIC RHINITIS
DYSPEPSIA
HYPERCHOLESTEROLEMIA
HYPERTENSION
LAP CHOLECYS
LOW BACK PAIN ___
NEPHROLITHIASIS
PROSTATE CANCER
CARPAL TUNNEL SYNDROME
Social History:
___
Family History:
Patient is unaware of any family members with diabetes.
Physical Exam:
Admission physical exam:
Vitals: 97.9, 138/67, 59, 18, 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, left eye
with dilated pupil, not reactive to light (baseline), right eye
reactive
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no focal neurologic deficits, gait deferred.
Discharge physical exam:
Pertinent Results:
ADMISSION LABS:
=================================
___ 11:00AM BLOOD WBC-12.3*# RBC-4.39* Hgb-13.0* Hct-36.7*
MCV-84 MCH-29.6 MCHC-35.4 RDW-12.6 RDWSD-38.4 Plt ___
___ 11:00AM BLOOD Neuts-86.2* Lymphs-9.1* Monos-3.8*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.57* AbsLymp-1.12*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.02
___ 11:00AM BLOOD Glucose-817* UreaN-42* Creat-1.6* Na-125*
K-4.6 Cl-90* HCO3-18* AnGap-22*
___ 11:00AM BLOOD ALT-72* AST-53* AlkPhos-83
___ 11:00AM BLOOD PSA-0.2
___ 04:26PM BLOOD ___ pO2-70* pCO2-32* pH-7.40
calTCO2-21 Base XS--3
.
___ A1c-12.9 eAG-324
___ Acetone - Negative
___ Beta-Hydroxybutyrate - 0.1 mmol/L (ref <0.4)
.
UA - negative
.
IMAGING:
===============================
___ CXR IMPRESSION:
Bibasilar opacit atelectasis without definite acute
cardiopulmonary process
.
DISCHARGE LABS:
==============================
___ 05:30AM BLOOD WBC-6.3 RBC-4.16* Hgb-12.2* Hct-35.5*
MCV-85 MCH-29.3 MCHC-34.4 RDW-13.0 RDWSD-39.8 Plt ___
___ 05:30AM BLOOD Glucose-249* UreaN-26* Creat-1.0 Na-136
K-4.8 Cl-104 HCO3-23 AnGap-14
___ 05:30AM BLOOD ALT-56* AST-38 CK(CPK)-317 AlkPhos-62
TotBili-0.7
___:30AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2
Brief Hospital Course:
Mr. ___ was treated for the following problems during his
hospital course:
# Hyperosmolar hyperglycemic syndrome. Patient presented with
blood sugars in the 800s. A1c from ___ was 6.3; on ___ A1c
was 12.9. While he had what appears to be an anion-gap acidosis
on admission, this was likely due to ___ as opposed to DKA.
There were no ketones in the urine and acetone is negative.
Serum beta-Hydroxybutyrate was checked on ___ and was normal
(0.1). The anion-gap closed in the ED with fluids and insulin
gtt. Presenting blood glucose level was likely due to in part to
the L5-S1 steroid injection for spinal stenosis on ___, although
he has chronically elevated blood glucose as evidenced by his
A1c of 12.9. Interestingly, Lupron can also cause glucose
dysregulation with prolonged use, and could be contributing to
his rapid development of diabetes over the past year. The
patient was seen by ___ who did diabetic teaching and insulin
teaching. At discharge, patient is on Lantus 30mg QHS, Humalog
sliding scale up to 12 units, Metformin 500mg daily, and
Glipizide XL 5mg daily. Patient was able to demonstrate insulin
use with wife prior to discharge. He will have home ___ and he
is scheduled to follow up with ___ for further teaching.
- uptitrate metformin
- Per ___, goal is to have patient on Lantus and oral agents
# ___: Patient presented with Cr 1.6. Fluid resucitated and Cr
down to 1.1 after fluid resuscitation. Lisinopril and HCTZ held.
Lisinopril was restarted at half of home dose prior to
discharge, given normal labs and stable vital signs he was
discharged on his home dose of lisinopril.
# Hypertension: Lisinopril and HCTZ held initially. Lisinopril
restarted prior to discharge at half dose.
- HCTZ continued to be held at time of discharge.
# Spinal stenosis and chronic pain: Held ibuprofen in setting of
___.
# Hyperlipidemia: contineud Atorvastatin 20 mg PO QPM
# Metastatic prostate cancer: Followed by Heme/Onc. Leuprolid
and denosumab held during heme-onc visit immediately prior to
admission, due to the patients presenting symptoms. Given
possibility of some contribution of Lupron to hyperglycemia, we
recommend that patient follow up with Heme/Onc to discuss
further use of Lupron.
TANSITIONAL ISSUES:
======================
- further diabetic and insulin teaching
- uptitrate metformin
- adjust glipizide as necessary
- Per ___, goal is to have patient on Lantus and oral agents
- monitor blood pressures and adjust medications accordingly.
Lisinopril was halfed during this admission and HCTZ stopped.
CODE: FULL
CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
2. Atorvastatin 20 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Ibuprofen 600 mg PO Q6H:PRN pain
6. Multivitamins 1 TAB PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Leuprolide Acetate Dose is Unknown IM Frequency is Unknown
9. Denosumab (Prolia) Dose is Unknown SC Frequency is Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Multivitamins 1 TAB PO DAILY
4. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] QID ASDIR
Disp #*100 Strip Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 30 Units before
BED; Disp #*5 Vial Refills:*0
RX *blood-glucose meter QID ASDIR Disp #*1 Kit Refills:*0
RX *insulin lispro [Humalog ___] 100 unit/mL AS DIR Up to 12
Units QID per sliding scale Disp #*5 Syringe Refills:*0
RX *lancets [FreeStyle Lancets] 28 gauge QID ASDIR Disp #*100
Each Refills:*0
7. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Type 2 diabetes mellitus
Discharge Condition:
Mental status at baseline, A&Ox3
Ambulating independently
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure participating in your care. You were
admitted to ___ for management of your high blood sugar, and
were diagnosed with diabetes during this visit. Your blood
sugar was in the 800s when you arrives. We treated you with
insulin, which decreased your blood sugar.
Dear Mr. ___,
It has been a pleasure participating in your care. You were
admitted to ___ for management
of your high blood sugar, and you were diagnosed with type 2
diabetes during this visit.
Your blood sugar was extremely high, in the 800s, when you
arrived. We treated you with insulin, as well as oral
medications, which decreased your blood sugar. We also
performed lab tests, and determined that your blood sugar has
been high for at least a few months. High blood sugar causes
thirst and increased urination; this would explain the symptoms
you have been having over the past few weeks.
While you were hospitalized, our diabetes specialists saw you
and determined that you will need to continue taking two oral
medications, metformin and glipizide, as well as injections of
insulin in order to keep your blood sugar from becoming
dangerously high. We taught you and your wife how to use
insulin; please get in touch with your doctor if you have any
questions.
Please take all of your medications as prescribed, and be sure
to follow up with Dr. ___ will be helping you manage your
diabetes.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10468704-DS-20 | 10,468,704 | 26,508,376 | DS | 20 | 2177-08-21 00:00:00 | 2177-08-23 07:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / ethambutol / linezolid
Attending: ___.
Chief Complaint:
Fever, Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with h/o disseminated TB
involving
pancreas, lungs, abdominal/supraclavicular LN dx'd ___,
hyperlipidemia, GERD who presents with new fevers to 100-101 for
the last week and severe neck pain for the last ___.
Patient has a history of disseminated TB initially treated with
RIPE, but later found to be resistant to INH and PZA, so changed
to rif/ethambutol/levofloxacin c/b prolonged admit in ___ with
drug-induced liver injury and rash, briefly treated with
steroids
with resolution and discharged on amikacin/ linezolid/
ethambutol
started ___ with plan to restart additional TB medicaitons
in
clinic. Patient had begun to have some pruritis after starting
that regimen that was being treated with antihistamines. She
continued to do well without rash so was started on rifampin
___ and cycloserine on ___ with hopes to maintain patient
on
3 drug regimen as thought she would eventually develop toxicity
to amikacin and/or linezolid. During this time patient continued
to have rising eosinophilia from 6.8% at discharge ___ to 14%
___, and now 31.9% ___. Rifampin was stopped on ___ and
ethambutol stopped ___ due to concern if was causing
eosinophilia but numbers continued to climb. Rash has waxed and
waned during this time.
On ___, patient was visited by ___ who noticed patient's face
had become more erthythematous and patient was complaining of
new
neck pain and fevers for past 3 days. Of note, per ___ patient
has had low grade fevers to 99, low 100s since discharge in
___ but now noted to have fevers in higher 100s consistently
and today Tmax of 101.6. Patient was seen in the infectious
disease clinic by Dr. ___ today felt fevers and neck
pain
were concerning for TB meningitis vs possible DRESS syndrome or
___ phenomenon involving the upper spine or brain. Recommended
that patient present to the ED for emergent imaging of neck and
head to rule out new lesions or inflammatory process causing her
symptoms with possible LP if imaging negative.
Past Medical History:
- HLD
- GERD
- OA
- Hyperthyroidism
- Depression
- Disseminated TB (see HPI for details)
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam
VITALS: T98.4 BP 140/74 HR 79 RR 18 SpO2 99 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Face notably with some mildy
swollen cheeks. Pupils equal, round, and reactive bilaterally.
Cataracts noted bilaterally. Extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: No cervical lymphadenopathy. Tenderness to palpation over
left anterior neck. Limited ROM with neck flexion due to pain.
Negative Kernig and brudzinski sign. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mild tenderness to
palpation over epigastric area w/o rebound or guarding. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Diffuse erythematous papular rash with some plaques on her
arms, legs, stomach and back. There are superficial abrasions on
back and legs from scratching. Also with skin peeling involving
legs back and feet (most notable on feet due to thicker skin)
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
Discharge Physical Exam
***
Pertinent Results:
Admission Labs
___ 06:32PM BLOOD WBC-11.7* RBC-4.01 Hgb-12.7 Hct-37.7
MCV-94 MCH-31.7 MCHC-33.7 RDW-14.0 RDWSD-48.1* Plt ___
___ 06:32PM BLOOD Neuts-52.4 Lymphs-7.5* Monos-11.1
Eos-27.5* Baso-0.9 Im ___ AbsNeut-6.12* AbsLymp-0.87*
AbsMono-1.29* AbsEos-3.21* AbsBaso-0.10*
___ 06:32PM BLOOD ___ PTT-30.1 ___
___ 06:32PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-142
K-4.1 Cl-102 HCO3-27 AnGap-13
___ 06:32PM BLOOD ALT-10 AST-22 CK(CPK)-65 AlkPhos-102
TotBili-0.2
___ 06:32PM BLOOD Lipase-71*
___ 05:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:32PM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.1 Mg-2.2
___ 06:41PM BLOOD Lactate-2.0
___ 08:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 02:00PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-4 Polys-6
___ ___ 02:00PM CEREBROSPINAL FLUID (CSF) TotProt-66*
Glucose-60 LD(LDH)-23
ADENOSINE DEAMINASE, CSF 0.5 <7.0 U/L
___ 09:45PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 6:32 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:00 pm CSF;SPINAL FLUID Source: LP TUBE 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
Pertinent Findings
___ 08:44AM BLOOD Neuts-46.3 Lymphs-8.9* Monos-11.1
Eos-31.9* Baso-1.1* Im ___ AbsNeut-4.09 AbsLymp-0.79*
AbsMono-0.98* AbsEos-2.82* AbsBaso-0.10*
___ 05:20AM BLOOD Neuts-39.9 Lymphs-9.1* Monos-12.2
Eos-36.6* Baso-1.2* Im ___ AbsNeut-4.19 AbsLymp-0.95*
AbsMono-1.28* AbsEos-3.84* AbsBaso-0.13*
___ 04:55AM BLOOD Neuts-37 Bands-0 Lymphs-7* Monos-17*
Eos-37* Baso-2* ___ Myelos-0 AbsNeut-3.48
AbsLymp-0.66* AbsMono-1.60* AbsEos-3.48* AbsBaso-0.19*
___ 05:18AM BLOOD Neuts-39 Bands-0 Lymphs-11* Monos-12
Eos-37* Baso-1 ___ Myelos-0 AbsNeut-4.45
AbsLymp-1.25 AbsMono-1.37* AbsEos-4.22* AbsBaso-0.11*
___ 05:29AM BLOOD Neuts-36.6 Lymphs-7.5* Monos-11.6
Eos-42.6* Baso-1.1* Im ___ AbsNeut-3.91 AbsLymp-0.80*
AbsMono-1.24* AbsEos-4.55* AbsBaso-0.12*
___ 06:31AM BLOOD Neuts-63.9 Lymphs-9.8* Monos-14.2*
Eos-10.8* Baso-0.7 Im ___ AbsNeut-7.32* AbsLymp-1.12*
AbsMono-1.63* AbsEos-1.24* AbsBaso-0.08
___ 05:16AM BLOOD Neuts-37.8 Lymphs-12.5* Monos-9.5
Eos-38.5* Baso-1.1* Im ___ AbsNeut-4.06 AbsLymp-1.34
AbsMono-1.02* AbsEos-4.14* AbsBaso-0.12*
___ 05:52AM BLOOD Neuts-35.0 Lymphs-10.2* Monos-10.7
Eos-42.1* Baso-1.2* Im ___ AbsNeut-4.03 AbsLymp-1.17*
AbsMono-1.23* AbsEos-4.84* AbsBaso-0.14*
___ 05:33AM BLOOD Neuts-32.6* Lymphs-13.0* Monos-12.4
Eos-40.1* Baso-1.0 Im ___ AbsNeut-3.29 AbsLymp-1.31
AbsMono-1.25* AbsEos-4.05* AbsBaso-0.10*
___ 05:08AM BLOOD Neuts-36.8 Lymphs-8.3* Monos-12.5
Eos-40.6* Baso-1.1* Im ___ AbsNeut-3.84 AbsLymp-0.87*
AbsMono-1.31* AbsEos-4.24* AbsBaso-0.12*
___ 05:29AM BLOOD Cortsol-4.9
___ 05:16AM BLOOD Cortsol-12.4
___ 05:16AM BLOOD ___ Titer-1:1280*
Cntromr-POSITIVE*
___ 05:16
ANTI-HISTONE ANTIBODY
Test Result Reference
Range/Units
HISTONE AB <1.0 <1.0 U
___ HSV, PCR, CSF Negative
___HEST W/CONTRAST
1. Essentially complete resolution of previous findings of
disseminated TB.
Specifically, pleural effusion, omental nodularity, psoas
collections,
peritonitis, and left supraclavicular nodal mass have resolved.
There persist
numerous retroperitoneal lymph nodes, however these have
decreased in size and
are not enlarged by CT size criteria.
2. 9 mm soft tissue nodule anterior to the right breast
glandular tissue in
the lower outer quadrant has increased in size and likely
represents a low
axillary lymph node. However, correlation with mammography may
be considered.
RECOMMENDATION(S): Correlation with mammography may be
considered for
possible right breast nodule/low axillary lymph node.
___ Miscellaneous Audiology/Hearing Evaluation
Decreased in hearing thresholds from 6000-8000 Hz since last
hearing test in both ears.
___ Cardiovascular ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 65%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is no pericardial thickening.
IMPRESSION: no evidence of tuberculous cardiac disease
___ Imaging MR HEAD W & W/O CONTRAS
1. No acute intracranial abnormality on contrast enhanced MRI
brain. No
abnormal mass, enhancement or evidence of acute infarct. No
intracranial
hemorrhage.
2. No evidence of osseous or disc abnormality to suggest Potts
disease.
3. Multilevel degenerative changes are identified, resulting in
C4-C5 moderate
to severe left, moderate right, C5-C6 severe bilateral, C6-C7
severe bilateral
and C7-T1 severe left neural foraminal narrowing.
4. Multilevel disc protrusions are most prominent at C5-C6 where
there is
moderate to severe spinal canal narrowing, remodeling the cord
without
definitive underlying cord signal change and at C6-C7 where
there is moderate
spinal canal narrowing.
5. Additional findings as described above.
Discharge Labs
***
Brief Hospital Course:
PATIENT SUMMARY
==================
Ms. ___ is a ___ year old female with h/o disseminated TB
(diagnosed in ___ c/b drug resistance and toxicities),
hyperlipidemia, and GERD who presented with pruritic rash,
fevers, and neck pain, in the setting of worsening eosinophilia
concerning for drug hypersensitivity reaction thought to be
related to ethambutol. No end organ damage was seen with rising
eosinophilia. All of her TB medications were stopped and a 5-day
prednisone course was started for eosinophilia and symptomatic
rash. All TB meds were held at time of discharge. No plan to
reintrouduce Amakacin given concerns of ototoxicity on follow-up
audiology testing.
# Severe eosinophilia
# Diffuse erythematous papular rash
# Hypersensitivity drug reaction: Patient presented with acute
worsening of a full-body rash since ___ that had been
waxing and waning rash since last discharge from hospital
___. Previously rash was attributed to meds and d/c'd
rifampin ___. In this admission, we suspect that ethambutol was
the culprit of the hypersensitivity reaction, which was d/c'd on
___ but with continual rising eosinophilia. All TB medications
(amikacin, linezolid and cycloserine) were stopped on ___, and
linezolid and cycloserine w/ B6 were reintroduced but there was
persistent eosinophilia. Amikacin was d/c'd due to suspected
ototoxicity seen on f/u audiology exam. Strongyloides IgG was
negative, but she received an empiric dose of ivermectin prior
to result. No evidence of eosinophilic myocarditis on TTE with
negative Troponin. Low suspicion for DRESS given liver and
kidney function stable.
All TB Meds were stopped on ___ and a 5-day prednisone burst
was started. Plan will be for close follow up of eosinophils and
rash as well as stepwise reintroduction of TB meds.
Symptomatic management by sarna lotion PRN pruritis,
hydrocortisone cream/Betamethasone cream with saran wrap
covering for rash, clobetasol solution for scalp, hydroxyzine
TID, fexofenadine.
# Neck pain
# Fevers, now resolved: Patient presented with neck pain and
fevers with Tmax 101.6 over the 3 days PTA in setting of
disseminated TB, persistent rash, and worsening eosinophilia to
36.6. MRI head and spine without inflammatory findings or
tuberculomas. LP studies and culture, blood cx, urine cx, HSV
PCR negative for bacterial and viral meningitis.
# Disseminated TB
Her prior TB course was been well documented in infectious
disease notes, But briefly, patient has a history of
disseminated TB involving pancreas, lungs,
abdominal/supraclavicular LN dx'd ___ initially treated with
RIPE, but later found to be resistant to INH and PZA, and
changed to rif/ethambutol/levofloxacin c/b prolonged admit from
___ with rash and biopsy-proven drug-induced liver
injury, that was treated with steroids with resolution and
discharged on amikacin/linezolid/ ethambutol. Cycloserine
started on ___ with hopes to maintain patient on 3 drug regimen
if toxicity to amikacin/linezolid develops. Rifampin trialed
___ drug reaction. Ethambutol was initially held at
admission but eosinophilia continued to worsen. Management of
medications per above. CT abdomen in this admission showed
resolution of previous disseminated TB.
#Visual floaters
No acute visual changes but noting floaters. Optho evaluated and
did not think pt had ethambutol
toxicity. Recommended follow up with primary eye doctor in ___
weeks.
================
CHRONIC ISSUES:
=================
# GERD
# Epigastric pain
Patient endorsed epigastric pain since ___. History of
abnormal GI findings early in patient's TB evaluation. Currently
not on medications. Previously on omeprazole and ranitidine.
Lipase 70, 72.
# Osteoarthritis
Patient endorsed diffuse joint pains in hands, knees, and feet
that has been ongoing. Treated with Tylenol.
# Hyperlipidemia: Previously on Atorvastatin 20mg daily but
stopped given high pill
burden with TB medications.
====================
TRANSITIONAL ISSUES:
====================
[] TB: All medications stopped ___
[] Eosinophilia: Follow up CBC/Diff ___ faxed to ___
[] Steroid taper: Continue 40mg prednisone ___
[] Floaters: Plan for outpatient eye exam/ophtho follow-up in
___ weeks.
[] Breast nodule: 9 mm soft tissue nodule anterior to the right
breast glandular tissue in the lower outer quadrant has
increased in size and likely represents a low axillary lymph
node. However, correlation with mammography may be considered.
#CODE: FULL (Confirmed)
#CONTACT: ___
Relationship: DAUGHTER
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amikacin 600 mg IV Q24H
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Linezolid ___ mg PO DAILY
4. CycloSERINE 250 mg PO Q12H
5. Cetirizine 10 mg PO DAILY:PRN allergies
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/cough
7. Docusate Sodium 100 mg PO BID
8. Naproxen 500 mg PO Q8H:PRN Pain - Mild
9. Pyridoxine 50 mg PO BID
Discharge Medications:
1. Aquaphor Ointment 1 Appl TP BID:PRN dry skin/rash
RX *white petrolatum [Aquaphor Original] 41 % Apply to itchy
areas twice a day Refills:*0
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES QID
RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1
%-0.3 % ___ drops in each eye four times a day Disp #*1 Bottle
Refills:*0
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Rash
RX *betamethasone dipropionate 0.05 % 1 application twice a day
Refills:*0
4. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
RX *clobetasol 0.05 % 1 application to scalp twice a day
Refills:*0
5. Fexofenadine 180 mg PO BID
RX *fexofenadine 180 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Hydrocortisone Cream 2.5% 1 Appl TP BID
RX *hydrocortisone 2.5 % 1 application to face twice a day
Refills:*0
7. HydrOXYzine 25 mg PO TID
RX *hydroxyzine HCl 25 mg 1 tab by mouth three times a day Disp
#*45 Tablet Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 patch Q AM Disp #*30 Patch Refills:*0
9. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*4 Tablet
Refills:*0
10. Sarna Lotion 1 Appl TP QID:PRN pruritis
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % 1 application
four times a day Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/cough
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14.Outpatient Lab Work
Please draw CBC with differential ___
ICD: ___
Please fax result to ___ ATTN: Dr ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
================
Eosinophilia
Hypersensitivity reaction
Rash
Neck pain
Disseminated tuberculosis
Visual floaters
9 mm soft tissue nodule
SECONDARY DIAGNOSES
=================
GERD
Osteoarthritis
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital, because you had a rash and
you were having an allergic reaction to one of your tuberculosis
medications.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We stopped your TB medications, because we were concerned
about a reaction to them. It is unclear which medicine caused
this.
- We started you on oral steroids.
- We treated your rash with topical medications and oral
medications.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- The infectious disease doctors are working on making a follow
up appointment. If you do not hear about an appointment in the
next 2 days, please call ___ to make an appointment.
- Complete your prednisone course through ___.
- Call your doctors if your ___ gets worse or you get itchier.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10469058-DS-21 | 10,469,058 | 26,099,851 | DS | 21 | 2157-07-27 00:00:00 | 2157-07-27 22:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Shellfish Derived
Attending: ___.
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Cardiac Cath (___) without stenting
History of Present Illness:
___ with chest pain. Patient states her chest pain began last
evening approximately 10 ___ and continued to worsen through the
night. Pain is in the ___ her chest traveling to the arms
bilaterally worse in the right arm. Pain worse when laying flat
and not associated with any shortness of breath. Patient seen at
outside hospital where CTA was performed concerning for small
subsegmental pulmonary embolism and infrarenal aortic
dissection. Pain improved with morphine given at OSH. Troponin
increased from undetectable to 1.9. Patient with history of
achalasia and family history of cardiac disease. Patient smokes
one pack per day. Of note patient reports h/o superficial blood
clot in leg last year. Patient denies any recent travel or
immobilization. Mother also with history of clots, but no PE.
In the ED, initial vitals were 98.5 82 108/70 14 100%. EKG
remarkable for: Sinus 70, normal axis, Q V2, no ST seg changes,
normal intervals. Labs largely normal except Trop of 0.2. Second
read of CTA chest read without aortic dissection. Started on
Heparin IV Bolused: 3800 units and started on Infusion Rate: 750
units/hr Target PTT: 50 - 80 seconds.
Past Medical History:
- Achalasia status post dilation
- ___ esophagitis
- Gastroesophageal reflux
Social History:
___
Family History:
- Positive for multiple sclerosis, kidney disease, alcohol
abuse.
- No family history of achalasia.
- History of early MI (grandfather with MI in ___, uncle in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=98.2 BP=111/70 HR=84 RR=20 O2 sat= 100% RA
General: Laying down, in NAD, well-appearing
HEENT: NC/AT, EOMI, sclera anicteric, MMM, oropharynx clear
Neck: Trachea midline, no JVD
CV: RRR, normal s1 and s2, no r/m/g appreciated
Lungs: CTAB, no wheezes or rhonchi appreciated
Abdomen: Soft, non-distended, NTTP
GU: Deferred
Ext: 1+ peripheral pulses, no c/c/e
Neuro: Speech fluent, moving all extremities
Skin: No rashes noted
DISCHARGE PHYSICAL EXAM:
VS: Wt=54.7 kgs T=98-98.7 BP=102/56 HR=53-59 RR=18 O2 sat= 100%
RA
General: Laying down, in NAD, well-appearing
HEENT: NC/AT, EOMI, sclera anicteric, MMM, oropharynx clear
Neck: Trachea midline, no JVD
CV: RRR, normal s1 and s2, no r/m/g appreciated
Lungs: CTAB, no wheezes or rhonchi appreciated
Abdomen: Soft, non-distended, NTTP
GU: Deferred
Ext: 1+ peripheral pulses, no c/c/e
Neuro: Speech fluent, moving all extremities
Skin: No rashes noted
Pertinent Results:
ADMISSION LABS:
___ 08:30AM BLOOD WBC-7.6 RBC-4.18* Hgb-12.9 Hct-38.7
MCV-93 MCH-30.9 MCHC-33.4 RDW-12.5 Plt ___
___ 08:30AM BLOOD Neuts-93.9* Lymphs-4.7* Monos-0.7*
Eos-0.4 Baso-0.3
___ 08:30AM BLOOD ___ PTT-29.2 ___
___ 08:30AM BLOOD Glucose-125* UreaN-7 Creat-0.6 Na-138
K-4.4 Cl-101 HCO3-27 AnGap-14
___ 08:47AM BLOOD cTropnT-0.20*
___ 08:30AM URINE Color-Straw Appear-Clear Sp ___
___ 08:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:30AM URINE UCG-NEGATIVE
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-6.7 RBC-3.87* Hgb-11.9* Hct-35.7*
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.7 Plt ___
___ 06:00AM BLOOD ___ PTT-69.2* ___
___ 09:10AM BLOOD Glucose-75 UreaN-10 Creat-0.5 Na-139
K-4.1 Cl-102 HCO3-30 AnGap-11
___ 06:00AM BLOOD UreaN-9 Creat-0.4 Na-137 K-4.3 Cl-102
HCO3-27 AnGap-12
___ 06:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
IMAGING/STUDIES:
ECG ___: Sinus rhythm. Possible septal myocardial
infarction, age indeterminate, although could be due lead
placement. No previous tracing available for comparison.
CT ABD (OSH wet read): IMPRESSION:
1. Subsegmental pulmonary embolism demonstrated within the
lateral basal segment of the right lower lobe.
2. No acute aortic dissection. A region of partially calcified,
atypical atherosclerotic plaque with an adjacent region of
scarring moderately narrows the infrarenal aorta. Although no
comparisons images are available, this finding appears chronic
and is referenced in the OSH radiology report to be similar in
appearance when compared to a CTA chest performed in ___
3. Significantly dilated esophagus with distal narrowing,
compatible with thevpatient's known history of achalasia.
4. Mild to moderate centrilobular emphysema.
CARDIAC CATH (___):
Coronary angiography: right dominant
LMCA: normal
LAD: occluded D2 with collateral filling; otherwise no
significant disease
LCX: normal
RCA: normal
Assessment & Recommendations
1. Occluded LAD D2; otherwise no significant CAD
ECHO (___):
The left atrium and right atrium are normal in cavity size. The
left atrial volume is normal. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the mid to distal anterior wall
and distal lateral wall. The remaining segments contract
normally. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Diastolic function could not be assessed.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular dysfunction c/w CAD,
with overall low-normal global systolic function. Normal right
ventricular free wall systolic function.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ year old female with PMHx notable for
achalasia s/p dilation, now with chest pain x1 day and CTA at
OSH c/f PE.
# NSTEMI: EKG without ischemic changes. Troponin elevated.
Trop elevation may be secondary to heart strain from PE, versus
intrinsic coronary disease. Patient was initially treated with
heparin drip, ASA 81, metoprolol 12.5 TID, and plavix 75 daily.
Echo abnormalities seen: specifically mild regional left
ventricular systolic dysfunction with hypokinesis of the mid to
distal anterior wall and distal lateral wall. Given echo
abnormalities, cardiac cath was pursued. Cardiac catheterization
showed LAD: occluded D2 with collateral filling; otherwise no
significant disease. No intervention was done. Patient was
discharged on ASA 81 and metoprolol XL 25 mg daily.
# Pulmonary embolism: noted on CT imaging, history of
superficial clots in leg per patient. Also mother with history
of clots, but no PE. Patient was transferred on heparin gtt.
This was continued during her admission. She was transitioned
to Xarelto on discharge. Given PE was unprovoked, patient will
need at least 6 months of anticoagulation.
# Barretts/Achalasia: patient on aciphex at home, was
non-formulary at ___ pharmacy. Thus was treated with Zantac
150 qd. On discharge continued on aciphex.
Transitional issues:
- Pulmonary embolism: discharged on Xarelto (20 mg daily).
Likely requires 6 months of oral anticoagulation for unprovoked
PE if not lifelong. Recommend PCP ___ to assist in
determining length of anticoagulation.
- ___ benefit from thrombophilia work up in the outpatient
setting once off oral anticoagulation
- CAD/NSTEMI: patient underwent cardiac cath on ___: showed LAD:
occluded D2 with collateral filling; otherwise no significant
disease. Is being discharged on aspirin, and metoprolol. Would
consider starting atorvastatin on outpatient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aciphex (RABEprazole) 20 mg oral BID
2. Ferrous Sulfate Dose is Unknown PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth QDinner
Disp #*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Aciphex (RABEprazole) 20 mg oral BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP < 90 or HR < 60
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth Daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
NSTEMI
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during you admission to ___
___. You were admitted here for
further management of your pulmonary embolism and due to concern
for a cardiac event. While you were admitted you were given
medications to treat the clot in your lung. In addition, you
underwent a cardiac catheterization which did show some coronary
artery disease, but not requiring any stenting. You will be
discharged on medications to treat your clot (Xarelto) which you
should continue to take daily for at least 6 months, you should
follow up with your primary care physician regarding whether you
should take this for a longer period of time. In addition, you
should take a baby aspirin daily to reduce the risk of a heart
attack, and you will be prescribed a new medication for blood
pressure (Metoprolol) which you should take as prescribed. You
should also keep your follow up appointments as scheduled.
Should you develop any chest pain, progressive shortness of
breath, or swelling/pain in your legs/calves, please seek
evaluation at a medical facility or your nearest emergency
department.
Followup Instructions:
___
|
10469200-DS-9 | 10,469,200 | 26,039,147 | DS | 9 | 2185-02-17 00:00:00 | 2185-02-17 11:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, lower extremity swelling and pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a past medical history of hypertension,
hyperlipidemia, gout, presenting with chief complaint of 2 days
of fever and 1 day of left lower extremity swelling, redness and
pain. Patient returned from ___ on ___, and noted that
he had a fever of 101.9. Patient said he had laid in bed for 2
to
3 days because he was not feeling well. Patient woke up this
morning to take a walk and noticed his left lower extremity was
painful, swollen and red. Patient states is worse in the calf
area feels like cramping worse when trying to walk. Patient has
not tried to take anything at home for it. Patient denies any
cigarette smoking, no recent infections in the lower extremity,
no recent injuries, trauma, or insect bites.
In the ED, initial VS were 99.9 89 138/97 18 98% RA. Tmax was
100.8.
The patient received acetaminophen, LR, ibuprofen, IV cefazolin,
and IV vancomycin.
Labs were notable for a BUN/Cr of ___, CRP of 281, and a CBC
with WBC 13.7, Plt 140. Lactate was 1.1.
A unilateral ultrasound of the left showed no evidence of DVT.
Upon arrival to the floor, the patient tells the story as
follows. He confirms the story as above. He was on a trip to
___ and just prior to boarding the plane, ate some
shellfish for lunch. On the plane, he was very ill, felt sweaty,
fatigued, with some shortness of breath, needing to lay across a
whole row of the plane. He was escorted home in a taxi by his
friend and has stayed in bed for a day and a half. He was
febrile, but felt better when the fever broke. It was only
recently that his wife noticed that his leg was significantly
red
and swollen. He himself did not notice so he is not sure when it
started. He was then sent to the ED to rule out a blood clot. He
attributes everything to these shrimp tacos that he feels
"started the whole thing," but he is unsure when his leg rash
started. He otherwise denies joint pain, other rashes, easy
bruising.
He endorses some nausea, but no vomiting, no abdominal pain, no
chest pain, some mild shortness of breath which occurred on the
plane but has not recurred since. Patient has no history of DVTs
or blood clotting disorders.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Benign renal mass
- Gout
- HLD
- HTN
- GERD
- Allergic Rhinitis
- Microscopic hematuria
Social History:
___
Family History:
No history of autoimmune illnesses. Mother has asthma. Brother
has HLD.
Physical Exam:
Admission Physical EXAM
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
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
EXT: + swelling of the LLE,
SKIN: + spotchy erythema that is warm to touch, demarcated with
a
skin pin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Discharge Exam:
VITALS: temp 98.0; BP 146/83; HR 66; RR 18; O2 98% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
EXT: mild swelling LLE, warm
SKIN: resolving splotchy erythema that is warm to touch not
palpable, outlined with marker
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
___ 02:51PM BLOOD WBC-13.7* RBC-4.67 Hgb-13.7 Hct-42.0
MCV-90 MCH-29.3 MCHC-32.6 RDW-14.4 RDWSD-47.0* Plt ___
___ 02:51PM BLOOD Plt ___
___ 02:51PM BLOOD Glucose-110* UreaN-27* Creat-1.3* Na-137
K-6.3* Cl-101 HCO3-21* AnGap-15
___ 02:51PM BLOOD ALT-32 AST-80* AlkPhos-39* TotBili-0.5
___ 02:51PM BLOOD CRP-281.3*
Discharge Labs:
___ 06:35AM BLOOD WBC-6.6 RBC-4.62 Hgb-13.8 Hct-40.8 MCV-88
MCH-29.9 MCHC-33.8 RDW-13.5 RDWSD-43.9 Plt ___
___ 06:35AM BLOOD Glucose-95 UreaN-12 Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-23 AnGap-12
___ 06:20AM BLOOD ALT-27 AST-21 AlkPhos-52 TotBili-0.5
___ 06:35AM BLOOD Mg-2.2
___ 06:35AM BLOOD CRP-59.9*
Micro:
MRSA screen ___- negative
blood culture ___- NGTD
Imaging:
___- LLE ultrasound
No evidence of deep venous thrombosis in the left lower
extremity
veins.
Brief Hospital Course:
___ male with a past medical history of
hypertension,hyperlipidemia, gout, presenting with fever and LLE
erythema and warmth, undergoing treatment for LLE cellulitis.
# Sepsis
# LLE cellulitis: Patient presenting with ___ SIRS criteria
(fever, leukocytosis) with LLE erythema and warmth, consistent
with lower extremity cellulitis. No obvious source of entry or
known trauma. CRP elevated to 280. Lactate was WNL. He was
started on vancomycin and ceftriaxone that was transitioned to
cefazolin. MRSA screen was negative and blood culture ___ have
shown NGTD. He remained afebrile >24hrs and leukocytosis had
resolved on discharge. CRP downtrended to 60. He denied any
further ___ pain and his erythema was resolving. He was
transitioned to Keflex ___ QID through ___ to complete 7 day
course of abx.
# Acute Renal Failure: Admission Cr of 1.3, up from a distant
baseline of 0.9-1.1. BUN not elevated and the patient does not
look currently hypovolemic,however, has had decreased intake in
the setting of acute illness. Suspect pre-renal from sepsis and
dehydration. It was resolved back to baseline with IVF and abx.
Creatinine on discharge was 1.
#transaminitis- He had mild transaminitis with AST to 80 suspect
___ to sepsis. Resolved with IVF and abx.
# Gout: Continued home allopurinol ___ daily
# HTN: Continued home lisinopril 40mg daily, metoprolol
succinate 50 mg daily, and home amlodipine 10 mg daily
# HLD: Continued home pravastatin 20 mg daily
# Allergic rhinitis: Continued home flunisolide
Transitional Issues:
[] continue to monitor LLE cellulitis and consider extending abx
course as needed
Greater than 30 min spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. flunisolide 25 mcg (0.025 %) nasal BID
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Pravastatin 20 mg PO QPM
9. tadalafil 10 mg oral ASDIR
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
continue taking through ___
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times
a day Disp #*20 Capsule Refills:*0
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. flunisolide 25 mcg (0.025 %) nasal BID
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Pravastatin 20 mg PO QPM
10. tadalafil 10 mg oral ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with redness, pain and left lower extremity
swelling felt to be consistent with an infection called
cellulitis. You were started on IV antibiotics with improvement
of symptoms. You remained stable so were discharged home with
oral antibiotics to complete your course.
New Medications:
1)Keflex is an antibiotic to treat your infection. Please take
4x a day through ___
Followup Instructions:
___
|
10469621-DS-21 | 10,469,621 | 25,790,664 | DS | 21 | 2193-10-06 00:00:00 | 2193-10-08 17:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Plavix / Actos / Ciprofloxacin / Iodinated Contrast
Media - IV Dye / Ecotrin / metoprolol
Attending: ___.
Chief Complaint:
Dyspnea on exertion, GI bleed
Major Surgical or Invasive Procedure:
EGD: ___
History of Present Illness:
___ year old female, ___ CAD s/p CABG ___, stroke, HTN, NIDDM,
pAF who presents from clinic dyspnoea on exertion for two weeks.
Of note, Call-in notes 78% RA O2 sat. We had some difficulty
getting a good pleth here, but when pleth is good she is satting
96-100% RA.
Pt reports that her symptoms began ___ days ago. However, review
of OMR shows that she first called in about this complaint on
___. At that time, her lasix was increased from 20 to 40 mg
daily over the phone given her report of worsened lower
extremity edema. Increasing her lasix did not improve the
symptoms, and she stated that her symptoms began after her
carvedilol was changed to metoprolol on ___. Therefore, her
cardiologist Dr. ___ her to go back to the carvedilol on
___. Her symptoms persisted so she came in to her PCP's office
today. In the clinic, she appeared pale and had an O2 sat of 78%
so she was referred to the ED by ambulance.
In the ED, initial vitals: 98.0 75 119/52 22 100% 3L NC. She had
no sob at rest, but had DOE w/ only a few steps. Denies cp,
cough, wheezing, f/c/n/v, constipation/diarrhea, bleeding from
anywhere, melena, BRBPR. On arrival, patient's Hb was noticed to
be 4 and INR was 7. Patient received one unit of blood and two
units of FFP. On receiving the second unit of FFP, patient
developed hives, rash and shortness of breath. CXR showed fluid
in lungs. She was given 20mg IV lasix, IV solumedrol, Benadryl
and Epi IM. Blood bank informed and transfusion reaction sent.
Repeat INR 2.7. EKG showed <1mm depressions in V4-V6 and
inferior lead.
On transfer, vitals were:80 122/65 18 100% RA . On arrival to
the MICU patient was comfortable.
Past Medical History:
Diabetes Mellitus
Hypertension
Hyperlipidemia
Carotid Artery Disease
Peripheral arterial disease
History of Right brachial artery embolus s/p embolectomy
History of CVA - Right MCA infarct - on Coumadin
- Appendectomy, tonsillectomy, cholecystectomy
Social History:
___
Family History:
One sister, age ___, with diabetes. One brother with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T:98 BP:132/59 P:81 R:16 18 O2:99
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilateral Crackles
CV: Regular rate and rhythm, ___ EM, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Pale, Dry
NEURO: PERRLA
DISCHARge PHYSICAL EXAM:
AM vitals: 98.2 144/66 87 19 98% on RA
General: sitting in best cringing from pain
HEENT:moist mucous membranes, anicteric sclera
Neck: some muscle fullness on left neck, non tender to palpation
Lymph:no cervical LAD
CV: RRR
Lungs: CTA b/l
Abdomen: soft, NTTP, +bs
Ext: 2+ swelling on lower legs
Neuro: Normal speech, symmetric facial movements, moves all four
extremities symmetrically.
Pertinent Results:
ADMISSION:
___ 02:50PM BLOOD ___-6.6 RBC-2.09*# Hgb-4.5*# Hct-15.5*#
MCV-74*# MCH-21.6*# MCHC-29.2* RDW-16.3* Plt ___
___ 04:00PM BLOOD ___ PTT-47.1* ___
___ 02:50PM BLOOD Glucose-280* UreaN-33* Creat-1.5* Na-135
K-4.4 Cl-98 HCO3-24 AnGap-17
___ 05:50PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.3*
___ 02:50PM BLOOD Hapto-180
___ 02:50PM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:50PM BLOOD ALT-16 AST-16 CK(CPK)-75 AlkPhos-73
TotBili-0.3 DirBili-0.1 IndBili-0.2
___ 05:20PM URINE Color-Straw Appear-Clear Sp ___
___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:20PM URINE RBC-2 WBC-14* Bacteri-FEW Yeast-NONE
Epi-<1
IMAGING:
EGD ___: Erythema and sloughing in the distal esophagus
just proximal to the GE junction compatible with esophagitis
Normal mucosa in the stomach Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
___ ECG
Atrial flutter with rapid ventricular response and ventricular
premature beats.
Compared to the previous tracing of ___ atrial flutter is
new.
___ TEE No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is mildly depressed, but this is in the context of
atrial flutter with rapid ventricular response which may account
for much of this. Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 35 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. Mildly depressed
biventricular systolic function. Mild mitral regurgitation.
Moderate tricuspid regurgitation.
Dr. ___ was notified in person of the results on ___ at
10:15 AM.
___ cxr EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old woman with transfusion reaction //
?interval worsening COMPARISON: Chest radiographs ___. IMPRESSION: Mild interstitial pulmonary edema unchanged
since ___ at 21:58. Mild to moderate cardiomegaly
stable. Generalized hyperinflation reflects COPD. No
consolidation or appreciable pleural effusion.
___ cxr INDICATION: ___ with sob // ?pulmonary edema, interval
change //History: ___ with sob TECHNIQUE: Single AP portable
view of the chest COMPARISON: Radiograph from 4 hr prior
FINDINGS: In the interval since the prior study, there has been
no relevant change. Mild cardiomegaly remains stable. No focal
consolidations. The a sternotomy wire and mediastinal clips are
again noted. No pleural effusion and no pneumothorax. Heavily
calcified aorta. IMPRESSION: No significant interval change from
the prior radiograph. Continued cardiomegaly.
Brief Hospital Course:
___ year old female, ___ CAD s/p CABG ___, stroke, HTN, NIDDM,
pAF who presents from clinic dyspnoea on exertion for two weeks
in the setting of crit drop. EGD did not reveal source of bleed,
patient deferred colonoscopy. Found to be in aflutter to 150
had TEE and ablation procedure done during this hospitalization.
Was discharged on coumadin after a heparin bridge.
ACTIVE ISSUES:
#GIB: Patient symptomatic likely in setting of subacute blood
loss from severe esophagitis. Patient not hemodynamically
unstable but did have EKG changes suggestive of demand ischemia.
Last colonoscopy did show multiple diverticula and
angioectasias. Patient recieved 3 units pRBCs and and 2 units
FFP. EGD without obvious bleeding source but with esophageal
sloughing that could be responsible. Patient refused colonoscopy
and would like to follow up as outpatient. Patients hemtocrit
remained stable after the three units of blood. Hct 24.5 on
discharge.
#AFlutter: After discharge from the ICU patient was found to be
in flutter to the 160s remained asymptomatic, hemodynamically
stable. Rate was unable to be controlled with medication alone
so she had a flutter ablation procedure on ___. Rates were
subsequently well controlled on home medication at ___ and were
regular. Patient remained asymptomatic.
#DYSPNEA: Subacute dyspnea on exertion x 2 weeks most likely due
to anemia due to slow blood loss as hemoglobin was 4.5 on
admission. Patient was transfused PRBC and dyspnea resolved.
Hemoglobin was stable at discharge at 24.5 and patient was
breathing comfortably.
#TRANSFUSION REACTION: Patient developed reaction after 2nd bag
of FFP. Developed Hives,rash and SOB. Initial transfusion work
up negative. Discussed with blood bank, if she needs products,
she can receive but with slightly increased risk. Transfuse
blood products at slower rate. Will need to premedicate with
benadryl/steroid if need to administer FFP. Transfusion reaction
evaluation was not published by pathology at the time of
discharge.
#AFib: CHADS2 of 5, presented with elevated INR of unclear
etiology. INR was 7 in the ED and was reversed with 2 units of
FFP. No changes in medication per patient. After GI bleed
resolved patient was bridged to coumadin due to CHADS score of
7.
___: Baseline creatinine 1.1-1.3. Now peaked at 1.5 this
admission. Likely pre-renal in setting of volume loss. Improved
to 1.1 upon discharge.
#UTI: pt. found on UA to have evidence of a urinary tract
infection on presentation. Treated with ceftriaxone ultimately
transitioned to oral cefpodoxime after culture result proved
sensitive e coli.
CHRONIC ISSUES:
#CAD: s/p 3 vessel disase repair and CABG in ___. Continued
aspirin, statin. Held Valsartan in setting ___ and restarted
on discharge.
#HTN:Currently stable- restarted home hypertensive regimen.
#HLD: continued home statin dose.
#DM: stable was maintained on ISS.
****TRANSITIONAL ISSUES*****
-Patient restarted on coumadin. INR 2.1 at discharge
-Patient discharged on 40mg of omeprazole daily. She should
follow up with GI regarding adjusting this dose.
-GI will call patient with follow up appointment. If she does
not hear from them by midweek she will call at ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. GlipiZIDE XL 5 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Omeprazole 40 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Valsartan 40 mg PO BID
8. Warfarin 2.5 mg PO 3X/WEEK (___)
9. Warfarin 3.75 mg PO 4X/WEEK (___)
10. Carvedilol 12.5 mg PO BID
11. Digoxin 0.125 mg PO EVERY OTHER DAY
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral Daily
15. Furosemide 40 mg PO DAILY
16. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
17. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. Furosemide 40 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral Daily
8. Carvedilol 12.5 mg PO BID
9. Digoxin 0.125 mg PO EVERY OTHER DAY
10. Docusate Sodium 100 mg PO BID:PRN constipation
this will prevent constipation while ___ are on iron
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth
BID:PRN Disp #*40 Capsule Refills:*0
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
12. GlipiZIDE XL 5 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Sertraline 50 mg PO DAILY
15. Valsartan 40 mg PO BID
16. Warfarin 2.5 mg PO 3X/WEEK (___)
17. Warfarin 3.75 mg PO 4X/WEEK (MO,WE,TH,FR)
18. Bengay Cream 1 Appl TP PRN pain
RX *menthol [BenGay] 5 % Apply to affected area as needed twice
a day Refills:*0
19. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*12 Tablet Refills:*0
20. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 capsule(s) by
mouth twice a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
GI bleed
elevated INR
atrial flutter
Secondary Diagnosis:
Coronary Artery Disease
paroxismal Afib
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 had shortness of
breath and were found to have low blood counts because of a
bleed in your gastrointestinal tract. You were given blood
cells to correct your anemia. You had an endoscopy to find the
source of your bleeding. Although the endoscopy did reveal some
irritation of the esophagus this was not thought to account for
such a dramatic drop in your blood count. The
gastroenterologists recommended a follow up colonoscopy to find
the site of bleeding. You declined this colonoscopy despite the
risk of a recurrent serious bleed at home. You can follow up
with the gastroenterology doctors as ___ outpatient to arrange
further follow up.
You were also found to have a high INR putting you at increased
risk for a bleed. Your INR was reversed with plasma products to
which you unfortunately had an allergic reaction. When the
bleeding stopped you were restarted on your coumadin and had
heparin to thin your blood until the coumadin was at the right
levels.
You were also found to have a hard to control heart rate. While
hospitalized you had an ablation procedure and your heart rate
was subsequently well controlled.
Please take all you medications at home as you did before coming
to the hospital including your coumadin. Please follow up with
your primary care doctor to make sure your INR is at target as
the coumadin was stopped while you were inpatient. Please
follow up with your primary care doctor and have your INR
checked within one week of leaving the hospital. PLEASE SEEK
URGENT MEDICAL ATTENTION IF YOU DEVELOP SHORTNESS OF BREATH,
LIGHTHEADEDNESS, OR SEE BLOOD IN YOUR VOMIT OR YOUR STOOL.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you.
All the best,
Your ___ care team
Followup Instructions:
___
|
10469621-DS-23 | 10,469,621 | 21,154,724 | DS | 23 | 2194-12-29 00:00:00 | 2195-01-02 04:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Plavix / Actos / Ciprofloxacin / Iodinated Contrast
Media - IV Dye / Ecotrin / metoprolol
Attending: ___.
Chief Complaint:
Headache, elevated INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of CHF (EF ___, atrial
fibrillation on warfarin, CAD s/p CABG, and history of CVA who
presents with headache. Headache started 5 days ago. It is
located on the Rt temporal region, constant, and characterized
as throbbing and pounding. She reports sore throat, which has
since improved. She also has some She denies associated fevers,
neck pain, photophobia, jaw pain, weakness, and parasthesias.
She reports new productive cough that started today. She also
reports labored breathing, orthopnea, and peripheral edema. She
has been taking Tylenol without relief. She saw her PCP one day
prior to admission. INR was 5.0 and the patient was instructed
to hold warfarin. However, she forgot to hold the dose and took
it last night. Given worsening headaches and supratherapeutic
INR, she was referred to the ED for further workup.
In the ED, initial VS were: 98.8 68 134/80 24 100% RA.
- Labs: WBC 13.0, INR 5.0, Cr 1.4. UA small blood, 5 RBC.
- CT HEAD: No acute intracranial process. Chronic right MCA
infarct.
- CXR: Hyperinflated lungs with superimposed right middle mlobe
opacity, suspicious for pneumonia.
- Patient received: ceftriaxone, fioricet, and 1L NS.
Vitals prior to transfer: 98.6 88 122/73 18 100% RA
On arrival to the floor, patient reports worsening productive
cough and shortness of breath. She reports some relief after
receiving fiorcet in the ED. Current headache is not similar to
prior. Denies falls or trauma.
Patient triggered overnight for Afib with RVR (HR 160s). SBP
decreased by 20mmHg. Patient complained of shortness of breath.
She was given diltiazem 5mg IV x 2 and carvediolol 12.5mg PO. HR
improved after intervention.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, congestion,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other ___ review negative in detail.
Past Medical History:
- Atrial fibrillation on warfarin
- CAD s/p CABG in ___
- CHF (EF 55%)
- History of Rt MCA CVA- patient presented with fall
- NIDDM
- Hypertension
- Hyperlipidemia
- Carotid artery disease s/p CEA
- S/p Appendectomy, tonsillectomy, cholecystectomy
Social History:
___
Family History:
Mother: ___ dementia
Father: ___ heart failure, emphysema
Sister: CAD, heart failure, DM2
Brother: DM2
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.0 151/66 69 20 96RA 77.0kg
GENERAL: Slightly uncomfortable appearing, speaking in full
sentences. No acute distress.
HEENT: Atraumatic. Sclera anicteric. EOMI, pupils 5mm, equal and
reactive to light. Oropharynx clear.
NECK: Nontender, JVP ___ while at 45 degrees.
CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs.
LUNG: Bibasilar crackles. No wheezes.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Pulses 2+. ___ pitting
edema.
NEURO: A+Ox3. CN ___ intact. Sensation intact. Strength ___.
DISCHARGE PHYSICAL EXAM
Vitals: T98.8 BP 139/54 HR 84 RR 18 Sats 95 RA
GENERAL: nad, oriented x 3, speaking in full sentences.
HEENT: Atraumatic. Sclera anicteric. EOMI, pupils 5mm, equal and
reactive to light. Oropharynx clear.
NECK: Nontender, JVP ___ while at 45 degrees.
CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs.
LUNG: Bibasilar crackles. faint expiratory wheezing.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Pulses 2+. ___ pitting
edema.
NEURO: A+Ox3. CN ___ intact. Sensation intact. Strength ___.
Pertinent Results:
ADMISSION LABS
___ 05:20PM BLOOD ___
___ Plt ___
___ 05:20PM BLOOD ___
___ Im ___
___
___ 05:20PM BLOOD ___ ___
___ 05:20PM BLOOD ___
___
___ 05:20PM BLOOD ___
___ 05:20PM BLOOD ___
___ 08:55PM URINE ___ Sp ___
___ 08:55PM URINE ___ ___
___
___ 08:55PM URINE ___ WBC-<1 ___
___
MICROBIOLOGY
___ URINE CULTURE CONTAMINATED
___ BLOOD CULTURES PENDING X ___ SPUTUM CULTURE CONTAMINATED
IMAGING
___ CT head noncontrast
1. No acute intracranial process.
2. Sinus disease, as described above
3. Chronic right MCA infarct.
___ CXR
Hyperinflated lungs with superimposed right middle lobe opacity,
suspicious for pneumonia in the proper clinical setting.
DISCHARGE LABS
___ 07:13AM BLOOD ___
___ Plt ___
___ 10:25AM BLOOD ___ ___
___ 07:13AM BLOOD ___
___
___ 07:13AM BLOOD ___
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of Afib, CHF,
CAD s/p CABG, and Rt MCA CVA who presents with headache in the
setting of supratherapeutic INR and productive cough.
# HEADACHE: Likely secondary to tension headache. Reassuring
that CT head was negative in the setting of supratherapeutic
INR. Meningitis and influenza were thought to be less likely
given lack of fevers and persistent symptoms for 5 days.
Temporal arteritis was also thought to be less likely given lack
of jaw claudication. Lastly, cluster headaches were considered,
but patient described constant pain rather than attacks.
Furthermore, she did not have associated lacrimation and
conjunctival infection. Patient had immediate relief with
fioricet suggesting this is tension headache. Patient was
maintain on fioricet while hospitalized and discharged with
short course of fioricet as well.
# RML Pneumonia, CAP: Patient reports 1 day of productive cough.
No fevers though admission labs notable for leukocytosis. CXR
with right middle lobe opacity. Received ceftriaxone/azithro on
admission and was transitioned to levofloxacin to complete 7 day
course (day1: ___, last dose ___.
# AFIB, reverted to sinus: Patient triggered for Afib with RVR
with HR 160 and stable blood pressure though systolics with
20mmHg decreased from admission vitals. Afib with RVR resolved
with diltiazem IV. Etiology thought to be likely secondary to
pain causing increased sympathetic tone and volume overload from
fluid administered in ED. Patient was diuresed as below and
restarted on home carvedilol. Coumadin was held in the setting
of supratherapeutic INR.
# CHF: Patient reported dyspnea on exertion, orthopnea,
peripheral edema, and weight gain. Clinically she appeared
overloaded though CXR was without pulmonary edema. Patient did
have dyspnea and decreased SpO2 during Afib with RVR, suggesting
a component of flash pulmonary edema. Patient also received 1L
NS in ED. Patient was dosed with 40mg IV lasix on admission with
rapid improvement in dyspnea. She was also restarted on home
carvedilol and valsartan. On discharge, she was restarted on
home po lasix.
CHRONIC ISSUES:
# CAD: Continued ASA 81mg, atorvastatin 40mg, carvedilol, and
valsartan.
# DM: Held glipizide while hospitalized and maintained on HISS.
TRANSITIONAL ISSUES:
- Complete 7 day course of levofloxacin (day 1: ___, last dose
___
- Patient was prescribed short course of fioricet. Once INR is
no longer supratherapeutic, consider encouraging patient to use
NSAIDs such as 400mg ibuprofen for tension like headaches since
___ use of fioricet can lead to rebound headaches
- Patient should hold coumadin until told to restart by her PCP
- ___ on ___ and have them faxed to ___
clinic
- Reassess volume status and need to titrate lasix further
# CODE: FULL CODE
# CONTACT: ___ (DTR) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Valsartan 40 mg PO BID
3. Carvedilol 12.5 mg PO BID
4. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
6. Warfarin 2.5 mg PO 6X/WEEK (___)
7. Warfarin 3.75 mg PO 1X/WEEK (___)
8. Atorvastatin 40 mg PO QPM
9. Ferrous Sulfate 325 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Omeprazole 40 mg PO DAILY
13. magnesium 250 mg oral DAILY
14. Aspirin 81 mg PO DAILY
15. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
16. Sertraline 50 mg PO DAILY
17. GlipiZIDE XL 10 mg PO DAILY
18. Vitamin D Dose is Unknown PO DAILY
19. Calcium 600 + D(3) (calcium ___ D3) 600
mg(1,500mg) -400 unit oral DAILY
Discharge Medications:
1. ___ 5 mL PO Q6H:PRN cough
RX ___ [Delsym Cough+Chest Congest DM]
100 ___ mg/5 mL 5 mL by mouth every 6 hours Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
3. Calcium 600 + D(3) (calcium ___ D3) 600
mg(1,500mg) -400 unit oral DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. GlipiZIDE XL 10 mg PO DAILY
6. magnesium 250 mg oral DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Levofloxacin 750 mg PO Q48H Duration: 5 Days
Next dose ___. Last dose ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth every
other day Disp #*2 Tablet Refills:*0
9. Atorvastatin 40 mg PO QPM
10. Furosemide 40 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Valsartan 40 mg PO BID
14. Aspirin 81 mg PO DAILY
15. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
17. Sertraline 50 mg PO DAILY
18. Carvedilol 12.5 mg PO BID
19. ___ 1 TAB PO Q8H:PRN headache
Do not use this medication more than 2 days/wk - it can cause
dependence.
RX ___ 50 ___ mg 1
capsule(s) by mouth every 8 hours Disp #*15 Capsule Refills:*0
20. Outpatient Lab Work
Please obtain ___ on ___.
ICD___: ___
Please fax results to ___, to the attention of
___ MD ___
Phone: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: tension headache, community acquired
pneumonia
Secondary diagnosis: supratherapeutic INR
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 headache, cough, and high INR
level. You underwent CT head imaging which was found to be
normal. We treated your headache with fioricet. You should not
take this medication more than three days a month because you
may become dependent on it. You can discuss other medication
options and management of your headaches with your primary care
doctor. You were also found to have a pneumonia for which you
were started on antibiotic called levofloxacin. Please take this
antibiotic every other day, your last dose will be ___. Your
INR level was also found to be high. Please do not take your
coumadin again until told to do so by your primary care doctor.
Please have your bloodwork taken on ___. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs. We wish you
all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10470097-DS-8 | 10,470,097 | 29,090,994 | DS | 8 | 2197-03-20 00:00:00 | 2197-03-20 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ativan / clindamycin / Haldol / iodine
Attending: ___.
Chief Complaint:
diffuse abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ M to F transgender patient (___) w/ hx
HIV, DM1 and polysubstance abuse p/w abd pain and hyperglycemia.
Patient began having diffuse abdominal pain 3 days ago. Pt
reports that her sister died from ovarian cancer 2 days ago and
that she resumed drinking after ___ yrs of sobriety. Pt was
recently discharged in ___ with DKA and drug use, no
mention in DC summ of ETOH use. She has been using cocaine daily
w/ last use yesterday and drinking ~2 pints of liquor daily with
last use earlier today (2 am ___. Also c/o decreased appetite
with nausea and several episodes of small amounts of nb/nb
emesis. Poor insulin compliance over past 2 days but did take 30
units of lantus yesterday (regular home dose is 55 units at
bedtime and novolog with meals). She has been unable to eat over
the last 2 days. No diarrhea. States last BM 4 days ago.
In the ED, initial VS were: 99.7 121 128/63 20 99% ra. Labs were
concerning for diabetic ketoacidosis with anion gap of 37 with
ketonuria and glucosuria. CT abd with contrast did not reveal
any acute abdomenal process. CXR revealed pulmonary vascular
prominence presumed to be related to volume resuscitation. Pt
was given morphine 5 mg, ondansetron 4mg, insulin gtt at 10u/hr.
Pt was volume resuscitated 3L IVF.
On arrival to the MICU. Pt is in NAD, and feels hungry. States
pain improved but still present.
Review of systems:
(+) Per HPI, + chronic ___ neuropathy
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
IDDM x ___ years
HIV
Chronic Pain ___ diabetic neuropathy
Asthma
h/o GONORRHEA
Polysubstance abuse including cocaine and ETOH
DIABETIC PERIPHERAL NEUROPATHY
ANXIETY DISORDER
PTSD
BIPOLAR AFFECTIVE DISORDER
TOBACCO ABUSE
Social History:
___
Family History:
pt report sister died of ovarian cancer 2 days prior to
admission
Physical Exam:
ADMISSION Physical Exam: VSS
Vitals:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: thin, soft, mildly tender to deep palp in ruq more than
elsewhere, 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: grossly intact
DISCHARGE PHYSICAL EXAM:
VS: 97.6 73 112/78 RR 20 98% RA
Fingerstick:
___ AM - ___ L - 266
___ D - ___ HS - 168
General: Alert, oriented, pleasant, cooperative
HEENT: NC/AT, EOMI, Oropharynx clear, MMM
CV: RRR, S1, S2, no murmurs/rubs/gallops
LUNGS: CTA b/l, no w/r/r
ABD: Soft, no tenderness to palpation, no rebound/guarding,
non-distended, + BS
Ext: No clubbing/cyanosis/edema
Pertinent Results:
Admission labs:
___ 02:15PM BLOOD WBC-16.4*# RBC-5.21 Hgb-16.6 Hct-53.6*
MCV-103*# MCH-31.8 MCHC-30.9* RDW-13.2 Plt ___
___ 02:15PM BLOOD Glucose-697* UreaN-35* Creat-2.1*#
Na-130* K-5.3* Cl-83* HCO3-10* AnGap-42*
___ 05:05PM BLOOD Calcium-8.6 Phos-6.3*# Mg-2.9*
Discharge labs:
___ 07:00AM BLOOD WBC-4.9 RBC-4.57* Hgb-15.1 Hct-44.1
MCV-97 MCH-33.0* MCHC-34.2 RDW-13.8 Plt ___
___ 06:40AM BLOOD Glucose-91 UreaN-18 Creat-1.0 Na-140
K-4.3 Cl-100 HCO3-31 AnGap-13
___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0
___ EKG:
Sinus rhythm. Non-diagnostic Q waves in the inferior leads. No
previous
tracing available for comparison.
___ CT Abdomen/Pelvis:
IMPRESSION: No acute intra-abdominal process to explain the
patient's symptoms with normal appearance of the appendix.
___ Portable CXR:
IMPRESSION: Normal chest radiograph.
Brief Hospital Course:
___ is a ___ M to F transgender patient, with PMH of
HIV, polysubstance abuse, DMI, admitted for diabetic
ketoacidosis due to medication non-adherence and ETOH.
ACTIVE ISSUES:
# Diabetes Type I: Patient presented to MICU in DKA. Etiology
is likely secondary to medication non-adherence and alcohol
usage. No apparent underlying sepsis (CXR and abdominal CT
benign), ischemia, pancreatitis, or other etiologies noted. Gap
closed, pt taking POs. Patient is sp insulin gtt and IVF with
gap closure. On day 3 of admission, she was taking POs and was
transitioned to glargine and ISS. Her HgbA1c was found to be 9.
___ was consulted and helped to manage patient's
hyperglycemia while in the hospital. Patient with very labile
blood glucose during admission. Her hyperglycemia improved
throughout admission. At discharge, she was on lantus 50 units
QHS and insulin sliding scale.
# Nausea/abdominal pain: Benign abdominal exam and CT without
any findings to explain abdominal pain. Possible early
gastroparesis/delayed emptying time given diabetes. Patient was
started on reglan during hospitalization, which helped with
nausea and abdominal pain.
# Domestic Violence: As per patient, her boyfriend made threats
against her and was allegedly in the building trying to reach
her on the telephone. Patient was given a privacy alert and was
moved to a different floor. ___ police were made aware.
Social work assisted patient with safe disposition to a domestic
violence shelter.
# ? Passive Suicidal Ideation/Anxiety: Patient was very anxious
while her boyfriend was making threats against her life patient
attempted to leave the hospital to smoke cigarettes. She was
not allowed to leave his room especially given security alert.
In response, patient threatened to leave AMA, stated "if my
boyfriend wants to kill me, just let him finish the job" and
"you will see me on the front page of the newspaper tomorrow."
Denied suicidal ideation. Security was called and code purple
was called, Dr. ___ from psychiatry came to evaluate.
Patient was given 1:1 security sitter given ? passive suicidal
ideation. Patient was later re-evaluated by psychiatry, found
not to be suicidal and 1:1 sitter was discontinued. Patient
remained stable throughout rest of hospitalization. Klonopin
was uptitrated during hospitalization only, for anxiety. She
was discharged on home dose of klonopin.
# ETOH abuse: Last drink was on ___ per patient. Patient was
on thiamine/folate/multivitamin and CIWA during hospitalization.
CIWA was dicontinued as patient was not scoring on it and was
past the risky period for alcohol withdrawal.
INACTIVE ISSUES:
# HIV: Last HIV-related studies were in ___ with CD4 487.
Continued HIV medications including emtricitabine-tenofovir,
ritonavir, fosamprenavir.
# Anxiety and bipolar: Continued clonazepam and buspirone.
# Hormone disorder/Transgender M to F: Continued estradiol.
Initially spironolactone was held given electrolyte
abnormalities, but was restarted prior to discharge. Subsequent
chemistries did not show any abnormalities.
# Asthma: No symptomes. Continued proair prn.
# Chronic pain: Continued lyrica.
TRANSITIONAL ISSUES:
# Patient will follow-up at ___ because she will not
be able to travel to ___ for follow-up appointments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clonazepam 1 mg PO DAILY:PRN anxiety/insomnia
2. BusPIRone 7.5 mg PO BID
3. NovoLOG Mix 70-30 *NF* (insulin asp prt-insulin aspart)
unknown Subcutaneous ISS
4. Glargine 55 Units Bedtime
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
6. Pregabalin 75 mg PO BID:PRN nerve pain
7. Spironolactone 100 mg PO BID
hold for sbp<100 and hr<60
8. Estradiol 2 mg PO BID
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. RiTONAvir 100 mg PO DAILY
11. Fosamprenavir 1400 mg PO Q24H
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
RX *albuterol sulfate 90 mcg ___ puffs inh QACHS Disp #*1
Inhaler Refills:*0
2. BusPIRone 7.5 mg PO BID
RX *buspirone 7.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Clonazepam 1 mg PO DAILY:PRN anxiety/insomnia
RX *clonazepam 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [Truvada] 200 mg-300 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
6. Estradiol 2 mg PO BID
RX *estradiol 2 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Fosamprenavir 1400 mg PO Q24H
RX *fosamprenavir [Lexiva] 700 mg 2 tablet(s) by mouth daily
Disp #*60 Tablet Refills:*0
8. Pregabalin 75 mg PO BID:PRN nerve pain
RX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
9. RiTONAvir 100 mg PO DAILY
RX *ritonavir [Norvir] 100 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
10. Senna 1 TAB PO BID
11. Spironolactone 100 mg PO BID
hold for sbp<100 and hr<60
12. lancets *NF* 25 gauge Miscellaneous QID
RX *lancets ___ Softclix Lancets] 1 lancet four times a
day Disp #*120 Unit Refills:*1
13. FreeStyle Lite Strips *NF* (blood sugar diagnostic) 1
Miscellaneous QID
RX *blood sugar diagnostic [Freestyle InsuLinx Test Strips] 1
test strip QACHS Disp #*2 Bottle Refills:*1
14. NovoLOG *NF* (insulin aspart) AS DIRECTED Subcutaneous
QACHS
RX *insulin aspart [Novolog Flexpen] 100 unit/mL As directed
units SC QACHS Disp #*5 Bottle Refills:*0
15. Lantus *NF* (insulin glargine) 50 Subcutaneous QHS
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 50
units SC at bedtime Disp #*5 Bottle Refills:*1
16. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. Metoclopramide 10 mg PO TID nausea
RX *metoclopramide HCl 10 mg 1 tablet by mouth TID prior to
meals Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Diabetic ketoacidosis
SECONDARY: Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Ms. ___. You
were admitted to the hospital with diabetic ketoacidosis because
your diabetes was not well controlled. You were initially
admitted to the ICU. You blood sugars improved and you were
seen by the diabetes specialist from ___ for assistance with
diabetes.
We were concerned because you reported domestic violence. We
had the psychiatrists see you and the social workers see you to
help make a safe plan for your discharge. You will be going to
The ___ in ___.
For your diabetes regimen you will take:
1. Lantus 50 units at night.
2. Humalog insulin sliding scale with meals (see sliding scale).
3. START reglan 10 mg TID with meals. This is a new medication
to help with nausea.
Followup Instructions:
___
|
10470481-DS-15 | 10,470,481 | 22,244,774 | DS | 15 | 2182-10-10 00:00:00 | 2182-10-10 21:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right back abscess
Major Surgical or Invasive Procedure:
Bedside Incision & Drainage
History of Present Illness:
___ with hx of IDDM with p/w right back abscess; patient states
she noticed a 'boil' in the right back area 5 days ago, applied
warm compresses, but found minimal relief. She received one dose
of IV ceftriaxone as an out-patient, then was prescribed a 10
day
course of bactrim. She has noted increasing pain as well as
spontaneous drainage of this abscess with purulent fluid within
the past 2 days. Given the increased swelling, pain and
drainage,
she presented to the ED for further evaluation.
She denied fevers, chills. Denied nausea, vomiting. Her appetite
has been well-maintained, and her blood glucose checks within
normal range.
Past Medical History:
IDDM, morbid obesity, iron deficiency anemia, ambylopia,
cervical dysplasia, depressive d/o
Social History:
___
Family History:
NOn contributory
Physical Exam:
Gen:AAOx3, NAD, morbidly obese
Heart:RRR
Lungs:CTAB
Abdomen:SOft, nontender, non distended
Right back: Abscess cavity with minimal serosanguinous drainage.
No induration or fluctuance.
Pertinent Results:
___ 08:00PM URINE UCG-NEGATIVE
___ 08:00PM URINE GR HOLD-HOLD
___ 06:28PM LACTATE-0.9
___ 06:20PM GLUCOSE-104* UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
___ 06:20PM estGFR-Using this
___ 06:20PM WBC-8.7 RBC-4.12* HGB-10.5* HCT-33.1* MCV-80*
MCH-25.6* MCHC-31.8 RDW-14.1
___ 06:20PM NEUTS-73.2* LYMPHS-13.5* MONOS-8.8 EOS-4.1*
BASOS-0.4
___ 06:20PM PLT COUNT-389
___ 6:30 pm ABSCESS Source: R side abscess.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
Ms ___ was admitted to the ___ service after she presented to
the ED with a right sided abscess on her back. She underwent
bedside incision and drainage,and the wound was backed wet to
dry. She was also started on vancomycin, cefepime and She
remained afebrile with stable vital signs. On HD2, the wound
looked improved and dry gauze dressings were started. She was
discharged with bactrim for 10days. She was sent home with ___
services for wound checks.
Medications on Admission:
. Information was obtained from .
1. Glargine 50 Units Breakfast
Ibuprofen 400mg q6 prn
Discharge Medications:
1. Glargine 50 Units Breakfast
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*50 Capsule Refills:*0
3. Ibuprofen 400-600 mg PO Q6H:PRN headache
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
Every ___ Disp #*40 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Right back abscess s/p bedside incision and drainage
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 because of your right back
abscess. You underwent a bedside incision and drainage
procedure. You were started on IV antibiotics and switched to
oral antibiotics at discharge.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*place a dry gauze over the wound as needed.
Followup Instructions:
___
|
10470555-DS-4 | 10,470,555 | 25,629,836 | DS | 4 | 2113-12-30 00:00:00 | 2113-12-30 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypertension and abdominal pain
Major Surgical or Invasive Procedure:
Abdominal CT (at OSH) and Liver MRI
History of Present Illness:
Patient is a ___ y/o female who presents to ___ with c/o
abdominal pain. In addition, patient's blood pressure was noted
to be high with SBP > 200. An abdominal ultrasound was
completed which showed a liver mass which led to the performance
of a CTA of the abdomen. This not only confirmed a large liver
mass but also revealed a small infrarenal aortic dissection.
Patient was transferred to ___ for blood pressure management
and further evaluation.
Past Medical History:
PMH: HTN, HLD, DM2, CAD s/p 2 stents ___ years ago (at ___),
renal cell carcinoma
PSH: Cardiac stent x2, R renal ablation
Social History:
___
Family History:
Negative for family history of aneurysms
Physical Exam:
Vital Signs: 97.7 138/76 64 18 95%/RA
General: alert and oriented x 3, lying in bed, NAD
HEENT: normocephalic, skin anicteric, PERRL, MMM, neck with full
ROM
CV: RRR
Lungs: breathing unlabored
Abdomen: soft, NTND
Extremities: + CSM
Pertinent Results:
___ 04:25AM BLOOD WBC-6.6 RBC-4.57 Hgb-12.1 Hct-37.1
MCV-81* MCH-26.5 MCHC-32.6 RDW-13.2 RDWSD-38.5 Plt ___
___ 08:00PM BLOOD Neuts-76.8* Lymphs-14.1* Monos-6.2
Eos-1.3 Baso-0.5 Im ___ AbsNeut-8.48* AbsLymp-1.55
AbsMono-0.68 AbsEos-0.14 AbsBaso-0.06
___ 04:25AM BLOOD Plt ___
___ 04:25AM BLOOD Glucose-197* UreaN-19 Creat-0.8 Na-142
K-4.2 Cl-103 HCO3-25 AnGap-14
___ 04:25AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
Brief Hospital Course:
Patient was transferred to ___ from ___ for severe
hypertension and evaluation of an infrarenal aortic dissection
as well as, a liver mass found on an abdominal CTA. This was
performed after patient complained of severe right sided
abdominal pain x 1 week. She was admitted to the vascular
surgery service and transferred to the ICU for strict blood
pressure monitoring. Her blood pressure was well controlled on
esmolol and nicardipine drips. She was easily transitioned to
PO medications consisting of metoprolol and amlodipine,
maintaining her SBP less than 140. She was transferred to the
vascular surgery floor on hospital day 2.
Patient underwent and MRI of the liver w/ and w/o contrast,
further demonstrating the size of the liver mass and possible
renal mass. Her PCP was contacted with the information on these
findings and an appointment was made for follow-up.
The imaging obtained during this hospitalization demonstrated a
focal infrarenal aortic dissection. There is no aneurysmal
degeneration and there is good flow beyond this area to the
iliac arteries. She will require a follow up CTA and an
appointment with vascular surgery in 6 months. In addition, she
will need regular blood pressure checks and follow up of her new
antihypertensive regimen with her PCP.
Patient denies any continuation of the abdominal or flank pain.
She is tolerating a regular diet and is ambulating
independently.
Patient is discharged home with ___ services in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Simvastatin 40 mg PO QPM
4. Glargine 44 Units Breakfast
Glargine 30 Units Bedtime
5. GlipiZIDE XL 15 mg PO DAILY
6. azelastine unknown nasal DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. azelastine 137 mcg nasal DAILY
4. Glargine 44 Units Breakfast
Glargine 30 Units Bedtime
5. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. GlipiZIDE XL 15 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Infrarenal aortic dissection,
Hypertension,
Liver mass,
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 during your hospitalization
at ___. You were admitted with abdominal pain and
hypertension. Pictures of your abdomen were taken which showed
that you have a small abdominal aortic dissection, which is a
weakness in the vessel wall. At this time, it will just need to
be watched for any changes over the next few months.
In addition, you were found to have a liver mass for which you
will require follow up with oncology. Your PCP is aware of
these findings and has scheduled an appointment with you to
review your options for oncology referrals.
Your blood pressure was found to be very high when you arrived.
You were admitted to the ICU for special intravenous medications
to lower your blood pressure. This was successful and you are
now weaned down to blood pressure medications that you can take
by mouth. It will be very important for you to continue to take
these medications and follow up with your PCP for blood pressure
checks.
Please contact your PCP or go to the emergency department for
any of the following symptoms:
Worsening or severe abdominal or back pain;
Headaches, dizziness, lightheadedness;
Chest pain, shortness of breath, heart palpitations.
Followup Instructions:
___
|
10470555-DS-7 | 10,470,555 | 25,435,709 | DS | 7 | 2114-06-24 00:00:00 | 2114-06-25 05:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with metastatic HCC,
sp
TACE and more recently sorafenib, who is admitted from the ED
with several days of weakness found to have new ___ in the
setting of rising bilirubin and progression of liver tumor.
Patient has had relatively rapid progression of her liver tumor
over the last several weeks despite initiation of sorafenib. She
had an MRCP on ___ that showed This has led her oncology team
to
plan for initiation of FOLFOX, which was scheduled for tomorrow.
However, over the last three days, patient developed increasing
difficulty walking, which she attributes to bilateral leg
heaviness and weakness. She denies frank shortness of breath.
She
continues to have chronic band-like epigastric abdominal pain
well controlled with her oxycodone. She also has persistent
nausea and non-bloody emesis. She denies fevers or chills. No
dysphagia. No URTI. She has atypical chest pain, including at
present. Mild intermittent cough. No frank SOB. No diarrhea,
last
BM this am was normal. Denies dysuria. She has chronic bilateral
lower extremity edema. She has some new pain in the back of her
right thigh. No new rashes. Her weakness progressed to the point
she was essentially bedbound, and she presented to the ED.
In the ED, initial VS were pain 5, T 97.1, HR 111, BP 122/66, RR
18, O2 96%RA. Initial labs notable for Na 132, K 4.5, HCO3 21,
Cr
1.5, WBC 15.5, HCT 37.0, PLT 581, INR 1.4, ALT 139, AST 335, ALP
1441, TBili 5.3, Alb 2.4, lactate 3.7. RUQ US showed no biliary
ductal dilation and cirrhotic liver with known nectrotic mass
and
right hydronephrosis similar to recent MRCP. CXR showed no acute
process. Patient was given IV dilaudid, IV Zofran, LR, and IV
zosyn. VS prior to transfer were pain 4, HR 112, BP 130/75, RR
18, O2 97%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
?___:
- ___: s/p cryoablation (___)
___:
- Presented with abdominal pain, found to have infrarenal aortic
dissection, hepatic mass
- ___: planned resection aborted due to carcinomatosis.
Performed laparoscopic peritoneal biopsy and hernia repair. Bx
showed HCC in peritoneal nodules and liver.
- ___: TACE
- ___: Start sorafenib
PAST MEDICAL HISTORY:
- HTN
- HLD
- DM2
- CAD s/p 2 stents ___ years ago (at ___)
- Infrarenal aortic dissection
- Colon polyps (adenomas and hyperplastic)
Social History:
___
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___ CORONARY ARTERY
DISEASE
CORONARY BYPASS
SURGERY
CHOLECYSTECTOMY
DIABETES MELLITUS
Father ___ ___ CORONARY ARTERY
DISEASE
CORONARY BYPASS
SURGERY
CHOLECYSTECTOMY
Sister Living ___ CHOLECYSTECTOMY
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================================
VS: T 97.7 HR 96 BP 119/64 RR 14 SAT 96% O2 on RA
GENERAL: Pleasant, but chronically ill and tired appearing woman
laying in bed in no apparent distress.
EYES: Icteric sclerea, PERLL, EOMI;
ENT: Oropharynx with very dry MM, no other lesions. JVD not
elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears mildly tachypeic and speaking in short
sentences, clear to auscultation bilaterally with only moderate
air movement
GASTROINTESTINAL: Normal bowel sounds; distended; diffusely
tender but soft without guarding. Marked hepatomegaly noted with
liver tracking into right pelvis. Tympanic left side of abdomen.
MUSKULOSKELATAL: Warm, well perfused extremities with 2+ pitting
edema bilaterally into the thighs. Decreased bulk.
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact, no asterixis
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
==========================
VS: 97.8 ___
GENERAL: Pleasant, chronically ill, tired appearing woman
sitting
in bedside chair in no apparent distress.
EYES: Icteric sclerea, PERLL, EOMI;
ENT: Oropharynx with very dry MM, no other lesions. JVD not
elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears mildly tachypeic and speaking in short
sentences, clear to auscultation bilaterally with only moderate
air movement
GASTROINTESTINAL: Normal bowel sounds; distended; diffusely
tender but soft without guarding. Marked hepatomegaly noted with
liver tracking into right pelvis. Tympanic left side of abdomen.
Tender in upper quadrants.
MUSKULOSKELATAL: Warm, well perfused extremities with 2+ pitting
edema bilaterally into the thighs. Decreased bulk.
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact, no asterixis
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
=================
___ 05:48PM BLOOD WBC-15.5* RBC-5.11 Hgb-11.3 Hct-37.0
MCV-72* MCH-22.1* MCHC-30.5* RDW-23.8* RDWSD-58.4* Plt ___
___ 05:48PM BLOOD Neuts-88.0* Lymphs-7.1* Monos-3.9*
Eos-0.1* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-13.60*
AbsLymp-1.09* AbsMono-0.60 AbsEos-0.02* AbsBaso-0.02
___ 06:55PM BLOOD ___ PTT-29.7 ___
___ 05:48PM BLOOD Glucose-168* UreaN-59* Creat-1.5* Na-132*
K-4.5 Cl-90* HCO3-21* AnGap-21*
___ 06:55PM BLOOD ALT-139* AST-335* CK(CPK)-149
AlkPhos-1441* TotBili-5.3*
___ 06:55PM BLOOD Lipase-75*
___ 06:55PM BLOOD CK-MB-2
___ 06:55PM BLOOD cTropnT-<0.01
___ 06:55PM BLOOD Albumin-2.4*
___ 07:28PM BLOOD Lactate-3.7*
STUDIES:
=========
___ LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ OR GALLBLADDER US
IMPRESSION:
1. Cirrhotic liver with large ill-defined partially necrotic
mass better
visualized on recent MRCP.
2. Mild right hydronephrosis, similar compared to prior MR.
3. Trace perihepatic ascites.
4. No biliary ductal dilatation.
___ (PA & LAT)
IMPRESSION:
Low lung volumes. No acute findings in the chest. Port-A-Cath
tip in the cavoatrial junction.
___ ECG
NSR
Intervals Axes
RatePRQRSQTQTc (___) P QRS T
___ 9
DISCHARGE LABS:
=====================
___ 05:52AM BLOOD WBC-16.8* RBC-3.70* Hgb-8.5* Hct-27.5*
MCV-74* MCH-23.0* MCHC-30.9* RDW-23.2* RDWSD-59.2* Plt ___
___ 05:52AM BLOOD Plt ___
___ 05:52AM BLOOD Glucose-66* UreaN-73* Creat-1.7* Na-137
K-3.7 Cl-95* HCO3-21* AnGap-21*
___ 05:52AM BLOOD ALT-115* AST-289* LD(LDH)-551*
AlkPhos-808* TotBili-5.7*
___ 05:52AM BLOOD Albumin-3.1* Calcium-8.7 Phos-5.4* Mg-2.3
Brief Hospital Course:
Ms. ___ is a ___ year old woman with metastatic
HCC, s/p TACE most recently sorafenib, who initially presented
with fatigue, found to have worsening hyperbilirubinemia and ___
on admission. With T. bili 2.1 on admission that trended up to
5.9 during hospitalization, attributed to worsening metastatic
disease progression with known extensive progression of hepatic
disease on recent MRCP ___. ___ was also likely in the
setting of worsening hepatic function with poor PO intake in
several days prior to admission. Per ___, was not a candidate for
PTBD with no intervenable lesion identified on MRCP. Antibiotics
were deferred given lower suspicion for cholangitis. After
extensive goals of care conversation with primary oncologist Dr.
___, patient was transitioned to home with hospice prior
to discharge.
Acute Issues:
================
# Hyperbilirubinemia
# Metastatic HCC - History of metastatic HCC s/p TACE most
recently on sorafenib followed by primary oncologist Dr. ___,
presenting with fatigue, found to have worsening
hyperbilirubinemia on admission. With T. bili 2.1 on admission
that trended up to 5.9 during hospitalization. On recent MRCP
___, was found to have extensive progression of disease
progression, multiple new large confluent peritoneal implants,
innumerable new hepatic masses almost replacing the entirety of
the liver. Hyperbilirubinemia was predominantly direct in the
setting of worsening disease progression. Per ___ was not a
candidate for PTBD with no intervenable lesion identified on
MRCP. Antibiotics were deferred given lower suspicion for
cholangitis. After extensive goals of care conversation with
primary oncologist Dr. ___, patient was transitioned to
home with hospice prior to discharge. Plan to not continue with
sorafenib.
# ___ - Initially with ___ on admission Cr 1.5. Was thought to
be pre-renal give concurrent hyponatremia of 133 with history of
poor PO intake and also from hyperuricemia per below with uric
acid 14.6 on admission. Was thought to be intravascularly
depleted with extravascular volume overload given chronic lower
extremity edema. Given hypoalbuminemic, was administered albumin
50 x 2 doses. Creatinine trended up to 1.7, prior to discharge.
Did not pursue additional diagnostic workup or intervention
given goals of care per above and plan for discharge home with
hospice.
# Hyponatremia - Presented with Na 133 on admission, likely
hypovolemic hyponatremia, corrected to 137 prior to discharge
with albumin administration.
# Hyperuricemia - Presented with uric acid 14.6 on admission.
Did not meet criteria for rasburicase administration given Cr
<1.8. Received albumin per above, however additional
intervention was not pursued per goals of care.
# Portal vein thrombosis
# Tumor thrombus - With known portal vein thrombosis and tumor
thrombus. Was previously on apixiban, however given goals of
care per above, was discontinued and also held on discharge.
Chronic Issues:
===============
# Diabetes - In the setting of disease and poor PO intake, the
patient had recently stopped home lantus due to low blood sugars
in am, she continued to receive ISS during hospitalization.
# HTN
# CAD Prevention - Home ASA, amlodipine, and statin were held
during hospitalization and on discharge in order to help reduce
pill burden given discharge home with hospice. Metoprolol
tartrate 50 BID was continued.
Transitional Issues:
======================
[ ] NEW/CHANGED Medications
- Started Dexamethasone 1 mg PO QAM for appetite stiulation
- Started Morphine SR (MS ___ 15 mg PO Q12H for
cancer-related pain
- Started omeprazole 40mg PO QD
- Increased home oxycodone 5mg PO Q4-6H:PRN to Q2H:PRN
- Held Ascorbic Acid ___ mg PO DAILY
- Held Aspirin 81 mg PO DAILY
- Held Ferrous Sulfate 325 mg PO DAILY
- Held Multivitamins 1 TAB PO DAILY
- Held Thiamine 100 mg PO DAILY
- Held Apixaban 5 mg PO BID
- Held Cholestyramine Light (cholestyramine-aspartame) 4 gram
oral TID
- Held Simvastatin 40 mg PO QPM
[ ] Discharged home with hospice continue to assess indicated
hospice services
[ ] Titrate pain regimen as indicated given underlying
cancer-related pain
#CODE: DNR/DNI
#EMERGENCY CONTACT HCP: Husband, ___ ___
Greater than 30 minutes spent in discharge to hospice.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO Q4-6H PRN PAIN Pain -
Moderate
6. Simvastatin 40 mg PO QPM
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Furosemide 40 mg PO DAILY:PRN leg swelling
9. Apixaban 5 mg PO BID
10. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral
TID
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
12. LORazepam 0.5 mg PO Q8H:PRN anxiety/nausea
13. Metoclopramide 10 mg PO TID
14. Ascorbic Acid ___ mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Senna Laxative-Stool Softener (sennosides-docusate sodium)
8.6-50 mg oral BID:PRN
18. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Dexamethasone 1 mg PO QAM
RX *dexamethasone 1 mg 1 tablet(s) by mouth Daily Disp #*20
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*40 Tablet Refills:*0
5. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 by mouth BID:PRN Disp #*30
Tablet Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q2H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth Q2H:PRN Disp #*30 Tablet
Refills:*0
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
9. amLODIPine 5 mg PO DAILY
10. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral
TID
11. Furosemide 40 mg PO DAILY:PRN leg swelling
12. LORazepam 0.5 mg PO Q8H:PRN anxiety/nausea
RX *lorazepam 0.5 mg 1 by mouth Q8H:PRN Disp #*15 Tablet
Refills:*0
13. Metoclopramide 10 mg PO TID
14. Metoprolol Tartrate 50 mg PO BID
15. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30
Tablet Refills:*0
16. Senna Laxative-Stool Softener (sennosides-docusate sodium)
8.6-50 mg oral BID:PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Metastatic HCC
Hyperbilirubinemia
Secondary Diagnosis:
___
Hyponatremia
Chronic cancer associated pain
Portal vein thrombosis
Tumor thrombus
Type 2 Diabetes
Microcytic anemia
Hptertension
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You initially came to the hospital because you were feeling
weak.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent imaging to determine why you were feeling weak
and were found to have progression of your cancer
- You were found to have worsening liver function tests because
of your cancer
- You were treated with medications to help reduce your pain and
nausea
- You had a meeting with your husband and medical doctors where
___ that given the progression of your disease, you
would like to go home with hospice, reduce the number of
medications you take, defer further chemo and focus on spending
time with the people you love and being comfortable.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medications as prescribed and keep
your follow-up appointments as listed below
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10470859-DS-11 | 10,470,859 | 27,666,457 | DS | 11 | 2175-07-30 00:00:00 | 2175-07-30 18:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nsaids / Oxycodone
Attending: ___
Chief Complaint:
Trouble walking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman with history of obesity and
smoking who is transferred for evaluation of sudden onset
multiple neurologic complaints.
She states that she was last well at 11:30pm on ___. She
was
reading on her computer when suddenly when she reached for the
mouse, she noticed her right hand would miss the mouse and go to
the right of it. It was as if "it wasn't responding to me". She
then tried using her left hand and it felt similarly clumsy,
however not as severe as the right. She then stood up and walked
to the hallway; she suddenly felt as though her feet were "like
jelly". It was "as though they weren't listening to me and where
I wanted to go". She also endorses numbness in her bilateral
lower extremities but is unable to characterize this further.
She
felt like she was walking stiffly like a robot. However she was
still able to ambulate and not fall to one side or another,
though she thinks she may have been leaning to the right.
She then walked back to the computer and searched for stroke
symptoms online. She was not satisfied and called for her
husband
to take her to the hospital. Of note, she reports dizziness
after
bending down to tie her shoelaces, occurring when she sat back
up. She describes this as lightheadedness and faintness. She
denies sensation of room spinning or movement.
In the ambulance she also noticed she was feeling nauseous and
maybe that her speech was slurred. Upon arrival to ___ she
subsequently vomited x1 and then felt better. Initial evaluation
was concerning for a stroke and NIHSS was 3, but then
spontaneously improved to 1. Decision was made to defer tPA via
telestroke; she was given aspirin 81mg and Plavix 75mg and
transferred here for further evaluation. CT head noncontrast
negative; CTA head/neck with poor timing of flow but no obvious
vessel occlusion.
At time of evaluation, patient reports all of her symptoms have
resolved, including numbness, incoordination, and gait
abnormality.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
incontinence or retention. She endorses baseline "leaky bladder"
which is stable.
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:
Obesity
Arthritis
Social History:
___
Family History:
Mother with HTN, CHF. Father died of colon cancer
Physical Exam:
Physical Exam:
Vitals: 97.9 64 116/70 19 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 x3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 10
minutes and ___ with category cues. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI with few beats
of nystagmus on horizontal endgaze. Normal saccades. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, or
proprioception. No extinction to DSS.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
____________________________________
Discharge exam is unchanged from admission with no neurologic
deficits.
Pertinent Results:
___ 06:02AM BLOOD WBC-7.8 RBC-4.59 Hgb-14.4 Hct-42.9 MCV-94
MCH-31.4 MCHC-33.6 RDW-13.9 RDWSD-46.7* Plt ___
___ 06:02AM BLOOD Glucose-84 UreaN-16 Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-24 AnGap-15
___ 07:30PM BLOOD ALT-16 AST-22 AlkPhos-104 TotBili-0.2
___ 06:02AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8
___ 07:30PM BLOOD %HbA1c-5.5 eAG-111
___ 07:30PM BLOOD Triglyc-180* HDL-39 CHOL/HD-4.6
LDLcalc-106
___ 07:30PM BLOOD TSH-0.79
___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ Brain MRI/A
1. Study is moderately degraded by motion.
2. No acute intracranial abnormality, with no definite evidence
of acute
infarct.
3. Within limits of study, no evidence of dissection or
significant luminal
narrowing.
___ echo
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Normal left ventricular wall thickness,
cavity size, and global systolic function (3D LVEF = 62%). The
right ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: No ASD or PFO. Normal global and regional
biventricular systolic function. Mild mitral regurgitation.
Brief Hospital Course:
Ms. ___ was admitted to the neurology service for hand
clumsiness and difficulty walking. Brain MRI/A negative for
infarct and it is possible that her symptoms represented a TIA.
She therefore underwent work-up for TIA.
Echo with no PFO, EF 62%. LDL 106 and started on atorvastatin
40mg. A1C 5.1. TSH normal. Patient was initiated on ASA 81mg.
During the hospitalization, she was monitored with telemetry and
had a few episodes of sinus bradycardia. No other arrhythmias
detected. She does have notched p waves on EKG, otherwise
notable for sinus bradycardia. She will be discharged with a
___ of Hearts Monitor to monitor for arrhythmia.
She was evaluated by ___ who agreed she was stable for discharge
to home without services.
Of note, she was found to have a UTI with >100,000 enterococci,
awaiting speciation. She was started on macrobid as an
outpatient to continue x 7 days. Speciation should be followed
up by PCP.
TRANSITIONAL ISSUES:
1. Start atorvastatin 20mg daily and aspirin 81mg daily
2. ___ of hearts monitor to be worn and discussed at neurology
follow-up.
3. Follow-up speciation of urine culture, on macrobid
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
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 neurology service for concern of a
transient ischemic attack (TIA) or a mini-stroke. Your brain
imaging was normal, but your symptoms may have been due to a
blood clot to the brain that moved before it could cause changes
to your brain. You had high cholesterol and were started on a
medication called atorvastatin as well. You should take aspirin
81mg daily and follow-up with a neurologist and your PCP ___
2 weeks.
You were also found to have a urinary tract infection and will
be started on an antibiotic
Followup Instructions:
___
|
10470968-DS-2 | 10,470,968 | 27,208,679 | DS | 2 | 2126-07-08 00:00:00 | 2126-07-09 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye / morphine / fentanyl / Lyrica
/ Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Pancreatic head mass
Major Surgical or Invasive Procedure:
___:
1. Exploratory laparoscopy.
2. Exploratory laparotomy.
3. Radical pylorus-sparing pancreaticoduodenectomy, -22
modifier.
4. Extensive vascular dissection and mobilization.
5. En bloc resection of superior mesenteric vein with end-to-end
reconstruction with left internal jugular vein graft.
6. Duct to mucosa end-to-side pancreaticojejunostomy.
7. Hepaticojejunostomy.
8. Antecolic duodenojejunostomy.
9. Placement of gold fiducials.
10.Transgastric feeding jejunostomy tube.
History of Present Illness:
The patient is a ___ w PMH significant for obesity, IDDM, CAD
and resectable
pancreatic head ductal adenoCA p/w fever and hyperglycemia.
Patient is well known to ___ surgical service. Initially
seen ___ at the ___ Pancreatic ___ at which time
she was scheduled for elective resection of her clinically
staged IIA (T3 N0 M0) pancreatic head adenoCA. She was in her
usual state of health until ___ when she LUQ pain, pruritis
and jaundice. Was
seen at OSH ___ where she was initially evaluated w
transjugular liver bx given an elevated AMA. This showed
features of biliary obstruction prompting MRCP, CT scans which
showed a pancreatic head mass. ERCP/EUS were then performed with
placement of a biliary stent for decompression. Cytology proved
positive for adenoCA and she was referred to the ___
Pancreatic ___ further management. Following her visit on ___ she
was scheduled for elective Whipple on ___.
However, patient was found to be febrile to 101 with a
leukocytosis (WBC 16k) while visiting her cardiologist on ___.
Given complaint of dysuria and a positive UA she was started on
cipro. She completed a five day course of cipro with improvement
in subjective fevers and dysuria. Per patient report, she was
contacted by her doctor's office to say that the "urine was
clean" which presumably refers to a urine culture. Patient then
felt well until ___ when she had recurrent LUQ pain, chills and
hyperglycemia with tremulousness. She called the office and was
advised to seek emergent evaluation for which she went to OSH
ED. There she was found to have glucose in 700s, WBC 10k.
Received I- CT scan which was unrevealing. Admitted to OSH for
hydration and stabilization of glucose though patient elected
for xfer to ___ today.
Past Medical History:
PMH: HTN, HLD, CAD, peripheral artery disease, IDDM, spinal
stenosis, migraines, anxiety
PSH: appendectomy, open cholecystectomy, total abdominal
hysterectomy, lumbar laminectomy, rotator cuff surgery, breast
lumpectomy, tonsillectomy
Social History:
___
Family History:
Father: colon and gastric cancer; Paternal uncles: colon
and gastric cancer.
Physical Exam:
Prior to Discharge:
afebrile, vital signs stable
General: well appearing, NAD
HEENT: normocephalic, atraumatic, no scleral icterus
Resp: breathing comfortably on room air
CV: regular rate and rhythm on monitor
Abdomen: soft, NT, ND, incision c/d/i
Pertinent Results:
RECENT LABS:
___ 05:50AM BLOOD WBC-10.6* RBC-2.65* Hgb-8.0* Hct-25.1*
MCV-95 MCH-30.2 MCHC-31.9* RDW-13.5 RDWSD-46.8* Plt ___
___ 05:50AM BLOOD Glucose-225* UreaN-19 Creat-0.4 Na-134
K-4.4 Cl-102 HCO3-27 AnGap-9
___ 04:56AM BLOOD ALT-8 AST-15 AlkPhos-83 TotBili-0.3
___ 05:16AM BLOOD Lipase-8
___ 05:50AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.7
PREALBUMIN - 8L
___ 07:22AM OTHER BODY FLUID Amylase-6 TotBili-0.6
RADIOLOGY:
___ ABD US:
IMPRESSION:
1. Biliary ductal dilation appear overall similar to the most
recent CT exams in ___ with mild intrahepatic ductal
dilation and 16 mm CBD with CBD stent demonstrated when
accounting for differences in imaging modalities.
2. Persistent, overall unchanged main pancreatic ductal dilation
up to 7 mm.
3. 2.2-cm hypoechoic masslike structure in the region of the
pancreatic head likely corresponding to known malignancy, mass
or lymph node.
___ MRI ABD:
IMPRESSION:
1. Although incompletely imaged, there is marked narrowing of
the superior mesenteric vein extending from the portal venous
confluence inferiorly approximately 3.6 cm with an abrupt
transition on the last image. It is difficult to determine if
the graft is partially thrombosed or highly stenotic. The IMV
approaches the gastrocolic trunk (16:57-58) but it is difficult
to determine if they are connected and if it connects with the
SMV. A repeat MRV of the abdomen is recommended at no additional
charge. The portal and splenic veins are patent.
2. In segment 8, there is a hypoenhancing lesion. In
retrospect, this lesion was present but too small to
characterize on CT but new compared to the prior
MRI of ___. This lesion is indeterminate but suspicious.
3. In segment 5 there is an indeterminate lesion which was
apparently similar in size though ill-defined on the ___
CT but new compared to the prior MRI. This lesion is
indeterminate but suspicious is well.
4. Lesion within segment ___ suspected to be changed from prior
biopsy has decreased in size compared to ___.
5. Hepaticojejunostomy and pancreaticojejunostomy appear within
normal
limits.
___ MRV ABD:
IMPRESSION:
1. Occlusion of the SMV graft spanning approximately 3.6 cm in
keeping with partial thrombosis inferiorly in the graft. Native
SMV inferior to this, portal vein and spleniv vein are patent
and without thrombus. The IMV and and gastrocolic trunk come
together but do not connect with the superior mesenteric vein.
2. The study was optimized for assessment of the superior
mesenteric vein. For further details of the abdomen, please see
the MRI abdomen of the previous day.
___ MRA ABD:
IMPRESSION:
1. Occlusion of the superior mesenteric vein graft spanning
approximately 3.6 cm is unchanged compared to the prior exam.
The native superior mesenteric vein inferior to this, portal,
and splenic veins are patent and without thrombus.
2. There is mild inflammatory change around the site of the GJ
tube with a small rim-enhancing fluid collection but no
drainable collection.
3. The GJ tube terminates in a distal loop of jejunum in the
right lower
quadrant.
4. No intra-abdominal abscess or large fluid collection. .
5. Indeterminate lesion in segment 5 is unchanged.
6. The previously seen lesion in segment ___haracterized on
today's study.
Brief Hospital Course:
The patient with newly diagnosed pancreatic adenocarcinoma, who
scheduled for Whipple on ___ was admitted in ___ Surgery
service on ___ with fever and hyperglycemia. Patient was
started on broad spectrum antibiotics, ___, ERCP and ID teams
were consulted. Patient remained afebrile, and her WBC returned
back to normal on HD 2. She underwent ERCP on HD 2, plastic
stent was removed, study was negative for presents of pus or
other evidence of cholangitis. Patient's blood and urine
cultures were negative and antibiotics were discontinued, she
remained on Cipro for post-ERCP prophylaxis. On ___ patient
went in OR for planned Whipple. During the case patient was
found to have vascular involvement and she underwent pylorus
preserving pancreaticoduodenectomy and SMV resection with
end-to-end reconstruction with left internal jugular vein graft
(please see Op note for details). In the PACU patient received
fluid boluses for hypotension. She arrived on the floor NPO with
NGT, on IV fluids, with two JP drains to bulb suction, Foley
catheter and epidural for pain control. On POD 1 patient
received 1 unit of pRBC for Hct 21, her Hct was 26.7 post
transfusion. On POD 2 patient's NGT was removed and G-tube was
placed to gravity. Patient's epidural was split with Dilaudid
PCA. Patient's hyperglycemia was managed by Endocrine service.
On POD 3 patient's JP amylase was sent and was normal. Patient
was started on TF on POD 4. On POD 4 patient's epidural was
d/cd, Foley was d/cd, she voided without any problem. Her TF was
advanced to goal. On POD 5 patient's JP drain output started to
increase, ___ evaluated the patient and recommended to d/c home.
On POD 6, JP output increased again, patient underwent liver
Doppler, which demonstrated ___ hepatic vasculature and SMV.
At the same day, patient underwent MRV, which was not completed,
but demonstrated partially occluded graft, and segment ___ liver
lesions (please see Radiology report). Patient was started on
Heparin gtt and made NPO. The patient repeat MRV, which
demonstrate complete graft occlusion. Patient was started on
Spironolactone, PICC line was placed and patient was started on
TPN to decrease mesenteric blood flow and reduce ascites. At the
next days patient's diuretics were adjusted to keep her blood
pressure within normal ___ and decrease her JP drains
output. Patient's TPN was advance dto goal and was cycled.
Insulin was adjusted daily to control hyperglycemia. Patient was
transitioned to Lovenox. Patient's diet was advanced to clears.
On POD 14 patient developed severe left abdominal pain. She
underwent MRI, which demonstrated stable SMV graft occlusion, no
intraabdominal fluid collections or ascites. On POD 16 patient
was discharged home in stable condition.
Medications on Admission:
atorvastatin 20', Colace 100', ergocalciferol 50,000',
gabapentin 300 TID, hydroxyzine 10 TID prn itching, insulin
lispro 60u before breakfast/dinner, 20u before lunch, lisinopril
20', metoprolol XL 25', mirabegron ER 50', oxycodone prn,
protonix 40', tizanidine 2mg q8hr prn muscle spasm, ursodiol
300mg TID, nitro prn, Zofran
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Acetaminophen 1000 mg PO Q8H
3. Vitamin D ___ UNIT PO DAILY
4. Tizanidine 2 mg PO Q8H:PRN muscle spasms
5. Docusate Sodium 100 mg PO BID
do not take if having diarrhea
6. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*5
7. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Metoclopramide 10 mg PO QID
RX *metoclopramide HCl 10 mg 1 tab by mouth three times a day
Disp #*30 Tablet Refills:*0
10. Metoprolol Tartrate 12.5 mg PO BID
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*72 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*5
13. Spironolactone 50 mg PO BID
RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. mirabegron 50 mg oral DAILY
15. Glargine 26 Units Dinner
Insulin SC Sliding Scale using REG Insulin
16. Outpatient Lab Work
Please check twice a week on ___ and ___: Chem10
(electrolytes, Magnesium, Calcium, Phosphate, glucose),
triglycerides, transferrin, TIBC, albumin, ALT, AST, T.bili,
ALP, amylase, lipase, and ferritin weekly.
Fax results to ___, MD at
___ and Dr. ___ office at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Locally advanced pancreatic adenocarcinoma
2. SMV graft thrombosis
3. Large volume ascites
4. Poor controlled diabetes mellitus
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 surgery service at ___ for surgical
resection of your pancreatic mass. Your underwent Whipple
procedure with SMV reconstruction. You recovery was complicated
by SMV graft thrombosis with large volume ascites, which
required anticoagulation with Lovenox, and TPN to reduce
mesenteric blood flow. You are now safe to return home to
complete your recovery with the following instructions:
.
Please ___ Dr. ___ office at ___ or ___
___, RN at ___ if you develop: fever, nausea with
vomiting, increased or severely decreased output from JP drains,
or other concerns.
.
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
.
JP Drain x 2 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).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
___ 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.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
___
|
10471192-DS-20 | 10,471,192 | 28,299,148 | DS | 20 | 2118-11-08 00:00:00 | 2118-11-08 12:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ruptured AAA
Major Surgical or Invasive Procedure:
___ open AAA repair
___ abd closure, repair diaphragmatic hernia
___ trach/peg
History of Present Illness:
___ presented to ___ earlier today with wosening lower
abdominal pain after having 2 days of nausea at home. Bedside
ultrasound concerning for AAA. Patient then lost pulses, she was
intubated, and CPR was initiated for 30 seconds. She regained
pulses without any chemical resuscitation and she was ___
transferred to ___. En route she received 5 units of PRBC, 3L
crystalloid. She initially had radial pulses, but during the
ride
over lost these and had barely palpable carotid pulses, levophed
was started. It was also noted that at the beginning of the ride
over she had a flat, pulsatile abdomen, however by the end of
the
ride her abdomen had become very distended.
Past Medical History:
none per family
Social History:
___
Family History:
No known family hx of renal disease or AAA
Physical Exam:
Awake alert, NAD
trach on trach mask
RRR
CTA b/l
abd soft, nt, nd, staples removed and steri strips placed over
incision which is clean/dry/intact, peg site clean
extremeties warm and well perfused
Pertinent Results:
___ 11:30 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
MODERATE GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
___ 11:30 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 03:48AM BLOOD WBC-13.1* RBC-2.60* Hgb-8.0* Hct-26.3*
MCV-101* MCH-30.8 MCHC-30.5* RDW-17.5* Plt ___
___ 02:38AM BLOOD WBC-12.9* RBC-2.61* Hgb-8.3* Hct-27.0*
MCV-103* MCH-31.7 MCHC-30.6* RDW-17.9* Plt ___
___ 03:37AM BLOOD WBC-12.4* RBC-2.61* Hgb-8.4* Hct-25.9*
MCV-99* MCH-32.0 MCHC-32.2 RDW-18.3* Plt ___
___ 12:12PM BLOOD Hct-28.0*
Brief Hospital Course:
Ms. ___ first presented in hypovolemic shock w/ a ruptured
abdominal aortic aneurysm. She underwent endovascular, converted
to open, ruptured AAA repair ___. Initially, she went to the
cardiovascular ICU with an open abdomen, intubated, with
abdominal packing, on pressors, and in frank renal failure. She
was seen by our nephrology colleagues who felt that she
developed oliguric ___ with ATN, requiring renal replacement
therapy.
___ she was having high volume loose stool output, and a c.
diff pcr was negative. ___ she had sputum cx, which grew
H. flu and pseudomonas. She was started on vancomycin and zosyn
for empiric coverage.
___ she was taken back to the OR, and found to have a left
diaphragmatic hernia. This was reduced and repaired with
prolene suture. Her abdomen was closed successfully and a
post-pyloric dobhoff was placed. A postop CXR showed no
pneumothorax. She continued on pressors, intubated and sedated,
and was 10L positive.
By ___, she was extubated and started on CVVH for diuresis,
as she was making very little urine. ___ she failed a
speech and swallow evaluation, and CVVH continued. CVVH was
done again and she was -2600 ml.
___ Tube feeds were advanced to goal 40 cc/hr. She
aspirated on BiPAP and was re-intubated as a result. ___
she was started on flagyl for empiric coverage of anaerobes,
given recent history of aspiration and respiratory
decompensation.
___ she was weaned from pressors, tube feeds were
restarted, and she was given 1 u pRBC for hct trending down.
She continued on CVVH for fluid management, and was kept fluid
even at this point.
___ Dr. ___ from social work led a
family mtg in the cardiovascular ICU. The family decided to
continue aggressive management, and a right internal jugular
tunneled line was placed by interventional radiology for
nephrology to intiate intermittent hemodialysis.
___ Ms. ___ was successfully extubated again and tube
feeds were restarted. By ___, she was tolerating tube
feeds at goal. ___ she underwent a speech and swallow eval
for hoarse voice and prolonged intubation. She failed this exam
and was kept strictly nothing by mouth and transferred to the
vascular ICU. Her tube feeds were switched from nepro->jevity
and she tolerated this change well.
Unfortunately, on ___ she had several episodes of
desaturation to 80% on 6L face mask and was suctioned with a
nasotracheal catheter, but again had an episode of desaturation
and was transferred back to the cardiovascular ICU and back on
pressors for a short time period. A CXR showed left lung with
residual left lower lobe collapse accompanied by a moderate left
pleural effusion. A new patchy right lower lobe opacity was also
present, which was thought to reflect patchy atelectasis or
aspiration. There was a persistent small right pleural effusion.
she was started on zosyn in addition to vancomycin for for
presumed hospital acquired left lower lobe pneumonia.
On ___ she was re-intubated and a large mucous plug was
removed. She had a repeat CXR which showed improvement in her
pleural effusions. She was able to be transitioned from
CMV/AS->CPAP/PSV ventilation, and propofol and pressors were
weaned overnight. She was given fentanyl prn for pain.
___ she underwent bedside bronchoscopy, which looked clean.
No bronchialveolar lavage sample was sent, and she was weaned
off of pressors.
Over the next few days her pleural effusion continued to
improve, and she remained on CPAP/PSV. As she was unable to
completely wean off the vent, she required tracheostomy and PEG
which were completed on ___. She was able to tolerate trach
mask as early as ___ for progressive amounts of time each
day, however she still continued to go on CPAP/PSV in the
evenings as she would tire out and become tachypnic toward the
end of the day. Because of these episodes of tachypnea, another
sputum sample was sent, which was unrevealing.
She had intermittent episodes of melena with drifting crits, at
one point requiring a transfusion. GI was consulted and
performed an EGD and flexible sigmoidoscopy with revealed no
obvious source of bleeding. They have scheduled her for an
outpatient colonoscopy, with plan for possible capsule endoscopy
if colonoscopy is unrevealing. She has not had any significant
episodes of melena requiring blood transfusions since ___.
Her staples were removed and steri strips placed. She has been
working with physical therapy, and speach to use a passy muir
valve to speak, though she is currently having difficulty with
shortness of breath while using this.
Anticoagulation: Ms. ___ was treated with subcutaneous heparin
TID and wore bilateral sequential compression devices during her
hospital stay for DVT/PE prophylaxis.
On the day of discharge she was afebrile with stable vital
signs, tolerating tube feeds, able to tolerate trach mask for up
to 12 hours, having bowel function without melena since ___,
tolerating very short periods using the passy muir valve, making
adequate urine without dialysis in over 1 week. Her ___ count
is mildly elevated, but she has been afebrile, hemodynamically
stable, with no obvious source of infection and negative sputum
and urine cultures.
Medications on Admission:
none
Discharge Medications:
1. Heparin 5000 UNIT SC BID
2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever>101
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
4. Albuterol Inhaler ___ PUFF IH Q6H
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Sarna Lotion 1 Appl TP QID:PRN itch
9. OxycoDONE-Acetaminophen Elixir 5 mL PO Q6H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL 5 ml by
mouth q4-6 hrs prn Refills:*0
10. Pantoprazole 40 mg PO Q24H
11. Metoprolol Tartrate 50 mg PO TID
12. Tubefeeding: Jevity 1.2 Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 55
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q8h Supplements:
Banana flakes: Mix each packet with 120 ml water & stir until
dissolved
Administer by syringe through feeding tube
Flush each packet with 30 ml water; #packets: 1; times/day: 3
NPO as Diet except Meds;
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ruptured AAA
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:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. You should continue tube feeds at rehab. You will continue to
work with speech and swallow with your passy muir valve to work
on speaking and eventual reevaulation for swallowing function.
Until that time you should remain NPO
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications, and cleared by and discharged from your rehab
You should get up every day, get dressed and walk, gradually
increasing your activity; you may up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 101.5F for 24 hours
Bleeding from incision
New or increased drainage from incision or ___, yellow or
green drainage from incisions
Followup Instructions:
___
|
10471505-DS-11 | 10,471,505 | 24,824,464 | DS | 11 | 2185-04-03 00:00:00 | 2185-04-05 15:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Difficulty speaking, right facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo RHW with h/o HTN, HL, PAF, AAA and
dementia who presents with difficulty speaking and confusion.
The
patient was normal when seen by her husband at 8am. She was
picked up by her sister and they went to lunch. She seemed fine
around noon. At 12:30, she was noted to be speaking "less" but
still able to form appropriate sentences. Her left arm may have
dropped at one point only. She was dropped off at her home at
2pm, and her husband came home at 2:30pm. She was lying on the
couch under a blanket and seemed comfortable, except that she
was
not speaking. Her family did not notice a facial droop or focal
weakness. Her gait is unsteady at baseline but it did not seemed
worse.
At baseline, she is oriented to location usually but has
episodes
of disorientation. She usually would not know the date or
current
events. She ambulates with ___ or assistance, and is
able to eat independently. She is continent. She is requiring
increased help with ADLs recently such as dressing and washing.
She does not fall frequently, but had a fall about ___ year ago
with rib fracture.
She has had dementia workup at ___ with Dr. ___ and Dr.
___. She was evaluated for NPH because of unsteady gait
and
shuffling, but was not felt to be a candidate for VPS. She was
diagnosed with possible FTD. She also has peripheral neuropathy
for which the cause is unknown, followed at ___.
ROS:
(-) headache, loss of vision, dysphagia, lightheadedness,
vertigo, focal weakness, numbness, parasthesiae, bowel or
bladder
incontinence or retention, fever, chills, shortness of breath,
chest pain or tightness, nausea, vomiting, diarrhea, abdominal
pain.
Past Medical History:
-AAA followed annually
-HTN
-HL, not currently on statin
-PAF, not on coumadin for unclear reasons
-dementia, possible FTD followed at ___
-peripheral neuropathy
Social History:
___
Family History:
positive for dementia, negative for stroke or seizure
Physical Exam:
Vitals: T:afeb P:60 R: 16 BP: 140/70 SaO2: 100/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
Extremities: No C/C/E bilaterally
Neurologic: ***exam improved gradually over about an hour in the
ED, the documented exam is the last/best
Initially, she cannot state her name at all but says yes/no
appropriately with multiple choices, cannot read, cannot name,
able to repeat simple phrase, poor comprehension on following
commands, R hemianopia, possible R parietal drift, motor exam
extremely limited by cooperation but weakness of right grip, IP
and ham
-Mental Status: Alert and awake. Oriented to ___, not
date. Unable to say what happened to her today. Inattentive,
unable to name ___. She has little spontaneous speech, and
speaks in short phrases, nonfluent. intact repetition and
comprehension. There were no paraphasic errors. Pt. was able to
name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence neglect.
Possible R/L confusion, finger agnosia and dyscalculia.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation with moving
fingers.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: R lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue with normal quick lateral movements.
-Motor: Normal bulk, tone throughout, no cogwheeling. No
pronator
drift bilaterally. No adventitious movements, such as tremor,
noted. No asterixis noted.
Limited by attention, full strength bilateral biceps, triceps,
finger flexors, IP. 5- R ham and TA.
-Sensory: No deficits to light touch or pinch. Not possible to
test all modalities due to inattention and inconsistency.
Possible R/L confusion.
-DTRs: hypoactive trace throughout and absent at achilles
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysmetria on FNF
-Gait: deferred
Pertinent Results:
___ 03:35PM BLOOD WBC-9.1 RBC-4.30 Hgb-13.7 Hct-39.8 MCV-92
MCH-31.8 MCHC-34.4 RDW-12.8 Plt ___
___ 03:35PM BLOOD Plt ___
___ 03:35PM BLOOD ___ PTT-31.6 ___
___ 03:35PM BLOOD UreaN-16
___ 07:10AM BLOOD %HbA1c-PND
___ 07:10AM BLOOD Triglyc-PND HDL-PND
___ 07:10AM BLOOD TSH-PND
___ 03:44PM BLOOD Glucose-94 Na-138 K-4.0 Cl-97 calHCO3-30
MR ___ Wet Read: No acute intracranial process. T2/flair
hyperintense foci, predominantly within the periventricular
region, likely secondary to chronic small vessel ischemic
disease. Marked global atrophy. Fluid in the sphenoid sinus.
CT/CTA Preliminary Report IMPRESSION:
1. No evidence of intracranial hemorrhage or vascular
territorial infarction.
2. No evidence of stenosis, dissection or aneurysm within the
arteries of the thead and neck.
3. Global atrophy, particulary of the frontal and medial
temporal lobes, is
Preliminary Reportlikely related to the patient's known history
of dementia.
Brief Hospital Course:
___ yo right-handed woman with dementia, HTN, HL, AAA, and
paroxysmal atrial fibrillation not on coumadin for unclear
reasons presents with difficulty speaking, right facial droop,
and possible left hemispheric syndrome that improved in the ED.
Her examination was initially significant for a left hemisphere
syndrome including global aphasia, right hemianopsia, possible
right motor neglect and/or weakness, however many of these
findings resolved, and her most recent exam was clouded by
inattention and significant only for a mild right facial droop
as a localizing sign.
She does have moderate dementia, most likely of the
fronto-temporal type, and this can result in stepwise decline,
but to occur within hours would be usual without any
toxic/metabolic/infectious insult. Also on the differential is
TIA due to a new cardiac embolus. The vascular occlusion could
have quickly recanalized and could explain the rapid resolution
of the picture described above. Furthermore, the MRI did not
show any diffusion lesions and that could only be explained by a
short lasting hypo perfusion.
Last but not least, she could have had a seizure. She had a
period of time during which she was not observed and she could
have had a seizure during this time. We did do an EEG and did
not find any epileptiform activities or any increased risk for
seizures.
Thus, the most likely explanation was either a temporary
worsening of her underlying dementia or a TIA due to the AFib
(for which she was not on Coumadin), which quickly resolved, but
made symptoms that lingered for a few hours.
We discussed with the patient, her husband, and her children to
consult with her primary care physician the issue of whether or
not she should be on anticoagulation for her Afib. Our
recommendation would be to start her on Coumadin. The MRI did
not show any signs of amyloid angiopathy or any microbleeds,
thus, from a brain perspective, it would be safe enough to put
her on anticoagulation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Memantine 10 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. irbesartan *NF* 75 mg Oral Daily
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Memantine 10 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. irbesartan *NF* 75 mg Oral Daily
6. Outpatient Physical Therapy
Evaluate and Treat
7. Walker
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
possible TIA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro Status: A0x3 with prompting, no facial droop, no focal
weakness, inattention limits sensory examination but no clear
deficits.
Discharge Instructions:
You were admitted for your difficulty speaking. MRI of your
brain was reassuring that you did not have a stroke. It is still
unclear what caused your symptoms which could be do to a
transient ischemic attack, which would be caused by a blood clot
that traveled likely from your heart because you have a history
of atrial fibrillation. It could also have been a seizure, and
your EEG (brainwave test) showed some slowing consistent with
underlying dementia but no seiuzre activity. It could also have
been a fluctuation that occurred of your baseline dementia,
without any clear cause.
Followup Instructions:
___
|
10472364-DS-21 | 10,472,364 | 21,782,521 | DS | 21 | 2134-11-21 00:00:00 | 2134-11-23 14:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Walnuts
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Marphan's was well until 6 days prior when
he began to experience vague abdominal pain. The pain progressed
over the subsequent 24h, peaking on ___ night in severe
intensity after which point the pt began to feel better but
failed to continue improving over the past ___ days with
persistent, dull, lower abdominal discomfort. He has been
tolerating PO albeit with a decreased appetite. He has been
constipated taking MiraLax with good effect. No nausea or
vomiting, + subjective fevers and chills. ROS otherwise
negative.
Past Medical History:
___'s
HTN
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Exam:
Pain 98.2 97.5 61 129/69 18 94RA
Gen: Well, NAD, A&Ox3
CV: RRR, No R/G/M
RESP: CTAB
ABD: Soft, Non-distended, minimal RLQ tenderness to deep
palpation. No rebound, No guarding
Pertinent Results:
___ 06:06PM BLOOD WBC-8.3 RBC-4.43* Hgb-13.0* Hct-39.5*
MCV-89 MCH-29.4 MCHC-33.0 RDW-13.2 Plt ___
___ 06:06PM BLOOD Neuts-75.6* Lymphs-13.4* Monos-5.7
Eos-4.5* Baso-0.8
___ 09:40PM BLOOD PTT-32.3
___ 09:08PM BLOOD ___
___ 06:06PM BLOOD Plt ___
___ 06:06PM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-143
K-4.0 Cl-101 HCO3-32 AnGap-14
___ 09:52PM BLOOD Lactate-1.2
Brief Hospital Course:
Patient admitted to ___ service for management of acute
appendicitis. CT ABD/pelvis revealed Dilated appendix to 1.5 cm
with hyperemic thickened walls with
surrounding adjacent 2.5 cm organizing fluid collection at its
base compatible with a ruptured appendicitis. 2. Extensive
infrarenal abdominal aortic aneurysm with dissection in the
distal abdominal aorta with both dissection and aneurysmal
segments extending through the right common iliac artery into
the proximal portion
of the right external iliac artery. ___ was consulted for
possible drainage of fluid collection but declined stating it
was too small and not ideally accessible. Vascular surgery
subsequently saw the patient and recommended tight BP control
w/a SBP <130, to continue taking ___, and future
repair of the aforementioned aneurysm. Vascular surgery also
recommended a cardiac echo in preparation for surgery which was
performed at this time. Patient otherwise stable and will be
treated non operatively with ABX for appendicitis and be
reevaluated by ___ clinic and vascular surgery in the near
future.
Medications on Admission:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY aaa
3. Aspirin 325 mg PO DAILY aaa
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY aaa
3. Aspirin 325 mg PO DAILY aaa
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10473223-DS-13 | 10,473,223 | 22,595,902 | DS | 13 | 2156-04-30 00:00:00 | 2156-04-30 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman who unfortunately
developed a shooting LLQ pain yesterday with nausea/vomiting
that has not resolved. He has not experienced this pain before,
has no recent sick contacts and denies constipation, diarrhea,
black or bloody stools or fevers. He presented to the ED for
further evaluation.
.
.
-In the ED, initial VS: 98.6 66 161/83 18 98% RA
-Exam notable for: guaiac negative stool
-Labs notable for: Lactate 3.2->1.8
-The pt underwent: CT Abdomen which demonstrated diverticulitis
-The pt received: Morphine/Zofran, Cipro/Flagyl & IVF
-The pt was seen by:
-Vitals prior to transfer reviewed in chart.
.
On arrival Mr. ___ is uncomfortable due to his abdominal pain
but has no other complaints.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. All other ROS negative.
Past Medical History:
Hypertension
Hyperlipidemia
Depression/ADHD
History of Tongue Cancer s/p resection
BPH
CKD Stage III Baseline Cr 1.3-1.4
CAD s/p Cath ___ with no intervention
Social History:
___
Family History:
No history of diverticulitis obtained
Physical Exam:
VS: 98.2 124/20 80 20 98%Ra
GENERAL: Well-appearing man in NAD, mildly uncomfortable,
appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft, LLQ tenderness without rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Lactate:3.2, repeat 1.8
.
U/A WNL
___ 17
---------------<105
4.1 25 1.1
estGFR: 66 / >75 (click for details)
ALT: 31 AP: 66 Tbili: 0.6 Alb: 4.0
AST: 18 Lip: 22
.
14.3
7.8>----<205 14.3 205
43.2
N:78.6 L:14.9 M:5.3 E:0.5 Bas:0.8
.
MICROBIOLOGY: Blood Cx pending
.
STUDIES:
IMPRESSION:
Acute sigmoid diverticulitis. No evidence of perforation or
abscess formation at this time
.
EKG: None
Brief Hospital Course:
Mr. ___ is a very pleasant ___ year old gentleman with the
unfortunate fate of diverticulitis, apparently uncomplicated
thus far based on imaging and clinical status.
.
1) Diverticulitis: Mr. ___ has what appears to be
uncomplicated diverticulitis with an elevated lactate resolving
with hydration. Started on cipro/flagyl. Over 24 hrs his abd
pain resolved, he had no fever, and was able to tolerate low
residue diet. His antibiotics were converted to oral, which he
tolerated well.
- Discharged to complete ___ntbx
- should consider colonoscopy after resolution to exclude
malignancy
.
2) CKD Stage III- Per records, currently at baseline
.
3) Hypertension, CAD, Hyperlipidemia:
- Continued Atorvastatin, ASA, Atenolol & Lisinopril
.
4) Elevated MCV: No anemia but still could portend vitamin
deficiences
- B12/folate normal
.
5) BPH: Continued Flomax
.
6) ADHD/Depression: continued cymbalta and ritalin
Medications on Admission:
atenolol 50 mg PO daily
lisinopril 2.5 mg Tab PO daily
Cymbalta 20 mg Cap Oral PO BiD
Atorvastatin 40mg PO daily
Ritalin 20 mg Tab PO TID
___ Aspirin 325 mg PO Daily
Flomax 0.4 mg PO QHS
Testosterone (TESTIM) 50 mg/5 gram (1 %) Transdermal Gel use 1
packet daily AS DIRECTED
Cholecalciferol, Vitamin 1,000 unit PO daily
.
ALLERGIES: Simvastatin (muscle pain)OK on Lipitor
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for Pain, headache.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Acute sigmoid divertivulitis
CAD, native
Hypertension
Hyperlipidemia
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with left sided adominal pain, nausea, and
vomiting. You were found to have "Diverticulitis" on CT scan,
which is an infection in your colon around diverticula. With
antibiotics your symptoms improved.
Please complete your full course of your antibiotics. Please
resume your home medications. Please follow up with your PCP ___
___ weeks. You may need to have a follow up colonoscopy after
your symptoms have resolved.
Followup Instructions:
___
|
10473247-DS-16 | 10,473,247 | 24,567,780 | DS | 16 | 2193-06-09 00:00:00 | 2193-06-09 14:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
adhesive bandage / latex
Attending: ___
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Eu ___ is an ___ old ___ man with a past medical history of afib on
Coumadin, HTN and hyperlipidemia who presents with sudden onset
of right facial droop and right sided weakness.
According to EMS reports, patient was last seen well at 1030
this
morning at his adult daycare when he had sudden onset of right
facial droop and right-sided weakness. During that time,
patient
reports he suddenly felt "unwell" that he cannot describe
further
what he means. He denies any weakness. He also reportedly
stopped talking to staff members. He was taken emergently to
___ where initially ___, he had difficulty speaking,
difficulty lifting the right arm and lifting the right leg. On
my initial evaluation, with a ___ interpreter,
patient's
neurologic exam continued to improve, with an ___ stroke scale
of
5 for mild right facial droop, right arm pronator drift, right
leg weakness and dysmetria of the right arm. A code stroke was
called and patient was taking to the CT scanner. There, head CT
did not show any acute bleed. INR returned at 1.7 and therefore
patient was not a TPA candidate despite being in the window.
CTA head and neck showed a left M2 vessel occlusion and an
incidental finding of a 2 x 1.5 cm arteriovenous malformation in
the interhemispheric area near the bilateral A2 segments.
On repeat ___ stroke scale, patient's deficits had resolved and
therefore the decision was made not to intervene on the M2
thrombus.
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.
Past Medical History:
ATRIAL FIBRILLATION
HYPERTENSION
HYPERCHOLESTEROLEMIA
CATARACTS
H/O ADRENAL ADENOMA
HIP FRACTURE ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAMINATION:
Vitals: P: 80 R: 16 BP: 138/67 SaO2: 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented, interactive. Able to relate
history without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1.5mm and sluggish (cataracts).
EOMI
without nystagmus. Bilateral blink to threat.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally, though does have some curling of the fingers on the
right side. No adventitious movements, such as tremor, noted. No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 5- 4+ 4- 4+ 5 5- 4+ 5 4
-Sensory: No deficits to light touch. Extinction to DSS on the
right.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination: No intention tremor. Slowed finger tap on the
right. No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred
DISCHARGE EXAMINATION:
VS: 100.4, BP 152 / 70, HR 74, RR 18 SpO2 95 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert. Oriented to name, date, month, year,
hospital. Able to name all his kid's names. ___ is fluent
in ___. Speech was not dysarthric. Able to
name high and low frequency objects. Able to follow both midline
and appendicular commands.
-Cranial Nerves: Slight right facial droop with slightly slower
activation
-Motor: Normal bulk, tone throughout. Right arm pronator drift.
Right deltoid 5-, triceps 5-, IP 5-, otherwise full strength
throughout.
-Coordination: Dysmetria on FNF on the right hand.
-Gait: Able to stand unassisted, slightly wide based gait,
requires assistance with ambulation, mostly for balance.
Pertinent Results:
LABS ON DAY OF ADMISSION:
___ 11:05AM BLOOD WBC-5.9 RBC-4.33* Hgb-13.7 Hct-40.7
MCV-94 MCH-31.6 MCHC-33.7 RDW-15.0 RDWSD-52.2* Plt ___
___ 11:05AM BLOOD Neuts-46.0 ___ Monos-13.7*
Eos-2.4 Baso-0.5 Im ___ AbsNeut-2.70 AbsLymp-2.18
AbsMono-0.80 AbsEos-0.14 AbsBaso-0.03
___ 11:05AM BLOOD ___ PTT-32.6 ___ 11:13AM BLOOD Glucose-90 Na-135 K-3.8 Cl-100 calHCO3-21
___ 11:16AM BLOOD Creat-0.8
___ 11:05AM BLOOD UreaN-8
___ 06:52AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.7
___ 11:05AM BLOOD ALT-15 AST-31 AlkPhos-54 TotBili-0.7
___ 02:45PM BLOOD %HbA1c-5.8 eAG-120
___ 11:05AM BLOOD Triglyc-75 HDL-48 CHOL/HD-2.9 LDLcalc-78
___ 11:05AM BLOOD TSH-1.3
___ 06:52AM BLOOD CRP-27.1*
___ 12:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
LABS ON DAY OF DISCHARGE:
___ 08:16AM BLOOD WBC-6.1 RBC-3.94* Hgb-12.4* Hct-35.9*
MCV-91 MCH-31.5 MCHC-34.5 RDW-14.4 RDWSD-48.4* Plt ___
___ 05:05PM BLOOD Neuts-63.0 ___ Monos-13.4*
Eos-1.1 Baso-0.5 Im ___ AbsNeut-3.96 AbsLymp-1.37
AbsMono-0.84* AbsEos-0.07 AbsBaso-0.03
___ 05:10AM BLOOD ___ PTT-41.4* ___
___ 08:16AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-135 K-4.3
Cl-100 HCO3-22 AnGap-13
___ 08:16AM BLOOD Albumin-3.2* Calcium-7.7* Phos-1.8*
Mg-1.7
___ 05:23PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 05:23PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 05:23PM URINE RBC-8* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-3 TransE-<1
___ 05:23PM URINE WBC Clm-FEW* Mucous-RARE*
___ 03:07AM URINE Hours-RANDOM UreaN-446 Creat-100 Na-131
___ 03:07AM URINE Osmolal-540
URINE CULTURE ___ - FINAL REPORT:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURE ___ - prelim neg, final pending.
IMAGING EVALUATION:
CT head w/o contrast ___:
1. No evidence of acute hemorrhage. No interval demonstration
of acute large territory infarct within confines of CT
technique.
2. No gross change in a known anterior inter-hemispheric AVM
3. Involutional changes of the ventricles and sulci in addition
to relative disproportionate enlargement of the frontal and
temporal extra-axial CSF spaces is re-demonstrated.
4. Additional findings described above.
CTA head/neck ___:
1. Occlusion of a proximal M2 segment of the left middle
cerebral artery,
likely inferior division. No corresponding areas of hypodensity
on the
noncontrast CT head at this time. No hemorrhagic
transformation.
2. 2.0 x 1.5 cm arteriovenous malformation off of the left A2
segment the ACA, within the anterior interhemispheric fissure.
No aneurysmal dilatation at the AVM, no obvious hemorrhage. A
large draining vein superior sagittal sinus.
3. Relative enlargement of the frontotemporal extra-axial CSF
spaces relative to the sulci and ventricles, of unclear
significance. Correlation with history of dementia is
recommended.
4. Allowing for mild atherosclerotic disease, unremarkable CTA
of the neck.
5. Additional findings described above.
6. Please note, RAPID CT perfusion was not performed secondary
to technical failure.
MRI head noncontrast ___:
1. Multiple punctate acute infarcts in the posterior left corona
radiata in the distribution of the left MCA.
2. The left frontal AVM is again visualized, but was better
evaluated on prior CTA head neck done ___ and reference
is made to the report dated ___.
3. Generalized cerebral atrophy with ex vacuo dilatation of
ventricular
system.
4. Moderate periventricular white matter microangiopathic
changes.
Routine EEG ___, prelim: L hemisphere slowing (focal
dysfunction)
w/ generalized slowing (mild-mod encephalopathy). No
epileptiform
features, no seizures.
Brief Hospital Course:
The patient is a ___ year old ___ man with
history of atrial fibrillation on Coumadin, hypertension, and
hyperlipidemia, who presented with acute onset of right facial
droop and weakness, with possible speech difficulties. Immediate
evaluation showed a left MCA occlusion (M2 segment) on CTA head
as well as a subtherapeutic INR of 1.7. He was not given tPA due
to dramatic improvement of his motor deficits in the ED and
elevated INR. He was started on heparin infusion for
anticoagulation and admitted to the Neurology service for
further monitoring. MRI head confirmed left MCA distribution
embolic-appearing infarcts.
For permissive hypertension, his calcium channel blocker was
initially reduced to half dose and lisinopril was held, then
resumed at a reduced dose. Risk factor evaluation revealed A1c
of 6.7, TSH normal range, LDL 75. He was continued on home
atorvastatin 80mg daily.
After discussion within Stroke service, decision was made to
transition him from Coumadin to Apixaban for Coumadin failure.
This was started at 5mg BID prior to discharge. By time of
discharge, he had very mild weakness in the proximal right upper
and lower extremities, with preserved speech. He was evaluated
by ___ who recommended discharged to rehab.
Of note, he was found to have incidental finding of left ACA
AVM, which was previously visualized in ___ head CT. No follow
up is needed for this finding.
During the hospitalization, his mental status waxed and waned.
He was noted to have hyponatremia with FENa most c/w pre-renal
causes, which was treated w/ IV normal saline boluses, he was
started on salt tabs, and his sodium improved to 135 by day of
discharge. Given his confusion and hyponatremia, he was
evaluated with an extended routine EEG which was negative for
seizures or epileptiform activity but showed left hemisphere
slowing (focal dysfunction), w/ generalized slowing c/w mild-mod
encephalopathy.
He also became febrile to on ___ w/ a Tmax of 102.1,
infectious work-up which included blood cultures (thus far
negative), chest XR without concern for pneumonia, and
urinalysis which was concerning for UTI. He was started on
ceftriaxone, his urine culture showed mixed bacterial flora c/w
skin and/or genital contamination. However, given that his
mental status has improved significantly since starting the
antibiotics, a decision was made to complete a 7-day course of
antibiotic treatment, ceftriaxone was switched to cefpodoxime
(needs 5 more days to complete a 7 day course).
Transitional issues:
[ ] Patient's home lisinopril of 40mg was reduced to 10mg daily
for permissive hypertension. Please slowly titrate upwards to
maintain long term goal normotension.
[ ] Patient's Coumadin stopped, started instead on apixaban 5mg
BID for stroke prevention ___ atrial fibrillation.
[ ] Stroke clinic follow up scheduled as above
[ ] Continue cefpodoxime 100mg BID x 5 more days (scheduled to
be completed on ___ received ceftriaxone on ___ and ___
[ ] follow-up blood cultures sent on ___, thus far
negative
[ ] follow-up sodium, magnesium, calcium, phosphorus levels
[ ] address excessive alcohol use
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. olopatadine 0.1 % ophthalmic (eye) TID:PRN
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Omeprazole 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Diltiazem Extended-Release 120 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [___] 5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
2. Calcium Carbonate 1000 mg PO BID
3. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 5 Days
4. Ramelteon 8 mg PO QHS insomnia
5. Sodium Chloride 2 gm PO TID
6. Lisinopril 10 mg PO DAILY
slowly resume back to your home dose per MD
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Atorvastatin 80 mg PO QPM
9. Diltiazem Extended-Release 120 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. olopatadine 0.1 % ophthalmic (eye) TID:PRN
12. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left corona radiata ischemic infarcts
Atrial fibrillation
Coumadin failure
Hypertension
Hyperlipidemia
Urinary tract infection
Alcohol use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right sided weakness
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:
- Atrial fibrillation
- High cholesterol
- High blood pressure
- Alcohol use
We are changing your medications as follows:
- START taking apixaban (brand name ___ 5mg twice daily, to
prevent strokes from atrial fibrillation
- STOP taking warfarin (Coumadin)
- Your blood pressure medications were briefly held during this
admission, but then resumed and should be adjusted if needed by
your outpatient physicians.
Please take your other medications as prescribed.
We also advised you to stop excessive use of alcohol as it
increases your risk of irregular heart rhythm which can increase
your risk of stroke.
During the hospitalization, you had a period of confusion. We
re-evaluated you with imaging of your head which did not show
any new areas of injury. You were also evaluated with a test
called EEG which looks at the activity of your brain, which did
not show any seizures. On ___, you developed a fever and
the infectious work-up was concerning for a urinary tract
infection for which you were started on antibiotics. You should
complete the course of antibiotics as advised. Your sodium was
also low, which was treated with intravenous fluids and salt
tabs. Your sodium should be followed closely by your doctor
until stable. Your calcium, magnesium, and phosphorus were also
low and repleted, but should be monitored.
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:
___
|
10473631-DS-14 | 10,473,631 | 23,490,749 | DS | 14 | 2128-12-09 00:00:00 | 2128-12-09 16:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalosporins /
lisinopril
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
Patient is a ___ year-old man with PMH of HTN, HLD, DM2, CAD,
HFrEF (EF 40-45%) who presents as a transfer from ___
with
concern for acute decompensated heart failure and NSTEMI.
Patient reports sudden onset of dyspnea and shallow breathing on
___ afternoon ___ which has been getting progressively
worse. He also reports wheezing and PND at this time. Difficult
to determine if orthopnea is present, as he always sleeps
upright
due to esophageal issues. He felt like his chest was caving in,
thought denies any chest pain per se, denies palpitations, lower
extremity edema. Due to the severity of his symptoms, and the
fact that he has never had dyspnea and labored breathing like
this before, he presented to ___ on ___. Chest
x-ray at ___ was concerning for volume overload; he was
given
40mg IV lasix, nebulizers, and started on a nitro gtt. He was
also continuously tachypneic so he was started on BiPAP. Trop
came back at 0.023 so he was started on heparin gtt for possible
NSTEMI. Cardiology recommended transfer here to ___ given
patient's extensive cardiac history.
Patient notes that he is usually very active, works out 1.5
hours/day every day of the week without any issues - no prior
DOE, chest pain on exertion. No recent changes in medications,
has been compliant with medications. Adheres to a low salt diet,
eat home-cooked food. Does not check his weight at home. No
recent fevers, chills, sick contacts, travel.
In the ED:
Initial VS: T 98.0, HR 68, BP 166/71, RR 18, SpO2 99% bipap
Initial exam: on BiPAP with bibasilar crackles, RRR, normal S1
and S2, No edema, cyanosis, or clubbing
EKG: left bundle branch block (intermittently present over the
years)
Labs notable for:
Hgb 10.5, Plts 146 (unknown baseline)
BUN 45, Cr 1.6, HCO3 18, AG 20
Trop 0.03->0.03, flat CK-MB
BNP 2236
Patient was given:
___ 08:30IVHeparinrate continued at 1000 units/hr
___ 08:30IV DRIPNitroglycerinrate continued at 0.05
mcg/kg/min
___ 09:48IVHeparinincrease Rate by 150 units/hr to
1150
units/hr
___ 11:09IV DRIPNitroglycerinrate continued at 0.05
mcg/kg/min
___ 13:07IVHeparinrate continued at 1150 units/hr Stop
___ 13:24IVFurosemide 80 mg
Vitals on transfer: T 97.9F, BP 153/68, HR 78, RR 22, 97% 4L NC
On the floor, patient endorses the above history. He reports
that
his breathing is much better than when he initially came in,
though still feeling SOB, especially with movement. Denies any
chest pain.
REVIEW OF SYSTEMS:
See HPI, rest of ROS 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:
PMH:
- Gallstone pancreatitis s/p cholecystectomy (___)
- pancreatic pseudocyst s/p laparoscopic gastrostomy (___)
- chronic pancreatitis
- Hypertension
- Osteoarthritis
PSH:
- multiple oral surgeries including temporary plate following
MVA in ___
- laparoscopic pancreatic pseudocyst gastrostomy in ___
- Bilateral total knee replacement ___
- lap chole ___ (___)
- R arm plate/graft ___
- tonsillectomy childhood
- b/l hernia repair ___
- s/p appendectomy
Social History:
___
Family History:
Both parents with history of heart disease; mother died in a
fire, father died of CVA. otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
VS: 24 HR Data (last updated ___ @ 2312)
Temp: 98.2 (Tm 98.2), BP: 138/78 (138-153/68-78), HR: 63
(63-78), RR: 24 (___), O2 sat: 96% (96-97), O2 delivery: 4L,
Wt: 261.2 lb/118.48 kg
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
PSYCH: Mood good, consistent with affect. Appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: JVP difficult due to body habitus.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Short of breath with full sentences. Crackles at bases
R>L, faint wheezes.
ABDOMEN: Obese, soft, non-distended, chronically tender to
palpation.
EXTREMITIES: Warm, well perfused. Trace-1+ pitting edema in
lower
extremities to mid-shin.
DISCHARGE PHYSICAL EXAM:
T: 98.5 PO BP: 124 / 75 HR: 60 O2 96
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
PSYCH: Mood good, consistent with affect. Appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: JVP difficult due to body habitus.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Crackles in ___ bases. No wheezes, rhonchi.
ABDOMEN: Obese, soft, non-distended, chronically tender to
palpation.
EXTREMITIES: Warm, well perfused. Trace pitting edema in ___
extremities. ___ ankles non swollen or tender to palpation.
Pertinent Results:
ADMISSION LABS:
___ 06:20AM BLOOD WBC-9.1 RBC-3.39* Hgb-10.5* Hct-33.3*
MCV-98 MCH-31.0 MCHC-31.5* RDW-15.6* RDWSD-56.9* Plt ___
___ 06:20AM BLOOD Neuts-70.5 ___ Monos-7.5 Eos-1.4
Baso-0.7 Im ___ AbsNeut-6.41* AbsLymp-1.77 AbsMono-0.68
AbsEos-0.13 AbsBaso-0.06
___ 06:20AM BLOOD ___ PTT-74.8* ___
___ 06:20AM BLOOD CK-MB-3 proBNP-2236*
___ 06:20AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.5
___ 06:20AM BLOOD cTropnT-0.03*
___ 01:40PM BLOOD cTropnT-0.03*
PERTINENT STUDIES:
EKG: ___ LBB (old). Normal rate. PACs. Reduced voltage.
L ankle XR:
No evidence of fracture or dislocation. Slight mortise
asymmetry; this may
result from lateral ligamentous injury. Very small subchondral
lucency along
the medial talar dome, osteochondral defect versus degenerative
subchondral
cyst.
___ L foot XR
There are moderate degenerative changes involving the foot
joints. And
inferior calcaneal spur is seen. No acute fractures or
dislocations are seen.
Bone mineralization is preserved. The Ankle mortise is
congruent
R foot XR:
No evidence of fracture or dislocation. Slight mortise
asymmetry; this may
result from lateral ligamentous injury. Very small subchondral
lucency along
the medial talar dome, osteochondral defect versus degenerative
subchondral
cyst.
EKG: ___ LBB (old). Normal rate. PACs. Reduced voltage.
pMIBI ___:
1. Fixed, large, severe perfusion defect involving the LAD
territory.
2. Fixed, medium sized, severe perfusion defect involving the
RCA
territory.
3. Increased left ventricular cavity size. Severe systolic
dysfunction with
multiple wall motion abnormalities as described above.
___ Cardiac catheterization
Mild diffuse irregularities without focal obstruction. Patent
mid LAD stent.
DISCHARGE LABS:
___ 06:18AM BLOOD WBC-7.4 RBC-3.13* Hgb-9.6* Hct-30.4*
MCV-97 MCH-30.7 MCHC-31.6* RDW-14.9 RDWSD-53.2* Plt ___
___ 06:18AM BLOOD Plt ___
___ 06:18AM BLOOD Glucose-135* UreaN-62* Creat-1.5* Na-142
K-4.8 Cl-104 HCO3-22 AnGap-16
___ 06:18AM BLOOD Calcium-8.9 Phos-3.6 Mg-3.1*
Brief Hospital Course:
___ male with PMH CAD, CHF (EF 45%) transferred from
___ with concern for acute decompensated heart failure c/b
myocardial necrosis
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 115 kg (253.53 lb)
DISCHARGE Cr: 1.5
DISCHARGE DIURETIC: Bumex 3mg daily
[ ] Outpatient cardiologist to consider uptitration of diuretic
regimen as needed
[ ] For right ankle sprain, patient should follow up with
orthopedics (per inpatient ortho consult) within 2 weeks of
discharge if symptoms does not continue to improve (markedly
improved prior to discharge)
[ ] Pt had normocytic anemia around Hgb 10, which was stable. In
past has had workup consistent with ___ and is on iron. Consider
investigating other causes of anemia and ensure age-appropriate
malignancy screening.
[ ] Will need repeat formal TTE in 3 months to assess EF to
determine need for primary prevention ICD
[ ] Discharged with ZioPatch for monitoring of arrhythmias to
determine need for anticoagulation
[ ] Home hypoglycemic held upon admission, transiently started
on lantus and sliding scale w blood glucose levels in 300s.
Resumed home hypoglycemic upon discharge. f/u blood glucose
levels and consider escalating DM2 meds
ACUTE ISSUES:
==============
#Acute on chronic HFrEF:
#Acute hypoxemic respiratory failure:
#Dyspnea:
Patient presenting with progressively worsening dyspnea,
wheezing, PND, labored breathing for the past few days.
Initially
presented to ___ where CXR showed pulmonary edema, was
started on nitro gtt and BiPAP. Received IV lasix at ___,
transferred to ___, received additional lasix and weaned to NC
in
the ED. Nitro gtt stopped in the ED. Initially unclear trigger
for his HF
exacerbation - no medication noncompliance, adheres to low Na
diet, no recent illness/infection, no recent chest pain.
He wasn't significantly hypertensive in the ED. There was
initial
concern for NSTEMI given mild trop elevation, however low
suspicion for NSTEMI after eviewing data as Tn did not spike
significantly thereforse likely secondary myocardial necrosis
iso HF exacerbation. TTE w EF 45-50%. Pt received pMIBI ___
which showed EF 29% and Fixed, large, severe perfusion defect
involving the LAD territory, fixed, medium sized, severe
perfusion defect involving the RCA territory, and Increased left
ventricular cavity size. Discordance bt TTE and pMIBI EF, hoever
pMIBI EF likely more accurate after reveiwing w radiology.
Therefore an ischemic event may have led to worsening EF. Cath
on ___ showed no new coronary lesions.
On the floor, did not respond until receiving 200 lasix + 2.5 mg
metolazne, therefore transitioned to PO bumex 4 mg once
euvolemic however then overdiuresed and Cr increased.
He was discharged on ___ w wt: 115 kg (253.53lb) with bumex 3
mg PO daily. Plan to follow up with cardiology and PCP.
#CAD:
Patient with h/o NSTEMI in ___, 70% LCx, 90% mid and distal LAD
stenosis s/p 2 DES to mid LAD. No active chest pain, though does
report that he felt like his chest was caving in with his SOB.
Trops 0.03->0.___K-MB, likely c/f mmyocardial
necrosis iso HF exacerbation. LBBB on EKG though has had
intermittently in the past. Has good exercise tolerance, reports
1.5 hr/day without CP or SOB. S/p heparin gtt and nitro gtt in
the ED. pMIBI and cath results as per above. Cath on ___ as per
above with no new coronary disease. Imdur was stopped after cath
during this hospitalization. Continued home ASA 81mg,
atorvastatin 80mg, carvedilol 12.5mg BID. Home losartan
initially held for ___ then resumed prior discharge.
#C/f possible atrial fibrillation/ SVT:
EKG in ED with questionable atrial fibrillation. Reduced voltage
(iso larger habitus) and small p waves, however present. old
LBBB. On exam, rhythm sounded regular. He was monitored on tele.
Later during admission tele revealed short runs of SVT, the
longest being ~40s on ___ pm, however asymptomatic throughout.
EP consulted and recommended discharge on a ziopatch which the
patient received prior to discharge.
___ on CKD:
Baseline Cr ~1.4. Presented with Cr 1.6, improved to 1.4 after
diuresis initially then uptrended to 3.0 likely iso
overdiuresis. Diuresis and ___ initially held. He received
fluids. Cr peaked and downtrended back to baseline 1.5. Home ___
and diuretic agent resumed as per above.
#Anemia:
Hgb 10.5, unknown baseline. Patient was monitored and Hgb
remained stable.
CHRONIC ISSUES:
================
#HTN:
-continued home isosorbide mononitrate ER 30mg,
carvedilol 12.5mg BID. Initially held home losartan 100mg for
___ and resumed upon discharge.
#HLD:
-continued home atorvastatin 80mg
#DM2:
Initially held home repaglinide 0.5mg daily. Transiently placed
on Lantus 10u qhs with HISS with glucose still in the 300s.
Resumed home hypoglycemic before discharge. TI: [ ] f/u blood
glucose levels and consider uptitrating DM2 meds/ initiating
insulin.
#Gout:
-continued home allopurinol ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Losartan Potassium 100 mg PO DAILY
4. CARVedilol 12.5 mg PO BID
5. Bumetanide 2 mg PO DAILY
6. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate,
dried) 140 mg (45 mg iron) oral DAILY
9. Repaglinide 0.5 mg PO QPM
10. Allopurinol ___ mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Bumetanide 3 mg PO DAILY
RX *bumetanide 2 mg 1.5 tablet(s) by mouth daiy Disp #*45 Tablet
Refills:*0
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. CARVedilol 12.5 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Repaglinide 0.5 mg PO QPM
10. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate,
dried) 140 mg (45 mg iron) oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Distolic Heart failure Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you are feeling short of breath due
to a heart failure exacerbation
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given medicines through your IV to help remove excess
fluid in your blood and in your lungs. This led to improved
breathing
- You were given fluids through your IV to hydrate your kidneys
- You received a stress test which should that your heart pump
function was not normal
- You received a cardiac catheterization which showed your
coronary vessels were unchanged and open
- Your ankles were x rayed due to pain, and orthopedic surgery
recommended treating with physical therapy
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Weigh yourself every morning, call MD if weight goes up or
down by more than 3 lbs in one day or more than 5 lb in one
week.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10473662-DS-2 | 10,473,662 | 27,902,223 | DS | 2 | 2132-01-14 00:00:00 | 2132-01-14 16:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx HTN, DMII p/w fall while intoxicated resulting in acute
C1 posterior arch fracture. Patient reports that he was at a
___.'s ___ event and fell back while intoxicated
hitting his neck. He otherwise denies headstrike or LOC. He was
initially evaluated at ___ where CT C-spine
demonstrated unstable odontoid fracture and so he was
transferred to ___ for further care.
.
Upon evaluation by Trauma surgery, the patient is neurologically
intact. His sensorimotor function is intact in all four
extremities and he has good rectal tone. Spine has evaluated
patient and recommends nonoperative management w/ ___ brace.
His sobriety had improved moderately by this time. He continues
to report pain in his neck but otherwise denies headaches,
vision changes, numbness/tingling, saddle anesthesia, loss of
bowel or bladder function. Patient lives at home by himself and
has no close family to help take care of him. He has no other
injuries on exam.
Past Medical History:
Past medical history:
Hypertension, type 2 diabetes, right eye blindness (from war
injury)
Past surgical history:
Bilateral rotator cuff repair, left biceps repair, bilateral
knee
surgeries, left cataract removal
Social History:
___
Family History:
Noncontributory
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals: Temp 98.5 HR 87 BP 148/85 RR 18 SpO2 96% RA
General: awake, alert, no acute distress
HEENT: ___ brace in place
CV: regular rate and rhythm
Pulm: normal respiratory effort
GI: abdomen soft, non-distended, non-tender
Extremities: warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 10:45AM BLOOD WBC-6.2 RBC-4.19* Hgb-13.6* Hct-40.4
MCV-96 MCH-32.5* MCHC-33.7 RDW-12.4 RDWSD-43.9 Plt ___
___ 10:45AM BLOOD ___ PTT-24.8* ___
___ 10:45AM BLOOD Glucose-126* UreaN-22* Creat-1.1 Na-137
K-4.4 Cl-97 HCO3-20* AnGap-20*
___ 07:28AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.2
DISCHARGE LABS:
___ 04:30AM BLOOD Glucose-143* UreaN-31* Creat-1.5* Na-135
K-5.1 Cl-95* HCO3-30 AnGap-10
IMAGING:
___ CT head without contrast
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage. No acute displaced
calvarial fracture.
2. Re-demonstration of multiple fractures through the posterior
arch of C1
3. Additional findings described above.
Brief Hospital Course:
Mr. ___ is a ___ year old male who was brought in to ___
___ on ___ for evaluation after
a fall. He was found to have multiple minimally displaced
fractures of C1. He was evaluated by the spine team in the
Emergency Department who recommended ___ brace for at
least 1 month and outpatient follow up. He was then admitted to
the surgery service for pain control and home safety evaluation.
.
The patient was started on an oral pain regimen with adequate
control. He was initiated on a CIWA scale due to concern for a
history of alcohol use contributing to his fall. Social work saw
the patient and were not concerned that he had a drinking
history, so CIWA protocol was discontinued. Physical therapy
worked with the patient and recommended discharge to rehab.
.
The ___ hospital course was complicated by an acute kidney
injury. His creatinine peaked at 1.7 from a baseline of 1.1. His
home lisinopril and hydrochlorothiazide were held in this
setting. His creatinine was downtrending at the time of
discharge.
.
On ___, the patient was tolerating a regular diet, voiding
spontaneously without issue, ambulating with assistance, and his
pain was well controlled on oral pain medical alone. The patient
was deemed ready for discharge to rehab and was provided with
appropriate discharge instructions. Patient should have serum
chemistries rechecked on ___, and his home lisinopril
and HCTZ should be resumed if his renal function has normalized.
He is scheduled to follow up with neurosurgery in 1 month for
evaluation. His ___ brace should remain on at all times
until cleared by neurosurgery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
5. Atorvastatin 20 mg PO QPM
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until instructed by
your PCP.
8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed by your PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C1 fracture after a fall
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were brought to ___ on
___ for evaluation after a fall. You were found to have a
fracture in your neck. You were admitted to the trauma surgery
service for pain control, neck stabilization, and physical
therapy. The spine surgery team was consulted and recommended a
___ brace to stabilize your neck and allow the fracture to
heal properly. You are recovering well and are now ready for
discharge to rehab for further physical therapy and
strength-building. Please follow the instructions below to
continue your recovery:
.
ACTIVITY:
o WEAR YOUR NECK BRACE AT ALL TIMES.
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 or exercise until cleared by neurosurgery.
.
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:
___
|
10473696-DS-6 | 10,473,696 | 22,661,056 | DS | 6 | 2131-01-13 00:00:00 | 2131-01-13 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
speech abnormalities
dull headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ PMHx ulcerative colitis who presents with
lightheadedness followed by headache and transient word finding
difficulty lasting 30 minutes.
Over the last 2 days, pt had felt URI symptoms. He has had
subjective fevers (did not take temperature) and nasal
congestion.
On the day of presentation, he was cleaning the kitchen when he
stood up and felt lightheaded. This had happened before and
symptoms are typically brief but he grew concerned after
symptoms lasted longer than usual. He then went to lay down on
the couch. He again tried to get up but felt lightheaded. He
denies room
spinning sensation or disequilibrium. While laying on the couch,
he developed a sudden onset bifrontal dull ___ headache. He
does not typically have headaches and has no history of
migraines. He felt slightly nauseous. He then felt bilateral
paresthesias in his hands (entire hands); these symptoms did not
march.
While talking to his GF, he suddenly noticed he was having
difficultly getting his words out. His GF states he "couldn't
say sentences, only single words". He recalls having difficulty
thinking of the correct word. He denies any comprehension issues
or loss of awareness. This prompted presentation to the ED.
At the ED, he was a code stroke, although NIHSS 0. NCHCT
unremarkable. Word finding difficulty and paresthesias resolved
at time of presentation to ED (lasted a total of about 30 mins).
At the time of my evaluation, he reports feeling at his baseline
apart from mild hesitancy with speaking and persistent dull
bifrontal headache. He denies any neck stiffness, although
reports chronic neck muscle spasm. He has never had similar
symptoms before.
On neurologic review of systems, the patient denies
lightheadedness or confusion. Denies difficulty with
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
PMH/PSH:
Ulcerative colitis
Asthma
MEDICATIONS:
None
ALLERGIES:
NKDA
Social History:
___
Family History:
No family history of migraines, strokes, blood
clots or any neurological/rheumatologic disorders.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.5 63 148/88 15 100% RA
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Neck: Supple, no meningismus
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. No dysarthria. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
========================
DISCHARGE PHYSICAL EXAM:
========================
Gen: awake, alert, answering questions appropriately, appears
comfortable in NAD
CV: warm and well-perfused
Resp: breathing comfortably on RA
Neuro:
MS: oriented to name, place, and month/year/day of week (not
date). Speech is fluent but slowed but at baseline per
girlfriend.
CN: PERRL (5-->2), EOM intact without nystagmus, face with
flattening of the right nasolabial fold upon activation, but per
baseline according to girlfriend. ___ elevates in the
midline. SCM and trapezius muscles strong and symmetric. Tongue
midline without fasciculations.
Motor: ___ in the proximal and distal upper and lower
extremities
DTRs: symmetrical, not prominent; toes down; no spasticity
Sensory: intact to light touch, vibration, proprioception and
temperature
Gait: normal and steady.
Pertinent Results:
___ 05:20AM BLOOD WBC-2.9* RBC-5.04 Hgb-15.3 Hct-45.4
MCV-90 MCH-30.4 MCHC-33.7 RDW-12.1 RDWSD-39.5 Plt ___
___ 07:04PM BLOOD ___ PTT-29.4 ___
___ 05:20AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-141 K-4.0
Cl-101 HCO3-27 AnGap-17
___ 05:20AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.2
___ 07:04PM BLOOD ALT-22 AST-36 AlkPhos-94 TotBili-0.3
___ 07:04PM BLOOD TSH-2.9
___ 07:04PM BLOOD CRP-3.7
___ 07:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:04PM BLOOD Glucose-93 Na-144 K-4.6 Cl-103 calHCO3-27
========
IMAGING:
========
CT Head (___):
FINDINGS:
No evidence of infarction, hemorrhage, edema, or mass effect.
The ventricles and sulci are normal in size and configuration.
No evidence of fracture. Mucosal thickening of the right
frontal sinus is
mild. Many of the bilateral ethmoidal air cells are partially
or completely opacified. Mucosal thickening in the partially
imaged bilateral maxillary sinuses is moderate to severe with
fluid levels seen bilaterally. Mucosal thickening of the
bilateral sphenoid sinuses with suggestion of aerosolized
secretion of the right sphenoid sinus.
The mastoid air cells and middle ear cavities are clear. The
orbits are
unremarkable. The visualized portion of the orbits are
unremarkable. Dural calcifications are noted.
IMPRESSION:
1. No hemorrhage or evidence of acute infarct. Please note that
MRI is more sensitive detection of early infarct as clinically
indicated.
2. Extensive paranasal sinus disease above.
MRI Brain (___):
FINDINGS:
MRI Brain:
There is no evidence of acute infarction, hemorrhage, edema, or
midline shift. The ventricles are normal in size. There are a
few scattered nonspecific periventricular and subcortical FLAIR
hyperintensity including the pons, likely a sequela of chronic
small vessel microangiopathy. The visualized arterial flow
voids are preserved. There are bilateral mastoid sinus mucosal
opacification with fluid level, with partial mucosal
opacification of bilateral ethmoid and sphenoid sinuses. The
bilateral mastoid air cells appear clear.
MRA brain: The visualized principal arterial branches,
including the circle of ___ appear patent without stenosis,
occlusion, or aneurysm formation. There is a left dominant
vertebral artery. The right vertebral artery demonstrates
continuation with the ___, a congenital variant.
MRA neck: The bilateral common and internal carotid arteries
appear patent
without stenosis by NASCET criteria. There is a left dominant
vertebral
artery. There is no evidence of stenosis or occlusion.
IMPRESSION:
1. No evidence of acute infarction, hemorrhage, or edema.
2. No evidence of stenosis, occlusion, or aneurysm formation.
3. Right vertebral artery continuation with the ___, a
congenital variant.
4. Paranasal sinus disease with probable acute bilateral
maxillary sinusitis.
Brief Hospital Course:
Dr. ___ was admitted to the General Neurology Service at
___ to evaluate for possible stroke after developing speech
difficulties at home in the setting of lightheadedness, URI and
a mild headache. He was able to speak appropriate words clearly,
but had a difficult time putting together a full sentence. No
garbled speech or mixing up of words. This latter problem was
largely resolved by the time he was evaluated and did not recur
while being observed overnight.
A code stroke was called, but his initial ___ stroke scale was 0
(normal exam). His head CT showed no evidence of acute
hemorrhage and ultimately his brain MRI showed no evidence of
acute ischemic stroke or any other acute neurological disease.
He does, however, have extensive sinus disease.
Given his complaints of URI symptoms x1 week, subjective fevers
at home, and headaches, he was tested for and found to be
positive for Influenza A. We deferred treatment with Tamiflu, as
his symptoms had already been present for longer than the 48
hour treatment window.
Upon further questioning, he mentioned that he has had recurrent
tingling in both hands as well as right upper arm pain and
weakness as well as neck discomfort. This seemed to worsen after
he did a lot of writing several months ago; not active this
admission. Given the lack of signs (i.e. no sensory or motor
signs pointing to myelopathy or severe radiculopathy/severe
median neuropathy) we recommend outpatient workup for this, if
symptoms recur or worsen. In the meantime, he can try a soft
cervical collar to see if this improves his hand tingling.
We did not start any new medications during his hospitalization.
***TRANSITIONAL ISSUES***
- Outpatient work-up for bilateral intermittent hand tingling.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza A
headache in the setting of sinusitis, likely viral
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 General Neurology Service at ___ to
evaluate for possible stroke after developing speech
difficulties at home. Fortunately, your brain MRI showed no
evidence of stroke or any other acute neurological disease.
You were found to have Influenza A ("the flu"), which is an
infectious respiratory virus which causes cough, breathing
difficulties, headaches, fevers, and muscle pains. Because your
symptoms started about one week ago, you are already improving
from your infection, but be aware that you are still contagious,
so you should avoid contact with babies/children as well as
immunocompromised people, as they are at higher risk for
contracting the flu.
You mentioned that you have chronic tingling in your hands as
well as neck pain. We strongly recommend that you follow up with
a neurologist as an outpatient to further investigate these
symptoms. We recommend that in the meantime, you can try a soft
cervical collar (purchase at any local pharmacy) to see if this
improves your hand tingling.
We did not start any new medications during your
hospitalization.
If you develop any new symptoms or if symptoms with speech
problems recur, please contact us.
It was a pleasure caring for you while you were in the hospital.
Best wishes for a speedy recovery!
The ___ Neurology Team
Followup Instructions:
___
|
10474166-DS-6 | 10,474,166 | 22,557,003 | DS | 6 | 2112-02-29 00:00:00 | 2112-02-29 11:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
adhesive tape / bandaid / environmental / latex
Attending: ___.
Chief Complaint:
Abdominal pain, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a pmhx. significant for
metastatic cecal adenocarcinoma with signet-ring cell features,
obesity, NASH, and arthritis who is admitted from the ED with
nausea, constipation, and BRBPR. Ms. ___ was initially
diagnosed with a cecal adenocarcinoma during a colonoscopy in
___ she subsequently underwent laparotomy and omental biopsies
on ___ which were positive for poorly differentiated signet
cell carcinoma. Since this time, Ms. ___ has received one
treatment of Folfox. However, she has continued to have
abdominal pain, constipation, straining, and BRBPR. She was
admitted to the ___ surgical service on ___ with these
symptoms, and was managed conservatively with NG tube, NPO, and
fluids. Her symptoms resolved and she was discharged home with
services.
Since that time, patient has continued to have nausea, vomiting,
abdominal pain, and poor PO intake. She has been unable to keep
food or medications down.
Initial vitals were in the ED were: 98.4 89 157/80 18 96%.
Patient was given zofran, morphine, IV PPI, and rectal
disimpaction was attempted (but was unsuccessful). She went for
a CT abdomen/pelvis en route to the medical floor. On
admission, vitals were: 98.3 84 148/91 17 97%.
Past Medical History:
Carcinomatosis, angina, HTN, Sjogren's disease, rosacea,
type 2 diabetes, fatty liver disease, depression, rheumatoid,
osteoarthritis, GERD.
Social History:
___
Family History:
The patient's history is notable for breast cancer in her
father's side, otherwise, no known history of colon cancers or
uterine cancers.
Physical Exam:
general: Ambulating, tolerating a regular diet, pain controlled,
passing flatus, +BM
VS: 98.7, 97.5, 83, 79, 147/77, 20, 98%RA
Neuro: A&OX3
Cardiac: RRR
Lungs: CTAB
Abdomen: obese, soft, passing flatus
Pertinent Results:
___ 03:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-TR
___ 03:20PM URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-1
___ 03:20PM URINE HYALINE-3*
___ 03:20PM URINE MUCOUS-FEW
___ 01:37PM LACTATE-1.1
___ 01:30PM GLUCOSE-114* UREA N-14 CREAT-0.5 SODIUM-140
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
___ 01:30PM ALT(SGPT)-62* AST(SGOT)-37 ALK PHOS-61 TOT
BILI-0.7
___ 01:30PM LIPASE-18
___ 01:30PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 01:30PM WBC-5.4 RBC-4.57 HGB-13.0 HCT-39.0 MCV-85
MCH-28.5 MCHC-33.4 RDW-14.5
___ 01:30PM NEUTS-70.4* ___ MONOS-1.7* EOS-0.5
BASOS-0.2
___ 01:30PM PLT COUNT-320
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 3:41 ___
IMPRESSION:
1. Interval increase in inflammatory changes within the anterior
abdominal
wall and underlying omentum and mesentery, with suggestion of
omental soft
tissue nodularity are likely a combination of post-laparotomy
change and
progression of peritoneal carcinomatosis.
2. Multiple focal small bowel loops are tethered and dilated
within the
anterior abdomen with dilatation of proximal bowel loops to 3.7
cm and
mesenteric vessel engorgement, consistent with small bowel
obstruction. No
free fluid identified.
3. Stable splenic lesion, thought to represent atypical
hemangioma.
4. Stable nodularity of left adrenal gland.
5. Stable fibroid uterus with rightward tethering to area of
inflammation.
Brief Hospital Course:
Ms. ___ who is well known to the colorectal surgery service was
admitted to the inpatient colorectal surgery service with
nausea, vomiting, and abdominal pain. CT scan showed the patient
was not obstructed. The patient was given a bowel regimen and
was passing flatus and had a small amount of stool by the
afternoon of hospital day one. A collaborative effort of the
oncology, surgical, social work, palliative care team and nurse
case management team was undertaken to develop a discharge plan
for Ms ___ as her symptoms are likely related to the disease
burden in he abdomen. The patient determined that it would be in
her best interest to become DNR with OK to intubate, she stated
that she would like to be intubated if she became suddenly ill
however, would not want chest compressions. She would like to
continue with palliative chemotherapy however, be discharged
home with hospice to assist her with her abdominal symptoms as
the progress and emotional support for herself, partner, and
family. Dr. ___ Dr. ___ very involved with the
care of this patient and agreed with the discharge plan. The
patient was explained that her symptoms are related to the
progression of her cancer and her illness was serious and she
would likely not survive. The patient was educated regarding the
possibility of a venting Gtube if her conditioned worsened
however, at the time of discharge this was not required as he
was tolerating a regular diet without nausea.
Medications on Admission:
- Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
- Hydrochlorothiazide 12.5 mg PO/NG DAILY
- Amlodipine 5 mg PO/NG DAILY
- Lorazepam 0.25 mg IV Q6H:PRN anxiety
- Ascorbic Acid ___ mg PO/NG BID
- Polyethylene Glycol 17 g PO/NG DAILY
- Bisacodyl 10 mg PR HS
- Senna 1 TAB PO/NG BID
- Docusate Sodium 100 mg PO/NG BID
- Vitamin D 400 UNIT PO/NG DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Ascorbic Acid ___ mg PO BID
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
5. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
6. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Lorazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every six (6)
hours Disp #*100 Tablet Refills:*1
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
once a day Disp #*30 Packet Refills:*1
11. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
RX *sennosides [Senokot] 8.6 mg 1 tablet by mouth twice a day
Disp #*60 Tablet Refills:*1
12. Vitamin D 400 UNIT PO DAILY
13. Metoclopramide 10 mg PO EVERY 6 HOURS AS NEEDED nausea
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Carcinomatosis related to cecal adenocarcinoma causing abdominal
obstuctive symptoms.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted fo nausea, vomiting, and abdominal pain
associated with you advance colon cancer. During your admission
___ were seen by the palliative care team and you were referred
to a hospice provider for continued ___ of your symptoms
at home. It is very important that you reach out to these
providers, your oncologist Dr. ___ Dr. ___ if
you have questions or need support. You will be given a
prescription for atavan for anxiety and nausea as well as a
prescription for Reglan which ___ may take for nausea. You will
continue your palliative Chemotherapy infusion. Your next
infusion will be on ___.
It is very important that you continue to take the bowel regimen
prescibed for you everyday. If you develop loose stool you may
stop one of these medications at a time. Drinking liquids and
other foods can also prevent consipation such as prunes,
rasisins, or other foods that have fiber. Please add more
varitey into your diet over the next few days. It may be a good
idea to drink a nutritional supplement ___ times daily to be
sure that you are getting protient which is important for
healing.
Please reach out to the providers with the hospice ___ for
emotional support for you and your partner. This is a difficult
time and they will support you and your family through this
process.
Followup Instructions:
___
|
10474722-DS-21 | 10,474,722 | 22,944,756 | DS | 21 | 2119-11-12 00:00:00 | 2119-11-15 09:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Vistaril / prednisone
Attending: ___
Chief Complaint:
bilateral lower limb redness and pain for 1 week duration, and
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ gentleman with history of cirrhosis,
HCV, hypertension, alcohol abuse, and opiate abuse who presents
with history of bilateral lower limb swelling and soreness for 4
weeks, bilateral lower limb redness and pain for 1 week
duration, and fever for 1 day duration, admitted with concern
for complicated cellulitis.
The patient has noticed increasing swelling and soreness of his
bilateral lower extremities over the past four weeks. Over the
past week he has noticed redness and burning sensation spreading
from the area around his feet and ankles up to his calves. On
the day of admission to the hospital he developed fevers and
chills while at the train station. Someone called the EMTs for
help after seeing his red swollen legs and the patient was
brought to the ___ ED.
The patient denies any injection drug use in his feet or legs.
He denies any recent stab wounds in his legs but does endorse
getting in a recent fist fight without any breaking of the skin.
He has been sleeping on the streets but has not noticed any bug
bites or animal bites. He has noted broken blisters on the back
of his feet.
Of note, the patient endorses drinking a six pack of beer or
more per day over the last several weeks. His last drink was
yesterday before going to the ED. He denies any past symptoms of
alcohol withdrawal. He endorses a history of seizure but denies
that this was related to alcohol withdrawal. He denies recent IV
heroin use for a couple of months.
Also,
In the ED, initial VS were T 101.3 HR 96 BP 128/70 RR 16 O2 98%
RA.
Exam notable for:
Bilateral lower limb swelling involving the foot leg up to the
knee. With redness mostly on the anterior aspect of both feet
and legs, left greater than right. No limitation in joint
motion. There is a blister noted at the posterior aspect of the
ankle on the left side
Labs showed:
WBC 3.2 (appears chronic, 2.5 in ___
Diff notable for Neu 62%, L 19%, Mono 15%; ANC 2k, ALC 600
Hgb 11.5
Plt 51 (also appear chronic, nadir of 44 in ___
Elevated LFTs (also appear chronic from ___
Imaging of the lower extremities showed diffuse soft tissue
swelling about the lower extremities bilaterally without
subcutaneous gas or radiographic evidence for osteomyelitis
Patient received 1gm Vancomycin IV.
Transfer VS were T 98 HR 70 BP 104/61 RR 16 97% RA
On arrival to the floor, patient confirms the above story. He
reports that his last drink was yesterday before going to the
ED. He denies current fevers or chills. He denies leg pain while
resting in bed but reports they are worse when standing. He
endorses a history ___ rhabdomyolysis but does not feel that
his current symptoms are consistent with past episodes of
rhabdo.
Past Medical History:
- Extensive history of polysubstance use, including IV heroin,
cocaine, alcohol, and benzodiazepines
- Depression
- SI
- Tonic-clonic seizure (Patient denies alcohol-related)
- R leg stabbing
- Hepatitis C
- alcoholic/hepatitis cirrhosis
Social History:
___
Family History:
non-contributory
Physical Exam:
On Admission:
--------------
VS: 98.0PO 111/67 69 18 95 Ra
GENERAL: NAD, laying comfortably in bed
HEENT: Swelling of soft tissue above left eye, EOMI, PERRL,
anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Extensive edema and erythema extending from
bilateral feet to midway up lower legs. No purulence or
drainage. Warm, mild tenderness. R ankle with healing scab over
posterior foot, L anteromedial scab and posterior foot scab.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: See "extremities"
At Discharge:
--------------
vs- 98.4 PO 103 / 62 68 16 96 Ra
GENERAL: NAD, laying comfortably in bed
HEENT: Swelling of soft tissue above left eye, EOMI, PERRL,
anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: non-distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Extensive edema and erythema extending from
bilateral feet to midway up lower legs. No purulence or
drainage. Warm, mild tenderness. R ankle with healing scab over
posterior foot, L anteromedial scab and posterior foot scab.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: See "extremities"
Pertinent Results:
Labs on admission:
-------------------
___ 07:40PM WBC-3.2* RBC-3.58* HGB-11.5* HCT-32.7* MCV-91
MCH-32.1* MCHC-35.2 RDW-19.1* RDWSD-63.0*
___ 07:40PM PLT COUNT-51*
___ 07:40PM NEUTS-62.1 ___ MONOS-15.8* EOS-2.2
BASOS-0.3 IM ___ AbsNeut-1.96 AbsLymp-0.61* AbsMono-0.50
AbsEos-0.07 AbsBaso-0.01
___ 07:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 07:40PM GLUCOSE-96 UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11
___ 07:40PM ALT(SGPT)-66* AST(SGOT)-131* ALK PHOS-120 TOT
BILI-3.5* DIR BILI-1.2* INDIR BIL-2.3
___ 07:40PM ALT(SGPT)-66* AST(SGOT)-131* ALK PHOS-120 TOT
BILI-3.5* DIR BILI-1.2* INDIR BIL-2.3
___ 07:53PM LACTATE-1.5
___ 08:45AM ___ PTT-35.3 ___
___ 08:45AM ALT(SGPT)-53* AST(SGOT)-119* CK(CPK)-396* ALK
PHOS-100 TOT BILI-4.1*
Labs at Discharge:
-------------------
___ 05:20AM BLOOD WBC-3.2* RBC-3.51* Hgb-11.4* Hct-32.6*
MCV-93 MCH-32.5* MCHC-35.0 RDW-18.8* RDWSD-63.5* Plt Ct-57*
___ 05:20AM BLOOD ___ PTT-34.9 ___
___ 05:20AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-136
K-3.7 Cl-105 HCO3-24 AnGap-11
___ 05:20AM BLOOD ALT-53* AST-113* LD(LDH)-299* AlkPhos-100
TotBili-2.1*
MICRO:
--------
blood cx dated ___: no growth to date
IMAGING:
---------
XRAY BILATERAL TIB/FIB ___
Diffuse soft tissue swelling about the lower extremities
bilaterally without subcutaneous gas or radiographic evidence
for osteomyelitis.
XRAY BILATERAL FEET ___
1. Diffuse soft tissue swelling about the ankles and dorsum of
the feet
bilaterally without soft tissue gas or radiographic evidence for
osteomyelitis.
2. Juxta-articular erosion involving the distal aspect of the
proximal phalanx of the right great toe concerning for gout.
CHEST XRAY ___
1. Probable left lower lobe pneumonia
Brief Hospital Course:
___ PMH cirrhosis, HCV, hypertension, alcohol abuse, and opiate
abuse who presents with history of bilateral lower limb swelling
and soreness for 4 weeks, bilateral lower limb redness and pain
for 1 week duration, and fever for 1 day duration, admitted with
complicated cellulitis.
ACTIVE PROBLEMS:
#CONCERN FOR CELLULITIS:
___ swelling, warmth, erythema, edema are consistent with
cellulitis. The etiology of the cellulitis is unclear. There are
a few superficial scabs that may be the source of entry. The
patient denies recent animal bites, wounds, or injection drugs
into his legs. No evidence of venous stasis dermatitis or calf
tenderness and improvement in margins while on abx.
- F/u CXR, UCx, BCx- CXR with reported infiltrate but he had no
clinical evidence of pneumonia. He was initially on Vancomycin
and when improved transitioned to PO keflex and bactrim to
complete a seven day course. Recommended leg elevation for
swelling and venous stasis.
#SUBSTANCE USE DISORDER: Patient denies history of alcohol
withdrawal. Most recent drink approximately 12 hours prior to
presentation. Has not scored on CIWA. Social work consulted for
help with substance abuse counseling.
CHRONIC:
#HOUSING INSTABILITY: SW Consult as above. Unfortunately, sister
unable to take him in. Social work saw patient and recommended
___ for shelter.
#PANCYTOPENIA:
Appear to be chronic. WBC 2.5 in ___. Hgb at that time was
12
and plts 40. ANC 1.38. These labs were normal in ___. Likely
___ chronic EtOH and cirrhosis. HIV negative ___.
#CIRRHOSIS (ETOH AND HCV): Most recent labs in our system
___
labs with Total Bilirubin 1.9, Direct Bilirubin 0.7, AST 199, &
ALT 113. LFT abnormalities date at least to ___. Had positive
Hep C Ab in ___. Abdominal US in ___ showed "Nodular liver
with
coarsened echotexture compatible with cirrhosis". Patient
reports
that he does not follow any doctors for his ___ or HCV.
Currently, MELD 15 (6% 3-mo mortality). Patient was set up with
hepatology as outpatient. Alcohol cessation was encouraged.
***TRANSITIONAL ISSUES****
- discharged on Bactrim and Keflex to complete a seven day
course for cellulitis
- will need to establish care with a hepatologist (apt
scheduled)
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*24 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth every twelve hours Disp #*12 Tablet
Refills:*0
6. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower extremity cellulitis
chronic venous stasis changes
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___. You came in with a skin infection and you are
being treated with antibiotics. Your skin infection is improving
but it will be important for you to finish a full course of
antibiotics. It is also very important that you see a liver
specialist to take care of your cirrhosis. Please be sure to
follow-up; appointments are listed below. It is now safe for you
to be discharged from the hospital. We wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10475008-DS-13 | 10,475,008 | 23,665,727 | DS | 13 | 2172-09-26 00:00:00 | 2172-09-26 14:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
full body aches, fever, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history noted below who presents with 60 hours of debilitating
pain, spreading from the top of his head, involving all the
joints in his body. He thinks the pain in his head is very much
like when he had meningitis as a child, when he lived in
___. He reports fevers to 102, at home. He recently
had
dental work, including an extraction and cadaveric bone
placement
on the upper right jaw. He does frequently work outside in a
garden, and was plucked off multiple ticks from his body in the
recent past.
Past Medical History:
no significant ___
Social History:
___
Family History:
paternal uncle with rheumatoid arthritis
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert, in mild distress
EYES: Anicteric, pupils equally round
ENT: MMM
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:00PM PARST SMR-NEGATIVE
___ 08:45AM BLOOD WBC-4.6 RBC-4.68 Hgb-14.3 Hct-41.9 MCV-90
MCH-30.6 MCHC-34.1 RDW-13.1 RDWSD-43.1 Plt ___
___ 12:52AM BLOOD WBC-2.4* RBC-4.38* Hgb-13.4* Hct-38.6*
MCV-88 MCH-30.6 MCHC-34.7 RDW-12.8 RDWSD-41.7 Plt ___
Brief Hospital Course:
SUMMARY/ASSESSMENT: ___ without any significant past medical
history, admitted with approximately two days of fevers, total
body aches, headache and weakness. With extensive exposure to
ticks, admitted for treatment of a likely tick-borne infection,
workup pending.
ACUTE/ACTIVE PROBLEMS:
#Fevers
#Body aches
#Tick exposure
#Leukopenia/Thrombocytopenia
-labs pending from this morning. Initiated doxycycline therapy
yesterdays, as the most plausible diagnosis presently is a
tick-borne infection, either lyme or anaplasma. As he still was
febrile overnight, will clarify with ID if this is a normal
pattern of behavior for anaplasma, despite treatment. If not,
then more diagnostic testing may be required, in particular for
babesia.
- with 2 full days of doxycycline, he dramatically improved.
His platelets rose, as well as WBC count.
-Anaplasma, blood smear and lyme serologies are pending, as well
as CMV, and EBV
- monitor skin exam for rash, which may erupt a few days after
onset of symptoms.
- trending cbc, LFTs daily. LFTS normalized after one day. The
specimen was hemolyzed.
-doxycycline duration is 10 days total. ID to contact him with
results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO QHS
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*15 Tablet Refills:*0
2. Citalopram 20 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Tick borne illness (likely anaplasmosis)
Discharge Condition:
independent, eating, drinking, ambulatory, alert and oriented x3
Discharge Instructions:
You were admitted to the hospital with fevers, full bodyache and
headache. We think this is related to a tick borne infection,
which is now being treated with doxycycline. The infectious
disease team assisted with your care, and will be reaching out
to you about the final blood test results.
Followup Instructions:
___
|
10475084-DS-15 | 10,475,084 | 25,600,420 | DS | 15 | 2111-03-02 00:00:00 | 2111-03-02 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
___
Attending: ___.
Chief Complaint:
L2 compression fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for Consult: s/p fall
HPI: ___ presenting with lumbar and sacral pain after fall from
___ story rooftop. Pt was taking photographs on third story
rooftop, stepped backwards, fell ~3 stories, landing on her
buttocks, then rolled and fell additional approximate half story
landing on her wrists and her face. She was found in prone
position on ground by EMS; Pt denies LOC. She is taken to ___
where she was found to have a nondisplaced nasal bone fracture
as
well as lumbar and sacral fractures. Denies numbness, tingling,
weakness, bowel/bladder changes.PMH:
MED: Wellbutrin, Trileptal, Adderall XR, Klonopin
ALL: NKDA
SH:
Occupation: ___
Tobacco: <1ppd
EtOH: Occ EtOH
PE:
A&O x 3
Calm and comfortable
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U SITLT
EPL FPL EIP EDC FDP FDI ___ radial pulses
BLE skin clean and intact
Midline tenderness over L2 and sacrum
No step offs, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
Back pain w/ BLE hip flexion
Saph Sural DPN SPN MPN LPN SITLT
Quads, hamstrings, ___ FHL ___ TA PP ___ ___ and DP pulses
IMAGING:
OSH CT: L2 superior endplate fracture; nondisplaced sacral fx
MRI reviewed: No evidence of ligamentous injury
IMPRESSION & RECOMMENDATIONS:
___ s/p fall ~3 stories with L2 superior endplate fx and
nondisplaced sacral fx. NVI on exam.
PLAN:
-No urgent orthopedic surgery intervention indicated at this
time
-Recommend TLSO brace, activity as tolerated
-Follow-up in 2 weeks with Dr. ___ with standing plain films
in
TSLO brace
Past Medical History:
see HPI
Social History:
___
Family History:
see HPI
Physical Exam:
see HPi
Pertinent Results:
___ 07:11PM LACTATE-0.8
___ 07:00PM GLUCOSE-88 UREA N-11 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-20* ANION GAP-16
___ 07:00PM estGFR-Using this
___ 07:00PM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-2.0
___ 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:00PM WBC-9.2 RBC-3.72* HGB-12.4 HCT-36.1 MCV-97
MCH-33.3* MCHC-34.3 RDW-12.4
___ 07:00PM NEUTS-77.6* LYMPHS-16.3* MONOS-3.1 EOS-2.3
BASOS-0.8
___ 07:00PM ___ PTT-28.5 ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
Brief Hospital Course:
Patient was admitted for pain control, ___. Patient was provided
with TLSO brace and standing Xray was taken with no evidence of
increased kyphosis. Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. Standing Xray of the lumabar spine in brace was
done which did not reveal any increased kyphosis at the
fracture. On the day of discharge the patient was afebrile with
stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
amphetamine-dextroamphetamine 5 mg Capsule, Ext Release 24 hr
Sig: Six (6) Capsule, Ext Release 24 hr PO QAM (once a day (in
the morning)).
bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
3. amphetamine-dextroamphetamine 5 mg Capsule, Ext Release 24 hr
Sig: Six (6) Capsule, Ext Release 24 hr PO QAM (once a day (in
the morning)).
4. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L2 compression fracture (stable). No PLC injury or neurological
deficit.
Non displaced sacral fracture S23
Nondisplaced Nasal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity: You should not lift anything greater than 10 lbs for 4
weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o ___ times a day you should go for a walk for ___ minutes
as part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet.
- Brace: You have been given a brace. This brace is to
be worn when you are walking. You may take it off when sitting
in a chair or while lying in bed.
-
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
Followup Instructions:
___
|
10475473-DS-17 | 10,475,473 | 21,126,571 | DS | 17 | 2132-08-03 00:00:00 | 2132-08-03 16:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Angiogram. Lumbar Puncture
History of Present Illness:
Mrs. ___ is a ___ year old right-handed woman with PMH of tension
headaches and depression who has been transferred here from
___ after she presented ___ with headaches, confusion,
and vision changes and found ___ to have bilateral occipital
hypodensities on ___.
Mrs. ___ presented to the ___ 4 times over the last
two weeks: ___, and ___.
Mrs. ___ on ___ presented with headache that was located in
bifrontal area and described as sharp/stabbing. She reported
that her headache was different than the typical tension
headaches that she normally has. Her normal headache is bi
occipital. Her examination was normal. ___ was normal. Her
headache improved with headache cocktail and fluids. She was
discharged.
Mrs. ___ on ___ presented again with the same bi frontal
headache that was sharp/stabbing. She had a normal examination.
She was not reimaged. Her headache improved with headache
cocktail and fluids. She was discharged with a prescription for
sumatriptan. Ms. ___ took the sumatriptan once and felt that it
made her headache worse. Ms. ___ did not take sumatriptan
again.
Mrs. ___ on ___ went to see her primary care physician for her
headaches. She was prescribed verapamil ER 120 mg daily for
headache prophylaxis.
Mrs. ___ and ___ husband report from ___ in the evening onward
that things really took a turn for the worse. Mrs. ___ was now
not only having headaches, but was having bouts of confusion,
disorientation, and incoordination. She was also sleeping a lot.
Her husband can provide some stories regarding unusual things
that were occurring. There was no observed episodes concerning
for seizures.
Mrs. ___ on ___ presented again to the ED, but this time in
addition to headache she endorsed having additional symptoms
including repetitive speech and confusion, saying that she was
forgetting things and felt off balance. Her neurologic
examination was reported as normal. ___ was reported as
normal, but on my review there is some possible occipital sulcal
effacement. CTA was reported as normal, but on my review there
is some possible bilateral MCA beading . She was admitted to the
hospital for observation given her complaints for observation.
Mrs. ___ this morning had multiple complaints, including
confusion, loss of vision, left sided weakness, and
incoordination. She was participating in physical therapy this
morning and felt uncoordinated. ___ noticed this and a code
stroke was called. Mrs. ___ was 2 for blindness. NCHCT
revealed bilateral occipital lobe hypodensities. She did not
have an MRI brain, but MRV was without VST. She has been
transferred here for further management.
PTA there were periods of time when Mrs. ___ did not have a
headache.
Pertinently, her CRP was elevated at outside hospital at 1.2 and
ESR has been elevated on a couple of occasions ___. LDL 183.
TSH 1.09. B12 448. She endorses that she has been having
diarrhea.
She was admitted to the ___ ___. With the presumptive dx of
RCVS, she was started on mag 2g q6 IV and Nimodipine 30mg q6h w/
IVF. She was also given toradol. Overnight she had 2 seizures
(left side stiffening and the convulsions). She was loaded with
keppra 2g and started on 1g IV bid. Her exam worsened this
morning with worsening in visual fields with significant
increase in her ___. She went for CTA which was remarkable for
worsened vasospasm of all of her vessels, with significant
involvement of the ACA.
She was monitored in the Neuroscience ICU for concern for
deteriorating neuro exam potentially related to blood pressure
fluctuations. after a few days of close monitoring her exam
continued to improve independent of her blood pressure findings.
she was stabilized and transferred to the stroke team for the
remainder of her hospitalization
Past Medical History:
Tension headaches
Depression
Social History:
___
Family History:
Mrs. ___ denies family history of strokes at young age and of
autoimmune rheumatologic disorders.
Physical Exam:
ADMISSION:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Mental status:
She is awake, alert, and cooperative with the exam. She is
attentive, able to say months of the year backwards. Fund of
knowledge is intact. She is oriented to place and date.
Language is fluent. Memory for recent and remote history is
intact.
Cranial nerves:
She does not have a clear visual field cut, but when she looks
at my face when it is straight in front of hers she says that
she can clearly see my eyebrows upwards on both side. She tells
me that below this area she can make out where my face ends and
begins and where it is darker and lighter, but her vision is
off. She cannot describe how her vision is off, except to say
"things seem mushed together" and "things do not seem in order".
Pupils are equal and reactive. Extraocular movements are full.
Facial sensation and movement are intact and symmetric.
Hearing is intact to finger rub bilaterally. Palate elevates
symmetrically. SCM and trapezius are full strength bilaterally.
Tongue is midline.
Motor:
Tone is normal. She has no pronator drift and no parietal
drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 4 4 5 4
R 5 ___ 5 ___ 5 5 5 5 5
Sensation:
Crude touch and prick is intact in the hands and feet. Position
sense is intact in the toes bilaterally. No neglect or
extinction.
Coordination:
Finger-nose-finger and finger-to-nose are intact without
dysmetria bilaterally. No dysdiadocokinesia. She has accurate
movements of the fingers. No truncal ataxia.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-----------------
discharge exam:
Patient appears well, in no acute distress, RRR, respiratory
rate regular, good perfusion.
Patient reports difficulty with depth perception, but vision is
grossly improved with ability to read.
Strength grossly improved, still with some ___ on l foot
inversion and flexion and toe flexion.
sensation grossly intact. Resolved visual and sensational
extinction to double simultaneous extinction.
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-10.8* RBC-4.55 Hgb-13.6 Hct-40.9
MCV-90 MCH-29.9 MCHC-33.3 RDW-12.6 RDWSD-41.5 Plt ___
___ 03:00PM BLOOD ___ PTT-27.4 ___
___ 06:06AM BLOOD ALT-14 AST-15 LD(LDH)-169 CK(CPK)-47
AlkPhos-81 TotBili-0.6
___ 06:06AM BLOOD GGT-22
___ 06:06AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:06AM BLOOD TotProt-6.9 Albumin-4.3 Globuln-2.6
Cholest-279*
___ 04:06PM BLOOD Calcium-8.7 Phos-2.9 Mg-3.1*
___ 06:06AM BLOOD %HbA1c-5.1 eAG-100
___ 06:06AM BLOOD Triglyc-247* HDL-48 CHOL/HD-5.8
LDLcalc-182*
___ 06:06AM BLOOD TSH-1.5
___ 04:06PM BLOOD RheuFac-<10
___ 06:06AM BLOOD HIV Ab-NEG
___ 03:00PM BLOOD ASA-NEG Acetmnp-12 Tricycl-NEG
___ 03:21PM BLOOD ___ pO2-41* pCO2-39 pH-7.41
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 12:30PM URINE Color-Straw Appear-Clear Sp ___
___ 12:30PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:30PM URINE RBC-3* WBC-5 Bacteri-NONE Yeast-NONE
Epi-1
OTHER PERTINENT LABS:
___ 03:45PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-3 Polys-0
___ ___ 03:45PM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-87
HSV PCR CSF negative ___
VZV PCR CSF negative ___
IMAGING:
MR HEAD W & W/O CONTRAST Study Date of ___ 3:12 ___
IMPRESSION:
1. Multifocal irregular narrowing of intracranial arteries
involving the
anterior circulation.
2. Multiple areas of slow diffusion, likely infarction in the
left frontal, bilateral parietal and occipital lobes.
3. Increased cerebral blood flow in the regions of slow
diffusion.
4. These findings may be related to reversible cerebral
vasoconstriction
syndrome (RCVS) in the appropriate clinical setting with
associated subacute
infarcts and luxury perfusion.
EEG Study Date of ___
IMPRESSION: This is a normal continuous video-EEG monitoring
study. There are two pushbutton activations for unclear reason
and without ictal electrographic correlate. There are no
epileptiform discharges or electrographic seizures.
Study Date of ___ 5:16 AM
IMPRESSION:
Evolving ischemic infarcts involving the bilateral occipital,
parietal, and left frontal cortices, better assessed on recent
MRI brain performed ___. No evidence of intracranial
hemorrhage or new large vascular territory infarction.
CTA HEAD AND CTA NECK Study Date of ___ 8:23 AM
IMPRESSION:
1. Multifocal evolving infarcts including the left frontal,
right parietal and bilateral occipital lobes. No hemorrhage. 2.
Multifocal vascular narrowing of all of the major intracranial
vessels, which is predominantly moderate in severity . This
appearance could be seen in
are reversible cerebral vasoconstriction syndrome. Overall,
appears more than the recent MRA. A follow-up CT angiography
in ___ weeks would be
confirmatory. 3. Visual inspection of perfusion does not
demonstrate any large mismatch.
Transthoracic Echocardiogram Report
___ 24:00
Suboptimal image quality. Essentially normal study. Normal
biventricular cavity sizes and regional/global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Normal estimated pulmonary artery systolic pressure
CT HEAD W/O CONTRAST Study Date of ___ 6:05 ___
IMPRESSION:
1. New hypodensity within the right frontal lobe and centrum
semiovale,
compared to the prior study from ___, which is
concerning for a recent infarct.
2. Evolving infarcts in the bilateral parietal and occipital
lobes, along with the left frontal lobe. No evidence of acute
intracranial hemorrhage.
CTA HEAD W&W/O C & RECONS Study Date of ___ 11:41 AM
IMPRESSION:
1. Overlying hardware streak artifact limits examination.
2. The hypoattenuating areas in the bilateral occipital lobes
and left frontal lobe seen on ___ are no longer
visualized. Question hyperemia in these areas, which if not
artifactual, may be suggestive of subacute infarcts or resolving
edema. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
3. Multifocal areas of mild to moderate vessel narrowing
compatible with
reversible cerebral vasoconstriction syndrome. The bilateral
ACA A2-C4
segments have mildly worsened, and the bilateral proximal PCAs
as well as the right P3 segment appear more narrow when compared
to prior imaging. However, the bilateral M1 MCA segments appear
mildly improved. The mild narrowing of the basilar artery and
the M2, M3 segments of the MCA appear stable as compared to
prior.
CTA HEAD W&W/O C & RECONS Study Date of ___ 1:48 AM
IMPRESSION: 1. Increase hypodensity in the bilateral posterior
frontal lobes compared with ___, possibly representing
edema. MRI can be obtained for further evaluation if clinically
indicated.
2. Worsening diffuse multifocal moderate to severe intracranial
arterial
vessel narrowing since the prior study, predominantly involving
the bilateral ACA, distal branches of the bilateral MCA,
bibasilar artery and bilateral PCA compatible with reversible
cerebral vasoconstriction syndrome.
BILAT LOWER EXT VEINS Study Date of ___ 1:56 ___
IMPRESSION: No evidence of deep venous thrombosis in the right
or left lower extremity veins.
MR HEAD W/O CONTRAST Study Date of ___ 3:10 ___
IMPRESSION: 1. Bilateral cortical infarcts and right frontal
white matter infarction.
Brief Hospital Course:
TRANSITIONAL ISSUES
========
[] Continue Keppra 750mg BID until follow-up with neurology.
[] Taper Midodrine 15mg in 1 week: decrease by 5 mg each week.
[] f/u LDL: 182 atorvastatin 40mg daily for hyperliademia.
[] Can continue to take Gabapentin 300 mg at night time for
pain.
[] Avoid medications associated with RCVS: hormones, SSRI, SNRI,
triptans, etc.
SUMMARY
========
Ms. ___ is a ___ woman with history of tension headaches and
depression who presented to an outside hospital 4 times within 2
weeks for sudden-onset, recurrent, thunderclap headaches. She
was discharged on Sumatriptan and her headache worsened. She
returned to the hospital with worsened headache, left-sided
weakness, visual changes, repetitive speech, and confusion.
Head-CT indicated bioccipital hypodensities and CTA showed
vasoconstriction. Given the history, the concern was for
reversible cerebral vasoconstriction syndrome (___). She was
subsequently transferred to ___ on ___. On initial
neurological exam, she had visual impairment with no clear
visual field cuts and left leg weakness. Home triptans, SSRIs,
and vaginal estrogen were discontinued. On ___, she was
admitted to the Neuro ICU for closer monitoring due to new-onset
seizure and worsening symptoms of left lower leg weakness,
abulia, apraxia, and visual neglect. Neuroimaging also showed
evolving multifocal cerebral infarcts on MRI and multifocal
narrowing of intracranial arteries on MRA. She had 2 seizures
initially which were described as tonic clonic and she was
started on Keppra. EEG showed no epileptiform discharges but she
did have right hemispheric slowing. CSF studies were
unremarkable including VZV. She was started on vasopressor
therapy and magnesium and subsequently improved significantly.
She was also started on verapamil 40 mg q8h as well as po
magnesium supplementation. However, her neurological symptoms
continued to fluctuate and at one point was thought to be
pressure dependent so she was started on pressors. Ultimately,
her exam stabalized and no longer seemed pressure dependent. She
was moved down to the ___ on ___ when her symptoms were no
longer clearly pressor-dependent and were significantly improved
with only residual left lower extremity weakness ___ range).
============================================
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 = 182) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL ___ 70) (x) Yes - () No
[if LDL ___, reason not given: not etiology of stroke,
for outpatient PCP to start.
[ ] 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? (x) Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL
___, reason not given: not etiology of stroke for
outpatient primary care provider to start.
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () 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.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 30 mg PO DAILY
2. Verapamil SR 120 mg PO Q24H
3. Estrogens Conjugated 1 gm VG DAILY
4. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain or temp > ___
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. LevETIRAcetam 750 mg PO BID
5. Magnesium Oxide 400 mg PO BID
6. Midodrine 15 mg PO Q8H
to taper in a few weeks
7. Gabapentin 300 mg PO QHS
8. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Reversible Cerebral Vasoconstriction Syndrome
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 ___,
You were hospitalized due to your headaches resulting from
REVERSIBLE CEREBRAL VASOCONSTRICTION SYNDROME(RCVS), a condition
where a blood vessel providing oxygen and nutrients to the brain
spasms and fails to provide enough blood to your brain. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
RCVS can have many different causes, so we assessed you for
conditions or triggers that might raise your risk of having a
RCVS-related episode and possible subsequent stroke. In order to
prevent future episodes, we plan to modify those risk factors.
Your risk factors are:
- History of headaches
- Use of certain medications: Vaginal estrogen,
selective-serotonin re-uptake inhibitors (SSRIs), Triptans
Therefore, we discontinued the above-listed medications during
your hospitalization. Please avoid precipitating factors such as
marijuana, cocaine, exercise stimulants, amphetamines,
triptans, and serotonergic antidepressants.
We are changing your medications as follows:
- Leviracetam 750mg twice a day (to prevent seizures) until you
follow-up with neurology
- Midodrine 15mg every 8 hrs (to keep your blood pressure up)
- Verapamil 40mg every 8 hrs (to keep the blood vessels in your
brain open)
- Aspirin 81mg
- Can continue to take Gabapentin 300mg at nighttime for pain.
- atorvastatin 40mg daily for hyperliademia
Please take your other medications as prescribed.
You cannot drive for 6 months since you had a seizure. This is
___ law.
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:
___
|
10475521-DS-2 | 10,475,521 | 21,481,885 | DS | 2 | 2126-08-21 00:00:00 | 2126-08-22 11:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
L foot pain
Major Surgical or Invasive Procedure:
___: femoral angiogram w/ stent placement and balloon
angioplasty
History of Present Illness:
___ year old female with CAD, CVA,
COPD, and EtOH/HCV cirrhosis complicated by ascites presents
from
rehab with worsening left foot pain.
Per patient, pain initially started approximately 1 month ago
with itching/burning sensation. There was concern for vasculitis
vs. shingles, and she was treated for shingles (acyclovir -->
valacyclovir) without complete improvement. She was then found
to
have ___ + and RF +, so she was started on prednisone (___)
for presumed vasculitis. Her symptoms did not improve on
prednisone and instead progressed over the last two days. This
has been associated with purpling of the left great and second
toe. She was sent to ___ where she
reportedly had a CTA of the lower extremity that showed
"Atherosclerotic plaque with bilateral mod ileo-femoral stenosis
and severe stenosis in mid left SFA. No occlusion."
In the ED, patient was afebrile and normotensive. Toes were
noted
to be mottled though pulses were dopplerable. Labs were notable
for mild thrombocytopenia (117) and transaminitis (AST 129/ALT
134) with normal Tbili (0.2). Chem7 was within normal limits.
CXR
was suggestive of chronic pulmonary disease (hyperexpansion,
flattening of the hemidiaphragms, prominence of interstitial
markings) but was without focal consolidation.
Vascular surgery was consulted and recommended heparin gtt, pain
control, CTA torso to evaluate for aneurysmal disease or
dissection, full LFTs/hepatology consult given concern for
cirrhosis ni the setting of untreated HCV and alcohol use, and
TTE to evaluate cardiac function prior to surgery.
CTA torso was obtained and showed no evidence of aortic
dissection, moderate to severe atherosclerotic disease of the
thoracic and abdominal aorta, and GGO of the LUL concerning for
infection/inflammation.
Pain in the ED was managed with IV morphine, IV hydromorphone,
PO
gabapentin, ibuprofen, and acetaminophen. She also received PO
buspirone, PO furosemide 40mg, duoneb, and folic acid. She was
then admitted to medicine for further management.
Upon arrival to the floor, patient confirms the above history.
She complains of worsening intermittent pain in the left foot
over the last two days associated with discoloration that she
feels is spreading. She denies any other symptoms.
Past Medical History:
- CAD s/p PCI
- CVA
- COPD
- Cirrhosis complicated by ascites
- Tobacco use
- Alcohol use disorder with history of withdrawal
- Depression
- Chronic low back and hip pain
Social History:
___
Family History:
Patient did not know her biological mother. Father had diabetes.
Half sister is healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.2 122/84 82 18 97% 2L
___: Alert and interactive. Fidgeting in bed intermittently
secondary to pain in her left foot.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Distant heart sounds. Regular rhythm, normal rate.
Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Prolonged expiratory phase. Diffuse wheezing on the
right.
ABDOMEN: Normal bowels sounds, distended though without fluid
wave, non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: Left great toe and half of second toe is cyanotic
and cool. Plantar aspect of left foot is also cyanotic and cool.
Tender to palpation.
SKIN: No livedo reticularis present. Purpuric lesions on left
calf (new today, per patient) that are not palpable.
NEUROLOGIC: CN2-12 intact. ___ strength throughout, though
patient unable to dorsiflex left foot (several days per
patient).
Normal sensation.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 552)
Temp: 98.5 (Tm 99.0), BP: 103/62 (103-131/62-74), HR: 101
(92-102), RR: 18 (___), O2 sat: 92% (92-94), O2 delivery: Ra
___: NAD, Pleasant
CARDIAC: RRR, nl s1/s2
LUNGS: CTAB
ABD: softer than yesterday, ongoing distension but non-tender,
normoactive bowel sounds.
EXTREMITIES: Left great toe and second toe still with some
purple
discoloration, improved from yesterday ___. Toe still cool to
touch. Bilateral DP and ___ pulses are palpable. No lower
extremity edema.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout, unable
to fully dorsiflex left foot. Sensation intact. No asterixis.
Pertinent Results:
ADMISSION LABS
==============
___ 02:40AM BLOOD WBC-9.9 RBC-4.68 Hgb-12.4 Hct-41.2 MCV-88
MCH-26.5 MCHC-30.1* RDW-UNABLE TO RDWSD-UNABLE TO Plt ___
___ 02:40AM BLOOD Neuts-88* Bands-3 Lymphs-4* Monos-2*
Eos-0* Baso-0 ___ Metas-2* Myelos-0 Promyel-1* AbsNeut-9.01*
AbsLymp-0.40* AbsMono-0.20 AbsEos-0.0* AbsBaso-0.0*
___ 02:40AM BLOOD ___ PTT-26.2 ___
___ 02:40AM BLOOD Glucose-166* UreaN-15 Creat-0.9 Na-137
K-5.1 Cl-98 HCO3-25 AnGap-14
___ 02:40AM BLOOD ALT-134* AST-129* AlkPhos-123*
TotBili-0.2
___ 02:40AM BLOOD Albumin-3.8
INTERVAL LABS/MICROBIOLOGY/REPORTS
==================================
___ 06:57AM BLOOD Ret Aut-1.6 Abs Ret-0.07
___ 06:57AM BLOOD Hapto-162
___ 06:57AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 06:57AM BLOOD RheuFac-35* ___ CRP-1.3
___ 10:35AM BLOOD C3-107 C4-9*
___ 06:57AM BLOOD HIV Ab-NEG
___ 10:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-15
Tricycl-POS*
___ 06:57AM BLOOD HCV VL-6.0*
___ 11:50AM BLOOD Lactate-2.1*
___: Urine legionella: negative
___: Urine culture: no growth
___: Urine culture: no growth
___: Blood culture:
CRYOGLOBULIN
Test Result Reference
Range/Units
% CRYOCRIT SEE NOTE NONE DETECTED
%
A LOW cryoprecipitate was detected (Cryocrit = 0.75 %).
Test Result Reference
Range/Units
CRYOCRIT IMMUNOFIXATION SEE NOTE
No monoclonal proteins detected by immunofixation studies.
Test Result Reference
Range/Units
CRYOCRIT IMMUNODIFFUSION SEE NOTE
Immunodiffusion studies of the patient's cryoprecipitate
detected IGG,IGA,IGM,KAPPA,LAMBDA AND ALBUMIN.
Test Result Reference
Range/Units
RHEUMATOID FACTOR 33 H <14 IU/mL
CRYOGLOBULIN, QL POSITIVE A
Reference Range:
NEGATIVE IN NORMAL
INDIVIDUALS
This test was developed and its analytical performance
characteristics have been determined by ___. It has not been
cleared or approved by FDA. This assay has been validated
pursuant to the ___ regulations and is used for clinical
purposes.
THIS TEST WAS PERFORMED AT:
___
___ ___, ___ ___
___
CTA CHEST Study Date of ___
1. No evidence of aortic dissection.
2. Moderate to severe atherosclerotic disease of the thoracic
and abdominal aorta.
3. 7 mm ground-glass opacity of the left upper lobe,
indeterminate.
4. Other findings, as described above.
RECOMMENDATION(S): For an incidentally detected single
ground-glass nodule bigger than 6mm, CT follow-up in 6 to 12
months is recommended to confirm persistence. If persistent, CT
follow-up every ___ years until ___ years after initial detection
are recommended.
DUPLEX DOPP ABD/PEL Study Date of ___
1. Nodular liver contour liver consistent with cirrhosis. No
ascites or
splenomegaly.
2. Patent hepatic vasculature.
TTE ___
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional left ventricular function.
Overall left ventricular systolic function is normal.
Quantitative biplane left ventricular ejection fraction is 68 %.
Left ventricular cardiac index is normal (>2.5 L/min/m2). There
is no resting left ventricular outflow tract gradient. Diastolic
parameters are indeterminate. Normal right ventricular cavity
size with normal free wall motion. The aortic sinus diameter is
normal for gender. The aortic arch
diameter is normal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (?#) appear structurally
normal. There is no aortic valve stenosis. There is mild [1+]
aortic regurgitation (clip
92). The mitral valve leaflets appear structurally normal. There
is trivial mitral regurgitation. The pulmonic valve leaflets are
not well seen. The tricuspid valve leaflets appear structurally
normal. There
is physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is a very small
pericardial effusion (clips 42-45).
IMPRESSION: Poor image quality. Normal biventricular cavity
sizes and global biventricular systolic function. Mild aortic
regurgitation.
ART DUP EXT LO UNI;F/U LEFT Study Date of ___
> 50% stenosis of the mid superficial femoral artery.
Posterior tibial artery is totally occluded.
ART EXT (REST ONLY) Study Date of ___
Mildly abnormal left ABI when using the dorsalis pedis, but
severely abnormal in the posterior tibial with a toe pressure of
0 mm Hg consistent with severe obstructive arterial disease.
Left Doppler and PVR waveforms consistent with tibial disease,
most severe in the ___.
Mildly abnormal right ABI with Doppler and PVR waveforms
consistent with
tibial disease.
CHEST (PORTABLE AP) Study Date of ___
Interval worsening of right lower lung opacification concerning
for infection. Bibasilar atelectasis.
CT CHEST W/CONTRAST Study Date of ___
1. Diffuse lung parenchymal abnormalities, most prominent in the
posterior
segments of the right upper and lower lobes, suggestive of
multifocal
aspiration related pneumonia.
2. Bilateral nonobstructive nephrolithiasis.
3. Colonic diverticulosis with no evidence of diverticulitis.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. Diffuse lung parenchymal abnormalities, most prominent in the
posterior
segments of the right upper and lower lobes, suggestive of
multifocal
aspiration related pneumonia.
2. Bilateral nonobstructive nephrolithiasis.
3. Colonic diverticulosis with no evidence of diverticulitis.
DISCHARGE LABS
================
___ 05:54AM BLOOD WBC-12.4* RBC-3.42* Hgb-9.4* Hct-31.4*
MCV-92 MCH-27.5 MCHC-29.9* RDW-23.2* RDWSD-77.0* Plt ___
___ 05:23AM BLOOD ___ PTT-31.0 ___
___ 05:54AM BLOOD Glucose-130* UreaN-11 Creat-0.8 Na-134*
K-3.9 Cl-93* HCO3-31 AnGap-10
___ 05:23AM BLOOD ALT-99* AST-86* AlkPhos-175* TotBili-0.3
___ 05:54AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9
___ 06:57AM BLOOD HCV VL-6.0*
Brief Hospital Course:
___ year female CAD, MI, CVA, COPD, and HCV/ETOH cirrhosis who
presents from rehab with acute on subacute left foot pain with
severe atherosclerosis and stenosis of the left SFA, course
complicated by fever, hypotension, and leukocytosis, found to
have multifocal pneumonia. Was treated with 7 day course
vanc/cefepime for HAP. Underwent femoral angiogram on ___
which showed bilateral moderate disease in the iliacs, common
fem, left SFA, and proximal profunda, now s/p b/l iliac
PTA/stenting, L CFA shockwave, L SFA PTA.
TRANSITIONAL ISSUES
===================
[] Continue to taper prednisone (20mg QD ___, 10mg ___,
5mg ___, then OFF)
[] Needs systemic anticoagulation for 3 months (started apixaban
5mg BID prior to discharge) - end ___
[] Plavix 75mg QD for 30 days (until ___, and then transition
to aspirin 81mg QD. Needs 1 month follow up with vascular
surgery (can call ___ for follow up with Dr. ___
[] 7mm lung nodule: For an incidentally detected single
ground-glass nodule bigger than 6mm, CT follow-up in 6 to 12
months is recommended to confirm persistence. If persistent, CT
follow-up every ___ years until ___ years after initial detection
are recommended.
[] Patient should be treated for active HCV
[] Will require HAV and HBV vaccination
[] Should be started on a statin given significant peripheral
vascular disease but was held given persistent transaminitis.
Consider starting as outpatient.
[] Continue to encourage smoking cessation, provide with
lozenges/patches PRN
[] Patient discharged on PO hydropmorphone ___ mg PO/NG Q4H:PRN
Pain and Tylenol 1 g BID (due to liver dysfunction); please wean
as able
ACUTE ISSUES:
=============
# Acute on subacute L limb ischemia
Patient presented with progressively worsening lower extremity
pain over past several months prior to presentation and
diminished dorsiflexion on exam. CT here with evidence of
moderate/severe atherosclerotic disease in aorta that suggests
PAD most likely leading to her ischemia. There was also concern
for cryoglobulinemia with history of untreated hepatitis C but
patient was treated with prednisone 60mg as an outpatient with
no symptomatic improvement. Rheumatology was consulted and
rheumatologic workup (complement, inflammatory markers, etc.)
were not consistent with vasculitic cause of disease. Vascular
medicine was also consulted and recommended starting ASA,
statin. Vascular surgery consulted and felt presentation was
most consistent with atheroembolic disease and patient was
therefore started on a heparin gtt. ABIs showed > 50% stenosis
of the mid superficial femoral artery and total occlusion of the
posterior tibial artery. Patient went for angiogram on
___. An embolism was found in the L toe. The bilateral
iliac arteries were ballooned and stented. The superficial
femoral was also ballooned, and lithotripsy was used on the L
common femoral artery. She was started on a 30-day course of
Plavix (end: ___, during which aspirin should be held, and
systemic anticoagulation (needed for 3 months) with apixaban
given toe embolism (end: ___. After 30 days, she should switch
back to aspirin.
# Sepsis secondary to multifocal pneumonia
Patient developed acute leukocytosis, hypotension, fever, and
tachycardia and was found to have multifocal pneumonia on CT.
She was treated with vancomycin and cefepime for total of 7 day
course. There was concern for aspiration given the distribution
of the pneumonia, however speech and swallow eval did not find
evidence of aspiration.
# Acute hypoxic respiratory failure
# COPD
Patient developed new O2 requirement in the setting of
multifocal pneumonia likely triggering COPD exacerbation.
Treated pneumonia as above. Patient received 2 days of stress
dose steroids and was subsequently transitioned to prednisone
40mg daily. Continued duonebs q6h and albuterol nebs q2h PRN. At
time of discharge she was discharged on prednisone 30mg with
plan for taper. Her O2 need resolved, and she was discharged on
room air.
# Transaminitis
# Cirrhosis ___ Score A)
Presents with uptrending LFTs recently with previous records
showing AST/ALT in the
___. History of untreated HCV and alcohol use disorder
(planned to see GI in ___ for HCV treatment). Presents with
transaminases elevated to 100s with normal Tbili. Differential
includes medication effect (fluconazole) vs. viral hepatitis.
Patient denies alcohol use for 6 months. Of note, patient
recently started on 14 day course of fluconazole for
asymptomatic ___ on throat culture. HCV VL showing active
hepatitis C. LFTs downtrended with cessation of fluconazole.
Continued home furosemide 40mg daily for volume management.
Patient did not have evidence of ascites on abdominal
ultrasound. Patient had recent EGD which was negative for
varices. For encephalopathy, she was continued on lactulose.
Home folic acid and multivitamin were continued. Patient should
receive outpatient treatment for HCV and HAV and HBV vaccines.
# Thrombocytopenia
Mildly thrombocytopenic to 141 on presentation, but improving.
Per outpatient records, was previously 200-300 but has been
downtrending since ___. Likely secondary to underlying
liver disease.
# 7mm "Ground glass nodule" in LUL
Will place as transitional issue when patient leaves. CT
follow-up in 6 to 12 months is recommended to confirm
persistence. If persistent, CT follow-up every ___ years until ___
years after initial detection are recommended.
# Code Status
Patient presented with MOLST stating she was DNR/DNI. After
discussion with HCP present, patient states that she would like
to be full code as long as it was a limited trial and she could
still be interactive.
CHRONIC ISSUES:
===============
# Anemia
Ongoing anemia evaluation as outpatient. Denies melena, though
endorses intermittent hematochezia (since resolved). Received IV
iron as outpatient recently with plan to repeat labs in a few
weeks. Hgb appears to be well above recent baseline (___).
# Throat culture positive for ___ culture obtained as outpatient work up positive for
___. No obvious signs of esophagitis on interview or exam.
Attributed to ICS and recent systemic steroids. Received 14 day
course of fluconazole.
# Depression
Continued amitriptyline 50mg daily, buspirone 7.5mg BID,
trazodone 150mg daily
# GERD
Continued pantoprazole
#CODE: Full (see above)
#CONTACT: ___. Phone ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN Pain - Mild/Fever
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
4. Amitriptyline 50 mg PO QHS
5. BusPIRone 7.5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Fluconazole 200 mg PO Q24H
8. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
9. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. Lactulose 15 mL PO DAILY
14. Mirtazapine 15 mg PO QHS
15. Senna 8.6 mg PO BID:PRN Constipation - First Line
16. Tiotropium Bromide 1 CAP IH DAILY
17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
18. TraZODone 150 mg PO QHS
19. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
21. Multivitamins 1 TAB PO DAILY
22. Pantoprazole 40 mg PO Q24H
23. Thiamine 100 mg PO DAILY
24. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate
Duration: 14 Days
RX *hydromorphone 4 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*0
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
5. Nicotine Patch 7 mg/day TD DAILY
6. Sarna Lotion 1 Appl TP TID:PRN pruritis
7. Lactulose 30 mL PO TID
8. Acetaminophen 1000 mg PO BID:PRN Pain - Mild/Fever
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
10. Amitriptyline 50 mg PO QHS
11. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
12. BusPIRone 7.5 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. FoLIC Acid 1 mg PO DAILY
17. Furosemide 40 mg PO DAILY
18. Gabapentin 600 mg PO TID
19. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
20. Mirtazapine 15 mg PO QHS
21. Multivitamins 1 TAB PO DAILY
22. Pantoprazole 40 mg PO Q24H
23. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
24. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
25. Senna 8.6 mg PO BID:PRN Constipation - First Line
26. Thiamine 100 mg PO DAILY
27. Tiotropium Bromide 1 CAP IH DAILY
28. TraZODone 150 mg PO QHS
29. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until you are no
longer taking hydromorphone
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Peripheral Arterial Disease
Blue toe syndrome
SECONDARY DIAGNOSIS
====================
Hospital acquired pneumonia
COPD
Untreated HCV Cirrhosis
CAD s/p MI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having severe foot
pain.
What did you receive in the hospital?
- We found that you had some blockages in your leg. You had a
procedure performed which improved the circulation in your leg.
This was done by placing some stents to keep the blood vessels
open.
- You were also treated for a pneumonia that you developed while
in the hospital
- We started you on a blood thinning medication which you need
to take for 3 months.
What should you do once you leave the hospital?
- Please take all of your medications as prescribed and attend
all of your follow up appointments as scheduled.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10476129-DS-14 | 10,476,129 | 21,447,222 | DS | 14 | 2176-10-28 00:00:00 | 2176-10-29 09:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient presenting for evaluation of ongoing dyspnea. Symptoms
began a couple of weeks ago, so she went to see her primary care
Dr. ___ week. A chest x-ray was done which showed a
pneumonia, and patient was started on a azithromycin antibiotic
regiment. Last dose was on ___. She has also been taking
albuterol and Flovent inhalers with some relief. However she
continues to experience shortness of breath weakness and
fatigue. She also endorses some chest tightening and overall
reports feeling winded with exertion. For example just lifting
up a bag makes her short of breath, which is new for her. She
also noted DOE which is different form the the SOB she
experienced with her PNA.
Pt did get the flu shot this year. She has no history of heart
disease or family history of early heart disease. She denies any
leg swelling or recent travel. She has no history or family
history of PE or DVT.
In the ED
=============
Initial vitals: 97.0 109 126/97 22 100% RA
EKG: LBBB, new compared to ___
Labs were significant for
Trop-T: <0.01 x2
UCG: Negative
D-Dimer: ___ 16 AGap=19
-------------< 117
4.4 21 0.9
proBNP: 6915
13.6 MCV=98
12.3 >-------< 410
41.8
N:70.3 L:21.1 M:6.6 E:0.7 Bas:0.8 ___: 0.5 Absneut: 8.65
___ Abslymp: 2.59 Absmono: 0.81 Abseos: 0.08 Absbaso: 0.10
Imaging showed
CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Cardiomegaly with moderate right and small left pleural
effusions and mild bronchial wall thickening.
3. Partially imaged upper abdomen shows small amount of ascites
of unspecified etiology.
CXR: Moderate cardiomegaly with mild hilar congestion
The patient received:
___ 21:40 IV Furosemide 20 mg
She was evaluated by the cardiology fellow in the ED who
performed a Bedside TTE shows globally reduced LVEF ___ and
recoomemded admission to the heart failure service for further
work-up and treatment of CHF.
The patient was shifted to the floor. On the floor, the patient
does not have sob or chest pain.
Past Medical History:
ROSACEA
HYPERLIPIDEMIA
ATYPICAL LOBULAR HYPERPLASIA
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ COLON CANCER
Father ___ ___ PROSTATE CANCER
MGM BREAST CANCER
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 ___ 18 95%
Wt: 88.2kg
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor.
PERRLA, EOMI.
NECK: Supple without LAD
PULM: full air entry bilaterally, no crackle. no wheeze. no
rhonchi
HEART: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII intact, strength ___ in b/l ___, SLIT
========================
DISCHARGE PHYSICAL EXAM:
VS: Afeb, HR 88-101, BP 93-115/63-72, RR ___, O2 96-99% RA
Wt: 80.2 <- 81.8 <- 84.4 <- 88.2 kg (unknown dry weight)
I/Os: ___
GEN: Alert, siting upright in bed, no acute distress
HEENT: Moist MM, PERRLA, EOMI.
NECK: Supple, JVP 5 cm
PULM: bibasilar rales. no wheeze or rhonchi
HEART: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: WWP, no ___ edema
NEURO: moving all extremities equally, face symmetric
Pertinent Results:
ADMISSION LABS:
___ 03:55PM BLOOD WBC-12.3*# RBC-4.26 Hgb-13.6 Hct-41.8
MCV-98 MCH-31.9 MCHC-32.5 RDW-12.7 RDWSD-45.5 Plt ___
___ 03:55PM BLOOD Neuts-70.3 ___ Monos-6.6 Eos-0.7*
Baso-0.8 Im ___ AbsNeut-8.65*# AbsLymp-2.59 AbsMono-0.81*
AbsEos-0.08 AbsBaso-0.10*
___ 03:55PM BLOOD Plt ___
___ 03:55PM BLOOD Glucose-117* UreaN-16 Creat-0.9 Na-138
K-4.4 Cl-102 HCO3-21* AnGap-19
==========================
PERTINENT LABS:
___ 05:17AM BLOOD ALT-56* AST-37 LD(LDH)-232 AlkPhos-78
TotBili-0.4
___ 03:55PM BLOOD proBNP-6915*
___ 03:55PM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD cTropnT-<0.01
___ 05:17AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:17AM BLOOD TotProt-5.4* Albumin-3.5 Globuln-1.9*
Calcium-8.9 Phos-4.6* Mg-2.0 Iron-48
___ 03:55PM BLOOD D-Dimer-1183*
___ 05:17AM BLOOD calTIBC-347 Ferritn-76 TRF-267
___ 05:17AM BLOOD TSH-3.2
___ 05:17AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 09:45PM BLOOD HIV Ab-Negative
___ 05:17AM BLOOD HCV Ab-Negative
========================
IMAGING/STUDIES:
CXR ___:
FINDINGS:
PA and lateral views of the chest provided. Heart remains
moderately
enlarged. While there is no frank edema, the hila appear
slightly congested. Tiny pleural effusions are suspected. No
convincing evidence for pneumonia. No pneumothorax. Mediastinal
contour is stable. Bony structures are intact.
IMPRESSION:
Moderate cardiomegaly with mild hilar congestion. Tiny pleural
effusions.
ECHO ___:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is an inferobasal left
ventricular aneurysm. There is severe global left ventricular
hypokinesis with regional variation (inferior free wall is
frankly akinetic) (LVEF = 15 %) secondary to global contractile
dysfunction and, to a lesser extent, dyssynchrony. A left
ventricular apical mass/thrombus cannot be excluded. The right
ventricular free wall thickness is normal. The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. Moderate (2+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid regurgitation jet is eccentric and may be
underestimated. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. If clinically
indicated, a transthoracic study with transpulmonic microbubble
contrast is recommended to better define the endocardium of the
left ventricle.
Compared with the prior study (images reviewed) of ___,
left ventricular contractile function is now severely impaired.
B/l ___ VENOUS ULTRASOUND ___:
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
============================
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-7.9 RBC-4.78 Hgb-15.0 Hct-45.1*
MCV-94 MCH-31.4 MCHC-33.3 RDW-12.3 RDWSD-42.8 Plt ___
___ 06:05AM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-139
K-4.2 Cl-97 HCO3-24 AnGap-22*
Brief Hospital Course:
BRIEF COURSE:
___ with limited PMH presented with DOE and orthopnea 3 weeks
after viral URI. Found to have BNP 6915, CXR with cardiomegaly,
pulm vascular congestion, small b/l pleural effusions. Pt found
to have new systolic heart failure with TTE showing EF 15%,
global dysfunction (prior TTE in ___ w/ EF 50%). She was
diuresed with lasix IV 20 mg to a dry weight of 80.2 kg. Another
ECHO study with lumison showed a large apical LV thrombus.
Patient was started on anticoagulation with lovenox as a bridge
to therapeutic warfarin. She was discharged on the following
heart failure med regimen: lasix 20 mg, metoprolol XL 12.5 mg,
lisinopril ___s a life vest. She will follow up in
___ clinic as well as long-term with Dr. ___ to manage
this issue.
===========================
CARDIAC HISTORY:
# CORONARIES: ETT in ___ with inducible LBBB
# PUMP: HFrEF unclear etiology, EF 15%, LV severe global HK, RV
mod global HK.
# RHYTHM: NSR with LBBB
ACTIVE ISSUES:
# ACUTE SYSTOLIC HEART FAILURE: Pt presented with DOE and
orthopnea 3 weeks after viral URI. Found to have BNP 6915, CXR
with cardiomegaly, pulm vascular congestion, small b/l pleural
effusions. TTE w/ new EF 15%, global dysfunction (prior TTE in
___ w/ EF 50%). Only cardiac risk factor HLD. Previously had
stress test with rate-related LBBB and EF 50%. On admission,
Trop negative x2, EKG with full LBBB. Most likely non-ischemic
CMP of unclear source. Work-up negative for non-ischemic cuases:
HIV negative, iron studies normal, SPEP normal, ___ negative,
TSH normal, Free ___ normal. Ddx still includes viral
myocarditis vs idiopathic. ECHO with lumison showed large LV
thrombus. Defering cath at this time given LV thrombus, but will
need CAD ruled out definitively in future with LHC. Also would
benefit from cardiac MR to evaluate for myocarditis, scar as
outpatient. She was diuresied with Lasix IV 20 mg to dry weight
of 80.2 kg and started on metoprolol succ 12.5 mg and lisinopril
5 mg, then uptitrated to 10 mg, which were well tolerated. She
was discharged with a Life Vest after discussion with the
patient and her family. Consideration should be given to early
CRT depending upon her clinical and ECHO response to
___ medical therapy given that she is female with
likely non-ischemic cardiomyopathy and a relatively wide LBBB.
Her medical regimen at discharge included:
- Lasix 20mg daily
- Metoprolol succinate 12.5 mg
- Lisinopril 10 mg daily (consider switch to ___ if persistent
dry cough)
- Consider the addition of spironolactone after titration of
the beta-blocker and ACEi.
# LV Thrombus: ECHO with lumison ___ showed large (2.3 x 0.9
cm) mural thrombus along the apical inferior left ventricular
wall. ___ new HFrEF. Started on warfarin 5 mg and Enoxaparin 80
mg q12h ___. Goal INR 2.0-3.0 Continue enoxaparin until 2
therapeutic INRs as an outpatient. She will need at least ___
months of anticoagulation and follow up TTE/CMR to assess for
resolution of the LV thrombus.
# Transaminitis: ALT elevated to 56 on admission, previously
normal. Likely congestive hepatopathy in setting of HFrEF.
Resolved with diuresis.
# ?Asthma: Continued home fluticasone inh BID, alb neb PRN
===========================
TRANSITIONAL ISSUES:
- New Meds: Lovenox, warfarin, metoprolol succinate,
lisinopril, furosemide
- Post-Discharge Follow-up Labs Needed: INR within 2 days, Chem
10 within ___ weeks to check Cr
- Discharge weight: 80.2 kg
- Discharge diuretic: Furosemide 20 mg daily
- New HFrEF: Unclear etiology, likely non-ischemic. Will need
LHC down the road but deferred for now given LV thrombus. Should
have cardiac MR as ___. Should consider ICD vs CRT given
prolonged QRS if EF does not recover.
- Diuresis: Pt was euvolemic on discharge at weight above. Will
need evaluation within 7 days to determine need for adjusting
diuretic.
- Lisinopril: Pt developed cough after initiating lisinopril.
If persists, could consider ___
- LV thrombus: D/c on warfarin 5 mg and enoxaparin 80 q12h
- Iron deficiency: Ferritin 75. Hgb 15.0, but iron stores may
need repleted in the future
# CODE STATUS: full (confirmed)
# CONTACT: ___ husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Guaifenesin-CODEINE Phosphate ___ mL PO Q8H:PRN COUGH
2. Multivitamins 1 TAB PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob, wheezing
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC every twelve (12) hours
Disp #*14 Syringe Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
4. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*2
5. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth once a day Disp #*150
Tablet Refills:*0
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob, wheezing
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q8H:PRN COUGH
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1) Acute systolic heart failure
# Left ventricular thrombus
# Dyslipidemia
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 hospital because you had been feeling
short of breath and you were found to have fluid on your lungs.
This was due to a condition called heart failure, where your
heart does not pump hard enough and fluid backs up into your
lungs. The cause of this is still unclear. Many tests were sent
but did not show a clear cause. You were given a diuretic
medication through the IV to help get the fluid out. You were
also found to have a blood clot in your heart. This was treated
with blood thinners. You will continue injections of enoxaparin
(Lovenox) until your warfarin (Coumadin) levels come up.
When you were ready to leave the hospital, you were set up with
a device to monitor your heart. You will follow up closely with
our heart failure specialists to continue to manage this issue.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10476303-DS-23 | 10,476,303 | 22,223,417 | DS | 23 | 2183-02-02 00:00:00 | 2183-02-02 17:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex / Losartan
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man with medical history of ESRD secondary to
uncontrolled HTN and DM2, presenting with worsening cough and
shortness of breath. Pt is primarily ___ speaking and
is a poor historian. He states that he has struggled with
chronic cough and shortness of breath for several years. His
son, who is was at the bedside in the ED provided most of the
interpretation, states that his dad's breathing status and cough
worsened two weeks ago. His last HD session was ___ (he is
on a ___ schedule). He denies fevers, chills, chest
pain and worsening ___ edema. His son states that his dry weight
ranges between 152-154. The patient states that he tolerated his
HD session on ___ well, however, he was told that he had "a
lot of water that needed to be taken off."
Per report from patient's son, wet cough over last few weeks.
Cough not productive of any sputum. Has had runny nose for past
few months, chronic issue worked up recently. Workup
unrevealing. No fever or chills. Patient does report some pain
on urination and urinary dribbling with weak stream over the
past few days.
On arrival to ED, tachypneic to ___, tachycardic to 120s.
Resolved without intervention.EKG with peaked T Waves, ST elev
isolated to II, requested to bring pt back.
In the ED, initial vitals: 100.4 76 137/68 24 94% RA
Labs were significant for grossly positive UA, trop 0.10, and
INR 7.1.
CXR showed mild pulmonary edema with small bilateral pleural
effusions.
Vitals prior to transfer: 115 110/68 18 100% Nasal Cannula
Currently,
Past Medical History:
ESRD secondary to uncontrolled HTN and DM2
HTN
DMT2
HLD
chronic anemia
glaucoma
Afib
LVH
Recurrent flash pulmonary edema
Stroke in ___ with mild right sided defecits
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS: 99.5, 157/77, 103, 20, 95 on 2L NC
GEN: Alert, lying in bed, no acute distress
HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, no JVP elevated
PULM: Generally CTA b/l without wheeze or rhonchi. mild
bibasilar crackles
COR: RRR (+)S1/S2 no m/r/g, S1 early systolic murmur
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema in legs, left arm AV
fistula with good thrill and bruit
NEURO: CN II-XII grossly intact, motor function grossly normal
Discharge Exam:
VS: 97.5, 120s-140s/50s, 60s-70s, 18, 92% RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, no JVP elevated
PULM: Generally CTA b/l without wheeze or rhonchi. no crackles
in bases
COR: RRR (+)S1/S2 no m/r/g, S1 early systolic murmur
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema in legs, left arm AV
fistula with good thrill and bruit
Pertinent Results:
Admission labs:
___ 11:50PM BLOOD WBC-9.5# RBC-3.11* Hgb-9.6* Hct-29.9*
MCV-96 MCH-30.9 MCHC-32.1 RDW-15.0 RDWSD-52.9* Plt ___
___ 12:05AM BLOOD ___ PTT-62.8* ___
___ 11:50PM BLOOD Glucose-77 UreaN-47* Creat-5.5*# Na-140
K-4.3 Cl-98 HCO3-27 AnGap-19
___ 11:50PM BLOOD Calcium-9.2 Phos-3.2 Mg-2.3
___ 11:59PM BLOOD K-4.5
Discharge labs:
___ 06:45AM BLOOD WBC-7.7 RBC-2.66* Hgb-8.3* Hct-25.3*
MCV-95 MCH-31.2 MCHC-32.8 RDW-14.7 RDWSD-50.4* Plt ___
___ 06:45AM BLOOD ___ PTT-41.6* ___
___ 06:45AM BLOOD Glucose-153* UreaN-55* Creat-6.6*#
Na-128* K-5.1 Cl-89* HCO3-24 AnGap-20
___ 06:45AM BLOOD Glucose-153* UreaN-55* Creat-6.6*#
Na-128* K-5.1 Cl-89* HCO3-24 AnGap-20
___ 06:45AM BLOOD Calcium-8.6 Phos-4.9* Mg-2.1
Imaging/other studies:
___: CXR
Mild pulmonary edema with small bilateral pleural effusions.
Microbiology:
___ 3:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
___ male with a PMHx of ESRD, Afib, HTN, DM2, presenting
with SOB, fever and cough, likely related to component of volume
overload and question of HCAP, found to have a urinary tract
infection.
#Dyspnea: His dyspnea was most likely due to volume
overload/___ given pulmonary edema on CXR and resolution of his
symptoms after 3L fluid removal at HD on ___.
#UTI: He had a single fever to 100.4 in the ED and endorsed
dysuria and frequency so was treated initially with
vanc/cefepime and then ceftriaxone for UTI. His urine culture
grew yeast. Given that the patient's urinary symptoms and single
fever resolved on admission, it was decided not to treat his
candiduria, especially given the risk for causing recurrent
supratherapeutic INR.
#Supratherapeutic INR: 7.1 on admission. No evidence of bleeding
so warfarin was held and INR was allowed to trend down
naturally. 2.8 on discharge. Patient was likely taking too much
coumadin and it was unclear who was managing his coumadin. He
was set up with ___ and the ___ clinic prior to
discharge.
#Paroxysmal Afib w/ RVR: as high as the 120s in the ED.
Currently in sinus rhythm. CHADS2 of 6 (dCHF, HTN, Age, DM, hx
of strokes). Continued home dilt 60mg TID and metoprolol 100mg
BID with good rate control mostly ___.
#R/o ACS: Troponin 0.10 in ED, repeated at 0.12 on floor. Likely
elevated due to ESRD now three days removed from last dialysis
treatment. Troponins decreased from prior admissions. EKG
without evidence of acute ischemia. Continued ASA 81mg and
atorvastatin 80mg.
#HTN: continued home metoprolol, diltiazem, hydralazine,
losartan, furosemide 80mg
==========================
Transitional Issues:
==========================
-Follow up with PCP after discharge
-___ ___ and set the patient up to be
followed by them. Also discharged with ___ for medication
management and INR monitoring.
-Decreased warfarin dose to 3mg daily from 6mg daily given
supratherapeutic INR.
-If dysuria/frequency recur, would recommend treating with
Fluconazole 400mg after HD x 14 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Diltiazem 60 mg PO TID
4. Furosemide 80 mg PO DAILY
5. HydrALAzine 100 mg PO ONCE
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Pregabalin 75 mg PO DAILY
11. Tamsulosin 0.4 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Tizanidine 2 mg PO Frequency is Unknown
14. Warfarin 6 mg PO DAILY16
15. Loratadine 10 mg PO DAILY
16. Levemir 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Diltiazem 60 mg PO TID
4. Furosemide 80 mg PO DAILY
5. Levemir 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Loratadine 10 mg PO EVERY OTHER DAY
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Tartrate 100 mg PO BID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Pregabalin 75 mg PO DAILY
12. Tamsulosin 0.4 mg PO DAILY
13. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
14. Tizanidine 2 mg PO BID:PRN cramps
15. HydrALAzine 100 mg PO BID
16. Outpatient Lab Work
Please draw INR on ___ and fax to HCA Anticoag at
___. ICD-10 I48.0.
17. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
UTI
Pulmonary edema
Secondary:
Afib w/ RVR
ESRD on dialysis ___
Discharge Condition:
Mental status: awake, alert, oriented x3
Ambulatory status: ambulatory without assistance.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for cough and shortness of
breath. You were found to have a buildup of fluid in your lungs.
We took off fluid during dialysis and continued your home water
pills which helped improve your breathing.
You were found to have an infection of your urinary tract. We
treated you with antibiotics. If you have recurrent burning with
urination or fevers, you should call your doctor.
We continued you home heart medications and other home
medications while you were here.
You should follow up with your primary care physician after
discharge.
We wish you the best,
Your ___ primary care team.
Followup Instructions:
___
|
10476390-DS-8 | 10,476,390 | 24,793,792 | DS | 8 | 2146-03-15 00:00:00 | 2146-03-17 23:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain, shoulder pain and hip pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old lady with a history of asthma,
hypertension and a myofascial pain syndrome coming to the ER
with chest radiating to L arm, back, bilateral hip pain for ___
days with productive cough, dyspnea and chills with 3 episodes
of diarrhea. She was at ___ yesterday for evaluation of her
ongoing hip/knee pain during which an inflammatory arthritis
panel was drawn. She was advised to seek further medical care
should her symptoms not improve. As they had not, she presented
to the ED today.
.
In the ED, initial vital signs were 98.2 90 134/81 20 95%.
Patient was given levofloxacin 750mg x1, morphine and Zofran
after a CXR which showed ? RML consolidation.
.
On the floor, Ms. ___ is comfortably enjoying her dinner,
reports the pain above, but that her chest pain has somewhat
resolved. Her nausea/anorexia has subsided but continues to
have bilateral hip/knee pain. Of note, her significant other
passed ~3 months ago from corornary artery disease.
.
Review of sytems:
All other systems negative except above on review.
Past Medical History:
-myofascial pain syndrome
-Asthma
-Hypertension
-Allergic Rhinitis
-Uterine fibroids, history of depression,
-status post colostomy for bowel obstruction with subsequent
reversal, previous bilateral ankle surgeries, right knee
arthroscopy.
Social History:
___
Family History:
No family history of heart disease obtained
Physical Exam:
Admission PE
Vitals- 98.9 122/88 82 18 98%Ra
General- Alert, oriented, no acute distress, enjoying dinner
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Decreased breath sounds on RML, otherwise clear, no
rhonchi
CV- Chest tender to palpation. Regular rate and rhythm, normal
S1 + S2
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- Bilateral hip, trochanteric and buttock pain on exam. No ___
edema.
Neuro- CNs2-12 intact, motor function grossly normal
.
Discharge PE
VSS
Chest continued to be TTP in addition to shoulders, ROM is
slightly limited, none of joints are hot or swollen
Chest is clear
Abdomen is non tender
Pertinent Results:
Trop <0.01, Lactate 1.1
.
133 100 8
-------------<113
4.2 18 1.1
.
estGFR: 52/63 (click for details)
.
12.7
22.8>---<271
41.2
N:84.8 L:10.1 M:1.9 E:2.7 Bas:0.6
.
Inflammatory Arthritis markers: CRP 17, RF and ___ negative
.
Microbiology: Blood cultures pending at the time of the
discharge summary, urine cultures negative
,
___ serology:
___ 2:24 pm SEROLOGY/BLOOD CHM S# ___ ADDED ___.
**FINAL REPORT ___
___ SEROLOGY (Final ___:
EIA RESULT NOT CONFIRMED BY WESTERN BLOT.
POSITIVE BY EIA.
NEGATIVE BY WESTERN BLOT.
Refer to outside lab system for complete Western Blot
results.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of ___ disease should be retested in
___ weeks.
.
Imaging:
CXR:
IMPRESSION: Left lower lobe consolidation compatible with
pneumonia in the
appropriate clinical setting. Repeat after treatment is
recommended to
document resolution.
.
EKG: NSR @ 82, no evidence of ischemia
Brief Hospital Course:
A ___ year old woman with a myofascial pain syndrome presenting
with chest pain and leukocytosis, CXR and exam suggestive of
pneumonia.
.
## Pneumonia with chest pain, leukocytosis
Patient presented with many musculoskeletal complaints but her
chills myalgias and cough could best be explained by a community
acquired PNA. Cardiac causes of her chest pain were also
investigated, she had 3 negative set's of enzymes and her EKG
was normal. Her chest pain was reproducible on physical exam
and was thought to be part of her myofascial pain syndrome. She
has had several ER visits, but no admissions to ___, thus
community acquired. A CXR revealed a LLL consolidation and she
was started on levofloxacin in the ED. At that time her WBC was
22K with a left shift. Her WBC improved back to the normal
range by the day of discharge. She will be discharged to
complete a 7 day course of levofloxacin. A follow up CBC should
be done in 1 week. The patient has pending blood cultures at
the time of this note, her urine cultures were negative.
.
## acute on chronic pain likely due to myofascial pain syndrome
The acute component of this pain was thought to be an acute
exacerbation of her myofascial pain syndrome cause by her CAP.
Work up for inflammatory arthritis was done and negative,
including negative RF, ___ and ___ (positive by EIA, negative
by western blot). In house patients pain was controlled with
mostly non-narcotics analgesics. She was continued on her home
regimen of tizanidine and nortriptyline. NSAID's were tried for
synergy, but the patient reported dizziness so they were
stopped. Tramadol was not added due to interactions with her
other medications. Standing Tylenol was added in addition to
low dose gabapentin. The patient reported pain relief and
increased ability to sleep on this medication. She was
discharged on a starting dose of gabapentin, she should follow
up with her PCP and the outpatient pain team for further
medication titration. Lidocane patches were also tried with
some success.
.
## Constipation
The patient reported several days without bowel movements, which
is abnormal for her. She was sent home on docusate and miralax.
.
## Transitional Issues:
-Please follow up BC from ___ that are pending at the time of
this note
-Patient should follow up with PCP and pain team for further
pain regimen titration and routine pneumonia follow up with CBC
and consider repeat CXR
.
Medications on Admission:
tizanidine ___ mg PO BID
nortriptyline ___ mg PO QHS
albuterol sulfate HFA 2 pffs(s) q 4 hours
hydrochlorothiazide 25 mg PO Daily
amlodipine 10 mg PO daily
loratadine 10 mg Tab PO Daily PRN
Flovent HFA 220 mcg/actuation 2 puffs BID
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours: please do not exceed 4 g in 24 hours.
Disp:*80 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
Constipation.
Disp:*QS for 1 month Powder in Packet(s)* Refills:*0*
4. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*0*
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergies.
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for Dyspnea,
wheeze.
Disp:*QS for 1 month * Refills:*0*
10. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. fluticasone 110 mcg/actuation Aerosol Sig: Four (4) Puff
Inhalation BID (2 times a day).
12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 5 days.
Disp:*6 Tablet(s)* Refills:*0*
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain.
Disp:*QS for 1 month Adhesive Patch, Medicated(s)* Refills:*0*
14. Outpatient Lab Work
Please check a CBC in 1 week and fax to pcp ___
___ (482.9-pneumonia)
Discharge Disposition:
Home
Discharge Diagnosis:
left lower lobe pneumonia
myofascial pain syndrome exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ with complaints of chest pain,
shoulder pain and bilateral hip pain. You were found to have
pneumonia and were started on antibiotics. Your symptoms
improved. It is important that you follow up with your
outpatient team. We made the following medication changes:
1) levofloxacin 750 daily, please continue until ___, which
is when you should take your last dose
2) gabapentin 300 at bedtime for musculoskeltal pain
3) docusate 100 twice a day, to prevent constipation
4) miralax 17 g daily, as needed for constipation
5) tylenol ___ three times a day
6) lidocaine patches apply to back daily, as needed
Followup Instructions:
___
|
10476390-DS-9 | 10,476,390 | 25,528,721 | DS | 9 | 2146-03-26 00:00:00 | 2146-04-01 20:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of Breath, right chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with asthma, hypertension and
myofascial pain syndrome who was recently admitted for pneumonia
and presented to the ED with three days of worsening dyspnea.
She was admitted from ___ for chest pain, productive
cough, dyspnea and chills and was treated for LLL PNA with 9
days of Levofloxacin (___) last dose was 2 days ago). Also
ruled out for MI at that time. She feels that she was initially
improving after discharge, but he is still having continued
cough productive of greenish sputum and intermittent chills.
The chest pain also had initially gotten better but returned
earlier today on the right side, worse with movement and cough.
Not pleuritic. Came on after smoking cigarettes. Due to
worsened pain (and concern because she had a friend who died of
an MI a few months ago) she decided to call EMS who brought her
to ___.
In the ___ ED, initial VS were pain ___, T 97.8, HR 81, BP
113/60, RR 20, POx 100% RA. EKG and exam were reassuring. Labs
were notable for lactate 2.2, WBC 13.2 (66.5% N, no bands); on
last admission her WBC peaked at 22.8 but was 9.5 on discharge.
The ED felt that CXR suggested persistent LLL consolidation.
Blood cyltures were drawn and she received
Ceftriaxone/Azithromycin. She was admitted for failure of
outpatient pneumonia treatment. VS prior to transfer were: pain
___, T 97.5, HR 71, RR 14, BP 118/69, POx 100%RA.
On arrival to the floor, patient reports feeling well. Mild
cough, no SOB.
Past Medical History:
- Community acquired pneumonia (admitted to ___ ___
- Myofascial pain syndrome
- Asthma
- Hypertension
- Allergic Rhinitis
- Uterine fibroids
- Depression
- Bowel obstruction s/p colostomy with subsequent reversal
- Osteoarthritis s/p bilateral knee arthroplasty
- Ankle fractures s/p surgerical intervention
Social History:
___
Family History:
T2DM: Mother, 2 brothers. No family history of heart disease
noted.
Physical Exam:
ADMISSION EXAM:
VS: 97.8, 145/96, 80, 18, 97%RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: mild insp&exp wheezes throughout, no rhonchi
CV: RRR normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
MS: No swelling or deformity. Poor active ROM in upper and lower
extremity.
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: no ulcers or lesions
DISCHARGE EXAM:
VS: Temp/Tmax 98.1 BP 112/72 (105-113/65-75) HR 63 (63-77) RR 18
100%RA (92-97%RA)
GENERAL- Alert, oriented x3, lying in bed uncomfortable
reporting generalized body pain
HEENT: sclera anicteric, PERRLA 2>1mm, EOMI, MMM, OP clear
THORAX- clear to auscultation bilaterally in upper lobes.
Scattered bilateral bibasilar expiratory wheezes. No rales or
ronchi
CV- RRR, distant heart sounds with normal S1 + S2, no murmurs,
rubs, gallops. Carotid pulses brisk, no JVD
ABDOMEN- Soft, obese, non-distended w/ normoactive bowel sounds,
no organomegaly. Suprapubic and LLQ tenderness.
MS- No evidence of swelling or deformity. Limited active ROM
bilaterally in upper and lower extremity. Positive straight leg
raise bilaterally with pain in groin. Equivocal right shoulder
empty can test. Diffuse muscle tenderness.
EXT- WWP, 2+ pulses in DP, no clubbing, cyanosis or edema
SKIN- No rashes, ulcers, lesions
NEURO- CNs2-12 grossly intact
Pertinent Results:
ADMISSION LABS
___ 04:20PM BLOOD WBC-13.2* RBC-5.36 Hgb-12.0 Hct-39.4
MCV-74* MCH-22.4* MCHC-30.4* RDW-14.0 Plt ___
___ 04:20PM BLOOD Neuts-66.5 ___ Monos-2.3 Eos-4.7*
Baso-0.8
___ 04:20PM BLOOD ___ PTT-22.4* ___
___ 04:20PM BLOOD Glucose-126* UreaN-16 Creat-0.9 Na-140
K-3.2* Cl-101 HCO3-27 AnGap-15
___ 04:20PM BLOOD cTropnT-<0.01
___ 07:34AM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 07:34AM BLOOD WBC-10.4 RBC-4.67 Hgb-10.7* Hct-33.1*
MCV-71* MCH-22.9* MCHC-32.3 RDW-14.2 Plt ___
___ 10:10AM BLOOD Hct-33.7*
___ 07:34AM BLOOD Neuts-56.0 ___ Monos-2.3 Eos-4.6*
Baso-0.6
MICROBIOLOGY DATA
___ 06:35AM URINE Color-Straw Appear-Clear Sp ___
___ 06:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 06:35AM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
___ Urinary Antigen - NEGATIVE
___ CULTURE - NEGATIVE
___ CULTUREBlood Culture,
Routine-NEGATIVE
___ CULTUREBlood Culture,
Routine-NEGATIVE
CXR (PA & LAT) ___ :
FINDINGS: PA and lateral views of the chest were obtained. The
lungs appear clear bilaterally without focal consolidation,
effusion, pneumothorax. Cardiomediastinal silhouette is normal.
Bony structures intact. No free air below the right
hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
Ms. ___ is a ___ lady with recent discharge for PNA who
presented w/ 3 days of SOB and 1 day of chest pain that was
initially concerning for unresolved pneumonia but her exam and
studies were reassuring that this represented post-infectious
pneumonia as well as musculoskeletal shoulder pain so she was
discharged home.
# Right chest pain: musculoskeletal.
She presented with right-sided chest pain that was focal and
reproducible with light palpation on exam. The pain is likely
due to myofascial pain syndrome given her hx and relief with
NSAIDs. Given recent negative work-up for rheumatological and
infectious causes, we did not perform repeat CK, ___ and ___
testing. Prior work-up showed elevated CRP and ESR. Shoulder
joint pain was considered due to equivocal shoulder impingement
testing and poor active range of motion. ACS is unlikely given
negative Troponin x 2 and normal ECG. Also unlikley to be
pericarditis due to focal pain and negative pericardial rub on
exam. She was treated with Naproxen and Morphine and experienced
some relief.
# Shortness of breath: Reactive airways.
Given her recent history of PNA 10 days PTA, her symptoms were
initially concerning for recurrent or undertreated pneumonia.
However, her CXR is not worsened from prior and she has been
afebrile. Due to her hx of Asthma, wheezing on exam, and relief
of dyspnea with Albuterol, she likely has a Post-pneumonia
reactive airway disease. We also considered chronic eosinophilic
pneumonia given the peripheral eosinophilia but were unimpressed
by the CXR findings. SOB is not likely to be PE given no leg
swelling and nl O2 sat on RA. She was initially given
Ceftriaxone 1g IV and Azithromycin 500mg IV in the ED but that
was subsequently discontinued due to low likelihood of
pneumonia. She was encouraged to use her home albuterol which
she reported improved the dyspnea.
# Myofascial pain syndrome: chronic.
Patient has a hx of myofascial pain syndrome and currently
reports diffuse muscular pain which was reproducible on exam
with light palpation. A rheum work-up for inflammatory arthritis
was negative during her last admission in ___ except for
elevated CRP and ESR. We controlled her pain with NSAIDs and
Morphine and increased the frequency of Gabapentin to 300mg TID.
On discharge, we added Acetaminophen, Ibuprofen, and increased
frequency of Gabapentin to 300mg TID.
# Hypertension: pt has a hx of HTN and was stable with SBP in
110s during admission. She was continued on her home medication
of Amlodipine 1 mg qd and HCTZ 25MG QD
# Allergic Rhinitis: stable.
She reported increased post-nasal drip. She was instructed to
follow the Loratadine 10mg qd prescription.
TRANSITIONAL ISSUES:
#. Pending at the time of discharge: None
# Code: Full (discussed with patient)
# Communication: Patient
# Emergency Contact: ___ ___
Medications on Admission:
amlodipine 10 mg daily
hydrochlorothiazide 25 mg daily
fluticasone 110 mcg/actuation Aerosol: 4 puff BID
albuterol sulfate 90 mcg/actuation HFA: ___ puffs Q6H PRN
loratadine 10 mg daily PRN allergies
acetaminophen 500 mg TID PRN [not taking]
tizanidine 2 mg BID
nortriptyline 50 mg QHS
gabapentin 300 mg QHS
lidocaine 5 %(700 mg/patch) Patch: 1 patch daily PRN back pain
[not taking]
docusate sodium 100 mg BID
polyethylene glycol 3350 17 gram Powder in Packet: 1 packet
daily PRN
---
levofloxacin 750 mg daily (was given 5 tabs on ___
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ibuprofen 400 mg PO Q8H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
4. Amlodipine 10 mg PO DAILY
please hold for SBP<100
5. Docusate Sodium 100 mg PO BID
6. Tizanidine 2 mg PO BID
7. Nortriptyline 50 mg PO HS
8. Gabapentin 300 mg PO TID
9. Loratadine *NF* 10 mg Oral daily allergies
10. Hydrochlorothiazide 25 mg PO DAILY
please hold for SBP<100
11. Fluticasone Propionate 110mcg 4 PUFF IH BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Lidocaine 5% Patch 1 PTCH TD DAILY lower back pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
post-infectious reactive airways
non-cardiac chest pain
SECONDARY
asthma
myofascial pain syndrome
tobacco use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with cough, shortness of breath, and chest
wall pain and were admitted because there was concern that your
previous pneumonia might not have been adequately treated. Your
history, exam, labs, and imaging were reassuring.
Your cough and shortness of breath are likely related to your
asthma. Please continue to take your Fluticasone inhaler twice
a day as prescribed (even if you do not have symptoms). Then
you can use the Albuterol as needed. It is VERY IMPORTANT that
you stop smoking completely, as this can cause your breathing to
become much worse and also increases your risk of lung cancer.
As for your chest wall pain, we made sure you were not having a
heart attack. On your previous admission, you were ruled out
for inflammatory causes of pain. Your symptoms likely represent
a flare of chronic musculoskeletal pain; please see your doctor
for further workup. We increased the frequency of your
Gabapentin. Also, you should take Acetaminophen and Ibuprofen
as needed.
We made the following changes to your medications:
-START Acetaminophen
-START Ibuprofen
-INCREASE frequency of Gabapentin
-CONTINUE Lidocaine patch as previously prescribed (please see
your PCP if you require a prior authorization)
Followup Instructions:
___
|
10476475-DS-20 | 10,476,475 | 22,016,160 | DS | 20 | 2166-10-25 00:00:00 | 2166-10-31 16:32:00 |
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 forearm crush injury
Major Surgical or Invasive Procedure:
1. On ___, left forearm compartment fasciotomy and
left carpal tunnel release.
2. On ___, hand compartment releases x 10.
3. On ___, radial and ulnar artery bypasses with
saphenous vein grafts.
4. On ___, debridement of left upper extremity and
placement of Integra dressing.
5. On ___, debridement of left thenar, hypothenar
and dorsal hand wounds.
6. On ___, debridement of left thenar wound and
closure of the hypothenar wounds.
History of Present Illness:
Pt is a ___ yo left-handed male w/ h/o asthma who presents
s/p crush injury to L forearm and hand at 7:45am this morning.
Pt
presented to OSH 30 minutes thereafter. Due to concern for
compartment syndrome, transferred by MedFlight to ___. Xrays
at OSH showed multiple fractures ? locations. Upon arrival, pt
complains of extreme pain, numbness, coolness, tingling in L arm
and forearm. Denies CP, dyspnea, fevers/chills.
Past Medical History:
asthma, no meds currently
Social History:
___
Family History:
NC
Physical Exam:
Admission:
vitals WNL, stable
Gen- middle aged male, appears uncomfortable
Extrem- L forearm and hand with significant swelling, pain with
movement, no palpable pulses, skin appears dusky, forearm and
hand feel tense, no doppler pulses, ___ compartment
pressures
in mid ___ in dorsal compartment, 35 on volar forearm
Discharge:
Integra dressing over his left volar forearm, which is
appropriately taking. At this point, the color is a pinkish hue
and requires more time prior to skin grafting. In terms of his
dorsal forearm wound, it is well healed. He has a thenar wound
that is about 3 x 4 cm in dimension. It is about 2 cm deep
also. There is a clean
granulating base with one area of fibrinous material most ulnar
and deep into the wound. There is no purulent drainage. There
are no signs of cellulitis. The patient has minimal flexion and
extension of the wrist and fingers at this point.
Pertinent Results:
___ 10:00AM GLUCOSE-213* UREA N-15 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
___ 10:00AM WBC-17.8* RBC-4.34* HGB-13.8* HCT-41.4 MCV-96
MCH-31.9 MCHC-33.4 RDW-13.5
___ 10:00AM NEUTS-84.3* LYMPHS-10.5* MONOS-3.9 EOS-1.0
BASOS-0.3
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have a severe left forearm crush injury and compartment syndrome
and was taken emergently to the OR for forearm compartment
fasciotomies and ligation of a lacerated radial artery. He
remained stable on the floor without issues until ___ when he
was found to have sluggish capillary refill and cool digits on
the left hand. Angiography revealed no flow in the ulnar artery
past the level of the wrist, with minimal reconsitution
distally. He was then taken back to the OR for irrigation and
debridment, hand compartment fasciotomies, and revascularization
of the ulnar and radial arteries with autologous vein graft and
coverage with alloderm. He was then taken back to the OR on ___
for irrigation and debridment and replacement of the alloderm
with integra bi-layer graft for planning for future skin
grafting. On ___ he underwent debridement of left
thenar, hypothenar and dorsal hand wounds, on ___,
debridement of left thenar wound and closure of the hypothenar
wounds. For full details of the procedures please see the
separately dictated operative reports. The patient was taken
from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor following each procedure. The patient was given
___ antibiotics throughout his stay and was initially
placed on a heparin drip following revascularization prior to
being bridged to therapeutic lovenox and aspirin.
The patient worked with ___ who determined that discharge to home
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact with the
integra dressing and wet to dry dressings over the thenar wound.
The patient was voiding/moving bowels spontaneously. The patient
is NWB in the LUE extremity, and will be discharged on
therapeutic lovenox for a total of one month for his vein graft.
The patient will follow up in one week with Dr. ___. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN temp/pain
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. Docusate Sodium 200 mg PO BID
4. Enoxaparin Sodium 100 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 100 mg SC twice a ___ Disp #*14 Syringe
Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3-6H
Disp #*100 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID
8. Cephalexin 500 mg PO Q12H Duration: 14 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth twice a ___ Disp #*28
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left forearm and hand crush injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Instructions After Orthopedic 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.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
___.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take <<>> for <<>> weeks to help prevent the formation
of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
Activity
- Your weight-bearing restrictions are: Non weight bearing in
the left upper extremity.
- You should wear your splint at all times until follow up.
Follow up
- Please follow up with your primary care doctor regarding this
hospitalization
- Please follow up with your surgeon <<<>>>
Physical Therapy:
Non weight bearing left upper extremity. Passive ROM of the
digits.
Treatments Frequency:
Daily dressing changes as described. Patient's left forearm has
integra graft in place with staples around it. This should be
left in place and covered with xeroform, gauze, kling and loose
ace wrap. The hand has an open wound on the palmar surface. This
wound should have daily changes with adaptek dressing and gauze
over the top. The adaptek should be cut to cover the wound and a
gauze fluff should be used to push and hold the adaptek against
the wound surface to prevent any fluid collection. The closed
incisions on the rest of the hand should have xerform and gauze
placed over them. The hand and forearm should then be loosely
wrapped with kling and a loose ace wrap as above and the patient
should be kept in his custom OT splint.
Followup Instructions:
___
|
10476496-DS-17 | 10,476,496 | 21,574,117 | DS | 17 | 2201-12-08 00:00:00 | 2201-12-08 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L hand swelling, redness, pain
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
Mr. ___ is a ___ with history of HIV with ___ 275
(not on ARV therapy) and recent admission for left hand
cellulitis who presents with worsening erythema and induration
in the same location. The patient was admitted at the end of
___ for left hand redness, swelling, and pain at the site of
crystal meth injection. He was evaluated by ortho hand in the ED
on that presentation who did not feel as though there was a
drainable abscess. XR of hand did not show foreign body or
evidence of osteo. The patient was initially treated with
vancomycin and piperacillin-tazobactam, but transitioned to
amoxicillin-clavulanate and TMP-SMX for discharge. He completed
a fourteen day course with today being the last day, and reports
only missing two doses of antibiotics toward the beginning of
the course.
Over the last day the hand has worsened again. No F/C/N/V. Ok PO
intake. Associated with some elbow discomfort, mild pain at ___
finger MCP joint. Worse when hand is in dependent position. Has
not used IV drugs since. No dysuria.
In the ED intial vitals were:6 98.3 105 138/89 16 97%
Exam revealed: Fluctuant/erythematous area 2cm across. Mild
tenderness of ___ MCP with passive flexion of associate digit.
No elbow tenderness. No embolic phenomena. No murmurs/signs of
CHF. Tender along ventral forarm but no palpable cord.
Patient was given: vancomycin 1gm IV once, zosyn 4.5mg IV once.
Vitals on transfer: 97.5, 95, 16, 122/77, 99%RA.
On the floor VS 97.8, 115/67, 94, 18, 99%RA. He reports ongoing
tenderness to palpation of the left hand.
Past Medical History:
PSYCHIATRIC HISTORY:
no current psychiatrist or therapist
___ hospitalized in ___, ___ after using Ecstasy "
depression and anxiety"
___ hospitalized at the ___ in ___ after using crystal meth,
transitioned to a day program for substance abuse
___ hospitalized in ___ for suicidal ideations
PAST MEDICAL HISTORY:
HIV dx'd ___
depression since childhood
Hepatitis B
Social History:
___
Family History:
father alcoholic
brothers with substance abuse
one brother had a "manic" episode not treatment
one brother "out there" and lives alone in ___.H
uncle with depression
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 97.8, 115/67, 94, 18, 99%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSCIAL EXAM
Vitals: T: 98.5 BP: 142/80 P: 102 R: 18 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Left hand improved compared to yesterday w/ decreased
erythema, swelling and warmth, no palpable abscess or fluid
collection. No tenderness to palpation at MCPs, wrist, elbow
with passive or active motion, strength and sensation intact.
Right forearm with swelling and tenderness to palpation w/o
erythema. Lower extremity warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema.
Neuro: A&Ox3, CNII-XII intact, gross motor and sensory intact
bilaterally
Pertinent Results:
ADMISSION LABS
___ 08:25PM BLOOD WBC-4.3 RBC-4.27* Hgb-12.1* Hct-35.3*
MCV-83 MCH-28.2 MCHC-34.1 RDW-13.2 Plt ___
___ 08:25PM BLOOD Neuts-35.7* Lymphs-51.4* Monos-5.9
Eos-6.0* Baso-1.0
___ 06:12AM BLOOD ESR-38*
___ 08:25PM BLOOD Glucose-120* UreaN-12 Creat-0.7 Na-139
K-4.1 Cl-105 HCO3-22 AnGap-16
___ 06:12AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.9
___ 08:41PM BLOOD Lactate-1.3
INTERVAL LABS
___ 06:40AM BLOOD Vanco-8.2*
DISCHARGE LABS
___ 06:15AM BLOOD WBC-4.9 RBC-4.49* Hgb-12.8* Hct-36.3*
MCV-81* MCH-28.4 MCHC-35.3* RDW-13.0 Plt ___
___ 06:15AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-139 K-4.2
Cl-101 HCO3-29 AnGap-13
MICRO
None
IMAGING
Imaging and studies:
Left Upper Extremity US ___
IMPRESSION: No deep venous thrombosis in the left upper
extremity. Ultrasound over the dorsum of the left hand over the
area of concern shows no drainable fluid collection.
Left Hand Plain Films ___
There is no evidence of fracture, dislocation, lytic or
sclerotic lesion demonstrated as well as no degenerative change
is seen. There is no radiopaque foreign body or soft tissue gas
demonstrated. No substantial change in the dorsal swelling of
the hand demonstrated. Correlation with cross-sectional imaging
might be considered if clinically indicated.
Brief Hospital Course:
Mr. ___ is a ___ with history of HIV with ___ 275
(not on ARV therapy) and recent admission for left hand
cellulitis who presents with worsening erythema and induration
in the same location.
# Left Hand Cellulitis
Patient was recently treated with a 14 day course of bactrim and
augmentin (missing two doses). Ultrasound of left upper
extremity negative for DVT. Plain films of left hand w/o
evidence for osteomyelitis. Started on IV vancomycin with plan
for 10 day course given failed outpatient PO regiment as well as
other social issues including homelessness, IV drug use,
untreated HIV, and poor medication compliance. Currently on
Vancomycin IV 1500mg q12 after vanco trough subtherapeutic (8.2)
on 1000mg q12.
# Untreated HIV
Diagnosed in ___. Has not been on antiretrovirals for several
years. Reports last CD4 was 250. Will plan to follow-up with
Dr. ___ to re-initiate treatment as outpatient.
# IV drug abuse
Patientt uses methamphetamine several times/ week. On last
admission he stated that he does not have the motivation to quit
at this time. Notes that he has not used since last admission
but still reports no motivation to quite.
Transitional Issues:
- Please draw labs for vancomycin trough as well as chem 7,
including BUN and Cr, prior to ___ vancomycin dose evening of
___. Please adjust vancomycin for goal vancomycin trough
___.
- Please continue Vancomycin for a 10 day course, first dose
___ and will finish ___.
- Will need to follow-up with primary care doctor for starting
HIV treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Sulfameth/Trimethoprim DS 2 TAB PO BID
Discharge Medications:
1. Vancomycin 1500 mg IV Q 12H
First day ___, plan for 10 day course to end ___.
2. Outpatient Lab Work
Please draw labs for vancomycin trough as well as chem 7,
including BUN and Cr, prior to ___ vancomycin dose evening of
___. Please adjust vancomycin for goal vancomycin trough
___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Recurrent Cellulitis
Secondary Diagnosis: Uncontrolled, untreated HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted because you had a
skin infection of your hand called cellulitis. You will need to
take IV antibiotcs to treat your infection.
All the best,
Your ___
Followup Instructions:
___
|
10477053-DS-7 | 10,477,053 | 23,253,930 | DS | 7 | 2188-11-18 00:00:00 | 2188-11-20 19:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
not speaking, R sided weakness
Major Surgical or Invasive Procedure:
TPA administration
TEE
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 1 minutes
Time (and date) the patient was last known well: 19:45 (24h
clock)
___ Stroke Scale Score: 23
t-PA given: Yes Time t-PA was given 21:11 (24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
HPI: The pt is a ___ y/o RHW with a history of DM, HTN
presented
to the ED after having dinner with her brother then suddenly
going mute with a right facial droop. The history was obtained
from the brother as the patient could not provide any history.
The symptoms came on around 19:45. EMS was called. THey noted a
right hemiplegia. When she came in Neuro was made aware before
arrival and was there on arrival. She was completely mute at
that
time. She was able to nod her head to some questions and said no
to pain. Later on in the day she began to recover some use of
her
language and did not know why she was in the hospital. Her
brother said she did have a stroke ___ years ago but he was not
aware of what type or the symptoms and as far as he knows had no
residual symptoms.
Past Medical History:
Prior stroke ___ yrs ago
HTN
DM
Social History:
___
Family History:
No Sz, early strokes
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98 P:80 R: 16 BP:153/80 SaO2:100
General: Awake NAD.
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
___ Stroke Scale score
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 1
2. Best gaze: 2
3. Visual fields: 2
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 3
6a. Motor leg, left: 0
6b. Motor leg, right: 3
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 3
10. Dysarthria: 2
11. Extinction and Neglect: 2
Neuro: She was completely mute, was only able to follow some
commands like close your eyes, open your eyes, and make a fist
but could not show me two fingers, could not stick out her
tongue
on command. She had a forced left gaze deviation. No blink to
threat from the right. Her right side was completely plegic
including to pain. No grimace to pain on the right. The left
side
was antigravity at least. Toe was up on the right and equivocal
on the right.
On re-evaluation she was able to speak,. did not know why she
was
hear, was able to follow commands. Had some phonemic paraphasic
errors, and only able to name glove, chair, key on the NIHSS
card. She was able to read. There was a right facial droop. EOMI
were now intact. PERRL. There was a subtle RUQ quadrantsenopsia.
Writing was not tested. She had a left pronation drift.
*************
Physical Exam on Transfer to floor:
Significant only for slight R NLF flattening. Otherwise speech
fluent, naming and repetition intact, answers questions
appropriately and follows simple and complex commands. Strength
is full throughout.
******************
Physical exam on discharge:
Patinet is A+Ox3. Has slight R NLF flattening. Speech is fluent.
Able to name index finger, knuckle, thumb, button, button hole.
Motor strength is normal bilaterally in all extremities.
Sensation is normal. Cerebellar function is normal. Gait is
normal.
Pertinent Results:
___ 08:40PM CREAT-1.0
___ 08:40PM estGFR-Using this
___ 08:38PM UREA N-27*
___ 08:38PM GLUCOSE-191* NA+-143 K+-4.3 CL--102 TCO2-24
___ 08:38PM WBC-10.1 RBC-5.72* HGB-12.2 HCT-39.8 MCV-70*
MCH-21.3* MCHC-30.6* RDW-15.9*
___ 08:38PM PLT COUNT-256
___ 08:38PM ___ PTT-33.1 ___
___ 04:56AM BLOOD %HbA1c-6.7* eAG-146*
___ 04:56AM BLOOD Triglyc-123 HDL-46 CHOL/HD-3.6 LDLcalc-95
CT/A/P:
Plain CT negative for acute process. CTA shows occlusion of
proximal L MCA with large perfusion deficit in L MCA territory
on CTP.
MRI brain ___:
IMPRESSION:
1. Two small foci of slow diffusion in the left frontal and
parietal regions as described above, likely represent acute
infarcts.
2. Volume loss with chronic blood products in the left basal
ganglia may
represent a sequela of prior hemorrhage or infarction.
3. Small vessel ischemic disease.
4. Few scattered foci of abnormal susceptibility in bilateral
cerebral
hemispheres may represent microhemorrhages or cavernomas.
.
TTE:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
.
Brief Hospital Course:
___ is a ___ yo woman with history of DM, HTN, and a prior
stroke ___ years ago (unclear characterization, no residual
symptoms) who presented with acute onset aphasia and R sided
weakness, consistent with L MCA syndrome. She presented within 1
hour of symptom onset and was given IV TPA within 1.5hrs at
21:11. Her symptoms had begun to improve prior to tPA but
continued to have some naming difficulties, R sided weakness,
and subtle R upper quadrantanopsia. She was admitted to the ICU
for post-TPA monitoring and remained stable overnight. Her
neurological symptoms resolved with the exception of slight R
NLF flattening.
Neuro:
BP was closely controlled with goal SBP < 180. She was
maintained on close neurochecks overnight and remained stable.
Antiplatelets/anticoagulants and venipunctures were avoided for
the first 24 hours post-tPA. By the morning of ___ her exam had
markedly improved and she was essentially back to baseline
except for mild R NLF flattening. MRI showed two small infarcts
in the left frontal and parietal lobes. Lipid panel was
significant for LDL of 95, HbA1c was 6.7%. On HD 3, the patient
went into atrial fibrillation. She was given 10mg metoprolol IV.
30 minutes later, she went into SR. The decision at this point
was made to switch her daily home atenolol dose to metoprolol.
Furthermore, the patient was started on pradaxa in place of
plavix. A TEE that was scheduled for that day was cancelled,
given the likely source of the stroke had been identified. The
remaining home antihypertensives were started as usual.
Cardiovascular:
She was maintained on telemetry monitoring. BP was closely
monitored as above. Home lisinopril and nicardipine were held,
and atenolol was given at half of home dose (50). She was also
started on plavix. TTE showed no abnormalities. On HD3, the
patient went into atrial fibrillation for approximately 30
minutes. She exhibited RVR to 150s. She was given 10mg IV
lopressor to help control the rate. Given that the likely
source of her stroke had been identified, the patient's home
atenolol was changed to metoprolol, and she was started on
pradaxa. Her scheduled TEE was cancelled. Her simvastatin was
changed to atorvastatin given her elevated LDL. This was done
after confirming that this would be ok with the PCP. Her home
antihypertensives were restarted on HD 2 (with atenolol being
switched to metoprolol on HD 3)
Pulm:
Respiratory status was monitored and she remained stable on RA.
Heme:
She had no clinical signs of bleeding post-tPA. Hct on ___ had
decreased a bit from 39.8 -> 35.2, likely at least partially
dilutional. This was repeated and improved without intervention.
All antiplatelets and anticoagulants were held for 24 hrs
post-tPA. She was started on plavix after this period. On HD 3
after going into AFIB, the patient was started on pradaxa and
plavix was discontinued.
ID:
She remained afebrile with no signs of infection during her ICU
stay.
Endo:
She was maintained on fingersticks ACHS and an insulin sliding
scale. Her home metformin and glipizide were held until
discharge. A1c was 6.7%.
PENDING RESULTS:
None
TRANSITIONAL CARE ISSUES:
Patient will need to be maintained on pradaxa and get her PTT
checked in the future to ensure it is effective.
Medications on Admission:
Metformin 1g BID
Glipizide 5mg BID
Atenolol 100 QD
Nifedipine ER 60 qd
Lisinopril 20 QD
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg daily Disp #*30 Tablet Refills:*2
2. Lisinopril 20 mg PO DAILY
3. NIFEdipine CR 60 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
5. Dabigatran Etexilate 150 mg PO BID
RX *Pradaxa 150 mg twice a day Disp #*60 Tablet Refills:*2
6. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg daily Disp #*90 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Ischemic Stroke
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: No deficits
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of inability to speak and
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. 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.
We are changing your medications as follows:
1. Please take pradaxa twice a day to prevent blood clots
2. Please switch atenolol to metoprolol daily
3. Please take atorvastatin daily in place of simvastatin
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 medical
attention. In particular, since stroke can recur, please pay
attention to the sudden onset and persistence of these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10477175-DS-5 | 10,477,175 | 22,811,759 | DS | 5 | 2123-10-08 00:00:00 | 2123-10-08 15:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with polysubstance abuse presents with altered mental status
and found to be febrile and hyponatremic.
Per report, patient was in her USOH on the morning of ___. She
then was reported to have undertaken EtOH binge throughout the
evening of the ___ into the ___. The afternoon of ___, she was
found to be confused and agitated in her room covered with
bloody vomit. Four empty vodka bottles were found in her room
along with a juice bottle smelling of 'rubbing alcohol'. EMS was
activated, and on arrival to scene patient was AAOx1, anxious,
and 'easily spooked'. VS were P96, BP 128/78, RR 14 and blood
glucose 138. She admitted to alcohol, prescription medicine
abuse, and may have voiced suicidal ideas. There was also report
of possible heroin and cocaine use. She was brought to ___
___ where she was noted to be uncooperative, responsive to
painful stimuli, with incomprehensible speech. Temperature was
reported to be 104, but only documented temperature was 98.2.
Initial labs were notable for Na of 124, PCO2 of 35, and
negative urine tox and serum EtOH. NCHCT showed no acute process
and EKG was unremarkable. She received 5mg haldol, 2mg ativan,
naloxone, and 2L NS. Hypertonic saline was started prior to
transfer to ___.
In the ED, initial vitals were 98.8 101 ___ 100%. Patient
was noted to be clammy and agitated on arrival, oriented x 1
requiring total Ativan 6 mg IV and soft restraints. Temperature
was measured at ___, and patient was given tylenol ___ mg PO x
1. CBC showed white blood cell count of 12.8K with 88%
neutrophils, no bands. Sodium was 131, and hypertonic saline
was stopped. Serum osmolality was 268. Lithium level was
normal. Serum and urine toxicology screens were negative. AST
was mildly elevated at 64. Lactate was 2.7. Urinalysis was
unremarkable. Blood cultures were sent. Patient was treated
empirically with vancomycin/ceftriaxone for possible bacterial
meningitis and received 100mg thiamine. Lumbar puncture was
performed and showed 0 WBCs, 1 RBC, protein 29, glucose 81.
Foley was placed with 2 liters urine output. Vitals prior to
transfer were 101.4 (ax), P: 89, RR: 17, BP: 110/75.
On arrival to the MICU, patient is initially awake, but
lethargic with incomprehensible speech. On re-evaluation,
patient is awake and conversant and has no complaints other than
fatigue. She denies recent substance use and is unclear of the
events leading up to her hospitalization. She denies any
suicidal thoughts.
Past Medical History:
-Polysubstance abuse
-anxiety/depression
Social History:
___
Family History:
Unable to be obtained
Physical Exam:
Admission Physical Exam:
General: Lethargic, but awake, oriented to person only.
Intermittently follows commands and answers simple questions.
HEENT: Sclera anicteric, dry MM with abrasions over anterior
tongue,, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Nonlabored on room air. Intermittent soft expirtory
wheeze. Somewhat distant breath sounds.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Awake, lethargic, oriented to person. PERLL, EOMI,
symettric face and tongue. Moving all extremities. No asterixis
noted.
Discharge Physical Exam:
Vitals- 98.4 121/84 60 18 100RA I/O 1610/2400
General- Alert, oriented, no acute distress, pleasnt,
cooperative, responding appropriately to questions
HEENT- Sclera anicteric, MMM, oropharynx clear
Skin-bruising on left arm in two areas from IVs. Scattered minor
bruising and cuts on legs. No large hematomas noted. Small
bruise on abd at ___ injection site.
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 08:40AM SODIUM-133 POTASSIUM-3.4 CHLORIDE-103
___ 08:40AM CK(CPK)-4573*
___ 05:20AM CEREBROSPINAL FLUID (CSF) PROTEIN-29
GLUCOSE-81
___ 05:20AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1*
POLYS-79 ___ ___ 01:59AM LACTATE-2.7*
___ 01:50AM GLUCOSE-112* UREA N-5* CREAT-0.6 SODIUM-131*
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
___ 01:50AM estGFR-Using this
___ 01:50AM ALT(SGPT)-20 AST(SGOT)-64* ALK PHOS-63 TOT
BILI-0.7
___ 01:50AM ALBUMIN-4.6
___ 01:50AM OSMOLAL-268*
___ 01:50AM TSH-1.3
___ 01:50AM LITHIUM-LESS THAN
___ 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:50AM URINE HOURS-RANDOM UREA N-206 CREAT-54
SODIUM-175 POTASSIUM-48 CHLORIDE-221
___ 01:50AM URINE HOURS-RANDOM
___ 01:50AM URINE OSMOLAL-517
___ 01:50AM URINE UHOLD-HOLD
___ 01:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:50AM WBC-12.8* RBC-3.99* HGB-12.7 HCT-37.7 MCV-94
MCH-31.8 MCHC-33.7 RDW-13.0
___ 01:50AM NEUTS-88.5* LYMPHS-5.6* MONOS-5.6 EOS-0.2
BASOS-0.1
___ 01:50AM PLT COUNT-207
___ 01:50AM ___ PTT-24.8* ___
___ 01:50AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:15AM BLOOD WBC-5.3 RBC-3.76* Hgb-11.9* Hct-36.1
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.1 Plt ___
___ 01:50AM BLOOD Neuts-88.5* Lymphs-5.6* Monos-5.6 Eos-0.2
Baso-0.1
___ 07:15AM BLOOD Plt ___
___ 07:14AM BLOOD Glucose-86 UreaN-4* Creat-0.5 Na-140
K-4.2 Cl-107 HCO3-23 AnGap-14
___ 07:14AM BLOOD CK(CPK)-___*
EKG ___ tachycardia. Slightly delayed R wave
progression. No previous tracing available for comparison.
CXR ___ IMPRESSION: Vague right basal opacity may be
present though study is limited and repeat evaluation,
preferably with conventional PA and Lateral views is
recommended.
CXR ___ IMPRESSION: Equivocal retrocardiac opacity.
Otherwise, no focal infiltrate
Brief Hospital Course:
___ with polysubstance abuse presents with delirium and found to
be febrile and hyponatremic, and elevated CK to 30,000. Delirium
resolved; given fluids, hyponatremia resolved, aggressive
hydration for elevated CK which resolved as well. Creatinine
remained stable throughout.
# Toxic metabolic encephalopathy secondary to ingestion: She was
delirious in the setting of ingestion, however, tox screen were
negative. Infectious work up including LP was negative. With
hydration and time the delirium completely resolved. She was
alter, oriented and clear (normal mental status) at the time of
discharge.
# Rhabdomyolysis: The CK was elevated to ___. She was given IV
fluid hydration and monitored closely while the CKs decreased to
3000. She did not have any evidence of kidney injury throughout
her state. She did have sore thighs, however, those resolved and
she did not have muscle aches at the time of discharge.
# Polysubstance abuse: She was seen by social work and is
committed to being sober. She will be discharged home and will
be going to ___ Program outpatient
therapy. She will also see her therapist. She ultimately plans
to re-enter living at a Sober House.
# Psychiatric history: She was on Zoloft. She denies suicidal
ideation during the admission or previously.
# Hyponatremia: Recorded at 123 at OSH, received normal saline
which corrected her to normal.
Transitional Issues:
-f/u electrolytes and CK with PCP ___ next week
-follow up with ___ Program
-follow up with outpatient therapist
Medications on Admission:
None - not taking medications for several weeks
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status
Rhabdomyolysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were found down in
your sober house. You were admitted to the Intensive Care Unit
where you were found to have a very low sodium level and you
were very confused. You were given fluids and your sodium level
normalized and you became less confused, and you were then
transferred to the medical floor. You were also found to have a
very high CK level, a product of muscle breakdown. You were
given lots of fluids to wash these products out of your body and
we monitered your kidney function, which was normal. Please
continue to drink 8 glasses of water daily for the next few days
to continue to wash these products out.
You were seen by social work to discuss new accomodations for
sober living. You stated that you were planning to work on
sobriety support plan with your parents. You discussed with us
your plans to go to ___ "The Discovery Program", an
outpatient program, as well as your plans to see your therapist
in the next few days to plan to move to a new sober house.
You agreed that if you were unable to secure placement at a
sober house which is the best plan, you will contact ___ at
___
contacts. In the meantime, your plan as discussed with us is
that you will return home with your parents.
It was a please caring for you.
Followup Instructions:
___
|
10477496-DS-21 | 10,477,496 | 23,822,939 | DS | 21 | 2179-10-24 00:00:00 | 2179-10-24 12:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ Lyft driver with the past medical
history of diabetes type 2 c/b mild peripheral neuropathy,
hypertension, tobacco dependence, remote hx of juvenile
arthritis
as teenager c/b PUD from NSAIDs, and an episode of right thigh
necrotizing fasciitis requiring debridement (___) who
presents with almost 20 days of atraumatic right medial knee
pain.
The patient reports that he started having knee pain about 19
days ago and after initial 2 days he was evaluated in ___ urgent
care ___ and given a corticosteroid injection into his has
anserine bursa. After this corticosteroid injection he had
increase in pain and presented to ___ and was eventually
admitted from ___ to ___ for suspected cellulitis
and
placed on IV vancomycin and cefazolin. He was then discharged on
oral cephalexin which he has been taking since. Since the start
of his symptoms the only thing that has changed his pain was the
corticosteroid injection which worsened the pain. He denies any
concerning erythema over his right medial knee when he was
initially admitted and the IV antibiotics did not relieve his
pain at all. Since being discharged on oral antibiotics his pain
has neither worsened or improved. He obtained an MRI on
___
that showed some edema which was reviewed on ___ by his
orthopedic provider ___ and subsequently he was
instructed to present to ___ given concern for deep knee
infection and need for IV antibiotics. His white blood cell
count
was initially 12 and CRP was about 60 on ___. He has been
afebrile this entire course. He denies any fevers, sweats,
chills, nausea, vomiting, dyspnea, difficulty breathing, change
in bowel or bladder function, abdominal pain, changes in hearing
or vision.
Upon arrival at the ___ ED in the morning ___ his VS were
T
97.8, HR 70, BP 178/94, RR 18, 96% on RA.
On exam he had tenderness of medial and lateral right knee joint
spaces with mild erythema on the medial aspect just below the
knee joint with reported associated warmth. Patient was
reportedly unable to range knee due to pain. Distal pulses were
intact and symmetric. Blood cultures were drawn and XR and US
were done of the knee which showed no evidence of fluid
collection, soft tissue edema, or joint effusion. Orthopedics
were consulted. Given the full range of motion, lack of redness,
minimal warmth, low inflammatory markers, lack of leukocytosis,
they felt very unlikely to be infection and recommended stopping
antibiotics and observing in the ED on NSAIDs for improvement.
Ortho attending subsequently saw the patient and agreed with
conservative management.
Patient received the following medications while in the ED:
___ 21:53 IV Ketorolac 15 mg ___
___ 21:53 IV Ondansetron 4 mg ___
___ 01:03 SC Insulin ___ Not Given
___ 01:11 PO/NG Acetaminophen 1000 mg ___
___ 01:11 SC Insulin 28 UNIT ___
___ 01:14 SC Insulin Lispro 5 UNIT ___
___ 06:15 IV Ketorolac 15 mg ___
___ 08:00 PO Omeprazole ___ Not Given
___ 08:07 PO Verapamil SR 360 mg ___
___ 08:07 SC Insulin 2 Units ___
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Diabetes type 2 c/b mild peripheral neuropathy
Hypertension,
Tobacco dependence (1PPD, 40+ pack years)
Hyperlipidemia
Remote hx of juvenile arthritis as teenager c/b PUD from NSAIDs
R thigh necrotizing fasciitis requiring debridement (___)
Social History:
___
Family History:
Mother COPD, Father DM
Physical ___:
Vitals: Temp 97.3, HR 83, BP 185/101, RR 15, 97% on RA
GENERAL: Pleasant man in hospital bed, in no apparent distress.
EYES: PERRL. Anicteric sclerae.
ENT: Ears and nose without visible erythema, masses, or trauma.
Posterior oropharynx without erythema or exudate, uvula midline.
CV: Regular rate and rhythm. Normal S1 S2. No S3, no S4. No
murmur. No JVD.
PULM: Breathing comfortably on room air. Lungs clear to
auscultation. No wheezes or crackles. Good air movement
bilaterally.
GI: Bowel sounds present. Abdomen non-distended, soft,
non-tender
to palpation.
GU: No suprapubic fullness or tenderness to palpation.
EXTR: R knee with mild fullness on the medial aspect of the
proximal tibia and moderate tenderness to palpation over the
area
of the pes anserinus. Full range of motion of right knee without
significant pain although tightness in the anterior medial area.
Normal drawer tests. Normal varus/valgus tests. Trace lower
extremity edema to midshins bilaterally. Distal extremity pulses
palpable throughout.
SKIN: No rashes, ulcerations, scars noted.
NEURO: Alert. Oriented to person/place/time/situation. Face
symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all
limbs spontaneously. No tremors, asterixis, or other involuntary
movements observed. Normal and symmetric distal extremity
strength and light touch sensation throughout.
PSYCH: Pleasant, cooperative. Follows commands, answer questions
appropriately. Appropriate affect.
Pertinent Results:
DATA:
I have reviewed the relevant labs, radiology studies, tracings,
medical records, and they are notable for:
Labs:
___ WBC: 9.4 RBC: 4.96 Hgb: 15.2 MCV: ___
___ Glu: 173 BUN: 23 Cr: 0.9 Na: 140 K: 4.4 Cl: 100 HCO3: 27
___ CRP: 5 ESR: pending
Micro:
___ Blood cultures x 2: pending
Imaging & Studies:
___ US extremity limited soft tissue right knee
**Preliminary report**
No evidence of fluid collection or subcutaneous edema the area
of
vein, indicated by the patient, the medial aspect of the distal
right femur.
___ Knee XR, AP, Lat, Oblique
**Preliminary report**
Normal right knee radiographs without evidence of joint
effusion.
Prior studies:
Note by ___ orthopedist Dr. ___ today:
"The MRI of the right knee from ___ was reviewed by me. It
demonstrates the following:
1. Extensive soft tissue edema, fluid, and posterior medial
peritendinous fluid at the medial knee with small fluid
collection in area of pes anserine bursa. No meniscal or
ligamentous significant injury identified.
2. Lateral tibiofemoral compartment chondromalacic changes.
Anterior lateral meniscal degenerative changes with possible
associated tear.
Brief Hospital Course:
Mr. ___ is a ___ Lyft driver with the past medical
history of diabetes type 2 c/b mild peripheral neuropathy,
hypertension, tobacco dependence, remote hx of juvenile
arthritis as teenager c/b PUD from NSAIDs, and an episode of
right thigh necrotizing fasciitis requiring debridement (___) who presented with almost 20 days of atraumatic right
medial knee pain.
BRIEF HOSPITAL COURSE BY PROBLEM
# Right knee pain
History, labs, and exam did not suggest infection or
rheumatologic process. No evidence of joint involvement. Likely
had some bursitis as a result of repetitive motion driving and
then the steroid injection recently perhaps irritated the pes
anserinus. Needs rest, stretching ice, and acetaminophen/NSAIDs.
Brace may or may not provide meaningful support although could
also make positioning a cold pack on his knee easier while
driving. Orthopedic attending agreed with plan and will see him
on ___ when his PA sees him in clinic. Counseled him to also
stay hydrated to protect his kidneys; renal function is normal
currently.
- ice, stretching, acetaminophen, ibuprofen prn right knee pain
- ortho gave brace before leaving today
- follow-up on ___ in ___ clinic
- counseled that it could take weeks for this pain to fade
# GERD
Of note, although patient says he's not been taking an antacid,
he's prescribed a PPI and we counseled him to take it while on
NSAIDs given a remote PUD history.
- continue home omeprazole
# Hypertension
Takes Candesartan 32 mg tablet daily (non-formulary) and
Verapamil ER 360mg ER daily (got dose in ED ___. Got
losartan 100mg daily as replacement while inpatient since his
home candesartan was nonformulary.
- continued home verapamil
- continue home candesartan after discharge
# Diabetes type 2
Takes 28 units of Lantus at bedtime, Lispro qACHS (5u except
dinner when he takes 7u), Lispro insulin sliding scale qACHS (2u
above 150 and 2u more per 50 up to 400 when he's supposed to
instruct MD). He eats a regular diet at home.
- continued insulin per home regimen
- continued regular diet
# Tobacco dependence
1PPD smoker, has 40+ pack years history (smoking since before
age ___).
- counseled on smoking cessation - pre-contemplative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. candesartan 32 mg oral DAILY
2. Glargine 28 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 7 Units Dinner
Humalog 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Multivitamins 1 TAB PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Verapamil SR 360 mg PO DAILY
7. Acetaminophen 1000 mg PO TID Right knee pain
8. Ibuprofen 800 mg PO TID Right knee pain
Discharge Medications:
1. Naproxen 500 mg PO TWO TO THREE TIMES DAILY AS NEEDED right
knee pain
RX *naproxen 500 mg 1 tablet(s) by mouth two to three times
daily Disp #*90 Tablet Refills:*2
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
3. Acetaminophen 1000 mg PO TID Right knee pain
4. Aspirin EC 81 mg PO DAILY
5. candesartan 32 mg oral DAILY
6. Glargine 28 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 7 Units Dinner
Humalog 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Multivitamins 1 TAB PO DAILY
8. Verapamil SR 360 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right knee pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for right knee pain.
You are now safe to be discharged home. Likely you had some knee
pain initially perhaps related to your driving and then the knee
injection may have irritated your tendons. There's not
significant evidence of infection. It will likely take weeks
more for the pain to resolve. We recommend continuing
acetaminophen, a non-steroidal anti-inflammatory medication,
ice, stretching, and you can try a brace. Orthopedic surgery
will see you in clinic on ___ to check in on your knee. If
you develop worsening pain, swelling, redness, fevers/chills,
contact your doctor or come back to the hospital.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10477496-DS-22 | 10,477,496 | 22,530,836 | DS | 22 | 2179-11-14 00:00:00 | 2179-11-14 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right leg infection
Major Surgical or Invasive Procedure:
R pes bursa I&D w wVAC placement ___, ___, I&D, wound
___, ___
History of Present Illness:
___ male with h/o HTN, HLD and T2DM presented to the ED
from ___ for worsening RLE cellulitis and developing abscess
seen on MRI. He developed pain in the right lower leg on ___
and was seen at urgent care where he was given a steroid
injection in the pes anserine bursa with brief relief in his
pain. He was seen by orthopedics at ___ the next day and told he
had arthritis, and was noted to have some redness along the
medial knee joint at that time. On ___ he was sent to ___
___ where he had a CRP 60 and WBC 12. He was started on
cefazolin and vancomycin, admitted to the hospital for
cellulitis, and discharged on ___ with Keflex. He was seen by
his PCP ___ ___ where he complained of severe pain and was
unable to walk. A MRI was performed, which identified extensive
soft tissue edema, fluid, and posterior medial peritendinous
fluid at the medial knee. On ___ he was seen by orthopedics and
sent to ___ for a possible joint infection. At that time his
ESR was 22 and CRP 5. He was observed and discharged the
following day with a diagnosis of bursitis. On ___ he went to
urgent care and had a negative lower extremity ultrasound and
was discharged with doxycycline. He continued to have persistent
pain, so had another MRI yesterday that identified a 5.8 by 1.9
by 8.9 cm abscess in the deep subcutaneous fat along the medial
aspect of the proximal tibia and approaching the medial head. He
was sent to ___ for further evaluation.
Upon arrival he notes some numbness and tingling in his toes
which has been present for several days. He notes chills but
denies fever, chest pain, SOB, abdominal pain, nausea, vomiting
or diarrhea.
Past Medical History:
Diabetes type 2 c/b mild peripheral neuropathy
Hypertension,
Tobacco dependence (1PPD, 40+ pack years)
Hyperlipidemia
Remote hx of juvenile arthritis as teenager c/b PUD from NSAIDs
R thigh necrotizing fasciitis requiring debridement (___)
Social History:
___
Family History:
Mother COPD, Father DM
Physical ___:
General: Well-appearing, breathing comfortably
MSK:
Right lower extremity exam
-dressing c/d/i, changed no ___
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot WWP
Pertinent Results:
___ 11:43PM VANCO-4.7*
___ 12:06PM ALT(SGPT)-8 AST(SGOT)-7 ALK PHOS-69 TOT
BILI-0.4
___ 12:06PM %HbA1c-8.2* eAG-189*
___ 12:06PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG
___ 12:06PM HIV Ab-NEG
___ 12:06PM HCV Ab-NEG
___ 05:45AM GLUCOSE-224* UREA N-17 CREAT-0.7 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12
___ 05:45AM WBC-13.0* RBC-3.80* HGB-11.6* HCT-34.8*
MCV-92 MCH-30.5 MCHC-33.3 RDW-12.6 RDWSD-42.2
___ 05:45AM PLT COUNT-157
___ 05:45AM ___ PTT-25.1 ___
Brief Hospital Course:
Mr. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a pes bursa infection and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ and ___ for right pes bursa I&D with wound
VAC placement and repeat I&D and wound closure, respectively.
The patient tolerated these procedures well. For full details of
the procedure please see the separately dictated operative
reports. 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 given IV fluids and IV
pain medications, and progressed to a regular diet by POD#1. The
patient was given antibiotics in consultation with infectious
disease service and anticoagulation per routine. The patient's
home medications were continued throughout this hospitalization.
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge, the patient's pain was well
controlled, incisions were clean/dry/intact, and the patient was
voiding/moving bowels spontaneously. The patient is WBAT in the
right lower extremity, and will be discharged on Aspirin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
1. Indomethacin 50mg capsule TID
2. Doxycycline 100mg Q12H x10 days
3. Colchicine 0.6mg tablet BID
4. Naproxen 500mg tablet TID
5. Omeprazole 20mg capsule, delayed release DAILY
6. Candesartan 32mg tablet DAILY
7. Verapamil 360mg ER capsule DAILY
8. Insulin glargine (100u/mL, 3mL insulin pen) 28units SQ QHS
9. Acetaminophen 1000mg Q8H
10. Insulin lispro (100u/mL) ___ + sliding scale
11. Semaglutide 0.50mg SQ WEEKLY
12. Aspirin 81mg DAILY
13. Multivitamin DAILY
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY Duration: 12 Doses
RX *aspirin [Ecotrin] 325 mg 1 (One) tablet(s) by mouth once a
day Disp #*12 Tablet Refills:*0
2. cefaDROXil 500 mg oral BID Duration: 2 Weeks
Please take this antibiotic by mouth after finishing the IV
antibiotics. Start taking on ___ and take until ___.
RX *cefadroxil 500 mg 1 (One) capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
3. CefTRIAXone 2 gm IV Q24H Duration: 9 Days
Please take this IV antibiotic until ___ before starting a 2
week course of the oral antibiotic
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2g once a day
Disp #*8 Intravenous Bag Refills:*0
4. Gabapentin 300 mg PO BID:PRN pain Duration: 12 Days
RX *gabapentin 300 mg 1 (One) capsule(s) by mouth every twelve
(12) hours Disp #*12 Capsule Refills:*0
5. Naproxen 500 mg PO Q12H:PRN Pain - Severe Duration: 12 Doses
Please take with food. Thank you.
RX *naproxen 250 mg 1 (One) tablet(s) by mouth once a day Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right leg infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
Weight bearing and activity as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add tramadol 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. PLEASE TAKE
YOUR COLACE 100 MG TWICE DAILY TO EASY CONSTIPATION.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
FOLLOW UP:
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Recommended Discharge: (x)rehab
Treatment Plan:
Patient/Caregiver ___ RE: HEP, importance of OOB, proper
gait mechanics
D/C planning
Functional Mobility training
Progression of ambulation including stair ambulation
Endurance Trianing
Frequency/Duration: ___ for 1 week
Recommendations for Nursing:
Promote knee extension of RLE in bed to prevent flexion
contracture
Amb 3x/day with Supervision
Amb to bathroom with supervision
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
Followup Instructions:
___
|
10477920-DS-12 | 10,477,920 | 20,022,932 | DS | 12 | 2173-03-22 00:00:00 | 2173-03-23 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, Leg Swelling
Major Surgical or Invasive Procedure:
___ TEE cardioversion
History of Present Illness:
___ year old female with history of CHF (EF 35-40%), severe
aortic stenosis s/p AVR, pulmonary hypertension, CAD s/p PCI,
CHB s/p PPM placement who presents with progressive shortness of
breath. Patient reports this is her ___ hospitalization this
year for shortness of breath (last hospitalized at ___
___ 1 month ago). She last felt like her normal
self in ___, prior to being diagnosed with complete heart
block. She feels her PPM is contributing to her symptoms. She
describes shortness of breath with very minimal activity such as
eating. Because of this, she is fearful of eating and claims to
have lost ___ lbs (though not verified per OMR). She describes
having to stop after climbing 4 steps to her house. She noticed
her Rt lower extremity has become more swollen. She complains of
abdominal bloating. She denies any orthopnea and PND. She has
tried to monitor her diet though becomes very anxious due to the
multiple dietary restrictions she is on. She reports being
compliant with furosemide and will often take an additional
dose, which helps her feel better. She also reports feeling cold
all the time whereas before she was always hot.
Of note, patient has stopped taking several medications due to
polypharmacy and being unable to afford medications. She was on
rivaroxaban, which she stopped a couple of months ago. She does
not know the indication for rivaroxaban but denies history of
atrial fibrillation.
In the ED initial vitals were: 97.5 65 116/90 22 97% RA.
- Labs: WBC 8.3, H/H 10.85/34.8, Cr 0.9, BNP 2901, troponin
<0.01, lactate 2.2.
- EKG: V paced, possible underlying Afib.
- CXR: Very minimal interstitial edema.
Patient did not receive anything in ED.
Vitals on transfer: 60 ___ 95% RA.
On the floor patient complaining of shortness of breath and
bloating.
Past Medical History:
- CHF (LVEF 35-40%)
- CAD s/p PCI to RCA and OM ___ followed by MI ___ due to
stent
thrombosis in OM, also restenosis in RCA which was stented
along
w/ the LAD w/ bare metal stents
- Severe aortic stenosis ___ 0.8cm2), s/p AVR with
___ pericardial tissue valve with ascending
aortic replacement
- Complete heart block s/p PPM
- Pulmonary hypertension
- Diabetes mellitus
- Dyslipidemia
- H/o incarcerated hernia ___
- History of rheumatic fever as a child
- Morbid obesity
- Osteoarthritis
- Chronic low back pain
- History of MRSA PNA
- History of UGIB
PAST SURGICAL HISTORY:
- Appendectomy
- Cholecystectomy
- Repair of incarcerated hernia requiring bowel resection
Social History:
___
Family History:
CAD, diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VS: 113/73 57 18 98RA 85.4kg
GENERAL: Appears anxious but speaks in full sentences.
Tangential speech. No acute distress.
HEENT: Atraumatic. Sclera anicteric. PERRL. Oropharynx clear.
NECK: Supple, JVP not visible while sitting at 90 degreesl
CARDIAC: RRR, normal S1, S2. No murmurs.
LUNGS: Faint crackles at the bases bilaterally.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. RLE slightly more edematous
than left with trace edema.
DISCHARGE PHYSICAL EXAM
======================
VS: 97.9 80/50 ___ 18 96%RA
weight:85kg <-84.9<-85<-84.4<-84.4 <- 84.5
Is/Os: 8h ___ 24h 1L/1.25L
GENERAL: WD/WN, NAD, Very pleasant.
HEENT: NCAT. Sclera anicteric. PERRL. Oropharynx clear.
NECK: Supple, JVP flat
CARDIAC: RRR, normal S1, S2. Loud systolic ejection murmur at
LSB.
LUNGS: Faint crackles at the bases bilaterally. Back with square
well defined resolved erythematous patch.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. minimal edema ___. Left arm
hematoma in antecubital fossa. Surrounding ecchymoses on left
forearm. Radial pulses 2+
NEURO: ___ strength ___ UE, full grip strength, light touch and
temperature sensation intact,
Pertinent Results:
ADMISSION LABS
==============
___ 04:10PM BLOOD WBC-8.3 RBC-3.92 Hgb-10.8* Hct-34.8
MCV-89 MCH-27.6 MCHC-31.0* RDW-14.9 RDWSD-47.8* Plt ___
___ 04:10PM BLOOD Neuts-71.4* ___ Monos-7.1 Eos-1.4
Baso-0.6 Im ___ AbsNeut-5.90 AbsLymp-1.60 AbsMono-0.59
AbsEos-0.12 AbsBaso-0.05
___ 05:20PM BLOOD ___ PTT-26.7 ___
___ 04:10PM BLOOD Glucose-197* UreaN-27* Creat-0.9 Na-140
K-3.8 Cl-104 HCO3-24 AnGap-16
___ 04:10PM BLOOD ALT-17 AST-26 AlkPhos-147* TotBili-0.7
___ 04:10PM BLOOD proBNP-2901*
___ 04:10PM BLOOD cTropnT-<0.01
___ 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:10PM BLOOD Lipase-32
___ 04:10PM BLOOD Albumin-4.1 Calcium-9.4 Phos-3.1 Mg-2.0
___ 04:10PM BLOOD TSH-1.8
___ 05:24PM BLOOD Lactate-2.2*
___ 11:13AM BLOOD Lactate-2.1*
___ 04:10PM BLOOD TSH-1.8
___ 09:45AM BLOOD calTIBC-430 ___ Ferritn-34 TRF-331
___ 04:10PM BLOOD Lipase-32
___ 11:16AM BLOOD Ret Aut-2.5* Abs Ret-0.0984
NOTABLE LABS
==============
___ 12:38PM BLOOD %HbA1c-8.2* eAG-189*
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-7.3 RBC-3.48* Hgb-9.4* Hct-30.1*
MCV-87 MCH-27.0 MCHC-31.2* RDW-14.7 RDWSD-46.6* Plt ___
___ 07:20AM BLOOD ___ PTT-23.5* ___
___ 07:20AM BLOOD Glucose-175* UreaN-35* Creat-1.0 Na-135
K-4.5 Cl-101 HCO3-23 AnGap-16
___ 07:20AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.9
IMAGING/STUDIES
==============
___ CXR
Left dual-lead pectoral pacemaker device appears intact and
unchanged in
position. The heart is moderately enlarged. Moderate central
pulmonary
congestion and edema, increased from the prior exam. A left
pleural effusion,
if present, is small. There is mild bibasilar atelectasis. No
pneumothorax.
Median sternotomy wires are unchanged.
IMPRESSION:
Findings consistent with congestive heart failure and/or volume
overload,
progressed from the prior exam.
___ ___
IMPRESSION: 1. Severely dilated left ventricular cavity,
increase in since
prior exam. 2. Left ventricular EF = 33% 3. Mild fixe defects
in the
anterolateral, inferolateral, inferior and apical left
ventricular walls.
___ TEE
No mass/thrombus is seen in the left atrium or left atrial
appendage. Moderate spontaneous echo contrast is present in the
left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No mass or thrombus is seen in
the right atrium or right atrial appendage. A small mobile
echogenic mass is associated with a catheter/pacing wire is seen
in the right atrium and/or right ventricle. The right atrial
appendage ejection velocity is depressed (<0.2m/s). No atrial
septal defect is seen by 2D or color Doppler. LV systolic
function appears depressed. The right ventricle has depressed
free wall contractility. There are complex non-mobile (>4mm)
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta to 28 cm from the incisors. A
well-seated bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis leaflets appear to move normally. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Moderate to severe (3+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: No thrombus in the atria or atrial appendages.
Moderate spontaneous echo contrast in the left atrial appendage
and decreased atrial appendage velocities. Small mobile
echogenic mass is associated with known pacemaker wire,
consistent with thrombus or fibrin strand. Moderate-severe
functional mitral regurgitation in the absence of degenerative
mitral valve disease. Well-seated bioprosthetic AVR.
___ TTE
Conclusions
The left atrial volume index is mildly increased. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the septum and inferolateral walls. There
is mild hypokinesis of the remaining segments (LVEF = ___ %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of mitral regurgitation.] The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. The diameters of aorta at the sinus, ascending
and arch levels are normal. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet motion and transvalvular gradients.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Moderate to severe (3+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is
mild-moderate pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
and global systolic dysfunction most c/w multivessel CAD or
other diffuse process. Well seated biologic AVR with normal
gradient and trace aortic regurgitation. Moderate to severe
mitral regurgitation. Moderate to severe tricuspid
regurgitation. Mild-moderate pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
___, the severity of mitral regurgitation and tricuspid
regurgitatoin have increased ans the aortic valve has been
replaced.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ LENIS
FINDINGS: There is normal compressibility, flow, and
augmentation of the right common
femoral, femoral, and popliteal veins. Normal and
compressibility is
demonstrated in the posterior tibial and peroneal veins. There
is normal respiratory variation in the common femoral veins
bilaterally. No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CXR
FINDINGS: Patient is status post median sternotomy and cardiac
valve replacement.
Left-sided dual lead pacer device is stable in position.No focal
consolidation
is seen. There is minimal interstitial edema. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are stable.
IMPRESSION: Very minimal interstitial edema. No focal
consolidation. No pleural
effusion.
Brief Hospital Course:
___ year old ___'s Witness female with a history of systolic
HF (EF 35-40%), severe AS s/p bioprostheric AVR in ___, PH, CAD
s/p PCI RCA, OM ___ followed by MI ___ due to OM stent
thrombosis, also restenosis in RCA which was stented along w/
the LAD w/ bare metal stents, CHB s/p PPM placement ___ who
presented with progressive shortness of breath secondary to
atrial fibrillation.
# Atrial fibrillation: Was paced on EKG with underlying atrial
fibrillation. Previously on rivaroxaban but self-discontinued
due to GIB. On EP interrogation, became symptomatic around the
same time as the atrial fibrillation started. CHADS-2 score 3
but complicated by concurrent dual antiplatelet therapy with
recent GIB and refusal of blood products. On admission, placed
on a heparin gtt, rate controlled with metoprolol/pacing and
underwent TEE with showed no clot followed by cardioversion on
___ with return of sinus rhythm. Started coumadin bridge
and discharged with therapeutic INR.
# Acute systolic and diastolic heart failure exacerbation: mild
pulmonary edema on admission CXR, BNP 2900, and volume overload
on exam, trops neg x2, EKG with no ischemic changes, ECHO showed
EF 35% with 3+ MR. ___ on ___ which showed diffuse
fixed defects in the anterolateral, inferolateral, inferior and
apical left ventricular walls. MR ___ excluding the
possibility of performing a mitral clip procedure. Diuresed wtih
IV lasix 60mg then changed to 40mg oral torsemide with
improvement in exam and symptoms. Carvedilol uptitrated to
6.25mg bid. Lisinopril uptitrated to 10mg nightly. EP was
consulted regarding potential benefit of ICD and CRT with
suggestion to repeat echo in 1 month and re-evaluate
cardiomyopathy.
# CAD s/p CABG: continued on ASA/statin (increasead to high
potency)/ACEi/b-blocker, no anginal symptoms while admitted.
Plavix was stopped.
# PVD: DES placed to L popliteal artery in ___. Plan for
DAPT x6 months however given the risks of recent GIB, her
vascular surgeon was contacted and agreed that it would be
appropriate to end her course early to minimize bleeding risk.
She was maintained on aspirin and coumadin.
# Recent GIB/anemia: continued home omeprazole, monitored CBC
with no significant change.
# Diabetes mellitus: A1c 8.2%, placed on ISS with aspart and qHS
glargine with fair glycemic control. Discharged on home insulin
regimen.
# Gastroesophageal reflux disease: continued home omeprazole
40mg daily
# Chronic pain: continued home tramadol 50mg q6h prn for pain
TRANSITIONAL ISSUES:
# ICD candidacy
- If she remains pacemaker dependent, recommend repeat imaging
to evaluate her LVEF in 1 month
- If her EF is unchanged it is unclear if CRT would provide much
benefit as the pacemaker would not appear to be worsening her
cardiomyopathy in the setting of her native right bundle branch
block at baseline. However, if her EF is further reduced, then ___
CRT (or CRT-D) may be indicated.
- Patient started on Coumadin (5mg daily) s/p cardioversion. Her
Plavix was stopped per patient discussion/risk of GIB in
___
- Patient to resume home diabetic regimen of 15 units 70/30 at
bedtime as well as 15 units Humalog bedtime. Given A1C of 8.2,
may need stricter compliance or alteration of regimen.
- Left arm hematoma developed on day of discharge without pain
or neurovascular compromise. Please evaluate for resolution at
next visit.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Furosemide 40 mg PO BID
3. Lisinopril 5 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. 70/30 15 Units Bedtime
Humalog 15 Units Bedtime
7. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Omeprazole 40 mg PO DAILY
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
5. Vitamin D 1000 UNIT PO DAILY
6. Vitamin E 400 UNIT PO DAILY
7. Lisinopril 10 mg PO QHS
RX *lisinopril 10 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
8. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID
RX *fluocinolone 0.01 % Apply to affected areas twice daily
Refills:*0
10. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
11. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth at 4 ___ daily Disp #*30
Tablet Refills:*0
___/30 15 Units Bedtime
Humalog 15 Units Bedtime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
Atrial fibrillation
Acute decompensated systolic and diastolic heart failure
Secondary Diagnoses
Anemia
Diabetes Mellitus
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You were admitted with shortness of breath and found to be in
atrial fibrillation along with worsening heart failure. While
you were here, we gave you diuretics, which are medications to
help you urinate. First, we did this through your IV and then we
switched you to an oral regimen. We also performed a procedure
(a cardioversion) to restore your heart rhythm to normal. You
should remain on medicines to thin your blood to prevent strokes
as we discussed. Please be very vigilant for any signs of
bleeding, especially black stools, as this may represent a
serious condition requiring immediate medical care.
At discharge, you weighed 85kg (187lbs). Weigh yourself daily
and notify your cardiology team if your weight increases more
than 3lbs in one day.
On the day of discharge we noticed a hematoma or a bruise on
your left arm at the site of one of your IVs. This should heal
on its own with the aid of heat packs 6 times a day and
elevation of your arm. If the bruise gets bigger or you develop
pain/tingling of your fingers, please call your PCP for further
evaluation.
We wish you all the best,
Your ___ Cardiology team
Followup Instructions:
___
|
10478147-DS-16 | 10,478,147 | 20,691,353 | DS | 16 | 2162-01-21 00:00:00 | 2162-01-21 13:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, emesis
Major Surgical or Invasive Procedure:
___: Retrievable IVC filter placed
History of Present Illness:
This is a ___ year old woman with dementia (baseline oriented to
self, location), seizures, HTN, on coumadin (reason unknown),
breast cancer,
carotid stenosis, presented to ___ with with nausea and
vomiting,
found to have SBP >200 and 3cm cerebellar bleed on NCHCT with
INR
4.9. She was given labetalol 10mg IV and Vit. K 10mg and
transfered to ___
On arrival her GCS was 14, her SBP was >210 and she was given
nicardipine gtt as well as profilnine for rapid reversal of INR.
Her dementia at baseline is significant but she can answer
simple
questions and follow simple commands. Her family has apparently
indicated that she is full code and they request all possible
interventions at this time.
Past Medical History:
Seizures:petit mal Seizures for ___ yrs, last ___ years ago
associated with hypokalemia always. PCP recently discussing
terminating Dilantin use.
Breast CA s/p left mastectomy
Dementia (alert and oriented X2 at baseline, lives in ___
R. hip fx (___) s/p ORIF
Carotid stenosis
dementia
hyponatremia
hypokalemia
DJD in spine
tmj
osteoporosis
htn
lacunar infarct
___ DVT ___
Social History:
___
Family History:
Unknown
Physical Exam:
On Arrival:
O: T: 97.2 60 201/111 99% 3L nc
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs: full/conjugate
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, but not date. Believes she is
in
a hospital but not sure which one.
Recall: could not perform
Language: Speech fluent but hypophonic, with good comprehension
of simple sentences and intact repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Mild cogwheeling
rigidity. No abnormal movements, tremors. Strength full power
___
throughout. No pronator drift
Sensation: Intact to light touch b/l
Reflexes: B T Br Pa Ac
Right ___ 1 0
Left ___ 1 0
Toes upgoing bilaterally
Coordination: slow on finger-nose-finger on the right, slow RAM
on right, heel to shin defered
Handedness: Right
Upon discharge:
Awake, alert, minimal speech, at times follows simple commands,
MAE. Oriented to self, at times she has been oriented to place.
Pertinent Results:
CXR ___
Dobbhoff tip is in the stomach, is not post-pyloric. This
examination was
centered in the thoracoabdominal region. The apices of the lungs
were not
included on the film. There is mild cardiomegaly. The aorta is
tortuous.
There are minimal bibasilar atelectases. There are bilateral
healed rib
fractures. Multiple surgical clips project in the left axilla
CT head ___
FINDINGS: Again seen in the right cerebellum is a 3.2 x 4.2 cm
hyperdense
focus compatible with known cerebellar hemorrhage. There is a
small amount of surrounding edema, not significantly changed
from the prior study, with mild mass effect on the fourth
ventricle. No new hemorrhage is identified. Gray-white matter
differentiation elsewhere is preserved. Prominent ventricles and
sulci are compatible with global age-related volume loss.
Hypoattenuation in the subcortical and periventricular white
matter is likely sequelae of chronic microvascular ischemic
disease. There is a right thalamic lacune, unchanged. There are
atherosclerotic calcifications in the cavernous portions of the
carotid arteries bilaterally. There is no shift from normally
midline structures. The visualized paranasal sinuses and mastoid
air cells are clear. No acute osseous abnormality is identified.
IMPRESSION: No significant change from ___ in right
cerebellar
hemorrhage with surrounding edema and mild mass effect on the
fourth
ventricle.
MRI Brain ___
IMPRESSION: Extensive early subacute right cerebellar hematoma
with
significant mass effect and distortion of the fourth ventricle
but no evidence of acute hydrocephalus. Ring enhancement along
the margins is less likely reactive, and raises suspicion for
underlying lesion. However, given the masking effect of T1
bright early subacute blood products, followup exam should be
obtained sustantiate concern for underlying mass.
LENIS ___
No DVT seen on bilateral lower extremities
CTA Pelvis/Abd ___
IMPRESSION:
1. Chronic thrombus within the left external iliac and common
femoral vein
which is diminutive in size. There is air and dense contrast
within these
vessels, likely from attempted opacification during IVC-gram
performed the
same date. The left internal iliac vein appears patent.
2. Extensive arterial atherosclerotic calcifications within the
caliber
abdominal aorta and iliac arteries.
3. Thickened, trabeculated bladder wall with Foley catheter in
place.
Superimposed cystitis cannot be excluded on CT.
4. Extensive colonic diverticula without evidence of
diverticulitis.
5. Osteopenia with chronic rib fractures, scoliosis and
degenerative changes.
Head CT ___
ReportIMPRESSION:
Stable right cerebellar hemispheric hemorrhage with mild mass
effect on the fourth ventricle with unchanged mild ventricular
dilatation as well as
unchanged mild right tonsillar herniation into the foramen
magnum.
Brief Hospital Course:
Ms. ___ was admitted to the NSICU on ___ and was on Q1hr
neuro checks. Repeat CT imaging was done on ___ and this was
stable. MRI was ordered to look for metastases with her history
of breast CT. Neurology was consulted and they agreed with our
current BP control and imaging plans. She was continued on her
home Dilantin and a level was drawn on ___ This was 7.9.
Patient's neurologic exam remained stable and was at her
baseline per her family. On ___ the patient's PCP was contacted
to confirm medications and PMH. She had ___ DVT in ___ and
has been on coumadin since. Because of her bleed, however,
coumadin is contraindicated, so patient was given an IVC filter
on ___. Of note, she has been on dilantin for petit mal seizures
since ___.
After reviewing her MRI it was discuess that she could benefit
from a craniotomy and evacuation of the hemorrhage, however,
after discussion with the family, it was decided to postpone
surgical intervention.
On ___, she remained stable and she was at her baseline per her
family. A head CT was stable. She met with physical therapy who
confirmed that patient would benefit from returning to her
facility.
On the DOD, patient is afebrile, VSS, tolerating POS and pain is
controlled. She is set for D/c to rehab in stable condition.
Medications on Admission:
Norvasc 10mg BID
colace 100mg PO BID
Isosorbide 60mg PO Daily
Lisinopril 40mg PO Daily
Ditropan 5 mg PO BID
Dilantin 200mg PO BID
Coumadin 5mg PO QHS
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. isosorbide mononitrate 20 mg Tablet Sig: 1.5 Tablets PO BID
(2 times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg PO
BID (2 times a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right cerebellar hemorrhage
Left femoral vein DVT
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Please do not discontinue Dilantin as this is a home
medication, please contact the PCP with any questions.
** Stroke Neurology would like to see you again in about ___
months with an MRI brain to assess for an underlying mass.
Given the size of the bleed, that time interval should be
sufficient for blood resolution so that we may better assess. **
Followup Instructions:
___
|
10478395-DS-19 | 10,478,395 | 23,640,413 | DS | 19 | 2150-04-03 00:00:00 | 2150-04-03 09:30:00 |
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: abd pain, CBD stone
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stone removal
History of Present Illness:
___ without PMH until ___, when he presented with abdominal
pain and was found to have impacted cystic duct stone, underwent
laparoscopic CCY ___. Since then he reports intermittent
post-prandial RUQ pain with fullness, anorexia, usually relieved
by tyelonol. Also with intermittent retrosternal discomfort and
"difficulty talking," described trouble getting voice fully out.
No odynophagia or SOB with talking. ALso reports loose brown
stools up to 3 daily since surgery (baseline 2 formed brown
stools daily). He has lost ~10lbs since CCY. On ___ he
developed RUQ pain which persisted even without eating, and he
had N/V x1. Presented to his PCP ___ ___, found to have ALT 901,
AST 624, TB 5.3> referred to ED today.
In the ED:
Temp: 98.6 HR: 59 BP: 125/72 Resp: 18 O(2)Sat:
Labs notable for: WBC 4.5, LFT ___. CT scan: 5mm CBD
stone at ampulla and IHD+EHD dilation.
Meds given: Ciprofloxacin 400 mg IV ONCE
Consulted: ERCP team
Currently reports ongoing RUQ pain, did not receive pain meds in
ED. No further emesis since ___, feels hungry. Denies F/C, no
URI sx, cough, SOB/DOE or CP. No dizziness with walking. No
dysuria. ROS otherwise unremarkable.
Past Medical History:
GERD
s/p CCY ___
Social History:
___
Family History:
Mother with HTN. No FH gallbladder disease or malignancy.
Physical Exam:
Admission PE:
VS: 98.1 143/92 57 98% RA
GEN alert, NAD
HEENT conjunctiva clear, sclera icteric, dry MM
LUNGS CTA
CV RRRs1s2
ABD ND +BS soft mild RUQ tenderness
EXT no edema, feet warm 2+ DP pulses
NEURO A&O x3, answers ques & follows commands
PSYCH flat affect, appropriate
ACCESS PIV
FOLEY none
Discharge PE:
VS: 98.4 124/74 59 18 94% RA
GEN alert, NAD
HEENT conjunctiva clear, sclera icteric, MMM
LUNGS CTA
CV RRR nl s1s2
ABD soft, NT, ND +BS
EXT no edema, feet warm 2+ DP pulses
NEURO A&O x3, answers ques & follows commands
PSYCH appropriate
ACCESS PIV
FOLEY none
Pertinent Results:
___ 01:45PM GLUCOSE-124* UREA N-14 CREAT-1.0 SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
___ 01:45PM ALT(SGPT)-754* AST(SGOT)-292* ALK PHOS-241*
TOT BILI-6.3* DIR BILI-5.4* INDIR BIL-0.9
___ 01:45PM ALBUMIN-4.7
___ 01:45PM WBC-4.5 RBC-4.99 HGB-15.1 HCT-46.5 MCV-93
MCH-30.4 MCHC-32.5 RDW-13.3
___ 01:45PM NEUTS-67.2 ___ MONOS-5.0 EOS-3.0
BASOS-1.1
___ 01:45PM PLT COUNT-158
___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-LG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 12:45PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
___ 05:26PM ALT(SGPT)-901* AST(SGOT)-624* ALK PHOS-207*
AMYLASE-53 TOT BILI-5.3* DIR BILI-4.1* INDIR BIL-1.2
___ 05:26PM WBC-4.4 RBC-4.70 HGB-14.6 HCT-43.9 MCV-93
MCH-30.9 MCHC-33.2 RDW-12.8
___ 05:26PM PLT COUNT-___holedocholithiasis with a 5 mm stone in the distal common bile
duct, at the level of the ampulla, with mild upstream intra and
extrahepatic biliary dilatation and mural enhancement of the
proximal extrahepatic common bile duct.
RUQ US PRELIM REPORT:
Status post cholecystectomy with no evidence of acute abdominal
pathology on this ultrasound. Normally sized common bile duct
status post cholecystectomy
ERCP ___:
The scout film revealed cholecystectomy clips.
There appeared to be an impacted stone in the major papilla.
During difficult biliary cannulation, the pancreatic duct was
partially filled with contrast and visualized proximally. The
course and caliber of the duct was normal with no evidence of
filling defects, masses, chronic pancreatitis or other
abnormalities.
To faciliate bile duct cannulation, a ___ x 4cm pancreatic duct
stent was placed.
The bile duct was deeply cannulated with the sphincterotome
along a pancreatic duct stent.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
The CBD was 8mm in diameter. A single filling defect consistent
with a stone was identified in the distal CBD.
The left and right hepatic ducts and all intrahepatic branches
were normal.
A biliary sphincterotomy was made with a sphincterotome.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation. A large stone was successfully removed.
The CBD and CHD were swept repeatedly until no further stones
were seen.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Recommendations: Return to ward under ongoing care.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Repeat ERCP in 2 weeks for pancreatic stent pull.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 06:35 7.4 4.27* 13.6* 39.4* 92 31.8 34.5 12.5 124*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:35 821 15 0.8 139 4.2 ___
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
___ 06:35 363* 87* 148 211* 2.8*
Brief Hospital Course:
___ with impacted cystic duct stone s/p lap CCY ___ now p/w
abd pain. WBC 4.5, LFT ___. Found to have
choledocholithiasis s/p ERCP with sphincterotomy and removal of
stone.
# choledocholithiasis with obstruction
# biliary colic
# GERD
# weight loss
Clinically stable without evidence infection/ cholangitis.
Underwent ERCP with sphincterotomy and stone removal on ___.
There was difficulty cannulating the bile duct and a pancreatic
duct stent was placed. Pain resolved post procedure. Tolerated
a regular diet and LFTs downtrending significantly on discharge.
- He will be called for follow-up ERCP in two weeks to remove
the pancreatic duct stent.
# DVT ppx: ambulation
# code status: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and you were found to have
a gallstone blocking your bile duct. You underwent an ERCP
procedure and the stone was removed. A stent was placed into
your pancreatic duct and you will be called to come back in two
weeks to have the stent removed.
Followup Instructions:
___
|
10478422-DS-16 | 10,478,422 | 29,676,118 | DS | 16 | 2136-06-25 00:00:00 | 2136-06-25 10:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Lower Extremity Weakness and Urinary Retention
Major Surgical or Invasive Procedure:
EMG Study
History of Present Illness:
Mr. ___ is an ___ year old right handed gentleman with a
history of hypertension, dyslipidemia, gout, gait instability,
cervical myelopathy with MRI findings and upper extremity
weakness bilaterally, who presents to the ED with an overall
feeling of unwellness, worsening weakness in his lower
extremities, as well as urinary retention since yesterday.
Mr. ___ was in his usual state of health until yesterday
morning. He felt "unwell", and started having difficulty
standing up, getting in and out of the car, and trouble going
upstairs. He denied headaches, neck pain or myalgias. He
reported that his legs felt equally weak, and it progressively
got worse since yesterday. He did no have any fevers or chills
at home. It is important to note that he has been unable to
urinate on his own since yesterday morning, while he felt he
needed to urinate, he was unable to. He did not have saddle
anesthesia. Mr. ___ is followed in clinic by Dr. ___
___ and Dr. ___ was last seen in ___. He
carries the diagnosis of cervical myelopathy based on upper
extremity weakness in a C4-5 and ___s MRI
findings. He has normal reflexes however. He also has weakness
at baseline in his IPs as well as EDBs bilaterally and was
diagnosed with lumbar polyradiculopathy on EMG in ___. Last
cervical MRI from ___ showed no significant change
from ___. This is the radiology report verbatum: " Focal
kyphosis in the mid cervical region with indentation of the
anterior aspect of the spinal cord secondary to both kyphosis
and
disc bulging is identified from C4 to C6 level. No abnormal
signal is seen within the spinal cord. There is
mild-to-moderate narrowing of foramina at C6-7 level which is
again unchanged from prior study." EMG ___ showed "evidence of
the distal median neuropathy. consistent with a carpal tunnel
syndrome. evidence of axon loss. These findings are similar
(minimally improved) in nature to the ___ report of ___. In addition, there was
neurophysiological evidence suggesting a mild left cervical
radiculopathy that localized to the left C7-8 nerve roots."
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel 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 dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
HTN
HL
Gait instability
Gout
Residual right eye visual impairment after trauma @ ___ year old.
Can distinguish some details at baseline. (glass going into
right eye)
Social History:
___
Family History:
His mother died of "old age" age age ___, father died with
___ disease complications at ___. Two of his four
children have hypertension and arthritis.
Physical Exam:
Vitals: T: 101 (down to 92.8 after tylenol) P: 101 R: 19 BP:
106/56 SaO2: 94-98% on R.A.
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,
he feels some stiffnes on the lateral aspects of his neck. His
range of motion is otherwise full.
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.
No prostate enlargement or tenderness on rectal exam (per ED
resident)
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Speech was not dysarthric. Able to follow both midline
and appendicular commands. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
He has pain in his knees upon flexion and extension which seems
to limit his range of motion.
Left:
Delt 4+/5, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, (Quad
___, Ham ___ --> limited by knee pain), TA ___, ___ ___, ___
___, ___ ___
Right:
Delt 4+/5, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, (Quad
___, Ham ___ --> limited by knee pain), TA ___, ___ ___, ___
___, ___ ___
-Sensory: Decreased pinprick, light touch, cold sensation,
vibratory sensation in feet, shins and calves bilaterally.
Slightly decreased sensation to pinprick in an L2-L3
distribution
bilaterally, which was not present on his last clinic exam. He
has intact proprioception in all toes.
-Absent rectal tone (Per Dr. ___
___:
DTRs
Right: ___ 2 Tri 2 ___ 2 Patellar 0 Achilles trace Toes
flexor
Left: ___ 2 Tri 2 ___ 2 Patellar 0 Achilles trace Toes
flexor
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF.
-Gait: Patient unable to stand.
DISCHARGE EXAM:
***************
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation, decreased
visual acuity on right.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L pain ___ ___ 5 5 5 5 5 5 5
R pain ___ ___ 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 2 1
R 2 2 2 2 1
Plantar response was now flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation with ___ support. Narrow-based, short
stride.
Pertinent Results:
___ 11:50PM CRP-164.1*
___ 11:50PM SED RATE-102*
___ 11:13PM CEREBROSPINAL FLUID (CSF) PROTEIN-35
GLUCOSE-77
___ 11:13PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-78*
POLYS-44 ___ ___ 11:13PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1665*
POLYS-17 ___ ___ 10:05PM PTT-30.0
___ 09:23PM ___
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE UHOLD-HOLD
___ 02:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 02:00PM URINE HYALINE-1*
___ 02:00PM URINE MUCOUS-OCC
___ 01:55PM LACTATE-1.2
___ 01:45PM GLUCOSE-121* UREA N-21* CREAT-0.9 SODIUM-126*
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-19* ANION GAP-19
___ 01:45PM estGFR-Using this
___ 01:45PM ALT(SGPT)-13 AST(SGOT)-19 CK(CPK)-123 ALK
PHOS-58 TOT BILI-0.7
___ 01:45PM ALBUMIN-3.9
___ 01:45PM CRP-137.2*
___ 01:45PM WBC-17.7*# RBC-4.10* HGB-12.5* HCT-35.8*
MCV-88 MCH-30.4 MCHC-34.7 RDW-14.0
___ 01:45PM NEUTS-76.3* LYMPHS-11.7* MONOS-11.8* EOS-0.1
BASOS-0.1
___ 01:45PM PLT COUNT-479*
US RENAL IMPRESSION:
1. Simple renal cyst and a small angiomyolipoma are noted along
the inferior pole of the right kidney.
2. Otherwise, normal renal ultrasound. No evidence of
hydronephrosis or
nephrolithiasis.
EMG STUDY IMPRESSION: Abnormal study. There is electrophysologic
evidence for a moderate sensori-motor polyneuropathy with axonal
features. There is no evidence for primary demyelination. There
is also no evidence for a generalized myopathic process or for a
motor neuron disease.
CT C/A/P IMPRESSION:
1. No confluent pulmonary consolidation. No intrathoracic
lymphadenopathy. Conspicuous mediastinal and supraclavicular
lymph nodes as described.
2. Normal caliber bowel loops with colonic diverticulosis
without acute
diverticulitis. Normal caliber appendix.
3. No fluid collection in the abdomen or pelvis.
4. Marked enlargement of the prostate gland. Please correlate
clinically.
5. Right renal exophytic lesion is indeterminate. Further
evaluation with
ultrasound may be helpful.
MRI HEAD IMPRESSION:
No acute abnormalities. Extensive small vessel ischemic changes
and lacunes. Questionable hyperdense focus noted on the CT
corresponds to an area of small vessel ischemic change without
acute findings. There is a small focus of susceptibility in the
right anterior pons, which could represent chronic microbleed
versus calcification, there is no associated mass effect or
edema.
MR ___ IMPRESSION:
Limited study. No large epidural abscess or evidence of
discitis,
osteomyelitis is seen. Significant degenerative changes in the
cervical and the lumbar spine. The cervical spine changes are
stable from ___.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
# Neurologic:
The patient was started on antibiotics as there was a concern
for Lyme infection causing his polyneuropathy given the presence
of an increase in inflammatory markers. Lyme titers were sent,
as well as other infectious markers. With Lyme serologies
returning as negative, additional workup was performed to
evaluate for potential neoplastic causes. CT torso revealed no
such process except for lymphadenopathy in the mediastinum, and
an exophytic mass on the renal pole which was later seen on
ultrasound imaging to be a simple cyst. Blood work did not
reveal any additional findings concerning for blood-borne
malignancy.
MRI Spine demonstrated no new processes which could explain his
weakness, only stable degenerative changes from previous
imaging. EMG Studies revealed no evidence for primary
demyelination, generalized myopathic process, or for motor
neuron disease. With these studies in hand, Neurosurgery c/s had
no immediate plans for intervention.
Concern for possible autoimmune causes, associated with Lyme or
neoplasm, of the patient's polyneuropathy prompted us to begin a
course of steroid treatment. Over the remainder of the
patient's stay (notably on hosp days ___ the patient was strong
enough to ambulate again with assistance on a course of both
antibiotic therapy initiated early in the patient's
presentation, and at this point a 2 day course of high-dose
prednisone.
With ___ evaluation, on the last day of hospitalization, the
patient was noted to be able to ambulate with support, and have
now ___ strength bilaterally in lower extremities. It was
determined that he would complete a 14-day course of antibiotics
despite being sero-negative for lyme disease, and continue high
dose steroids for 2 weeks before following up with Dr. ___
in clinic.
# GU:
Mr ___ was noted to have significant prostatic hypertrophy
which likely contributed in some capacity to his bladder
retention. He was noted to have issues with voiding on
presentation for which a foley was placed. On hospital day 4
this was removed, and the patient was able to void. PVR
revealed >300cc of urine in the bladder for which straight
catheterization was ordered. After this single intervention,
Mr. ___ was able to void with PVR's <50cc every episode.
# ID:
Lyme disease was considered unlikely by ID c/s; however, they
also noted Mr. ___ has been improving on his current
regimen of ceftriaxone. Per c/s, Lyme disease cannot be ruled
out definitively, thus a course of ceftriaxone 2grams IV
Q24hours should be completed which is consistent with the
regimen for Lyme disease with neurological manifestations for
generally two weeks. Total serum IgG was also sent to ensure Mr.
___ is able to produce immunoglobulins (if not, any
negative serology would be unreliable). This study returned
within reference ranges.
Medications on Admission:
Aspirin 162mg daily
Centrum Sliver 1 tablet daily
Lipitor 10mg daily
Vitamin B12 1000mg daily
Enalapril 20mg daily
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Aspirin 162 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. PredniSONE 60 mg PO DAILY <-- Patient will stay on this
medication until following up with Dr. ___ in clinic
6. Famotidine 20 mg PO Q12H
7. Enalapril Maleate 20 mg PO DAILY HTN hold for SBP < 100 or HR
< 60
8. CeftriaXONE 2 gm IV Q24H please administer 6 more doses of
this medication s/p discharge then may pull PICC line.
9. Insulin SC Sliding Scale, Fingerstick QACHS Insulin SC
Sliding Scale using HUM Insulin
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower extremity weakness secondary to inflammatory process
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were evaluated at the ___
for your chief complaint of worsening lower extremity weakness
and urinary retention. You were evaluated with a number of
imaging studies including MRI Brain which revealed no
intracranial process which could explain these symptoms, MRI of
the Spine which redemonstrated the Cervical and Lumbar pathology
for which you have been under the care of Drs. ___
___, and CT of your torso which noted some inflammatory
markers but no specific lesions which could explain your
symptoms. Because you had an elevated white blood cell count,
fever, and elevated markers of infection, you were started on
antibiotic therapy; however, the infection cultures which we
sent for evaluation including Lyme, Blood Cultures, and Urine
Cultures all were negative for signs of infection. Your Lumbar
Puncture was also negative for any signs of active infection and
were not remarkable for any bacterial / viral findings. The
Echocardiogram of your heart which was performed revealed normal
ejection fraction and function.
We will continue to treat you for suspected infection for a
course of 14 total days of therapy. You have received a
indwelling catheter called a PICC line which will allow for
antibiotic therapy to be administered outside of the hospital.
You have also been prescribed a course of steroid therapy which
will be maintained until further instructions by Dr. ___
___ evaluation in outpatient clinic. Please follow both of
these regimens for their total courses, and please follow up
with the appointments scheduled for you below. Please continue
to wear your neck collar to treat your cervical radiculopathy.
Followup Instructions:
___
|
10478422-DS-18 | 10,478,422 | 29,187,781 | DS | 18 | 2137-03-04 00:00:00 | 2137-03-04 18:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Leg weakness and edema
Major Surgical or Invasive Procedure:
EGD ___
Coil Embolization of bleeding diverticula ___
History of Present Illness:
Mr. ___ is an ___ with PMH significant for HTN, HLD,
multifactorial gait disorder, lumbosacral radiculopathy,
cervical spondylosis with peripheral neuropathy, and lower
extremity edema thought to be due to venous stasis on
furosemide, and possible mitochondrial myopathy who presents
with ___ weakness. Pt reports that over the past 1 week he has
developed worsening leg weakness and increasing leg edema.
Pt presented today because of inability to stand. Pt reports he
was sleeping in his recliner this morning and upon awakening
could not stand up. He usually ambulates with a walker at home.
He also reports extremely swollen legs. He reports no pain,
slight increase in bilateral ___ edema. Denies numbness or
paresthesias in his legs. He reports that he attempted to stand
earlier today, but couldn't maintain his stance, and sat down in
his chair, and ended up sliding to the ground. He reports no
head strike, neck pain, or LOC from the event. He denies any
fever, chills, night sweats, or n/v/d. He also denies chest
pain, palpitations, lightheadedness or dizziness, SOB or
orthopnea.
Of note patient had his furosemide dose decreased from 40mg
daily to 20mg daily on ___ by his PCP. He was just started
on lasix for the first time about one month ago at a dose of
20mg but was increased to 40mg due to edema, but patient was
urinating so much the dose was decreased again. He also had
recent Mohs surgery for Squamous cell carcinoma in situ of left
scalp on ___.
In the ED, initial vital signs were: 97.7 100 105/63 14 97% RA.
Exam notable for decreased strength for hip flexion. Patient's
examination was concerning for possible exacerbation of his
chronic leg weakness from mitochondrial abnormality. Labs and a
chest x-ray were obtained which showed Na 127, CRP: 76.9, CK
173, WBC 15.3 with 81.4 PMN, and hgb 12.1. Patient was found to
have a mild hyponatremia. Neurology was consulted for worsening
leg weakness given his mitochondrial myopathy and thought his
weakness is most likely due to his worsening edema. He is
admitted to medicine for management of his fluid retention.
On the floor, pt reports that his legs feel heavy. He states
that he has been having weight loss recently of about 20lbs. He
also reports poor appetite. He has been pretty active walking
with a walker and going up and down steps up until about a week
ago. He states that he recently he has had more difficulty going
down stairs than up stairs.
Review of Systems:
(+) per HPI, +constipation
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HTN
- HLD
- Gait instability
- Gout
- Residual right eye visual impairment after trauma @ ___ year
old.
- multifactorial gait disorder with lumbosacral radiculopathy
- cervical spondylosis and a peripheral neuropathy
-possible mitochondrial myopathy with proximal weakness and
thigh muscle biopsy in ___ with ragged red fibers likely
reactive
- Squamous cell carcinoma in situ left scalp s/p Mohs
Social History:
___
Family History:
His mother died of "old age" age age ___, father died with
___ disease complications at ___. Two of his four
children have hypertension and arthritis
Physical Exam:
Admission Physical Exam:
Vitals: 98.9 109/66 102 22 97%RA
General: Awake, Alert, Oriented x3, comfortable in NAD
HEENT: left scalp surgical wound with surrounding erythema,
edema and minimal purulence. multiple crusted lesions on scalp.
Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1, S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: 3+ pitting edema ___ up to thighs, warm, well perfused,
1+ pulses, +clubbing of toes
Neuro: CNs2-12 grossly intact, motor function grossly normal,
dorsiflexion and plantar flexion intact. hip flexor and extensor
intact once pt legs are lifted. Exam limited by edema in legs
Discharge Physical Exam:
Vitals: 98.4, 112/65, 94 (76-105), 16, 96% RA
General: Awake, Alert, Oriented x3, elderly male comfortable in
NAD
HEENT: left scalp surgical wound with mild surrounding erythema.
Multiple crusted lesions on scalp. Sclera anicteric, MMM,
oropharynx clear
Neck: supple, no JVD, no LAD, right IJ CVL c/d/i, min ecchymosis
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rhythm, normal S1, S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, +bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: 2+ edema ___ up to knees, WWP, deltoids ___ bilaterally,
proximal ___ weakness L>R, IPs ___ Left ___ right, b/l plantar
and dorsiflexion intact, right femoral access c/d/i, no bruit,
no hematoma, distal pulses 2+ rad, DP, ___ bilaterally
Pertinent Results:
Admission Labs:
___ 11:25PM GLUCOSE-108* UREA N-17 CREAT-0.7 SODIUM-128*
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-22 ANION GAP-16
___ 11:25PM MAGNESIUM-1.8
___ 05:35PM proBNP-250
___ 05:35PM SED RATE-81*
___ 01:57PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:57PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:00PM NEUTS-81.4* LYMPHS-8.7* MONOS-9.1 EOS-0.6
BASOS-0.2
___ 01:00PM PLT COUNT-370
___ 01:00PM ___ PTT-29.5 ___
___ 12:32PM URINE HOURS-RANDOM UREA N-1125 CREAT-215
SODIUM-31 POTASSIUM-77 CHLORIDE-25
___ 12:32PM URINE OSMOLAL-702
___ 12:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:32PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 12:32PM URINE HYALINE-1*
___ 12:32PM URINE MUCOUS-MOD
___ 11:20AM GLUCOSE-91 UREA N-14 CREAT-0.7 SODIUM-127*
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-21* ANION GAP-18
___ 11:20AM estGFR-Using this
___ 11:20AM CK(CPK)-173
___ 11:20AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.0
___ 11:20AM CRP-76.9*
Imaging Studies:
CXR (___): Frontal and lateral views of the chest were
obtained. Patchy left mid-to-lower lung opacity seen on the
frontal view, not well seen on the lateral, view but appearing
new since the prior study, may represent atelectasis; however,
in the appropriate clinical setting, early consolidation is not
excluded. There is no pulmonary edema. No pleural effusion or
pneumothorax. The cardiac and mediastinal silhouettes are
unremarkable.
TTE (___): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with mid- and distal septal and apical hypokinesis (distal LAD
disease). The remaining segments contract normally (LVEF = 45%).
Right ventricular chamber size is normal with focal hypokinesis
of the apical free wall. The aortic root is mildly dilated at
the sinus level. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional biventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the area of LV hypokinesis is similar.
___ US (___): No evidence of deep vein thrombosis in either
leg.
EGD (___):
Mucosa suggestive of ___ esophagus
There was patchy erythema in the antrum consistent with
gastritis.
Duodenal erosion
Polyp in the stomach
Otherwise normal EGD to third part of the duodenum
CTA Abd/pelvis ___:
1. Active extravasation in the sigmoid colon, most consistent
with a diverticular hemorrhage.
2. Stable hematoma in the left iliopsoas muscle.
___ embolization ___:
1. Active extravasation from a sigmoid branch of the inferior
mesenteric artery with technically successful coil embolization
of the marginal artery proximal and distal to the feeding
vessel.
2. Uncomplicated exchange of malpositioned ___ temporary central
venous line initially placed in the ICU.
Discharge Labs:
___ 07:50AM BLOOD WBC-8.1 RBC-2.99* Hgb-8.6* Hct-26.1*
MCV-87 MCH-28.8 MCHC-33.1 RDW-15.1 Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-135 K-4.3
Cl-102 HCO3-25 AnGap-12
___ 07:50AM BLOOD Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ with PMH significant for HTN, HLD,
multifactorial gait disorder, lumbosacral radiculopathy,
cervical spondylosis with peripheral neuropathy, and lower
extremity edema thought to be due to venous stasis on
furosemide, and possible mitochondrial myopathy who presents
with ___ weakness and edema in setting of a decrease in lasix
dose and also with leukocytosis in setting of recent Mohs
surgery for squamous cell carcinoma in situ of left scalp on
___.
# Leg weakness/Edema: Pt with history of lumbosacral
radiculopathy and multifactorial gait disorder with new leg
weakness in setting of increased leg swelling. Pt presented with
hypervolemic hyponatremia on labs and exam with significant
lower extremity pitting edema. Likely precipitant is recent
reduction in lasix dose. He had a TTE ___ with LVEF 50-55%
showing mild systolic dysfunction. Edema could also be secondary
to poor nutrition as well. BNP was not elevated so CHF
exacerbation less likely. Other etiologies include proximal
muscle myopathy since he previously was thought to have a
mitochondrial myopathy with ragged red fibers on biopsy.
Neurology was consulted does not think this is the case and
recommended that we did not start steroids given his poor
response to them in the past and since he has peptic ulcer
disease. We initially diuresed pt with no significant
improvement in lower extremity edema. Diuretics were stopped due
to persistent electrolyte abnormalities, ___, and because
patient appeared intravascularly dry. LENIs were negative for
DVT and CT pelvis did not reveal any lymphadenopathy or
lymphatic obstruction but did show a left iliopsoas hematoma
which may be contributing to the proximal weakness. ___ consider
repeat CT scan to ensure resolution of hematoma. Pt was found to
have a tick under left armpit so lyme IgG/IgM titer were sent
and are pending at time of discharge. His edema was treated with
leg elevation & compression stockings. His lower extremity
strength gradually improved. He will need aggressive ___ and f/u
with neuromuscular as outpatient. Lasix was held on discharge
since pateint was euvolemic on a 2000mL fluid restriction.
# LGIB s/p ___ embolization of sigmoid diverticula: Several days
into hospital stay pt developed episodes of melena with slowly
dropping H/H which then progressed to bloody bowel movements. He
had an EGD which showed Barretts esophagus and clean base
duodenal ulcer. He was started on high dose PO PPI and prepped
for a colonscopy. During prep he developed 500mL of bright red
blood from rectum and was taken for an emergent CTA which showed
bleeding in the sigmoid colon. He went to ___ and had
embolization of of the bleeding vessel. This was successful. He
was monitored in the medical ICU and he remained stable. He
recieved a total of 3 units of PRBCs and his Hct stablized. He
had no further bleeding and he was fit for transfer out of the
MICU. On the floor his Hct remained stable. He did not have
colonoscopy given acute bleed but per GI, he should have one in
___ years for regular screening. He was restarted on 81mg aspirin.
# Leukocytosis s/p excision of squamous cell carcinoma from
scalp: Pt with new leukocytosis and high PMN count concerning
for infection. His UA in the ED was negative. No evidence of PNA
on CXR. Although patient does have a surgical wound on his left
scalp which could be the source of infection. He got 2 days of
Abx and leukocytosis improved. Outpatient dermatologist
evaluated surgical wound and determined it was not infected but
inflamed with post-surgical changes so antibiotics were stopped.
Wound was cared for per dermatology and wound care
recommendations.
# Hyponatremia: Asymptomatic hyponatremia with admission NA of
127. Likely in setting of volume overload due to hypervolemia in
setting of lasix dose reduction. Could also be from SIADH vs.
hypothyroidism vs adrenal insufficiency. Old labs show that his
Na is always in low 130's. TSH and AM cortisol level within
normal limits. This was likely from ___ and improved with
fluid restriction of 2000mL. On discharge Na was 135.
# Patient Safety: Pt currently lives alone on second floor unit
and is unable to care for himself. His daughter is in the
process of applying to move patient to an ECF vs assisted living
facility since he is no longer able to care for himself. Case
management was able to help with placement in ECF.
Chronic Issues:
# HTN: Pt hypotensive and triggered for SBP in ______. We stopped
enalapril in setting of hypotension. He remained normotensive
off enalapril so this was held on discharge. If patient becomes
hypertensive would restart enalapril at prior home dose of 20mg
daily.
# HLD: We continued Lipitor 10 mg PO daily.
# BPH: Stable. We continued finasteride 5 mg PO daily and
tamsulosin ER 0.4 mg PO daily.
# Malnutrition: Pt with weight loss and poor PO intake while at
home. He was found to have an albumin of 3.0. We continued
calcium carbonate-vitamin D3 1,000mg (2,500 mg)-800 daily,
Vitamin B12 1,000 mcg daily, and MVI. He was started on ensure
supplementation.
Transitional Issues:
# Code: Full Code
# Emergency Contact: ___ (HCP) ___
___
# Pt has lyme IgG/IgM titer were sent and are pending at time of
discharge
# Pt should have an H.pylori stool antigen checked as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Enalapril Maleate 20 mg PO DAILY
5. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral Daily
6. Finasteride 5 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Vitamin D 800 UNIT PO DAILY
9. Calcium Carbonate 1250 mg PO DAILY
10. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Calcium Carbonate 1250 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Vitamin D 800 UNIT PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 2 TAB PO HS
10. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral Daily
11. Multivitamins 1 TAB PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
proximal muscle weakness secondary to myopathy
lower extremity venous insufficiency
___ Esophagus
duodenal ulcer
Diverticular Bleed s/p coil embolization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you had leg swelling and weakness. We
determined that this was likely from a combination of things
including a hematoma in your leg, increased leg swelling, and
myopathy. We gave you medication to remove the fluid but this
was not successful. We determined that you did not have a clot
in your legs and did/did not have obstruction of the lymphatic
drainage of your legs. You developed bleeding from your rectum
and we found that you had bleeding from a blood vessel into your
colon which was stopped we were able to stop via an
intervention. Your symptoms improved and your leg weakness
improved. We determined that you would benefit from
rehabilitation. We wish you the best in your recovery!
Followup Instructions:
___
|
10478422-DS-19 | 10,478,422 | 23,188,016 | DS | 19 | 2138-07-23 00:00:00 | 2138-07-27 19:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Atrial flutter
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx HTN, HLD, multifactorial gait disorder, lumbosacral
radiculopathy, cervical spondylosis with peripheral neuropathy,
and lower extremity edema thought due to venous stasis on
furosemide, hx LGIB s/p ___ embolization of sigmoid diverticula,
presents from assisted living-memory unit for abnormal EKG.
Per patient, he was seen by when seen by his ___ at ___
yesterday. He reports being completely asymptommatic, although
per night float notes, he reported palpitations last night. ___
found his HR to be fast, took EKG that revealed AFlutter. He has
not had prior episodes like this. He has chronic dizziness, no
worse with this episode. He denied lightheadedness, vertigo, CP
or chest pressure, difficulty breathing. No recent illnesses,
fevers, chills or night sweats. He has some swelling of his
lower extremities, which he reports is at his baseline. He has
no other complaints. In the ED, he felt he could not urinate,
which is also new for him.
In the ED initial vitals were: 98 87 124/76 16 97%.
- Labs were significant for H/H 11.6/34.0, K 5.3. Trop, proBNP,
remainder of Chem7 unremarkable. UA generally unremarkable.
- EKG showed AFlutter vs coarse AFib with poor baseline. CXR was
without acute cardiopulmonary process.
- Patient was given 10mg IV diltiazem and 30mg PO diltiazem. 1L
IVF was administered. Foley was placed.
Vitals prior to transfer were: 98 138/88 16 96% RA.
On the floor, relates history as above, ROS as below. Of note,
patient denies fevers, chills, n/v, abdominal pain, diarrhea, GU
numbness or weakness, loss of strength or sensation of the ___,
urinary or bowel hesitancy or incontinence.
Past Medical History:
- HTN
- HLD
- Gait instability
- Gout
- Residual right eye visual impairment after trauma @ ___ year
old.
- multifactorial gait disorder with lumbosacral radiculopathy
- cervical spondylosis and a peripheral neuropathy
-possible mitochondrial myopathy with proximal weakness and
thigh muscle biopsy in ___ with ragged red fibers likely
reactive
- Squamous cell carcinoma in situ left scalp s/p Mohs
Social History:
___
Family History:
His mother died of "old age" age age ___, father died with
___ disease complications at ___. Two of his four
children have hypertension and arthritis
Physical Exam:
GENERAL: Calm, AAOx3
HEENT: AT/NC, pupils symmetric, anicteric sclera, pink
conjunctiva, MMM, few missing teeth but no dentures
NECK: no LAD. No JVP.
CARDIAC: Irregularly irregular, no r/g/m
LUNG: No increased WOB. CTAB.
ABDOMEN: central obesity, +BS, NT, no rebound/guarding
EXTREMITIES: 3+ pitting edema through the mid-thighs, equal
bilaterally. Faint DP pulses, but WWP. No cyanosis, clubbing.
MSK: ___ Strenghth in upper and lower extremities, equal
bilaterally
NEURO: CN II-XII intact, ___ strength ___, intact light touch
sensation lower extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 05:35AM BLOOD WBC-12.5* RBC-3.68* Hgb-11.0* Hct-33.6*
MCV-91 MCH-30.0 MCHC-32.9 RDW-14.2 Plt ___
___ 03:45PM BLOOD WBC-7.9 RBC-3.80* Hgb-11.6* Hct-34.0*
MCV-89 MCH-30.4 MCHC-34.0 RDW-14.4 Plt ___
___ 05:35AM BLOOD ___ PTT-30.6 ___
___ 07:40AM BLOOD ___ PTT-107.6* ___
___ 03:45PM BLOOD ___ PTT-31.6 ___
___ 05:35AM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-133 K-4.2
Cl-96 HCO3-27 AnGap-14
___ 03:45PM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-133
K-5.3* Cl-97 HCO3-24 AnGap-17
___ 07:40AM BLOOD ALT-10 AST-13 AlkPhos-60 TotBili-0.3
___ 05:35AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9
___ 07:40AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
___ 05:35AM BLOOD TSH-2.1
___ 07:40AM BLOOD TSH-3.1
___ 10:16PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 10:16PM URINE RBC-10* WBC-90* Bacteri-FEW Yeast-NONE
Epi-<1
MICROBIOLOGY:
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING:
___ Chest X-Ray
IMPRESSION:
No evidence of acute cardiopulmonary process.
Brief Hospital Course:
#Atrial flutter: Mr. ___ was admitted after he was found at
his living facility to have atrial flutter. He was asymptomatic
and hemodynamically stable. He was started on diltiazam for rate
control. However, we did not feel that further anticoagulation
was immediately necessary during this hospitalization given that
his CHADS2 score was 2. He was monitored on telemetry and
remained in atrial flutter during this hosptialization without
RVR. Otherwise, there was not a clear precipitant of this
patient's atrial flutter. He was discharged with diltiazam with
a plan that he would call cardiology for a follow up
appointment. In addition, he will need an echocardiogram as an
outpatient.
#Venous stasis/fluid overload: On admission, patient's legs were
very swollen, and he appeared to be fluid overloaded. He was
aggressively diuresed with both PO and IV lasix.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ABC Plus (multivit-min-FA-lycopen-lutein) 0.4-300-250
mg-mcg-mcg oral daily
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Acetaminophen 325 mg PO Q4H:PRN pain
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 17.2 mg PO HS
14. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN pain
2. Ferrous Sulfate 325 mg PO DAILY
3. Pantoprazole 40 mg PO Q12H
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 17.2 mg PO HS
6. Tamsulosin 0.4 mg PO HS
7. Finasteride 5 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. ABC Plus (multivit-min-FA-lycopen-lutein) 0.4-300-250
mg-mcg-mcg oral daily
10. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
11. Cyanocobalamin 1000 mcg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Atorvastatin 10 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Atrial flutter
Secondary diagnosis: Venous stasis
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for evaluation of an abnormal finding on an
EKG. You were found to have something called atrial flutter,
which is an abnormal beat of your heart. We monitored your heart
beat overnight, and treated you with a medication called
diltiazam to slow down your heart beat. You will need to
continue this medication after you leave the hospital. You
should also follow up with a cardiologist to manage your
treatment. At that time, you should also have an echocardiogram.
During your hospitalization, we also felt that you may have had
too much water in your body. As such, we gave you lasix to help
remove that fluid.
Please follow up with cardiology as below and discuss getting an
echocardiogram (ultrasound of heart) to evaluate your heart.
It was a pleasure to help care for you during this
hospitalization, and I wish you all the best moving forward.
Sincerely,
Your ___ team.
Followup Instructions:
___
|
10478934-DS-18 | 10,478,934 | 24,454,328 | DS | 18 | 2153-01-25 00:00:00 | 2153-01-25 22:14:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ lady with h/o thyroid CA s/p
thyroidectomy, Klippel-Trenaunay syndrome (congenital
malformation of veins) but no h/o DVT/PE who presented to the ED
due to shortness of breath and palpitations and was found to
have pulmonary emboli.
.
Of note, she has RLE venous malformations up to the thigh, with
varicose veins and chronic RLE>LLE swelling. Has venous
malformations involving her uterus as well, and she was on
prophylactic anticoagulation during her pregnancies in the past.
Has no h/o DVT or PE. Did have 2 miscarriages but they were both
___ trimester (6 weeks, 10 weeks) in the setting of ___
fertilization. Her thyroid cancer was removed and per U/S in
___ she has no residual thyroid tissue. No family h/o blood
clots. She works a desk job and is seated for most of the day,
but tries to walk around every hour. No recent long travel.
.
Last week, she felt that one of the venous malformations behind
her right knee was swollen and tender, but had no more leg
asymmetry than usual so she did not think much of it. It
resolved spontaneously. For the past week, she has noticed that
even with minimal exertion (using the restroom, walking between
rooms) she feels extremely short of breath, associated with a
feeling that her heart is pounding in her chest. Denies any
chest pain. She established care with a new PCP on the day of
presentation and described these symptoms. Was found to have a
HR 128 (stable blood pressure). Did not desaturate with
ambulation but her HR became significantly elevated. She was
referred to the ___ ED.
.
In the ED, initial VS were: T 100.1, HR 108, BP 154/57, RR 20,
POx 100%RA. She was noted to be tachycardic to 130 with any
activity but aintained her BP and never desaturated. Labs
unremarkable. EKG did not suggest any RV strain. CTA showed
multiple bilateral pulmonary emboli throughout all lobes of both
lungs, as well as straightening of the interventricular septum
that could be seen with right heart strain. She was started on a
Heparin gtt and was admitted to Medicine.
.
On the floor, she is comfortable but very nervous that if she
moves at all she will be short of breath. She mentions that she
is supposed to be on baby ASA for her venous malformations but
she forgets to take it a lot.
.
REVIEW OF SYSTEMS:
(+) Ocassional dry cough. Has had mild intermittent nausea over
the past week with no vomiting.
(-) Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, sore throat, chest pain, abdominal pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Klippel-Trenaunay syndrome
large varicosities of RLE, uterus, vulva
prescribed ASA 81mg daily
was on SC heparin ppx with pregnancy ___
-congenital foot deformities with some fused digits; required
surgeries as a child and has residual deformities bilaterally
-thyroid cancer:
s/p I-131 and near-total thyroidectomy in ___
pathology showed bilateral multifocal disease, the largest focus
in the left lobe, which measured 1.9 cm. There was no
lymphovascular invasion,extrathyroidal extension or known lymph
node involvement.
Had a negative post-therapy scan, negative thyrogen stimulated
thyroglobulin and whole body scans in ___ and ___,
unremarkable
stimulated thyroglobulin in ___, and negative neck ultrasounds.
-h/o colonic adenoma: ___ ___ at ___ with 2 polyps ->
repeated ___ w/ one 10mm polyp -> adenoma. ___:
Polyp again -> HP. ___: ___ negative. Repeat ___.
-obesity
-vitamin D deficiency
-IBS
-asthma
-severe endometriosis (required ___ fertilization)
-s/p fibroidectomy for uterine fibroids
-s/p C-section x2
Social History:
___
Family History:
No family history of Klippel-Trenaunay syndrome.
No family history of DVT/PE or clotting disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.6F, BP 128/65, HR 97, R 18, O2-sat 98% RA
GENERAL - no acute respiratory distress
SKIN - hyperpigmented erythematous patches with irregular
borders along right trunk and right thigh; RLE with verruous
hyperpigmented skin plaques on dorsum of foot
HEENT - EOM intact, MMM
NECK - supple, scar from thyroidectomy; no palpable thyroid; no
JVD
LUNGS - CTA bilaterally
HEART - no RV heave, S1 and S2 audible with no murmur
ABDOMEN - obese but nondistended; no tenderness or masses
EXTREMITIES
-2+ DP pulses bilaterally
-bilateral LEs with foot malformations (joined toes,
asymmetrical toes)
-RLE>LLE girth; RLE with doughy nonpitting edema, large
soft/nontender varicose veins from calf to thigh posteriorly
LYMPH - no cervical lymphadenopathy
NEURO - awake, A&Ox3, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS - Temp 98.6F, BP 119/65, HR 77, R 16, O2-sat 99% RA
Otherwise unchanged
Pertinent Results:
LABS:
On admission:
___ 06:45PM BLOOD WBC-10.1 RBC-4.56# Hgb-11.6*# Hct-35.5*#
MCV-78* MCH-25.5* MCHC-32.8 RDW-16.5* Plt ___
___ 06:45PM BLOOD Neuts-77.3* Lymphs-16.0* Monos-4.3
Eos-1.7 Baso-0.7
___ 06:45PM BLOOD ___ PTT-25.4 ___
___ 06:45PM BLOOD Glucose-114* UreaN-15 Creat-1.0 Na-142
K-4.3 Cl-109* HCO3-22 AnGap-15
___ 06:45PM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.9
___ 06:45PM BLOOD D-Dimer-5274*
___ 06:45PM BLOOD TSH-0.093*
On discharge:
___ 04:25AM BLOOD WBC-8.3 RBC-4.18* Hgb-10.4* Hct-32.7*
MCV-78* MCH-24.9* MCHC-31.8 RDW-16.1* Plt ___
___ 10:55AM BLOOD ___ PTT-73.5* ___
___ 04:25AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-142
K-3.7 Cl-107 HCO3-24 AnGap-15
___ 04:25AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:25AM BLOOD CK(CPK)-96
___ 04:25AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1
IMAGING:
CTA chest: Multiple bilateral pulmonary emboli throughout all
lobes of both lungs. Straightening of the interventricular
septum could be seen with right heart strain. Suggest
echocardiogram for further evaluation.
RLE doppler US: Compressible veins without evidence of deep
venous thrombosis in the right lower extremity, however slow
flow is seen in the right common femoral and superficial femoral
veins. Incidental note made of duplicated right popliteal veins.
Brief Hospital Course:
___ female with congenital venous malformations who presented
with shortness of breath and tachycardia and was found to have
bilateral pulmonary emboli.
.
ACTIVE ISSUES:
#. Dyspnea, Tachycardia: CTA in the emergency room revealed
multiple bilateral pulmonary emboli. Though there was some
degree of interventricular septum straightening, this is
nonspecific as there is variation with respirations, and there
was no evidence of hemodynamically compromise that would merit
antithrombolytic therapy. EKG did not show evidence of right
heart strain, and cardiac enzymes were negative x2. An echo was
not obtained, as it would have not changed her management given
her clinical stability. She remained stable on room air with
BPs in the 120s/70s throughout her stay. She was started
initially on a heparin gtt and warfarin PO. By the morning
following admission, she was already experiencing an improvement
in her symptoms and no longer felt dyspnea or palpitations while
walking around the floor. Her walking O2 sats stayed in the
98-99% range, but her HR did increase to the 130s, returning to
normal at rest. She transitioned from heparin gtt to lovenox
injections on the morning after admission. She will continue on
lovenox for the next ___ days while her INR becomes therapeutic
on warfarin.
With regards to the cause of her PEs, she is a nonsmoker, not on
OCPs, no known hypercoagulable state. Has a h/o thyroid cancer
but this is not active. Her venous malformations make her at
more risk for DVT/PE. Also, she has a desk job with prolonged
sitting but does try to move around throughout the day. Note
that no DVT was seen on U/S though slow flow was noted - it is
likely that either an entire clot mobilized to the lungs (felt a
"tearing" pain from right knee last week) or she has clot in her
pelvic veins.
She will likely need to continue lifelong anticoagulation with
warfarin. She was counselled on diet changes and told that she
will need frequent INR checks initially. As she is being
discharged on a weekend, an appt in ___ clinic could not be
made for her, but she was told to have her INR check at day 3
and 5 of warfarin therapy and have results faxed/phoned to her
PCP.
#. Papillary thyroid cancer s/p ablation with hypothyroidism: On
U/S ___ there was no thyroid tissue visible. TSH checked in
the ED was 0.093, initially concerning because excessive
Levothyroxine could have been contributing to
tachycardia/palpitations. However this may be her TSH goal given
her h/o papillary thyroid cancer. She was continued on her
outpatient dose of levothyroxine, and it was recommended that
she (or her PCP) follow up with her endocrinologist to confirm
her TSH goal.
#. Klippel-Trenaunay syndrome: with large varicosities of RLE,
uterus, vulva. Given that there is increased risk of DVT/PE
with this disorder and she has now had a large PE, she will
likely need to be on lifelong anticoagulation. She had been
taking aspirin 81 mg, this has now been discontinued.
INACTIVE ISSUES:
#. Anemia: Microcytic, stable. Hct was 35.5 on admission
(higher than recent baseline). She has been diagnosed with Fe
deficiency and tries to take her pills but it is difficult b/c
she cannot take it with Levothyroxine. She was continued on her
iron supplementation.
#. Mild asthma: stable, no wheezing or hypoxia. Continued on
albuterol nebs PRN
TRANSITION OF CARE ISSUES:
- Anticoagulation: will need close follow up of INR while
transitioning from heparin to warfarin
- Thyroid: TSH extremely low on admission, should check with
her endocrinologist to see what the goal TSH is, given her
thyroid CA history
FULL CODE this admission
Medications on Admission:
ASA 81mg daily
Synthroid ___ daily
Ferrous sulfate 325mg daily
Cholecalciferol (vitamin D3) 50,000 unit every 2 weeks (last 1
wk ago)
Flovent HFA 110 mcg PRN
albuterol sulfate HFA 90 mcg PRN
Discharge Medications:
1. Lovenox ___ mg/mL Syringe Sig: One (1) injection (100 mg)
Subcutaneous every twelve (12) hours for 7 days.
Disp:*14 doses* Refills:*0*
2. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 50,000 unit Capsule Sig: One (1)
Capsule PO every 2 weeks.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: ___ puffs Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
6. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puffs
Inhalation twice a day as needed for asthma flare.
7. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO daily at 4 pm:
Please adjust this dose as directed by your primary doctor.
Disp:*60 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please draw INR on ___ and communicate results to Dr.
___ at phone: ___, fax: ___
9. Outpatient Lab Work
Please draw INR on ___ and communicate results to Dr.
___ at phone: ___, fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Klippel-Trenaunay 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 ___. You were admitted
to the hospital because of shortness of breath and heart
palpitations. A scan of your chest found that your symptoms
were coming from clots in your lungs. These clots probably
started in veins in your legs or pelvis and travelled to your
lungs. To prevent these clots from getting bigger, you were
started on blood thinners- first heparin, then lovenox and
warfarin. You will need to continue taking lovenox injections
for the next ___ days until your blood levels of warfarin are
high enough to thin your blood on its own.
You will need to get your INR (a measure of how thin your blood
is) checked fairly frequently at first, but these blood tests
will eventually be spaced out further once you are on a stable
dose of warfarin.
Changes to your medications:
STOP aspirin 81 mg daily
START warfarin 5 mg daily - this dose will be adjusted as needed
by your primary doctor based on your INR
START lovenox ___ mg injection every 12 hours for ___ days - you
will need to stay on this until your INR is high enough to stay
on warfarin alone
Followup Instructions:
___
|
10478984-DS-20 | 10,478,984 | 27,995,981 | DS | 20 | 2194-09-19 00:00:00 | 2194-09-19 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd pain LLQ
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with DM, depression, insomnia, epigastric
pain/dyspepsia undergoing workup, arthritis, diverticulosis, who
presents with 3 days of worsening LLQ abdominal pain and
bloody/mucousy stools.
She was in her usual state of fairly good health until 3 days
ago
when she began to notice LLQ abdominal pain. It would come and
go. It became increasingly severe and she described it as a
"strong pain." It was associated with a need to use the
bathroom,
though when she would go she passed only scant bright red blood
and some mucus. Pain worsened to the point where she had
difficulty sleeping. She ultimately decided to come to the ED
for
further eval.
In the ED, she had stable vital signs. Labs showed mild
leukocytosis. Imaging with CT abdomen showed diverticulitis. She
was admitted for IV antibiotics.
REVIEW OF SYSTEMS
A full 10 point review of systems was performed and is otherwise
negative except as noted above.
Past Medical History:
DIABETES TYPE II
? UTERINE PROLAPSE
DEPRESSION
POSITIVE PPD
HEADACHE
PERIAORTIC CALCIFICATIONS
RENAL CALCULUS
R FOOT/ANKLE FX
ATYPICAL CHEST PAIN
DEPRESSION
KNEE PAIN
Social History:
___
Family History:
Family history was reviewed and is thought impertinent to
current
presentation. She reports + for DM.
Physical Exam:
Vitals: ___ Temp: 99.7 PO BP: 134/75 HR: 87 RR: 16 O2
sat: 97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: Very tender in LLQ with some involuntary guarding. Mildly
distended. No rebound tenderness. Soft, BS+. No HSM.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Thought linear.
GU: No foley
Pertinent Results:
___ 12:00AM BLOOD WBC-5.1 RBC-4.37 Hgb-10.8* Hct-34.7
MCV-79* MCH-24.7* MCHC-31.1* RDW-14.6 RDWSD-42.3 Plt ___
___ 09:06AM BLOOD Neuts-74.3* Lymphs-16.9* Monos-7.8
Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.24* AbsLymp-2.10
AbsMono-0.97* AbsEos-0.05 AbsBaso-0.03
___ 12:00AM BLOOD ___ PTT-31.1 ___
___ 05:12AM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-143
K-4.6 Cl-105 HCO3-27 AnGap-11
___ 09:06AM BLOOD ALT-15 AST-14 AlkPhos-75 TotBili-0.7
___ 09:06AM BLOOD Lipase-31
___ 05:12AM BLOOD Mg-1.8
___ 09:19AM BLOOD Lactate-1.3
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
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.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
appendix is
normal.
There is extensive wall thickening associated with surrounding
fat stranding
involving a 7 cm segment of sigmoid colon in the lower mid
pelvis (2:70).
This is associated with small volume free fluid in the pelvis
(2:75). There
is no intraperitoneal free air. No fluid collections are
identified.
PELVIS: The urinary bladder is distended, without abnormal wall
thickening.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within
normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy. Calcified lymph nodes
are again
seen in the mesentery, unchanged from prior.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. A
sclerotic focus in the left L5 transverse process is unchanged
and likely
represents a bone island.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Acute uncomplicated sigmoid diverticulitis. No
intraperitoneal free air or
fluid collections.
2. If not recently performed, recommend colonoscopy after
resolution of acute
process exclude underlying mass.
RECOMMENDATION(S): Colonoscopy after resolution of acute
process, if not
recently performed.
Brief Hospital Course:
This is a ___ woman with DM2, depression, insomnia, epigastric
pain/dyspepsia undergoing workup, arthritis, diverticulosis, who
presents with 3 days of worsening LLQ abdominal pain and
bloody/mucousy stools, found to have acute diverticulitis
Acute diverticulitis:
Consistent with her sxs of LLQ pain with guarding and
bloody/mucous stool. She had no signs of complications
(abscess, perforation). She was treated initially with
CTX/Flagyl and bowel rest with definitive improvement after 48
hrs. She was transitioned to Cipro/Flagyl to complete a 10 day
course. She will need a colonoscopy following resolution of her
diverticulitis in ___ weeks, which can be combined with her EGD
which was cancelled due to her hospitalization.
DM2 uncomplicated: Stable
- Held metformin. resumed on DC
- ISS while here
Depression: Stable
- Continued paxil
Insomnia: Stable, though she reports incomplete response to
nortriptyline PRN.
- Trial Trazodone PRN insomnia
Intermittent epigastric pain and burning: EGD should be
rescheduled with colonoscopy in ___ weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO BID
2. PARoxetine 10 mg PO DAILY
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
over the counter
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
through ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
through ___
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*18 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe
avoid with alcohol or driving.
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
5. MetFORMIN XR (Glucophage XR) 500 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. PARoxetine 10 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Acute sigmoid diverticulitis
Epistaxis
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with inflammation in your colon from
diverticulitis. With antibiotics and pain control you have
improved. Please complete the course of antibiotics and follow
up closely with your doctor. Please eat a low fiber diet.
As we discussed, we recommend a follow up colonoscopy in ___
weeks to make sure your colon is healed. Your EGD test can be
scheduled at the same time. Please see your PCP to schedule
this test.
Followup Instructions:
___
|
10479570-DS-12 | 10,479,570 | 23,221,862 | DS | 12 | 2137-09-15 00:00:00 | 2137-09-15 13:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Latex
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: TIPS approach SMV thrombolysis catheter placement
___: SMV plasty to 10 mm, 10 mm TIPS placed - final PSG of 9
mmHg
History of Present Illness:
Mr. ___ is a ___ year old male with PMH significant for CVA
with ongoing left sided paralysis, bipolar disorder, T2DM,
hypothyroidism, hypertension, and BPH who presents with
abdominal pain. Patient states he had gradual onset of
periumbilical abdominal pain moderate in severity nonradiating
associated with nausea but no vomiting. He denies fevers chills
chest pain or shortness of breath. He has had a few episodes of
diarrhea since that time. Was in normal state of health prior to
this episode.
In the ED, initial vitals were: T 98.2, HR 62, BP 156/74, RR 18,
SpO2 98% on 2L NC
- Exam notable for:
Normocephalic atraumatic
Neck supple
Left-sided paralysis
Clear to auscultation bilaterally
Regular rate and rhythm
Soft with tenderness palpation of the periumbilical area
2+ pulses bilaterally
- Labs notable for: WBC 10.3, Hgb 15.9, Hct 45.7, Plt 124, Na
142, K 4.1, HCO3 21, BUN 15, Cr 0.6, ALT 30, AST 25, Lip 18,
Tbili 0.9, lactate 1.4
- Imaging was notable for:
CT ABD & PELVIS WITH CONTRAST:
1. Nonocclusive thrombus centered in the portal venous
confluence extending into the splenic vein, main portal vein and
the superior mesenteric vein. There is complete occlusion of the
more caudal superior mesenteric vein with associated upstream
hyperemia and bowel wall thickening involving numerous loops of
small bowel in the right mid abdomen and right lower quadrant.
No definite colonic wall thickening. Ascites in borderline
enlarged lymph nodes in the upper abdomen and the mesentery are
likely reactive.
2. Mild splenomegaly also may be due to impaired venous return.
3. Consolidation lingula could just represent atelectasis and
scarring but assessment is limited and based on the morphology
this could also represent pneumonia.
CXR:
Increased airspace opacity at the left costophrenic angle, is
concerning for pneumonia.
- Patient was given: heparin gtt, docusate 100mg, levothyroxine
200 mcg, lisinopril 10mg, baclofen 10mg, oxcarbazepine 300mg,
topiramate 50mg
Upon arrival to the floor, patient reports ongoing abdominal
pain. Pain started yesterday evening and has remained steady.
Endorses nausea and diarrhea yesterday but neither today.
Continues to pass flatus. Denies any hematochezia or melena.
Endorses poor appetite since yesterday. Pain has remained steady
and has not worsened or improved since yesterday.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
CVA
Hypertension
Hypothyroidism
Cirrhosis with h/o varices
T2DM
GERD
BPH
HLD
History of substance abuse (alcohol, narcotics)
Bipolar disorder
Lumbar fusion
Social History:
___
Family History:
Sister with stroke at age ___ (but was born premature and was
felt to have a weak blood vessel). She also had severe
scoliosis which required surgery.
Another sister with a cerebellar stroke at age ___ (?) neck
injury.
Another sister with type I diabetes.
Thyroid disease.
Father with carotid artery disease and MI at ___ (drinker and
smoker)
Mother died of pancreatic cancer at ___ yo.
Mother's side with cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITAL SIGNS: ___ 1340 Temp: 98.3 PO BP: 156/81 Lying HR:
66
RR: 18 O2 sat: 95% O2 delivery: 1l FSBG: 126
GENERAL: well developed male, NAD
HEENT: NC/AT. PERRL. EOMI. Poor dentition. MMM.
NECK: Supple. No elevation of JVD.
CARDIAC: RRR. Normal S1 and S2. No MGR.
LUNGS: CTAB. Nonlabored respirations.
ABDOMEN: Soft, hypoactive bowel sounds, tenderness to palpation
in RUQ and RLQ, no rebound/guarding
EXTREMITIES: no lower extremity edema.
NEUROLOGIC: residual left sided deficits with inability to move
left arm/leg against gravity, raises eyebrows bilaterally, smile
asymmetric with left not rising as high as right
SKIN: no discernible rashes.
DISCHARGE PHYSICAL EXAM:
===========================
Vitals: 24 HR Data (last updated ___ @ 824)
Temp: 98.1 (Tm 98.9), BP: 112/66 (112-131/63-80), HR: 79
(76-85), RR: 18, O2 sat: 96% (96-99), O2 delivery: Ra, Wt:
154.98
lb/70.3 kg
GENERAL: NAD, resting in bed, awake and alert, attentive
HEENT: NC/AT. No scleral icteruc
CARDIAC: RRR. Normal S1 and S2.
PULM: CTAB. Nonlabored respirations.
GI: Abdomen soft, nontender to palpation, no guarding, no
distension
EXTREMITIES: no lower extremity edema
NEUROLOGIC: residual left sided deficits with inability to move
left arm/leg against gravity (R side normal), asymmetric smile
(L lower facial droop). A+Ox3. No asterixis. DOWB intact but
slow. Slow speech.
Pertinent Results:
ADMISSION LABS:
====================
___ 04:30AM BLOOD WBC-10.3* RBC-5.08 Hgb-15.9 Hct-45.7
MCV-90 MCH-31.3 MCHC-34.8 RDW-15.3 RDWSD-50.2* Plt ___
___ 04:30AM BLOOD Neuts-85.2* Lymphs-6.7* Monos-7.3
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.73* AbsLymp-0.69*
AbsMono-0.75 AbsEos-0.00* AbsBaso-0.02
___ 05:35AM BLOOD ___ PTT-30.1 ___
___ 04:30AM BLOOD Glucose-183* UreaN-15 Creat-0.6 Na-142
K-4.1 Cl-108 HCO3-21* AnGap-13
___ 04:30AM BLOOD ALT-30 AST-25 AlkPhos-129 TotBili-0.9
___ 04:30AM BLOOD proBNP-143
___ 04:30AM BLOOD cTropnT-<0.01
___ 04:30AM BLOOD Lipase-18
___ 04:30AM BLOOD Albumin-4.0
___ 05:53AM BLOOD Lactate-1.4
IMAGING/RESULTS:
===================
CT ABD & PELVIS WITH CONTRAST ___:
1. Nonocclusive thrombus centered in the portal venous
confluence extending into the splenic vein, main portal vein and
the superior mesenteric vein. There is complete occlusion of
the more caudal superior mesenteric vein with associated
upstream hyperemia and bowel wall thickening involving numerous
loops of small bowel in the right mid abdomen and right lower
quadrant. No definite colonic wall thickening. Ascites and
borderline enlarged lymph nodes
in the upper abdomen and the mesentery are likely reactive.
2. Mild splenomegaly also may be due to impaired venous return.
3. Consolidation in the lingula could just represent atelectasis
and scarring but assessment is limited and based on the
morphology this could also represent pneumonia.
RUQUS ___:
Nonocclusive thrombus is seen at the junction of SMV, splenic
vein and portal vein. The main portal vein and intrahepatic
branches are fully patent.
There is evidence of ascites and splenomegaly, but the liver
itself shows no signs of cirrhosis and no focal abnormalities.
KUB ___:
No evidence of perforation. Persistent distention of several
small bowel
loops in the mid abdomen. Given the history portal vein
thrombosis and new rebound tenderness there is concern for bowel
ischemia, which is not well assessed with radiographs alone. CT
of the abdomen with IV contrast is more sensitive to detection
of the same.
RUQUS ___
The liver appears diffusely coarsened and nodular consistent
with known
cirrhosis. No focal liver lesions are identified. There is no
ascites. There is stable splenomegaly, with the spleen measuring
13.1 cm. There is no intrahepatic biliary dilation. The CHD
measures 4 mm. There is no evidence of stones or gallbladder
wall thickening.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
TIPS velocities are inaccurate as the patient could not hold his
breath and was somewhat combative during the examination.
Ranges of portal vein and intra-TIPS velocities are as follows:
Main portal vein: 40 cm/sec.
Proximal TIPS: 100 cm/sec.
Mid TIPS: 100-120 cm/sec.
Distal TIPS: 80 cm/sec.
Flow within the left portal vein is towards the TIPS shunt. Flow
within the right anterior portal vein is towards the TIPS.
Appropriate flow is seen in the hepatic veins and IVC.
MICROBIOLOGY
========================
___ 3:51 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
DISCHARGE LABS
==========================
___ 06:15AM BLOOD WBC-4.5 RBC-3.50* Hgb-10.6* Hct-31.5*
MCV-90 MCH-30.3 MCHC-33.7 RDW-16.4* RDWSD-52.5* Plt Ct-87*
___ 06:03AM BLOOD ___ PTT-43.7* ___
___ 06:03AM BLOOD Glucose-99 UreaN-8 Creat-0.5 Na-144 K-4.0
Cl-111* HCO3-19* AnGap-14
___ 06:03AM BLOOD ALT-64* AST-45* AlkPhos-206* TotBili-0.6
___ 06:15AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
Brief Hospital Course:
Mr. ___ is a ___ year old male with PMH significant for CVA
with ongoing left sided paralysis, bipolar disorder, T2DM,
hypothyroidism, hypertension, and BPH who presents with acute
onset abdominal pain and was subsequently found to have portal
venous thrombus extending into the splenic vein, main portal
vein and the superior mesenteric vein. He underwent catheter
directed thrombolysis and TIPS procedure. Course was complicated
by hepatic encephalopathy and Enterococcus UTI.
ACUTE ISSUES:
==================
#Portal venous thrombus
#Cirrhosis with h/o varices
Patient presented with new onset abdominal pain, and found to
have portal venous thrombus extending into the splenic vein,
main portal vein and the superior mesenteric vein. Vascular
surgery and general surgery were consulted in ED and recommend
ongoing AC with close monitoring. Patient was admitted to
medicine service for ongoing anticoagulation with heparin gtt.
Hematology-oncology was consulted and patient underwent
hypercoagulability work up with beta-glycoprotein and
anticardiolipin, both of which were negative. His pain improved
with bowel rest and lactate remained stable. However, his pain
worsened once diet was advanced to clear liquids. Hepatology and
___ were then consulted, and patient went for abdominal venogram
with catheter directed thrombolysis on ___. He was transferred
to ICU for monitoring. He then underwent TIPS procedure on ___.
He should continue Anticoag for 3 months, follow up with ___ in
one month, and see Hepatology as an outpatient. Per discussion
with Hepatology, Nadolol should be held now that his portal
venous system is decompressed. He is being discharged with
Lovenox bridge to warfarin; Lovenox can be stopped once INR is
2.0.
#Hepatic Encephalopathy
After his procedure, the patient developed hepatic
encephalopathy with asterixis, lethargy, and increased
confusion. At that point he was started on lactulose and
rifaximin, and infectious workup was done, which was notable for
Enterococcus UTI. With above treatment his mental status
returned to normal. He remained stable, in terms of mental
status and bowel movements, on Lactulose three times daily and
Rifaximin BID.
#Enterococcus UTI
This was identified as part of the infectious workup which was
done when he developed hepatic encephalopathy. The enterococcus
was Amp-sensitive, and he was started on Amoxicillin for a 7 day
course, which will need to be completed as outpatient, last day
___.
#Microscopic Hematuria
This was likely related to foley catheter placement and UTI.
Recommend to repeat a UA after completing antibiotics, and
consider Urology eval if still has microscopic hematuria.
#BPH
Had foley placed in ED. He was continued on Flomax and had foley
in place until procedures were completed. He was later able to
successfully complete a void trial.
#HTN
Home Lisinopril currently on hold as he was normotensive without
it.
#DM
Patient on metformin and glargine 15u at home, which should be
continued on discharge.
# hypernatremia: developed mild hypernatremia while
encephalopathic, improved with IVF (D51/2 and then D5W) while
encephalopathic and then with resolution of encephalopathy.
CHRONIC ISSUES:
==================
#Bipolar disorder
#Anxiety
Continue home mirtazapine, oxcarbazepine, topiramate,
venlafaxine
#CVA
#Muscle spasms
Continue home ASA, rosuvastatine. Continue home baclofen,
diazepam, gabapentin, pramipexole.
#Hypothyroidism
Continue home synthroid.
#GERD
Continue home omeprazole.
TRANSITIONAL ISSUES:
=======================
- Anticoagulation:
--- Warfarin 7.5mg daily (can be adjusted as needed based on
INR)
--- Lovenox ___ daily (to be stopped once INR is 2.0)
--- Discharge INR=1.8
- ___ Interventional Radiology would like to f/u with the
patient in one month to monitor his TIPS. They will call to
schedule, but can be reached at ___
- Plan for 3 months of anticoagulation, then re-assessing the
need for ongoing anticoagulation (anticoag was started ___
- Last day of Amoxicillin for UTI: ___
- Patient should follow up with Hepatology as an outpatient. Per
discussion with PCP, this will be arranged by PCP at ___.
- Nadolol on hold given portal venous system is now decompressed
(per Hepatology)
- Patient should follow up with Hematology as an outpatient.
This is currently scheduled for ___, but could be changed to
___ if PCP/patient prefers
- Hepatitis B panel showed he is non immune to Hepatitis B,
would consider vaccination as outpatient
- F/u microscopic hematuria as outpatient to ensure this
normalizes following treatment of UTI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 50 mg PO BID
2. Thera-M
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3. Tamsulosin 0.4 mg PO QHS
4. Senna 17.2 mg PO DAILY
5. Rosuvastatin Calcium 20 mg PO QPM
6. OXcarbazepine 300 mg PO BID
7. Nadolol 40 mg PO DAILY
8. Mirtazapine 30 mg PO QHS
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Lisinopril 10 mg PO DAILY
11. Levothyroxine Sodium 200 mcg PO DAILY
12. Gabapentin 300 mg PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
15. Docusate Sodium 100 mg PO BID
16. Diazepam 1 mg PO QHS
17. Baclofen 20 mg PO TID
18. Vitamin B-1 (thiamine HCl (vitamin B1)) 100 mg oral DAILY
19. Aspirin 81 mg PO DAILY
20. Glargine 15 Units Breakfast
21. Omeprazole 20 mg PO DAILY
22. Pramipexole 0.125 mg PO QPM
23. Venlafaxine XR 37.5 mg PO DAILY
24. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
25. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
26. Milk of Magnesia 15 mL PO Q12H:PRN Constipation - Second
Line
27. nystatin 100,000 unit/gram topical DAILY:PRN
28. TraMADol 25 mg PO Q6H:PRN Pain - Severe
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H Duration: 7 Days
Last day ___
2. Enoxaparin Sodium 100 mg SC Q24H
3. Lactulose 30 mL PO TID
4. Rifaximin 550 mg PO BID
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. Baclofen 20 mg PO TID
9. Diazepam 1 mg PO QHS
10. Docusate Sodium 100 mg PO BID
11. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
12. FoLIC Acid 1 mg PO DAILY
13. Gabapentin 300 mg PO BID
14. Glargine 15 Units Breakfast
15. Levothyroxine Sodium 200 mcg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Milk of Magnesia 15 mL PO Q12H:PRN Constipation - Second
Line
18. Mirtazapine 30 mg PO QHS
19. nystatin 100,000 unit/gram topical DAILY:PRN
20. Omeprazole 20 mg PO DAILY
21. OXcarbazepine 300 mg PO BID
22. Pramipexole 0.125 mg PO QPM
23. Rosuvastatin Calcium 20 mg PO QPM
24. Senna 17.2 mg PO DAILY
25. Tamsulosin 0.4 mg PO QHS
26. Thera-M
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ultivitamin,tx-iron-Ca-FA-min;<br>multivitamin,tx-iron-minerals)
___ mg oral DAILY
27. Topiramate (Topamax) 50 mg PO BID
28. TraMADol 25 mg PO Q6H:PRN Pain - Severe
29. Venlafaxine XR 37.5 mg PO DAILY
30. Vitamin B-1 (thiamine HCl (vitamin B1)) 100 mg oral DAILY
31. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until your blood pressures are stable
as an outpatient
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
================
Portal vein thrombosis
Hepatic encephalopathy
Hypernatremia
Enterococcus urinary tract infection
SECONDARY DIAGNOSES
=================
Cirrhosis
Hypertension
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you!
WHY WERE YOU ADMITTED?
- You were having abdominal pain.
WHAT HAPPENED DURING YOUR HOSPITALIZATION?
- You were found to have a blood clot in the blood vessels of
your abdomen.
- You were started on a medication to help prevent the clot from
growing.
- We placed a stent in your liver.
- You developed confusion, called hepatic encephalopathy, which
we treated by making you have bowel movements.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Continue to take all of your medications as prescribed.
- Follow up with all of your doctors as noted below.
- Continue taking Lovenox until your INR ("warfarin level") is
2.0 or higher.
Again, it was a pleasure to take care of you!
All the best,
Your ___ Team
Followup Instructions:
___
|
10479570-DS-13 | 10,479,570 | 25,527,016 | DS | 13 | 2138-06-16 00:00:00 | 2138-06-16 15:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Latex
Attending: ___.
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
bilateral ureteral stenting ___
History of Present Illness:
___ w/ CVA (L hemiplegia), bipolar, IDDM2, cirrhosis (HE, PVT on
___, EV) presents after fall w/ DKA, UTI, obstructing
nephrolithiasis.
He presents to the emergency department after being found down.
The patient presents from his skilled nursing facility
hypothermic after being found outside, where he fell out of his
wheelchair after being stuck in the snow. He was down for about
an hour before someone found him.
On arrival to the ED he was hypothermic with a rectal
temperature
of 31.9. His VBG 7.14/46 with lactate of 9.7. He was also found
to have FSBG 320 -> 425 with anion gap of 24 with ketonuria. He
was also noted to have a grossly inflammatory UA and
leukocytosis
to 14.
In the emergency department he was resuscitated aggressively
with
IVF and started on an insulin drip. His gap closed, and his
lactate trended down to 2.9. He was slowly rewarmed using a bear
hugger to a final temperature of 98.4. He was also appropriately
started on vancomycin and cefepime. CT of the head and neck did
not reveal any intracranial abnormalities but does demonstrate
old infarct. CT abd&pelvis demonstrated bilateral obstructing
calculus with bilateral hydronephrosis. Urology was consulted
who
will take the patient to the OR for stenting in the AM.
At the time of transfer, his vitals and labs are stable. He has
no anion gap and has received subcutaneous insulin. He has been
started on appropriate antibiotic therapy. His lactate has
trended down appropriately with fluids. He has completed
treatment for his DKA. The patient was evaluated by the ICU that
felt that he had no current ICU indications.
In the ED, initial vitals were:
___ HR:98 BP:153/100 RR:18 Spo2: 100% RA
- Exam:
Con: Shivering
HEENT: NCAT. no icterus.
Resp: Breathing comfortably on RA. No incr WOB, CTAB.
CV: RRR. No murmurs.
Abd: Soft, Nontender, Nondistended.
MSK: paresis of LUE and LLE, moves RUE and RLE to command. no ___
edema
Skin: No rash, Warm and dry.
Neuro: AOx3, speech fluent, no obvious facial asymmetry.
Psych: Normal mentation
- Labs:
WBC: 14.4
Hgb: 13.4
ALT: 47
Mg: 1.5
Anion gap: 24
Lactate: 9.7
Ph: 7.14
- Imaging:
CT Head W/O Contrast
1. No acute intracranial process.
2. Large area of encephalomalacia in the right cerebrum
consistent with prior right middle cerebral artery territorial
infarction.
CT C-Spine W/O Contrast
No acute cervical fracture or traumatic malalignment.
CT Abd & Pelvis With Contrast
1. No acute traumatic injury.
2. 1.0 cm obstructing calculus in the proximal right ureter with
moderate right hydronephrosis. Probable additional
nonobstructing
calculi in the right kidney.
3. 1.3 cm obstructing calculus in the left renal pelvis with
mild
left
hydronephrosis. Multiple left distal ureter calculi, just
proximal to the ureterovesical junction, measuring up to 0.6 cm
resulting in mild left hydroureter.
4. Associated urothelial thickening and hyperenhancement of the
right proximal ureter and left renal pelvis is likely
inflammatory in etiology, though correlation with urinalysis to
exclude infection is recommended.
5. Cirrhosis with splenomegaly and small volume ascites.
Gallbladder wall edema and ascending colonic wall edema is
likely
related to underlying liver disease.
6. Unchanged periportal lymphadenopathy, likely due to
underlying
liver disease.
CXR
Low lung volumes with mild bibasilar atelectasis. No focal
consolidation to suggest pneumonia.
- Micro:
UA: wbc 140, RBC >182, 1000glucose, 30 protein, Lg blood, leuk
sm
- ECG:
___: ECG: Unconfirmed ECG
-Consults:
-urology
-___
- Patient was given:
morphine sulfate
oxcarbazepine 300mg
atorvastatin 40mg
Vancomycin 1g
Cefepime 2g
___ @125/hr
Insulin
potassium repletion
mag repletion
On arrival to the floor, he confirms the history above. He
states
that he periodically has difficulty getting a stream going when
voiding. He denies dysuria, fevers. He states that he has some
reddish colored urine (for a few months). Denies any pain with
urination c/w nephrolithiasis. He states that he takes 5 ___ before he goes to bed every night. He states that he is
on
warfarin for PVT. he states that he does not use a CPAP at home
(OSA mentioned in facility notes).
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
CVA
Hypertension
Hypothyroidism
Cirrhosis with h/o varices
T2DM
GERD
BPH
HLD
History of substance abuse (alcohol, narcotics)
Bipolar disorder
Lumbar fusion
Social History:
___
Family History:
Sister with stroke at age ___ (but was born premature and was
felt to have a weak blood vessel). She also had severe
scoliosis which required surgery.
Another sister with a cerebellar stroke at age ___ (?) neck
injury.
Another sister with type I diabetes.
Thyroid disease.
Father with carotid artery disease and MI at ___ (drinker and
smoker)
Mother died of pancreatic cancer at ___ yo.
Mother's side with cancer.
Physical Exam:
======================
ADMISSION PHYSICAL EXAM
======================
VITALS: T 98.6 BP 129/72 HR 63 RR 18 94% Ra
GEN: Alert, cooperative, no distress, appears stated age
HENT: NC/AT, MMM. Nares patent, no drainage or sinus
tenderness.
EYES: PERRL, EOM intact, conjunctivae clear, no scleral
icterus.
NECK: No cervical lymphadenopathy. No JVD, no carotid bruit.
Neck
supple, symmetrical, trachea midline.
LUNG: CTA ___, good air movement, no accessory muscle use
HEART: RRR, Normal S1/S2, No M/R/G
ABD: Soft, non-tender, non-distended; nl bowel sounds; no
rebound
or guarding, no organomegaly
GU:Not examined
EXTRM: Extremities warm, no edema, no cyanosis, positive ___
pulses bilaterally
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: Tongue deviates to L, EOMI intact, uvula midline, unable
to
raise L shoulder, sensation intact to face, mild dysarthria, no
facial droop. LUE w/ contracture, ___ strength, LLE w/ ___
strength. ___ R upper and lower extremity. sensation intact b/l
upper and lower extremities.
PSYC: Mood and affect appropriate
======================
DISCHARGE PHYSICAL EXAM
======================
24 HR Data (last updated ___ @ 355)
Temp: 97.1 (Tm 98.6), BP: 100/57 (92-114/50-66), HR: 56
(54-67), RR: 18 (___), O2 sat: 94% (92-95), O2 delivery: Ra
HEENT: NC/AT, sclera anicteric and without injection
PULM: breathing comfortably on room air, CTAB
CARDIAC: normal rate, regular rhythm, normal S1 and S2, no m/r/g
ABD: soft, non-distended, non-tender
EXTRM: WWP, no ___ edema
Back: Stage 2 sacral decubitus ulcer 4x6 cm on left buttock
NEUR: Alert and grossly oriented. Mild left sided facial droop.
Patient cannot move left arm or leg.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 06:44AM ___ PTT-34.5 ___
___ 06:44AM PLT COUNT-143*
___ 06:44AM NEUTS-69.2 ___ MONOS-5.5 EOS-0.6*
BASOS-0.6 IM ___ AbsNeut-10.00* AbsLymp-3.20 AbsMono-0.79
AbsEos-0.09 AbsBaso-0.08
___ 06:44AM WBC-14.4* RBC-4.83 HGB-13.4* HCT-42.5 MCV-88
MCH-27.7 MCHC-31.5* RDW-18.9* RDWSD-59.6*
___ 06:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 06:44AM ALBUMIN-4.4 CALCIUM-10.0 PHOSPHATE-3.9
MAGNESIUM-1.5*
___ 06:44AM cTropnT-<0.01
___ 06:44AM LIPASE-39
___ 06:44AM ALT(SGPT)-47* AST(SGOT)-39 CK(CPK)-125 ALK
PHOS-128 TOT BILI-0.7
___ 06:44AM estGFR-Using this
___ 06:44AM GLUCOSE-448* UREA N-17 CREAT-0.9 SODIUM-147
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-14* ANION GAP-24*
___ 06:54AM estGFR-Using this
___ 06:54AM LACTATE-9.7* CREAT-0.7 K+-3.7
___ 06:54AM ___ PO2-47* PCO2-46* PH-7.14* TOTAL
CO2-17* BASE XS--13
___ 08:42AM URINE MUCOUS-RARE*
___ 08:42AM URINE RBC->182* WBC-140* BACTERIA-FEW*
YEAST-NONE EPI-0
___ 08:42AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-30*
GLUCOSE-1000* KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 08:42AM URINE COLOR-Red* APPEAR-Hazy* SP ___
___ 08:42AM URINE UHOLD-HOLD
___ 08:42AM URINE HOURS-RANDOM
___ 08:51AM O2 SAT-85
___ 08:51AM GLUCOSE-358* LACTATE-6.6* NA+-142 K+-4.5
CL--116* TCO2-16*
___ 08:51AM ___ PH-7.30*
___ 11:11AM O2 SAT-82
___ 11:11AM GLUCOSE-285* LACTATE-2.9* NA+-140 K+-4.2
CL--114* TCO2-19*
___ 11:11AM ___ PH-7.40
___ 03:35PM CK(CPK)-475*
___ 03:35PM GLUCOSE-84 UREA N-16 CREAT-0.7 SODIUM-146
POTASSIUM-6.5* CHLORIDE-121* TOTAL CO2-17* ANION GAP-8*
___ 03:41PM O2 SAT-82
___ 03:41PM GLUCOSE-80 NA+-140 K+-5.9* CL--123* TCO2-19*
___ 03:41PM ___ PH-7.42
___ 09:33PM GLUCOSE-128* LACTATE-0.9 CREAT-0.7 NA+-141
K+-3.5 CL--119* TCO2-21
================
PERTINENT STUDIES
================
CXR ___
Low lung volumes with mild bibasilar atelectasis. No focal
consolidation to
suggest pneumonia.
CT C-spine w/o contrast ___
No acute cervical fracture or traumatic malalignment.
CT a/p w/ contrast ___
1. No acute traumatic injury.
2. 1.0 cm obstructing calculus in the proximal right ureter with
moderate
right hydronephrosis. Probable additional nonobstructing
calculi in the right
kidney.
3. 1.3 cm obstructing calculus in the left renal pelvis with
mild left
hydronephrosis. Multiple left distal ureter calculi, just
proximal to the
ureterovesical junction, measuring up to 0.6 cm resulting in
mild left
hydroureter.
4. Associated urothelial thickening and hyperenhancement of the
right proximal
ureter and left renal pelvis is likely inflammatory in etiology,
though
correlation with urinalysis to exclude infection is recommended.
5. Cirrhosis with splenomegaly and small volume ascites.
Gallbladder wall
edema and ascending colonic wall edema is likely related to
underlying liver
disease.
6. Unchanged periportal lymphadenopathy, likely due to
underlying liver
disease.
___ ___
1. No acute intracranial process.
2. Large area of encephalomalacia in the right cerebrum
consistent with prior
right middle cerebral artery territorial infarction.
RUQUS w/ doppler ___
1. The TIPS appears occluded, with no definite color or Doppler
flow.
2. Patent main portal vein.
3. Stable splenomegaly.
============
MICROBIOLOGY
============
___ Blood Culture: Blood Culture, Routine (Final ___:
NO GROWTH.
___ Blood Culture: Blood Culture, Routine (Final
___: NO GROWTH.
__________________________________________________________
___ 8:42 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Urine Culture:
URINE CULTURE (Final ___: NO GROWTH.
INTERVAL LABS:
==============
___ 09:13AM BLOOD %HbA1c-8.3* eAG-192*
___ 08:35AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
IgM HAV-PND
___ 08:35AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 08:35AM BLOOD ___
___ 08:35AM BLOOD IgG-774 IgA-159 IgM-87
___ 08:35AM BLOOD tTG-IgA-5
___ 08:35AM BLOOD HCV Ab-NEG
___ 01:09PM BLOOD HCV VL-NOT DETECT
DISCHARGE LABS:
=================
___ 06:15AM BLOOD WBC-2.8* RBC-3.65* Hgb-10.4* Hct-31.8*
MCV-87 MCH-28.5 MCHC-32.7 RDW-18.6* RDWSD-57.8* Plt Ct-82*
___ 06:15AM BLOOD Plt Ct-82*
___ 06:15AM BLOOD ___ PTT-28.1 ___
___ 06:15AM BLOOD Glucose-200* UreaN-14 Creat-0.7 Na-141
K-3.9 Cl-112* HCO3-20* AnGap-9*
___ 06:15AM BLOOD ALT-132* AST-91* LD(LDH)-163 AlkPhos-165*
TotBili-0.4
___ 06:15AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.5* Mg-1.5*
Brief Hospital Course:
___ w/ CVA (L hemiplegia), bipolar, IDDM2, cirrhosis (HE, PVT on
___, EV) presents after fall w/ hypothermia, DKA, presumed UTI,
and bilateral obstructing nephrolithiasis.
#DKA
#DMII
The patient was originally found down outside after an unknown
period of time (1 hr per patient). The patient did have an anion
gap and blood sugars in the 400s with a pH of 7.14 and a lactate
of 9.7. In the ED the patient received IV fluids and was started
on an insulin drip with subsequent closure of his anion gap,
normalization of his ph, blood glucose and lactate. Etiology of
his DKA includes possible medication non-adherence iso being
found down. HbA1c performed 8.3%. He was started on his home
dose of glargine with insulin sliding scale once sugars
normalized. We held his home linagliptin and metformin while
inpatient, to be restarted on discharge. Home glargine increased
to 6U prior to discharge.
#Bilateral obstructing neprholithiasis s/p bilateral ureteral
stenting
#Post-procedural hematuria
The patient presented after being found down with leukocytosis,
inflammatory UA and CT a/p demonstrating bilateral obstructing
calculi with bilateral hydronephrosis. The patient has a history
of enterococcus sensitive to vanc and the patient was started on
vanc/cefepime, subsequently switched to Unasyn per pharmacy
recommendations. Underwent bilateral ureteral stenting with
urology on ___. Initially had post-procedural hematuria,
which resolved. Urine culture with no growth x 2 so Unasyn
ultimately d/c'd. He will follow-up with urology as outpatient
(Dr. ___ for planned lithotripsy. Will need medical
clearance to ensure okay for patient to be off Coumadin prior to
procedure.
#Cirrhosis (complicated by HE, PVT, and varicies)
#Hx of portal venous thrombus
#Transaminitis
The patient has a history of alcoholic cirrhosis complicated by
hepatic encephalopathy, esophageal varices, pvt for which he
takes warfarin at home. No evidence of HE on admission. Patient
developed transminitis during this admission and had a RUQ
ultrasound performed. The RUQUS showed an occluded TIPS with
patent portal vein. Mr. ___ outpatient physician, ___.
___ us that the patient developed worsening
encephalopathy after TIPS procedure and underwent a TIPS
down-size procedure at ___. Based on this information, we did
not pursue additional intervention to open up the TIPS this
admission. Patient will follow-up with Hepatology at ___. Given
the persistent transaminitis, hepatology service consulted with
concern for infectious etiology vs. drug-induced liver injury.
Hep A IgG positive ___ IgM pending at discharge), HepB
serologies negative (non-immune), HepC normal. Serum
immunoglobulins, ___, AMA, TTGA unremarkable. Liver
enzymes started to improve prior to discharge, supporting most
likely diagnosis of drug-induced liver injury likely secondary
to Unasyn. He will need follow-up with his hepatologist at ___
going forward regarding possible TIPS revision in future.
#Grade 2 Sacral Decubitus Ulcer
Patient noted to have sacral decubitus ulcer with blistering.
Evaluated by wound care and continued to improve prior to
discharge
#bipolar disorder
Continued home topamax, oxcarbazepine, venlafaxine
#Hypothermia
Likely secondary to being down in the snow for an hour.
Corrected in ED with Bair Hugger.
#BENIGN PROSTATIC HYPERTROPHY
We continued his home tamsulosin 0.4 mg qd.
#GASTROESOPHAGEAL REFLUX
We continued his home omeprazole 20 mg qd.
#HYPERLIPIDEMIA
We continued his home atorvastatin 40 mg qd.
#HYPOTHYROIDISM
W continued his home Synthroid ___ mcg qd.
=================
TRANSITIONAL ISSUES
=================
#discharge WBC: 2.8
#discharge Hgb: 10.4
#discharge plt: 82
#discharge INR: 1.7
[] Please review finger stick trend and HgbA1c as an outpatient
and adjust glycemic control accordingly
[] Patient will need follow-up lithotripsy with urology. Urology
requesting medical clearance for patient to be off Coumadin
prior to procedure in setting of hx portal venous thrombosis.
Please contact office of Dr. ___ (___) to discuss
ongoing urology needs/clearance.
[] Please recheck LFTs in one week to ensure continuing to
improve. Presumed etiology drug-induced liver injury from Unasyn
[] Monitor Grade 2 sacral decubitus ulcer, with wound care as
needed
[] Please ensure patient has adequate follow-up with ___
hepatology to discuss possible TIPS revision in 1 month
# CODE: full
# CONTACT:
Health care proxy chosen: Yes
Name of health care proxy: ___
Relationship: sister Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 37.5 mg PO DAILY
2. Glargine 5 Units Breakfast
3. Anbesol (benzocaine) (benzocaine) 10 % mucous membrane TID
4. Atorvastatin 40 mg PO QPM
5. Baclofen 10 mg PO BID
6. Biofreeze (menthol) (menthol) 4 % topical BID:PRN rash
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Ibuprofen 400 mg PO BID:PRN Pain - Mild
10. Levothyroxine Sodium 125 mcg PO DAILY
11. linaGLIPtin 5 mg oral DAILY
12. melatonin 3 mg oral QHS
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. OXcarbazepine 300 mg PO BID
16. polyvinyl alcohol 1.4 % ophthalmic (eye) QID:PRN dry eyes
17. Rifaximin 550 mg PO BID
18. Tamsulosin 0.4 mg PO QHS
19. Thiamine 100 mg PO DAILY
20. Topiramate (Topamax) 50 mg PO BID
21. Warfarin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Glargine 6 Units Breakfast
2. Warfarin 13 mg PO DAILY16
3. Anbesol (benzocaine) (benzocaine) 10 % mucous membrane TID
4. Atorvastatin 40 mg PO QPM
5. Baclofen 10 mg PO BID
6. Biofreeze (menthol) (menthol) 4 % topical BID:PRN rash
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Ibuprofen 400 mg PO BID:PRN Pain - Mild
10. Levothyroxine Sodium 125 mcg PO DAILY
11. linaGLIPtin 5 mg oral DAILY
12. melatonin 3 mg oral QHS
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. OXcarbazepine 300 mg PO BID
16. polyvinyl alcohol 1.4 % ophthalmic (eye) QID:PRN dry eyes
17. Rifaximin 550 mg PO BID
18. Tamsulosin 0.4 mg PO QHS
19. Thiamine 100 mg PO DAILY
20. Topiramate (Topamax) 50 mg PO BID
21. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
================
PRIMARY DIAGNOSIS
================
hypothermia
diabetic ketoacidosis
bilateral obstructing nephrolithiasis
urinary tract infection
===================
SECONDARY DIAGNOSIS
===================
diabetes mellitus, type II
cirrhosis
history of portal vein thrombus
bipolar disorder
benign prostatic hypertrophy
gastroesophageal reflux
hyperlipidemia
hypothyroidism
Transaminitis
grade 2 sacral decubitus ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were here because you fell out of your wheelchair and were
down on the ground for an extended period of time in the cold.
When you arrived to our hospital, you were dangerously cold so
you were re-warmed. You also had a dangerously high blood sugar
so you were given insulin to bring down your blood sugar.
You were also found to have stones that were blocking the flow
of urine out of your kidneys. You underwent a procedure in which
stents were placed in your ureters (tubes that carry urine from
the kidneys) to undo the blockage caused by the stones. You will
need surgery at some point to get rid of the stones. You will
follow-up with urology to discuss this further.
Finally, your liver enzymes were abnormal. We believed the cause
to be one of the medications you received, as your liver
function was improving prior to discharge after stopping the
medication.
After you leave the hospital, you should take all of your
medications as prescribed and attend all of your scheduled
appointments.
Sincerely,
Your ___ care team.
Followup Instructions:
___
|
10480035-DS-19 | 10,480,035 | 26,368,286 | DS | 19 | 2179-05-22 00:00:00 | 2179-05-22 18:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
acetaminophen / Tylenol-Codeine
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
CT-GUIDED BIOPSY OF PARASPINAL MUSCULATURE
TUNNELED RIGHT INTERNAL JUGULAR LINE PLACEMENT
History of Present Illness:
HPI(4): Mr. ___ is a ___ male with chronic back
pain since an injury ___ years ago with h/o HTN, VT/VF arrest
s/p DES to mLAD and ICD ___ iCMP EF = ___, CVA with R
sided weakness, ETOH use disorder, recently admitted to ___ in
___ with MRSA bacteremia c/b septic pulmonary/splenic
and CNS emobli, AoCKD newly on HD. He was transferred initially
transferred from ___ to ___ for the
hospitalization above. At ___ he presented with recurrent ICD
firing and a newly depressed EF to ___ down from 40%. Given
the multiple ICD firings he was he was bloused with amiodarone
twice and taken to the cath lab which did not demonstrate an
unstable lesion. He was started on amiodarone and Lopressor.
Other QTC prolonging medications were held. His Cr rose from 3
to
___ s/p cath and renal was consulted He wast started on HD
dailiy
for ___ L femoral catheter. He was then found to have
MRSA bacteremia and treated with IV vancomycin. He underwent
aspiration of the R hip for which the gram stain and cultures
were negative.
Of note he was found to have a PFO with R to L shunt. TTE
negative for valvular lesions or endocarditis. PFO was not
closed
because of the septic nature of the emboli and it was not
thought
to be a cryptogenic event. The plan was to complete 6 weeks of
IV
abx until ___ since ICD removed. ICD was replaced during
that admission.
Post discharge his Cr was 3.94.
He was found to have a small R hemothorax along with R anterior
___ rib fractures. He was advised to avoid anticoagulation
heparin/lovenox/NOAC for 6 weeks post discharge ? secondary to
rib fractures and hemothorax.
QTC on discharge was 569.
Discharge weight was 140 lbs.
With regards to his anemia, he was found to have iron deficiency
anemia and received IV iron for 3 days. He was also given epogen
and received 1 U PRBCS. His discharge HCT was: 7.4/24.5.
.
He presented to an OSH on the day of presentation with worsening
back pain. Per the call in, he was unable to tell the physician
at the OSH ED his medical history. He presents with several days
of worsening low back pain radiating to his abdomen. He was
found to be hypotensive initial blood pressure of 89/60. He had
abdominal tenderness without rebound or guarding. Per his ED
call in: "He had absolutely no neurological findings rectal exam
was guaiac negative with normal tone."He was afebrile at 99 to
rectally. EKG showed lateral T wave inversions but a negative
troponin no chest or pulmonary complaints. He did not have any
neurological complaints.
He was found to anemic with a hemoglobin of 7.2 and hematocrit
25.6 normal platelets. His Cr was 3.35 his lactate was normal.
Troponin negative. The OSH was unable to get records to confirm
whether both his creatinine and HCT were chronic from ___.
CT without contrast revealed a thoracic aneurysm and an aortic
aneurysm with evidence of chronic ulcers there was no
no evidence on I minus study of leak but given his severe pain
hypotension and large aneurysm it was felt that aortic anneurysm
could not be ruled out. He was thus transferred to ___ for a
vascular surgery evaluation.
At the OSH he received fentanyl and 1 U PRBCS.
.
Upon arrival to ___ VS:
96.8|64|122/64|24|97% RA
.
He had a CTA abdomen performed which demonstrated: "Diffuse
dilation of the thoracic aorta measuring up to 5.3 x 4.4 cm in
the mid descending thoracic aorta and up to 3.7 x 4.0 cm at the
infrarenal abdominal aorta. No evidence of acute rupture or
dissection."
He was seen by vascular surgery in the ED with the following
recommendations:
"Please work patient for pain ethology and hydrate as he had
high
creatinine on arrival and received contrast for CTA. There is no
need for vascular surgical intervention.
Plan: - workup pain etiology,
- IVF
- BP control
- No vascular surgical intervention needed"
.
In the ED he received:
IV Fentanyl Citrate 50 mcg X 2, IVF LR 1000 mL/
IV HYDROmorphone .5 mg x 2/
.
He does not report fevers, chills, chest pain, shortness of
breath. He has mild abdominal pain ___ only when pressed. He
reports severe b/l lower pain which radiates to his rectum. He
was hospitalized in ___ and lost a lot of weight then. He has
been unable to sleep because of the pain. No night sweats. He
denies urinary or bowel incontinence. He has chronic
constipation
and moves his bowels once ever 5 days. His last BM was a week
ago. He declined bowel meds overnight. He denies new weakness.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
s/p fall with R hip fracture and R humerus fracture in ___.
These were managed non-operatively given his recent ___.
Essential hypertension
Cardiac defibrillator in place
Central retinal artery occlusion
Cerebral artery occlusion with cerebral infarction
Ischemic cardiomyopathy EF = ___ in ___ down from 40%
thought to be secondary to sepsis.
Prolonged QT interval syndrome
Pseudoaneurysm of aorta
Status post insertion of drug-eluting stent into left anterior
descending artery in the setting of a V TACH arrest ___
Chronic systolic congestive heart failure
Ventricular tachycardia
Paralytic syndrome, post-stroke
AICD discharge
Respiratory
Chronic pulmonary edema
Endocrine
Pure hypercholesterolemia
Generalized gouty arthritis
Hypokalemia
Neuro and EENT
Insomnia
Mild cognitive impairment
Hemiplegia affecting dominant side, post-stroke
Vitreous hemorrhage, left
Lacunar infarction
Gastrointestinal
Adenomatous polyposis coli
Genitourinary
CKD (chronic kidney disease) stage 5, GFR less than 15 ml/min
Acute kidney injury superimposed on chronic kidney disease
Infectious Disease
History of MRSA infection
Behavioral and Developmental
Current moderate episode of major depressive disorder
Problem related to lifestyle
Opioid abuse
Musculoskeletal
T12 compression fracture
Dermatology
Pruritus
Maceration of skin
Xerosis cutis
Other
Foot-drop
Alcohol use disorder
History of CVA (cerebrovascular accident)
Social History:
___
Family History:
His father died of an MI at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS: 98.8, 164/80, 66, RR = 18, O2sat could not be obtained.
His hands are being warmed currently.
GENERAL: Alert and in no apparent distress. He looks ___
years
older than his stated age.
EYES: R pupil is surgical and L pupil is non-reactive
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. MMM.
CV: Heart regular, no murmur, no S3, no S4 but his heart sounds
are faint.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, + tenderness in the epigastrium
with palpation. There is no rebound or guarding.
RECTUM: Vault empty of stool. Preserved rectal tone. There is no
saddle anesthesia.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
in
LUE and grossly diminished ___ and contracted c/w old stroke.
Tenderness of thoracic spine to palpation.
Pain of R hip joint with palpation.
Pedal pulses are not easily appreciated b/l but they are
dopplerable. Both feet are warm. He does not have any hair on
his legs.
SKIN: Dry skin with multiple excoriations noted.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout. There is no evidence of delirium and he is an
appropriate historian.
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1427)
Temp: 98.2 (Tm 98.2), BP: 132/78 (125-159/72-85), HR: 76
(58-76), RR: 16 (___), O2 sat: 95% (95-99), O2 delivery: RA
Gen: Cachectic, in no apparent distress. Appears older than his
stated age.
HENT: NCAT. PICC line in place, dressing over previous tunneled
CVL is clean, dry and without drainage, no erythema or drainage
from site.
Eyes: Conjunctiva clear. L pupil 2mm. Surgical right pupil is
fixed and dilated.
CV: RRR. No m/r/g.
Resp: Lungs distant breath sound throughout. Breathing
non-labored.
Ext: No ___ edema or erythema. Legs are thin with muscle wasting.
Skin: Numerous excoriations in various stages of healing with
dry, cracked skin throughout.
Neuro: Face symmetric. AOx3. ___ strength in RUE with
contracture/withering. ___ strength in RLE. Sensation intact in
upper and lower extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:30AM BLOOD WBC-8.8 RBC-2.65* Hgb-6.8* Hct-23.3*
MCV-88 MCH-25.7* MCHC-29.2* RDW-16.7* RDWSD-53.1* Plt ___
___ 10:20AM BLOOD Neuts-61.5 Lymphs-13.7* Monos-10.0
Eos-13.5* Baso-0.6 Im ___ AbsNeut-4.25 AbsLymp-0.95*
AbsMono-0.69 AbsEos-0.93* AbsBaso-0.04
___ 03:30AM BLOOD ___ PTT-30.9 ___
___ 03:30AM BLOOD Glucose-136* UreaN-38* Creat-2.9* Na-138
K-3.8 Cl-97 HCO3-29 AnGap-12
___ 10:20AM BLOOD ALT-13 AST-15 LD(LDH)-130 AlkPhos-81
TotBili-0.3
___ 03:30AM BLOOD Albumin-2.8* Calcium-9.1 Phos-3.2 Mg-1.8
___ 06:20AM BLOOD calTIBC-152* VitB12-573 Ferritn-1192*
TRF-117*
___ 06:20AM BLOOD TSH-9.5*
___ 10:20AM BLOOD T4-10.0 T3-67*
___ 03:30AM BLOOD CRP-100.7*
PERTINENT INTERVAL LABS:
========================
___ 11:28AM BLOOD Glucose-82 UreaN-31* Creat-3.1* Na-140
K-4.4 Cl-101 HCO3-24 AnGap-15
___ 05:55AM BLOOD CK(CPK)-15*
___ 10:08AM BLOOD CRP-67.5*
___ 12:40PM BLOOD Vanco-6.6*
___ 05:14PM BLOOD Vanco-8.0*
___ 03:22PM BLOOD Vanco-14.4
___ 01:22PM BLOOD Lactate-0.9
DISCHARGE LABS:
===============
___ 08:05AM BLOOD WBC-8.2 RBC-2.56* Hgb-7.2* Hct-23.7*
MCV-93 MCH-28.1 MCHC-30.4* RDW-20.1* RDWSD-67.7* Plt ___
___ 08:05AM BLOOD Neuts-63.0 Lymphs-12.7* Monos-10.3
Eos-12.4* Baso-1.2* Im ___ AbsNeut-5.19 AbsLymp-1.05*
AbsMono-0.85* AbsEos-1.02* AbsBaso-0.10*
___ 08:05AM BLOOD Glucose-66* UreaN-31* Creat-2.1* Na-142
K-4.0 Cl-105 HCO3-21* AnGap-16
___ 08:05AM BLOOD CK(CPK)-42*
___ 08:05AM BLOOD Calcium-7.0* Phos-2.4* Mg-2.2
___ 08:05AM BLOOD CRP-16.4*
IMAGING:
========
MRI CERVICAL, THORACIC ___
IMPRESSION:
1. Persistent findings of osteomyelitis/discitis at T11-T12 and
possibly
T12-L1 with slightly decreased size of the epidural abscess and
cord
compression at the level of T11-T12 and slightly reduced
prevertebral soft
tissue swelling extending from T10-T11 to the level of L1-L2.
2. Similar probable discitis/osteomyelitis at the level of C5-C6
and T7-T8
with prevertebral soft tissue swelling. Additional areas of
endplate signal
changes and enhancement at L2-L3, possibly degenerative in
etiology or
infectious.
3. Persistent, subtle increased T2 signal intensity along the
dorsal cord from
C3-C6 possibly related to B12 deficiency or chronic inflammatory
process.
4. Multilevel degenerative changes of the spine as detailed
above.
5. Additional extra-spinal findings as detailed above.
PREVALENCE: Prevalence of lumbar degenerative disk disease in
subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal,
height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
___, et all. Spine ___ 26(10):___
Lumbar spinal stenosis prevalence- present in approximately 20%
of
asymptomatic adults over ___ years old
___ al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they
must be
interpreted with caution and in context of the clinical
situation.
CXR ___
IMPRESSION:
Comparison to ___. On today's radiograph, the
patient shows
signs of mild pulmonary edema. The heart is normal in size.
The presence of a small left pleural effusion is likely. No
pneumothorax. No pneumonia. Stable position of the monitoring
and support devices.
CT CHEST W/O CONTRAST ___
IMPRESSION:
1. More conspicuous destructive changes at the T7-T8 and T11-T12
levels.
2. Multilobar ground-glass opacities and bibasilar atelectasis
with diffuse
bronchial wall thickening is concerning for multifocal pneumonia
predominantly
located in the upper lobes.
3. Change in morphology of nodular focus in the lingula
suggesting a benign
entity. However, follow-up CT is recommended in 3 months to
reassess.
4. Increased, small to medium-sized bilateral pleural effusions
with
atelectasis.
5. Unchanged dilated, tortuous and heavily calcified aorta.
CT ABD/PELVIS W/O CON ___
IMPRESSION:
1. More conspicuous destructive changes at the T7-T8 and T11-T12
levels.
2. Multilobar ground-glass opacities and bibasilar atelectasis
with diffuse
bronchial wall thickening is concerning for multifocal pneumonia
predominantly
located in the upper lobes.
3. Change in morphology of nodular focus in the lingula
suggesting a benign
entity. However, follow-up CT is recommended in 3 months to
reassess.
4. Increased, small to medium-sized bilateral pleural effusions
with
atelectasis.
5. Unchanged dilated, tortuous and heavily calcified aorta.
CXR PORTABLE ___
There is stable positioning of the left chest wall single lead
ICD. Distal tip
of the right venous catheter overlies the right atrium. Both
costophrenic
angles are collimated out of the field of view. No
pneumothorax. There is
increased opacification at the left lung base obscures
retrocardiac structures
and left hemidiaphragm. Consider pneumonia.
TTE ___
IMPRESSION: Mildly dilated ascending thoracic aorta and
moderately dilated descending aorta.
Mitral valve and aortic valve seen well and were without
vegetation. The tricuspid valve was poorly
visualized. While no vegetation seen, this cannot be exclued on
the basis of this study. The pacer
lead was not well visualized. If high clinical suspicion exists
for endocarditis, TEE is recommended.
Normal global biventricular systolic function.No prior study
available for comparison. The visually estimated left
ventricular ejection fraction is 55-60%.
MRI CTL ___
IMPRESSION:
1. Epidural abscess with slight cord compression and possible
subtle spinal
cord edema at T11/T12. At this level there are also destructive
endplate
changes with loss of cortex with associated pre vertebral and
post vertebral
soft tissue swelling, consistent with of discitis or
osteomyelitis.
2. Additional endplate hyperintensities at C5/C6 and T7/T8
suggestive of
discitis or osteomyelitis as there is subtle increased fluid
signal in the
adjacent prevertebral soft tissue. Further endplate
hyperintensities of the
lumbar spine likely represent degenerative changes, however in
the context of
epidural abscess, early findings of discitis or osteomyelitis at
these levels
cannot be excluded.
3. Extensive degenerative changes of the spine as described
above.
4. T2 hyperintensity the dorsal cord from C3 to C6, suggestive
of B12
deficiency or sequelae of chronic inflammatory condition.
5. Chronic cerebellar infarcts.
6. Hyperintensity in the liver, likely a cyst versus a biliary
hamartoma.
7. Bilateral renal cysts.
8. Diffusely dilated aorta as seen on previous CTA.
___ CTA chest and abdomen
IMPRESSION:
1. Diffusely dilated thoracic and abdominal aorta with
atherosclerosis and
possible posterior penetrating ulcer along the descending
thoracic aorta. No
evidence of acute dissection or intramural hematoma.
2. T12 compression deformity with areas of bone destruction
along the superior
endplate with surrounding fat stranding. Recommend MRI to
further assess.
3. Chronic fractures as described including poorly healed right
acetabular
fracture with significant associated deformity.
4. Emphysema with left upper lobe nodule measuring 10 mm.
5. Tiny left pleural effusion.
RECOMMENDATION(S):
For incidentally detected single solid pulmonary nodule bigger
than 8mm, a
follow-up CT in 3 months, a PET-CT, or tissue sampling is
recommended.
MICROBIOLOGY:
=============
___ 12:02 pm TISSUE
SOFT TISSUE CORE BIOPSIES AND ASPIRATIONS FOR CULTURES.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 12:02 pm ABSCESS
Source: disktis/OM at T11/12 soft tissue.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___
9:15AM.
STAPH AUREUS COAG +. RARE GROWTH.
LINEZOLID , Daptomycin , AND CEFTAROLINE Susceptibility
testing
requested per ___ ___ ___.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Susceptible to CEFTAROLINE test result performed by
___.
Daptomycin MIC OF 0.25 MCG/ML test result performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 6:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture (3 total), Routine (Final ___: NO
GROWTH.
Brief Hospital Course:
SUMMARY STATEMENT:
==================
___ year old male with past medical history of CVA with residual
R sided weakness, prior hip and pelvic fractures with chronic
back pain, prior VT/VF arrest secondary to ischemic LAD lesion
s/p DES and AICD, known thoracic aortic aneurysm, recent MRSA
bacteremia complicated by septic emboli to lungs, spleen, brain
s/p daptomycin/ceftaroline presumed to be ___ endocarditis and
PFO in ___, who was admitted on ___ with back pain,
found to have MRSA epidural abscess at T11-12 and associated
osteomyelitis/discitis now on long-term daptomycin. His course
was complicated by difficult to control pain, HAP s/p 7 day
treatment with ceftazidime and hypercalcemia of immobility s/p a
single dose of denosumab.
TRANSITIONAL ISSUES:
====================
PCP/Rehab facility:
-INFECTION:
[] For the patient's osteomyelitis/epidural abscess, he should
be continued on antibiotics per the following regimen:
Antimicrobial Regimen: Daptomycin 500mg q48hr
Start Date: ___
Projected End Date: ___
He should receive the following monitoring labs:
WEEKLY: CBC with differential, BUN, Cr, CPK, CRP
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
[] IV team to remove PICC line after finishing antibiotic course
-HYPERCALCEMIA:
[] Patient was noted to have hypercalcemia, and inpatient workup
points to an etiology of hypercalcemia of immobility. He was
given a dose of prolia (denosumab) on ___ and is due to another
dose in 6 months (___).
[] Continue weekly albumin and calcium checks, can be drawn with
___ labs.
[] Please ensure that he follows up with endocrinology for
further management of his hypercalcemia. He will be scheduled to
follow up with Endocrine at ___, with Dr. ___, in 3
months.
-BLOOD PRESSURE:
[] Given the patient's thoracic aneurysm, his systolic BP goal
should be <160mmHg
[] The patient's carvedilol was discontinued as he was having
persistent bradycardia while on the medication. When you see the
patient, please evaluate if the medication should be restarted.
-OTHER:
[] Follow up IgE and strongyloides IgG levels outpatient,
continue trending absolute eosinophil count weekly with OPAT
labs
[] Upon PMP history review: the patient was noted to have 10
prescribers in the past 3 months; however, his
osteomyelitis/epidural abscess was an appropriate indication for
pain control. As he will be discharged on opiate medications and
was requiring large amount of pain control while in the hospital
he would benefit from an opiate agreement and frequent
monitoring.
[] Patient was found to have a subpleural nodular density in the
lingula measuring about 10 mm persists but has changed a
morphology somewhat and may represent a benign entity such is a
focus of infection or even chronic atelectasis. A follow-up CT
is recommended in 3 months to reassess.
[] During this hospitalization, the patient's TSH was high at
9.5 with a T4 of 10.0 and T3 of 67. This is consistent with
euthyroid sick syndrome and patient would benefit from a repeat
TSH in 6 weeks to reassess.
Cardiology:
[] Patient's aICD was interrogated and showed 1 treated episode
on ___ 08:20:15 ___. Episode of VT successfully terminated
with shock, shock impedance 66 ohms.
ACUTE ISSUES:
============
#Epidural abscess:
Patient with a history of MRSA bacteremia in ___ c/b
presumed endocarditis with brain/lung/spleen septic emboli and
was treated initially with daptomycin and ceftaroline, then
daptomycin only for a total course of 6 weeks (completed ___. Patient is known to have chronic back pain with multiple
admissions related to pain. MRI on admission showed an epidural
abscess at T11-12 with two other signals of possible
discitis/osteo at C5-6 and T7-8. Abscess sample was positive for
MRSA, likely from patient's recent MRSA bacteremia/
endocarditis. Surgical intervention was deferred as neurologic
exam not consistent with spinal cord compression. He was started
on vanc on ___, switched to daptomycin on ___ due to difficult
to control vancomycin levels related to his CKD. He had a
tunneled line placed on ___. There was concern for worsening
weakness in his RLE on ___, so patient underwent MRI spine
which showed stable epidural abscess, possibly mildly improved.
Lower extremity weakness improved on ___ and was thought to be
related to deconditioning and poor effort. Prior to discharge,
patient's weakness similar to his baseline with improving CRP.
His anticipated course of daptomycin will continue until ___, with monitoring as listed above. He had PICC line placed
___, and his tunneled line was removed ___.
# Eosinophilia
# Xerosis
# Pruritis
No sign of superficial infection. Very dry skin and pruritic.
CBC/diff halfway through hospital course showed continued
eosinophilia. No concern for DRESS Parasitic infections are less
likely due to no obvious risk factors. However Strongyloides IgG
sent to ensure neg. The patient has no recent exposures to PCN,
cephalosporins, H2-blockers, or antiepileptics. He has been on
torsemide which, as a loop diuretic has been known to cause
eosinophilia. The rash has been present for years according to
the patient so not suspected to be ___ eosinophilia. Daptomycin
was started around the time of increasing eosinophil count and
will be monitored as noted with ID. In the absence of end organ
damage and eos not > 1500, did not d/c dapto empirically.
Follow up strongyloides IgG and IgE levels outpatient.
# Hypercalcemia:
On admission, patient with normal corrected calcium levels.
During his hospitalization, his calcium slowly trended up,
reaching a peak of 12.5, corrected. He was asymptomatic, but due
to slow uptrend, a workup was sent to evaluate for etiologies.
He was found to have a low PTH with normal Vitamin D and PTHrP
levels. The etiology was believed to be hypercalcemia of
immobility, but as patient was expected to remain partially
immobile for the near future due to pain and chronic RLE
weakness, he was treated with a one time dose of denosumab ___.
SPEP/UPEP were unremarkable. Due to hypercalcemia, he was
changed from Ca-acetate to sevelamer for phosphate binding.
Patient understand that his initiating denosumab will require
permanent follow up and injections every 6 months and can be at
higher risk for fracture if stops. Patient to continued weekly
alb/Ca2+ checks.
# Hospital acquired pneumonia:
On ___, patient began having fevers with increased CRP/WBC
count and was found to have a multifocal pneumonia, with low
clinical suspicion for MRSA pneumonia due to low-normal O2
saturation and minimal symptoms. He completed a 7 day treatment
course with ceftazidime.
#Acute on chronic back pain
Patient with a history of pelvic and hip fractures and chronic
pain. Upon PMP history review: the patient was noted to have 10
prescribers in the past 3 months; however, due to his
osteomyelitis/epidural abscess this was likely an appropriate
indication for pain control. During his hospitalization, he
frequently was upset about the level of his pain control, and
was kept on IV diluadid. At the time of discharge, he was on a
regimen with daily lidocaine patches, dialudid 2mg PO q4h PRN,
tizanidine 2mg PO TID. He was not started on tylenol as he
reported an allergy to tylenol (itching) and it was expected
that it would make little difference in his pain management.
Patient was encouraged to work with ___ to improve mobility and
ultimately to improve his pain and he responded well to the idea
that his pain would improve with his mobility. As he will be
discharged on opiate medications and was requiring large amount
of pain control while in the hospital he would benefit from an
opiate agreement and frequent monitoring.
# Constipation
Patient was taking high doses of opiate medications for his pain
during his admission and required a standing bowel regimen to
maintain bowel movements. He was discharged on standing senna,
docusate, miralax, bisacodyl and lactulose.
CHRONIC ISSUES:
===============
# Sacral pressure wound
Patient with limited mobility during hospitalization and chronic
weakness of R side. He was seen by wound consult and was
agreeable to position changes, however he declined the
recommendation to be switched to an air bed as he reports
increased pain in the past.
#CKD-IV
Developed CKD requiring temporary HD after cardiac cath contrast
load, with baseline Cre ~2.5. Due to contrast load with CTA on
___, patient had a mild ___ which downtrended to his baseline.
He had been on Calcium acetate TID for phosphate binding,
however he was transitioned to sevelamer due to hypercalcemia.
#Ischemic cardiomyopathy
Patient with known HFrEF with EF of ___ CAD s/p DES to mLAD
in ___ and VT/VF arrest s/p aICD. He was continued on his home
ASA, statin, amiodarone and isosorbide. His home torsemide was
held initially due to ___ from contrast and NPO for tunnel line
placement, but it was restarted when his Cre returned to
baseline. During his admission, he was bradycardic to 50-60s so
his carvedilol was held.
#Insomnia:
Patient reported difficulty sleeping secondary to pain. At home,
he takes melatonin for sleep. As his pain control improved, he
reported improvement in his sleep, however continued to rely
upon ramelteon with trazodone as a second line. He was
discharged with only remelteon due to trazodone causing
potential effects on mental status and prolonged QTc in setting
of polypharmacy.
#Normocytic anemia:
Patient with a Hgb 6.8 on admission, s/p 1u PRBCs with
appropriate response. He displayed no signs of active bleeding.
Iron studies were consistent with anemia of chronic disease and
also iron deficiency contributing. He received a total of 3
units of pRBCs while inpatient, with Hg stable since ___.
#Aortic aneurysm
Due to back pain, CT chest/abdomen/pelvis was performed and was
found to have stable abdominal/thoracic aortic aneurysm. He was
seen by vascular surgery who did not believe urgent surgical
intervention was needed. His goal was maintained at SBP <160
with isosorbide dinitrate 10mg TID and terazosin.
# CVA:
History of CVA with residual R-sided weakness. He also had
additional CVAs in the setting of embolic disease from MRSA
bacteremia in ___, though he has no residual deficits
from these CVAs. He was continued on his home ASA, statin.
# Alcohol Use Disorder:
Patient with a history of alcohol use disorder. Low suspicion
for withdrawal as he had been in the hospital for most of the
days prior to his admission, so he was not started on CIWA
protocol or given any medication for withdrawal. He was
continued on his home thiamine PO, folic acid PO, multivitamin.
# BPH
He was continued on his home terazosin 5 mg po qHS.
# GERD
He was continued on his home pantoprazole 40 mg po q12h.
# GOUT
He was continued on his home allopurinol ___ mg po daily.
CORE MEASURES:
==============
# CODE: Full
# CONTACT: HCP is ___ (Son): ___
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 is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP DAILY
5. CARVedilol 6.25 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 100 mg PO TID
8. HydrALAZINE 50 mg PO TID
9. HydrOXYzine 25 mg PO Q6H:PRN pruritis
10. Isordil (isosorbide dinitrate) 10 mg oral TID
11. melatonin 5 mg oral QHS
12. Pantoprazole 40 mg PO Q12H
13. Terazosin 5 mg PO QHS
14. Tizanidine 2 mg PO DAILY
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
16. Amiodarone 400 mg PO DAILY
17. Calcium Acetate 667 mg PO TID W/MEALS
18. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - Second Line
19. Silver Sulfadiazine 1% Cream 1 Appl TP BID
20. Torsemide 40 mg PO DAILY
21. Vitamin D ___ UNIT PO 1X/WEEK (___)
22. Docusate Sodium 100 mg PO BID
23. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY
2. Daptomycin 500 mg IV Q48H
3. Dronabinol 2.5 mg PO BID:PRN nausea
4. Heparin 5000 UNIT SC BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*20 Tablet Refills:*0
6. Isosorbide Dinitrate 10 mg PO TID
7. Lidocaine 5% Patch 1 PTCH TD QAM back pain
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Sarna Lotion 1 Appl TP QID
10. Senna 17.2 mg PO BID
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Thiamine 100 mg PO DAILY
13. TraZODone 25 mg PO QHS:PRN insomnia
14. HydrALAZINE 25 mg PO Q6H:PRN SBP >160
PRN SBP >160
15. Tizanidine 2 mg PO TID:PRN muscle spasm
16. Allopurinol ___ mg PO DAILY
17. Amiodarone 400 mg PO DAILY
18. Aspirin 81 mg PO DAILY
19. Atorvastatin 80 mg PO QPM
20. Docusate Sodium 100 mg PO BID
21. FoLIC Acid 1 mg PO DAILY
22. HydrALAZINE 50 mg PO TID
23. HydrOXYzine 25 mg PO Q6H:PRN pruritis
24. melatonin 5 mg oral QHS
25. Pantoprazole 40 mg PO Q12H
26. Polyethylene Glycol 17 g PO DAILY
27. Silver Sulfadiazine 1% Cream 1 Appl TP BID
28. Terazosin 5 mg PO QHS
29. Torsemide 40 mg PO DAILY
30. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
31. HELD- CARVedilol 6.25 mg PO BID This medication was held.
Do not restart CARVedilol until heart rates improve and are
consistently >65-70
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Epidural abscess
Vertebral osteomyelitis
SECONDARY DIAGNOSIS:
====================
Hypercalcemia of ___ acquired pneumonia
Acute kidney injury
Chronic kidney disease
Heart failure with reduced ejection fraction
Chronic back pain
Pelvic fracture
Thoracic aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had severe back pain and
weakness in your legs
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had an MRI that showed multiple areas of infection in your
back
- You were treated with antibiotics for your infection.
- After several weeks of antibiotics you had repeat imaging of
your back which showed that the infection had improved.
- You developed a pneumonia and received a different set of
antibiotics for that infection.
- The calcium in your blood was found to be high, likely related
to your limited mobility due to pain. To treat this, you were
treated with a medication to help strengthen your bones.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Be sure to weigh yourself daily. If you gain more than 3 lbs
in a day, please call your regular doctor or go to an Emergency
Department.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10480035-DS-20 | 10,480,035 | 26,532,273 | DS | 20 | 2179-06-27 00:00:00 | 2179-06-27 23:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
acetaminophen / Tylenol-Codeine
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
DISCHARGE EXAM:
==============
24 HR Data (last updated ___ @ 1341)
Temp: 98.3 (Tm 98.3), BP: 133/68 (110-164/56-77), HR: 54
(53-67),
RR: 18, O2 sat: 98% (95-98), O2 delivery: ra, Wt: 128.31 lb/58.2
kg (126.54-128.31)
Gen: comfortable, NAD
HEEN: PERRL, EOMI, OP clear
CV: RRR, nl S1, S2, no m/r/g, no JVD
Chest: CTAB
Abd: + BS, soft, NT, ND
MSK: lower ext warm without edema
Neuro: AOx3, CN II-XII intact, ___ L-sided strength, ___ RUE,
3+/5 RLE, sensation grossly intact to light touch, gait not
tested
Psych: pleasant, appropriate
Access: RUE ___ c/d/I
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-6.6 RBC-2.74* Hgb-7.8* Hct-26.7*
MCV-97 MCH-28.5 MCHC-29.2* RDW-16.3* RDWSD-57.6* Plt ___
___ 06:00AM BLOOD Glucose-77 UreaN-32* Creat-2.2* Na-144
K-5.0 Cl-109* HCO3-21* AnGap-14
___ 06:00AM BLOOD Calcium-7.1* Phos-3.7 Mg-2.5
___ 06:00AM BLOOD CRP-43.1*
ADMISSION LABS
==============
___ 08:45PM BLOOD WBC-7.6 RBC-2.73* Hgb-8.0* Hct-26.4*
MCV-97 MCH-29.3 MCHC-30.3* RDW-18.3* RDWSD-65.7* Plt ___
___ 05:15AM BLOOD ___ PTT-35.1 ___
___ 08:45PM BLOOD Glucose-92 UreaN-42* Creat-2.3* Na-137
K-3.8 Cl-102 HCO3-22 AnGap-13
___ 05:36AM BLOOD ALT-21 AST-22 LD(LDH)-196 CK(CPK)-61
AlkPhos-92 TotBili-0.2
___ 05:15AM BLOOD Calcium-6.6* Phos-3.7 Mg-1.8
___ 08:45PM BLOOD CRP-56.8*
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:51PM BLOOD Lactate-0.8
___ 05:30AM BLOOD SED RATE-Test
CRP TREND
=========
___ 06:00AM BLOOD CRP-43.1*
___ 05:30AM BLOOD CRP-48.5*
___ 08:45PM BLOOD CRP-56.8*
IMAGING:
======================
MRI T/L spine (___):
1. Stable findings of discitis-osteomyelitis at T11-T12. 2. Mild
interval decrease of epidural enhancement at T11-T12 level, with
decrease of mass-effect on the ventral spinal cord. There is no
evidence of severe spinal canal stenosis or cord compression at
this level. 3. Slightly decreased prevertebral soft tissue
enhancement spanning from T10-T11 through L1-L2. 4. Unchanged
loss of T1 marrow signal with STIR hyperintensity at T7-T8,
raises concern for persistent discitis/osteomyelitis. There is
no epidural or prevertebral soft tissue enhancement. 5. Stable
L1 compression deformity with focus of enhancement in the
posterior aspect of the vertebral body compatible with
osteomyelitis. 6. No new abnormalities are identified within the
intervertebral discs or vertebral bodies. 7. Multilevel
degenerative disease as described above.
R ___ (___):
Negative for DVT
Brief Hospital Course:
TRANSITIONAL ISSUES
===================-
[ ] Continue to check BUN, Cr, CBC w/ diff, CPK and CRP weekly
on daptomycin
[ ] Tentative end date of daptomycin is ___ (12 weeks)-- Pt
should see ID prior to stopping therapy (ID will arrange)
[ ] AVOID diphenhydramine given QTc >560 - Continue sarna lotion
[ ] Monitor QTC; avoid addition of QTC prolonging agents
[ ] Will need to taper off opiates prior to leaving rehab--
patient is being discharged on 10mg PO BID PRN of Oxycodone.
This should be tapered down to 10mg PO QD PRN a few days prior
to discharge from rehab and then completely off. He should not
leave rehab with opiates. He may be a good Suboxone candidate in
the future, and can consider seeking provider for this.
[ ] He was continued on his home isosorbide TID for afterload--
consider transitioning to Imdur from Isordil as outpatient.
[ ] Will need PCP and cardiology follow up on discharge from
rehab
SUMMARY
=======
___ year old male with past medical history of CVA with residual
R sided weakness, prior hip and pelvic fractures with chronic
back pain, systolic CHF, prior VT/VF arrest secondary to
ischemic LAD lesion s/p DES and AICD, known thoracic aortic
aneurysm, CKD stage 4, recent MRSA bacteremia c/b septic emboli
to lungs, spleen, brain s/p dapto/ceftaroline presumed to be ___
endocarditis and PFO in ___, admitted ___ with back
pain, found to have MRSA epidural abscess at T11-12 and
associated osteomyelitis/ discitis now on long-term daptomycin,
course complicated by HAP s/p ceftazidime and hypercalcemia of
immobility s/p denosumab. He was recently discharged on IV
daptomycin ___, re-presenting from rehab for worsening back
pain. Repeat MRI T/L spine unchanged to improved. Pain likely
due to ongoing inflammation vs MSK etiology. Daptomycin course
extended and supportive care provided with analgesics.
# Acute on Chronic Back Pain:
The patient presented initially with an acute worsening of his
back pain that was not responsive to his dilaudid. Neurologic
exam non-focal with exception of stable R-sided post-CVA
weakness. The patient underwent an MRI of his back given his
known recent spinal osteomyelitis which was negative for any
acute process/changes (see below). Previously seen by orthopedic
surgery on last admission, who opted to defer surgical
intervention. The ___ current pain seems localized to the
paraspinal muscles and most consistent with muscle spasm.
Notably allergic to APAP & codeine (itching). His pain was
initially managed with dilaudid in the ED before being switched
over to oxycodone on the inpatient medicine floor. The inpatient
attending, Dr. ___ the ___ case with his
PCP, ___ reported that the patient has multiple
issues at home including a difficult family situation (adult son
has issues, unable to care for him, wife is ailing) and a long
history of substance use issues. Dr. ___ discontinued
all prescriptions for controlled substances for him due to abuse
related issues. She does not think he is capable of living at
home any more. Given this history, addiction psychiatry was
consulted for assistance with management of his pain
medications. ultimately, the ___ oxycodone was spaced out
to 10mg PO BID PRN at the time of discharge(from 10mg PO Q4hrs
initially) with a plan to ultimately taper the patient off of
opiates prior to leaving rehab. He was continued on a lidocaine
patch for pain. His muscle relaxant regimen was up titrated and
he was discharged on tizanidine 6mg QHS standing and 4mg QAM &
QPM standing. He was started on gabapentin and discharged on a
dose of 200mg PO TID. He was continued on Trazodone QHS. He was
continued on an aggressive bowel regimen. Physical therapy was
consulted and recommended return to rehab.
# Epidural abscess, +MRSA
# Discitis/osteomyelitis:
# Hx MRSA bacteremia (___) c/b endocarditis with
brain/lung/spleen septic emboli:
Of note, he has chronic back pain with multiple admissions ___
pain and has known pelvic fx and multiple vertebral compression
fracture. The patient was recently diagnosed with an epidural
abscess that was positive for MRSA with discitis/osteomyelitis
and was subsequently treated with different antibiotics
including vancomycin while inpatient. Seen by ortho spine, who
opted to defer surgical intervention. The patient was discharged
on daptomycin and has been on daptomycin since ___
for a ___ course. During the ___ prior admission, the
patient was switched to dapto from vanc due to ___ and
difficulty maintaining therapeutic levels. Per outpatient OPAT
notes, the patient was planned to be on Daptomycin until ___.
He then presented with progressive back pain. MRI T/L spine this
admission showed persistent phlegmon/epidural abscess which was
smaller than prior. Other findings on the MRI were stable to
improved. ID consulted and recommended continuing Daptomycin
with a new tentative end date of ___. ___ inpatient the
patient was continued on IV Daptomycin 500mg IV q48hrs. ID will
arrange outpatient f/u to determine final discontinuation date
for daptomycin. Pain was controlled as detailed above.
# Hand Rash
# ___ Disease
The patient initially presented to outpatient dermatology visit
___, with biopsy demonstrating features of ___ disease
and eczematous dermatitis, which are both benign but pruritic
skin conditions. He was prescribed topical betamethasone
dipropionate 0.05% ointment, which he had not been using while
inpatient. Dermatology was re-consulted while admitted, and they
recommended resuming betamethasone dipropionate 0.05% ointment
BID x2 weeks on, 2 weeks off to affected areas on body, avoiding
face/skin folds/groin. He resumed this medication and noted
improvement in his this symptoms.
___ on CKD-IV, baseline SCr ~2.5
During the ___ last admission, he developed CKD requiring
temporary HD after cardiac cath contrast load. Improved despite
recent contrast load with CTA on ___ (received some pre/post
hydration). SCr peaked at 3.1, which downtrend to baseline of
2.2-2.5 by ___. While inpatient this admission the patient was
continued on torsemide 40mg QD and Sevelamer for phosphate
binding. His Cr remained stable between 2.1-2.3.
#Ischemic cardiomyopathy, HFrEF = ___, grade I diastolic
dysfunction.
#Medication-induced bradycardia
#CAD, s/p DES TO mLAD in ___
#Hx of VT/VF arrest s/p aICD
Throughout the ___ hospitalization the patient remained
euvolemic on exam and with normal O2 saturation. The patient did
not require aggressive diuresis during this admission--
continued home torsemide 40mg PO QD . The patient was continued
on his home ASA and statin. The patient continued his home
amiodarone while inpatient. He was continued on his home
isosorbide TID for afterload-- consider transitioning to Imdur
from Isordil as outpatient. He was also continued on his home
carvedilol. Of note, he is not on ACE due to chronic renal
failure.
# Prolonged QTC:
QTC 567 on ___. ICD in place. Would trend QTC and avoid
addition of QTC prolonging medications.
# CVA:
Residual R-sided weakness, ___. Continued home ASA, statin.
# Alcohol Use Disorder:
Pt has been in the hospital or rehab most days this month so low
risk for withdrawal at this time. Continued home thiamine PO,
folic acid PO, MVI
# BPH
Continued home terazosin 5 mg po qHS
# GERD
Continued home pantoprazole 40 mg po q12h
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 400 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. HydrALAZINE 50 mg PO TID
8. HydrOXYzine 25 mg PO Q6H:PRN pruritis
9. Pantoprazole 40 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY
11. Terazosin 5 mg PO QHS
12. Lidocaine 5% Patch 1 PTCH TD QAM back pain
13. Thiamine 100 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Isosorbide Dinitrate 10 mg PO TID
17. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
18. Heparin 5000 UNIT SC BID
19. melatonin 5 mg oral QHS
20. Silver Sulfadiazine 1% Cream 1 Appl TP BID
21. Torsemide 40 mg PO DAILY
22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
23. CARVedilol 6.25 mg PO BID
24. Bisacodyl 10 mg PO/PR DAILY
25. Dronabinol 2.5 mg PO BID:PRN nausea
26. HydrALAZINE 25 mg PO Q6H:PRN SBP >160
27. Tizanidine 2 mg PO TID:PRN muscle spasm
28. Daptomycin 500 mg IV Q48H
29. Sarna Lotion 1 Appl TP QID
30. Senna 17.2 mg PO BID
31. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP BID Rash--
apply to hands where rash is
RX *betamethasone, augmented 0.05 % twice a day Refills:*0
2. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 1 capsule by mouth three times a day Disp
#*90 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q12H:PRN Pain -
Moderate
Continue BID PRN x4 days and then QD PRN x4 days and then taper
off
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*15
Tablet Refills:*0
4. Tizanidine 4 mg PO BID muscle spasm
RX *tizanidine 2 mg 2 tablet by mouth three times a day Disp
#*98 Capsule Refills:*0
5. Tizanidine 6 mg PO QHS
6. Allopurinol ___ mg PO DAILY
7. Amiodarone 400 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Bisacodyl 10 mg PO/PR DAILY
11. CARVedilol 6.25 mg PO BID
12. Daptomycin 500 mg IV Q48H
13. Docusate Sodium 100 mg PO BID
14. Dronabinol 2.5 mg PO BID:PRN nausea
15. FoLIC Acid 1 mg PO DAILY
16. Heparin 5000 UNIT SC BID
17. HydrALAZINE 50 mg PO TID
18. Isosorbide Dinitrate 10 mg PO TID
19. Lidocaine 5% Patch 1 PTCH TD QAM back pain
20. melatonin 5 mg oral QHS
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Pantoprazole 40 mg PO Q12H
23. Polyethylene Glycol 17 g PO DAILY
24. Sarna Lotion 1 Appl TP QID
25. Senna 17.2 mg PO BID
26. sevelamer CARBONATE 800 mg PO TID W/MEALS
27. Silver Sulfadiazine 1% Cream 1 Appl TP BID
28. Terazosin 5 mg PO QHS
29. Thiamine 100 mg PO DAILY
30. Torsemide 40 mg PO DAILY
31. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
--------
Musculoskeletal back pain
Discitis/osteomyelitis
Epidural abscess w/MRSA
Secondary:
------------
# Chronic systolic heart failure:
# VT/VT arrest s/p ICD:
# CKD stage IV:
# ___ disease:
# Hx CVA w/residual R-sided weakness:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulates with walker
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you were having
severe back pain and had a known infection of your back/spine.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
- You had an MRI of your back and spine done which showed
improvement of your infection.
- You were continued on IV antibiotics for your infection.
- You were seen by the infectious disease doctors who
recommended continuing the same antibiotics for the infection
- You were seen by pain specialists who helped us with your pain
medication regimen
- You pain medications were adjusted
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Continue to take all your medicines and keep your
appointments.
- You should continue to take all of your medications exactly as
prescribed
- You should go to all of your follow up appointments as listed
below
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10480346-DS-17 | 10,480,346 | 24,670,465 | DS | 17 | 2185-05-11 00:00:00 | 2185-05-13 21:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left Hemibody sensory changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
The pt is a ___ year old woman with hypertension who presents
with
left sided numbness and tingling.
The patient was at her usual self at 10pm when she went to
sleep.
She woke up a few minutes later acutely with left hand/finger
numbness. She describes it as "tingling". This then spread up
her
arm and down her left leg, and finally involved her face,
occurring over the course of an hour. Concerned, she present to
ED where code stroke was called.
Neuro ROS is negative for headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. No
bowel or bladder incontinence or retention. Denies difficulty
with gait. She does endorse mild neck pain and stiffness,
especially upon awakening in the morning, but no recent trauma
or
manipulation.
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:
RA, s/p hysterectomy, HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: tepm 97.2 HR 73 BP 139/100 RR 14 spO2 100% RA glucose
342
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity. Point tenderness to palpation
of paraspinal cervical muscles as well as left occipital notch.
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 x3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation decreased on left V1-3, on light touch 80%
of
left, decreased pinprick which crosses midline, but does not
cross hairline and extends to the posterior scalp.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii; SCM spasm limiting testing
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- 5- 5- ___ 5 5-* 5 4+ 5- 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
*may be limited by poor effort given initially ___ strength in
hip flexors and positive Hoover sign; strength improved to 5-
after maximal encouragement to patient
neck flexor ___, neck extensor ___
-Sensory: complex, somewhat inconsistent examination. On the
left
upper extremity, there is reduced sensation to light touch and
cold in the entire limb, about 80% of right, but reduced
pinprick
only over the palmar aspect of hand and anterior forearm up to
the elbow, with preserved pinprick in the dorsal hand and
forearm. In the left lower extremity, there is reduced sensation
to light touch and pinprick sparing a strip of pinprick
sensation
in the right lateral aspect of the lower shin and ankle, however
this disappears on repeat testing. Pt is inconsistent on
pinprick
testing of the anterior trunk and back, at times endorsing
decreased sensation with midline crossing, at other times
sensing
fully. Proprioception is slightly decreased in the left great
toe
with correct response rate of 75%.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2+ 3 2
R 3 2 2+ 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Some difficulty walking in tandem. Romberg present with
mild sway on eyes closed.
DISCHARGE PHYSICAL EXAMINATION:
Largely unchanged with mild resolution of sensory changes on
left side of body approximately ___ improvement.
Pertinent Results:
Hematology
WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD
7.8 4.46 13.4 40.4 91 30.0 33.2 12.8 42.2
PLT: 210
11.6*# 5.04 15.0 45.2* 90 29.8 33.2 12.7 41.9 266
Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 05:55AM 210 Import Result
___ 01:10AM 266 Import Result
___ 01:10AM 9.8 30.6 0.9 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 03:35PM 121* 20 1.2* 138 3.8 ___
Import Result
___ 05:55AM 160* 25* 1.3* 138 3.5 100 25 17
Import Result
___ 01:10AM 38* 1.6* Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 01:10AM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos
Amylase TotBili DirBili
___ 01:10AM 20 23 148* 0.4 Import
Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd
Iron
___ 03:35PM 10.1 2.6* 1.9 Import
Result
___ 05:55AM 9.7 3.4 1.9 Import
Result
___ 01:10AM 4.2 10.4* 3.3 1.7 Import
Result
DIABETES MONITORING %HbA1c eAG
___ 01:10AM 10.0* 240* Import Result
LIPID/CHOLESTEROL LDLmeas
___ 01:10AM 126 Import Result
PITUITARY TSH
___ 01:10AM 0.03* Import Result
THYROID T3 Free T4
___ 05:55AM 139 1.2 Import Result
IMAGING:
Non Contrast Head CT ___: 1. Normal study.
MRI Cervical Spine ___:
1. Mild cervical spondylosis as described above without
significant spinal canal narrowing. Neural foraminal narrowing
is most prominent at C4-C5 where there is moderate left neural
foraminal narrowing.
2. Multinodular goiter previously evaluated and biopsied.
MRI/MRA Brain ___:
1. 8 mm acute infarct of the right thalamus. No evidence of
intracranial
hemorrhage.
2. Scattered periventricular and subcortical T2/FLAIR white
matter
hyperintensities are nonspecific, but compatible with chronic
microangiopathy in a patient of this age.
3. Unremarkable MRA of the head and neck.
4. The thyroid gland is diffusely enlarged demonstrating
multiple T2
hyperintense nodules measure up to 1.3 cm. The thyroid gland
has been
previously evaluated by prior thyroid ultrasound and biopsy.
Brief Hospital Course:
Ms. ___ is a ___ woman with a past medical
history of hypertension, an occasional smoker, multinodular
thyroid disease, and bilateral knee replacements, who presents
with the acute onset of left sided sensory disturbances
primarily starting in the hand, traveling up from the toes and
into her face. The patient was activated as a code stroke and
admitted to the Neurology Service to the Stroke team for further
management. The following issues were managed during the
patient's hospitalization:
#Right Thalamic Infarct:
- Patient first received a non-contrast head CT in the ED which
did not show any pathology. Aspirin was started as initial
management.
-The patient underwent MRI imaging of the brain, vessel images
and the C-spine to look for etiology of the patient's symptoms.
MRI of the brain showed an acute right thalamic infarct of 8mm
in size.
-As the patient had a stroke, laboratory testing to assess her
stroke risk factors were completed and significant for a
hemoglobin A1C of 10 indicating type 2 diabetes mellitus. In
addition, the patient was found to have hyperlipidemia. Given
these poorly controlled risk factors and the location of
infarct, her stroke was linked to small vessel disease from
diabetes and HTN.
#Newly Diagnosed DM:
-As her hemoglobin A1C was discovered to be elevated to 10
without a prior diagnosis, the ___ Diabetes team was
consulted for initial management. The patient was started on
oral medication as well as an insulin sliding scale. She was
educated about diabetes and how to manage her lifestyle risk
factors such as diet and exercise. In addition, she was educated
about insulin use.
#HLD:
-The patient was started on a statin given her HLD as well as
evidence of an infarct. She was also counseled on healthy diet
and nutrition.
___:
-The patient was noted to be in pre-renal azotemia and was
hydrated with normal saline. This brought her creatinine down to
normal limits. The patient maintained good urine output
throughout her hospitalization.
#Cardiovascular:
-The patient is to receive an echocardiogram in the outpatient
setting for further management and evaluation of stroke risk
factors.
The patient was safely discharged home with stroke neurology
follow-up.
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 = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() 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? (x) Yes - () 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
Transitions of Care Issues:
1. Please follow up with the Stroke Attending Dr. ___ on your
appointment day: ___ at 10:30 AM.
2. Please have your primary care physician coordinate an
echocardiogram in the outpatient setting.
3. Please follow up with the Diabetes Endocrinology Specialists
at ___ , If you do not hear from them in ___ days please call
the following number- ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. triamterene-hydrochlorothiazid 37.5-25 mg oral Q24H
2. Atenolol 50 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
3. GlipiZIDE 10 mg PO BID
RX *glipizide 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
4. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [OneTouch Verio] Test BG 4 Times
daily Disp #*100 Strip Refills:*2
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) ___ Units before BED; Disp #*2 Syringe Refills:*2
RX *blood-glucose meter 1 Disp #*1 Kit Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL As per sliding
scale Up to 12 Units QID per sliding scale Disp #*2 Syringe
Refills:*2
RX *lancets [OneTouch Delica Lancets] 30 gauge Test BG 4 times
daily Disp #*100 Each Refills:*2
RX *insulin syringe-needle U-100 [Advocate Syringes] 31 gauge x
___ Use to inject insulin 5 times daily Disp #*100 Syringe
Refills:*2
5. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
6. Atenolol 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. triamterene-hydrochlorothiazid 37.5-25 mg oral Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
- Right Thalamic Stroke- Likely Lacunar
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 left sided numbness and
tingling 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 Cholesterol
- Diabetes
We are changing your medications as follows:
You were started on Insulin, Metformin and Glipizide to control
your blood sugars.
- You were started on Atorvastatin to control your high
cholesterol.
- You were started on Aspirin to help prevent recurrent stroke.
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
Followup Instructions:
___
|
10480346-DS-18 | 10,480,346 | 22,180,245 | DS | 18 | 2188-03-31 00:00:00 | 2188-03-31 19:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sudden Epigastric and Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with
a past medical history significant for poorly controlled
hypertension, type 2 diabetes on metformin, GERD, tobacco use,
prior CVA with residual left arm weakness, who developed sudden
onset epigastric and chest pain during dinner today. This is
never happened her before. The pain was sharp, felt like it was
in the back of her ribs and upper abdomen. At the time was not
having any trouble breathing, tingling in her arm, double
vision,
dizziness, syncope. The pain was so severe that she could not
eat. She skipped dinner, but the pain on relented. She was
brought into the hospital for this pain. In transit, her blood
pressures were in the 150s to 180s, but on arrival, her systolic
blood pressure primarily was in the 200s, peaking at 250. This
is never happened her before. Blood pressure control, she
normally takes losartan only. Per the present family member,
she
may have been prescribed another blood pressure control agent,
but is uncertain if the patient has taken it.
Upon arrival, patient was started on beta-blockers (labetalol,
then esmolol). Given history of GERD and concerning for a
possible perforated gastric ulcer, a chest x-ray was obtained,
which did not show any free air concerning for a perforation. A
CTA of the torso was performed, which showed a small segment of
a
dissection flap in the aortic arch just distal to the takeoff of
the left subclavian artery. For this reason, vascular surgery
is
consulted for evaluation and management recommendations.
Past Medical History:
PMH: HTN, T2DM, GERD, tobacco abuse, prior CVA
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 98.8 (Tm 98.8), BP: 125/60 (101-156/59-78), HR: 83
(67-87), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA
General: NAD, AAOx3
CV: RRR, extremities warm and well perfused
Pulm: Breathing unlabored on room air, no respiratory distress
Abd: Soft, nontender, nondistended
Ext: wwp, no edema
Pulses: palpable throughout
Brief Hospital Course:
Patient presented to the hospital on ___ with epigastric chest
pain and SBP in the 200s with max at 250. She was found to have
aortic dissection type B on CTA torso and was admitted to the
vascular surgery service and sent to ICU for close blood
pressure management. In the unit she received esmolol,
clevidipine, nitroglycerin gtt, which were weaned as tolerated,
as well as nifedipine XL 90mg daily , PO hydralazine 25mg q6h
and PO labetaol 500mg q8. Her blood pressures were controlled
and she was transferred out of the unit on ___. Vascular
medicine were on board during the hospitalization and uptitrated
her BP meds as needed as well as initiating diltiazem. Her
repeat CTA and MRA were stable, and she remained asymptomatic.
Since the beginning of her hospitalization her creatine started
to increase, reaching of 3.0 on ___ Nephrology were consulted
for her ___ and she was hydrated and nephrotoxic medications
were avoided, UOP was closely monitored. Of note renal cysts
were identified on her CTA on ___ and nephrology outpatient
follow up were set up. Patient continued to do well, but on ___
her WBC started to trend up. Additionally she was hypernatremic
and hyperchloremic. UA was positive, and reflex Urine culture
was sent. CXR was significant for pleural effusions, but
unlikely pneumonia. She was started on broad spectrum
antibiotics. Due to her stable aortic dissection, but
outstanding comorbidities and medical issues a transfer was
initiated to the medicine team to continue work up for her
increasing WBC and electrolyte imbalance. However at this time
patient was persistent that she wished to go home, and after
lengthy discussion regarding the reasons we recommended her to
stay she decided to leave against medical advice. Patient was
given prescriptions for required meds including antibiotics and
urged to follow up with her PCP this upcoming week. A tentative
appointment was made with her. The vascular medicine team will
also reach out to her to schedule outpatient follow up in the
next 4 weeks. At the time of discharge patient was tolerating a
regular diet, ambulating independently, and remained afebrile.
Patient was informed of danger signs to look out for and
directed to go to nearest urgent care facility should any of
these signs arise.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 180 mg 1 capsule(s) by mouth
once a day Disp #*30 Capsule Refills:*0
5. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous As directed
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL 1 As
directed Disp #*1 Box Refills:*0
6. HydrALAZINE 25 mg PO Q6H
RX *hydralazine 25 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
7. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Labetalol 500 mg PO Q8H
RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
9. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous as directed
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) 1 as directed Disp #*15 Syringe Refills:*0
10. pen needle, diabetic 32 gauge x ___ miscellaneous as
directed
RX *pen needle, diabetic [Comfort EZ Pen Needles] 32 gauge X
___ Disp #*1 Box Refills:*0
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*3 Tablet Refills:*0
12. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic Dissection Type B
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 visit the
nearest acute care facility if you experience the following:
*Sudden, acute pain in the chest or back; A change in pulse;
Shortness of breath; Losing consciousness
*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 is 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 driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Please monitor your Blood pressure as able and call your doctor
if persistently high
Followup Instructions:
___
|
10480647-DS-3 | 10,480,647 | 22,506,841 | DS | 3 | 2126-03-29 00:00:00 | 2126-04-23 14:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ healthy female who presents with n/v, RLQ abdominal pain.
She reports pain that developed in her RLQ her abdomen
approximately around 3:00am in the morning, pain associated
with nausea and vomitting. She is had multiple episodes of
nonbloody, nonbilious vomiting since that time. Her last bowel
movement was 24 hours ago and was nonbloody . She denies any
history of pain
like this. She reports chills but denies any fever. She denies,
chest pain, shortness of breath, diarrhea, dysuria, or vaginal
bleeding. Her last period was normal and it was 2 weeks ago. US
in the ED showed acute cholecystitis, WBC 12.4. CT confirmed
the diagnosis of acute appendicitis.
Past Medical History:
PMH:
None
PSH:
Wisdom tooth extraction
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS: T:98.5 HR:113 BP:139/70 RR:20 O2:100% RA
General: A/O X3 in no acute distress, HEENT: NCAT, PEERL, MMM
Neck: Supple, trachea midline
Heart: RRR, no MRG.
Lungs: CTAB. No W/R/R
Abd: Soft, tender to palpation in the right lower quadrant, no
rebound or guarding.
GU: No CVA tenderness.
EXT: WWP
Neuro: grossly intact
Discharge Physical Exam:
VS: T: 98.2 PO BP: 105/54 HR: 65 RR: 16 O2: 98% Ra
GEN: A+Ox3, NAD
HEENT: normocephalic, MMM
CV: regular rate
PULM: No respiratory distress, breathing comfortably on room air
ABD: soft, mildly distended, appropriately tender at incisions.
Incisions with dermabond intact, no s/s infection
EXT: wwp, no edema
Pertinent Results:
IMAGING:
___: US Appendix:
Findings consistent with acute appendicitis.
___: CT Abdomen/Pelvis:
Acute appendicitis with mild mesenteric stranding. No evidence
of
extraluminal air or drainable fluid collection.
LABS:
___ 12:28PM URINE UCG-NEGATIVE
___ 12:28PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 12:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-TR*
___ 12:28PM URINE RBC-1 WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-3
___ 12:28PM URINE MUCOUS-OCC*
___ 10:25AM LACTATE-2.4*
___ 10:17AM GLUCOSE-108* UREA N-12 CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-17* ANION GAP-20*
___ 10:17AM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-86 TOT
BILI-0.6
___ 10:17AM LIPASE-27
___ 10:17AM ALBUMIN-4.9
___ 10:17AM WBC-12.4* RBC-4.79 HGB-13.8 HCT-39.2 MCV-82
MCH-28.8 MCHC-35.2 RDW-12.6 RDWSD-37.9
___ 10:17AM NEUTS-79.8* LYMPHS-13.9* MONOS-5.2 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-9.92* AbsLymp-1.73 AbsMono-0.65
AbsEos-0.04 AbsBaso-0.05
___ 10:17AM PLT COUNT-331
___ 10:17AM ___ PTT-24.9* ___
Brief Hospital Course:
Ms. ___ is an ___ year-old female who was admitted to the
Acute Care Surgical Service on ___ for evaluation and
treatment of abdominal pain. Admission abdominal/pelvic CT
revealed acute appendicitis, WBC was elevated at 12.4. On HD1,
the patient underwent laparoscopic appendectomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor on IV fluids, and acetaminophen and
oxycodone for pain control. The patient was hemodynamically
stable.
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:
OCPs
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Take with food
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with acute appendicitis
(inflammation of the appendix). You were taken to the operating
room and had your appendix removed laparoscopically. You are
now tolerating a regular diet and your pain is manageable with
oral pain medication. You are now ready to be discharged home
to continue your recovery.
Please note the following discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until 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 You have a glue-type dressing, called Dermabond, covering your
incisions. This dressing will fall off on its own over the next
___ weeks.
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:
___
|
10481162-DS-14 | 10,481,162 | 26,806,018 | DS | 14 | 2173-02-24 00:00:00 | 2173-02-27 13:21:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LUE infection, fungating chest mass
Major Surgical or Invasive Procedure:
Incision and drainage of L axillary abscess
History of Present Illness:
___ w/ metastatic breast cancer with local recurrence left chest
i9n ___ now s/p XRT completed ___, on chemotherapy with
Eribulin, presenting with open wound/mass on her anterior chest
wall with purluent drainage. Patient also notes localized pain
at wound site radiating to L shoulder, along with swelling of
LUE, which started over the past week. Pt states pain increased
over weekend, despite home pain meds. Fungating mass on sternum
began as a small sprout after XRT in ___, has increased,
draining serous fluid with no pain. Area of induration in left
axilla began over the weekend, with subsequent left arm
swelling. Chronic chills, has measured temperature during
chills, normal. No fever/nausea/vomiting, CP/SOB.
ED course:
VS: 98.1 101 140/80 18 99% RA
LUE u/s- no DVT
ultrasound abscess - pocket in left axilla
I&D - done, with wick placed, blood cultures sent, received one
gram vancomycin
Currently feels well, denies pain.
Past Medical History:
PAST ONCOLOGIC HISTORY (per Dr. ___:
___ Thyroid cancer, papillary carcinoma (Dr. ___
radioactive ablation
___ Right lung nodule seen on chest CT. RUL wedge resection
(Dr. ___, negative path.
___ Left breast cancer: +Invasive ductal carcinoma. multifocal,
1.2cm. ER-/PR-/Her2neu -. ___ lymph nodes +. Grade II.
Mastectomy (Dr. ___. Adriamycin 60mg/m2 IV and
Cytoxan 600mg/m2 IV q 21 days x 4 cycles
___ Sternal fullness notes by patient. +subcutaneous mass.
___ Taxotere
___ Surgery had to be postponed due to SVT but once stabilized,
had excision (Dr. ___: poorly diff carcinoma involving the
subq and dermis wi th tumor cells present at deep margin (which
is rib). ER-/PR-/Her2neu -.
___ XRT (Dr. ___
___ New anterior chest wall pain. CT with pulmonary lesions.
___ PET (___): Large FDG-avid soft tissue mass extending
from the left pectoralis muscle to the anterior mediastinum with
associated osseous lytic destruction as detailed above
consistent with a focus of disease. 2. Multiple scattered
pulmonary nodules as detailed above measuring up to 5mm as
detailed above with a right upper lobe nodule demonstrating
increased FDG-avidity. 3. Non-specific mildly increased avidity
involving the left adrenal gland without focal associated
nodularity for which attenuation can be paid on follow-up
examinations. 4. Calcified uterine fibroid.
___ Chest wall muscle biopsy (___): poorly differentiated
carcinoma. ER-/PR-/Her2neu -.
___ - ___ Carboplatin AUC4 IV and Taxol 175mg/m2 IV q
21 days x 5 cycles.
___ Treatment holiday due to peripheral neuropathy
___ Chest CT: resolution of soft tissue mass involving
sternum and ribs. Decrease in pulmonary nodules.
___ Patient reports chest pain. Chest CT: Pumonary nodules
5mm and smaller with marginal increase. Mixed lytic and
sclerotic lesions of the sternum and rubs with increase in lytic
lesion. Minimally displaced fracture of sternum previously noted
with partial healing however new pathological fracture
inferiorally
___ radiation therapy who could
offer further radiation for symptom management. Decision made to
treat with chemotherapy initially
___ - ___ Navelbine 20mg/m2 IV day 1,8 and 15 q 21 days
___nd arm pain.
___ CT: IMPRESSION: 1. There is no significant right
foraminal stenosis. 2. There is a moderate-sized central disc
herniation at C6/7 which indents the spinal cord. 3. There is
bony stenosis of the left T2/3 foramen 4. No lesion is seen that
suggests cervical spine metastatic disease
___ Started on monthly Zometa 4mg IV
___ PET:1. Multiple subcentimeter pulmonary nodules overall
increased in size and FDG activity. 2. Lytic, FDG avid lesion of
anterior chest wall which has progressed from the prior exam. 3.
Focus of activity at the right hilum unchanged from the prior
exam and could represent a lymph node.
___ - ___ Xeloda 1500mg po bid x 14 days with 7 day rest.
S/p 3 cycles
___ CT chest/abd/pelvis: Increased number and size of
pulmonary nodules. Left upper anterior chest wall mass with soft
tissue component and mixed sclerotic lytic involvement of the
left side of the sternum and anterior left first rib. The
central low density within the soft tissue component may
represent necrosis. A small amount of abnormal soft tissue
extends into the anterior mediastinum. Enlarging solid left
upper pole renal mass. Stable right adrenal nodule
___ Cycle #1 Carboplatin and Taxol
___ Cycle #2 Carboplatin and Taxol
___ to sternum (Dr. ___ along with Xeloda
500mg BID x 14 days q 3 weeks
___ PET (___): 1. Large peripherally FDG-avid left chest
wall mass invading the soft tissues of the left chest and
sternum. Findings likely represent a combination of neoplasm
with possible necrosis, and effects of infection or
instrumentation. 2. There is a 3.0 x 3.7 cm mass arising from
the superior pole left kidney concerning for primary renal
malignancy. This is not significantly changed compared to
outside examination performed ___. 3. Upper lobe
predominant FDG-avid pulmonary nodules concerning for
metastases.
___ Started Eribulin, last dose ___, received Neulasta
___
PAST MEDICAL HISTORY:
leiomyoma
h/o thyroid cancer
HTN
spinal stenosis
sciatica
breast cancer s/p mascectomy, metastatic to bone, lung, and
chest wall
peripheral neuropathy ___ chemotherapy
Social History:
___
Family History:
no history of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 98.8 BP: 109/71 HR: 100 RR: 18 02 sat 96% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: central, 3 cm x 3 cm fungating mass without erythema,
with drainage
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis or
clubbing. LUE with 2+ non-pitting edema. Left axilla with I
and D of abscess, wick in place, no drainage, some faint
erythema around left shoulder
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - 98.9 144/80 92 20 95RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: central, 3 cm x 3 cm fungating mass without erythema,
with drainage
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis or
clubbing. LUE with 2+ non-pitting edema. Left axilla with I
and D of abscess, wick in place, no drainage, some faint
erythema around left shoulder, swelling improved this AM
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-19.9*# RBC-3.98* Hgb-12.1 Hct-35.9*
MCV-90# MCH-30.4# MCHC-33.7 RDW-19.4* Plt ___
___ 02:45PM BLOOD Neuts-83.7* Lymphs-11.7* Monos-3.7
Eos-0.8 Baso-0.1
___ 02:45PM BLOOD Glucose-198* UreaN-8 Creat-0.8 Na-139
K-3.9 Cl-100 HCO3-25 AnGap-18
___ 06:40AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.6
___ 02:53PM BLOOD Lactate-2.1*
DISCHARGE LABS:
___ 06:44AM BLOOD WBC-12.1* RBC-3.81* Hgb-11.2* Hct-33.7*
MCV-89 MCH-29.5 MCHC-33.3 RDW-19.5* Plt ___
___ 06:44AM BLOOD Glucose-159* UreaN-6 Creat-0.6 Na-143
K-3.8 Cl-106 HCO3-29 AnGap-12
___ 06:44AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
___ 06:44AM BLOOD Vanco-14.1
IMAGING:
UPPER EXTREMITY ULTRASOUND (LEFT)
IMPRESSION: No left upper extremity DVT with extensive axillary
and humeral
subcutaneous edema and ___ircumscribes extremely
superficial fluid
collection in the left axilla.
Brief Hospital Course:
___ yo female with metastatic breast cancer (bone, lung, chest
wall) admitted with chest wall wound and left axillary abscess.
#. LUE abscess/cellulitis- s/p I and D, wound cultures NGTD. No
LUE DVT on ultrasound. Patient was treated with vancomycin until
day of discharge, at which time she was switched to PO bactrim
and amoxicillin on discharge. She is to complete a 10 day
course. Her LUE had significant swelling on admission, however
this improved significantly with antibiotics.
# Chest wall mass- likely ___ to recent XRT, no e/o infection,
patient was seen by wound care team who had no further
recommendations. There was no acute exacerbation of her chronic
wound.
# HTN- no acute exacerbation of chronic condition, continued
___, BB
# Metastatic breast cancer- received Eribulin on ___, and
Neulasta ___. Further management is deferred to her
outpatient provider.
#. h/o thryoid cancer s/p RAI-no acute exacerbation of chronic
condition, patient to cont levothyroxine
TRANSITIONAL ISSUES:
-Blood CX x 2 are pending and should be followed up by
outpatient provider.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN nausea
3. Levothyroxine Sodium 88 mcg PO DAILY Start: In am
4. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP < 100, HR < 55
5. eriBULin *NF* 1 mg/2 mL (0.5 mg/mL) Injection per oncology
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN nausea
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP < 100, HR < 55
5. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*24 Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
7. eriBULin *NF* 1 mg/2 mL (0.5 mg/mL) Injection per oncology
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abscess
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for an infection in your arm. You
had the infection drained and you were started on antibiotics
and should continue them through ___. Please keep your
appointments listed below.
Followup Instructions:
___
|
10481162-DS-15 | 10,481,162 | 26,132,850 | DS | 15 | 2173-04-06 00:00:00 | 2173-04-06 20:47:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with complicated metastatic breast cancer history,
cardiomyopathy with EF 30% and "history of palpitations" who
presents from ___ clinic with palpitations and rapid heart
rate.
She was in her usual state of health utnil earlier on the day of
presentation. At that time she presented to her chemotherapy
appointment and received normal saline and decadron as routine
prior to her chemotherapy. At that time she developed
palpitations with a heart rate around 180-200. This lasted over
30 minutes and EMS was contacted. They administered adenosine
with improvement in her HR to 120-130s. She was transfered to
___ for further evaluation and management. Of note, she
reports feeling relatively well. She states it is not uncommon
for her to get palpitations that often last for 15 minutes. She
does not recall ever having palpitations that lasted as long as
todays. With the rapid heart rate she denies lightheadedness and
reports her blood pressure was actually elevated. She denies any
fevers, chills, nausea, vomiting, diarrhea, constipation,
thirst, dehydration, lightheadedness, chest pain, shortness of
breath. She does endorse a mild cough which is nonproductive.
She denies any leg pain. She does endorse swelling of her left
arm and possible infection.
In the ED, initial vitals were: 98.3, 116, 140/80, 16, 93% RA.
She had labs which showed mild anemia. CXR showed a left sided
opacity of unclear etiology (worsening known metastatic disease
vs effusion vs infection). She was treated with levofloxacin and
admitted to the OMED service for further evaluation and
management.
On admission, she felt well and did not have palpitations.
ROS: per above. Denies other symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY (per Dr. ___:
___ Thyroid cancer, papillary carcinoma (Dr. ___
radioactive ablation
___ Right lung nodule seen on chest CT. RUL wedge resection
(Dr. ___, negative path.
___ Left breast cancer: +Invasive ductal carcinoma. multifocal,
1.2cm. ER-/PR-/Her2neu -. ___ lymph nodes +. Grade II.
Mastectomy (Dr. ___. Adriamycin 60mg/m2 IV and
Cytoxan 600mg/m2 IV q 21 days x 4 cycles
___ Sternal fullness notes by patient. +subcutaneous mass.
___ Taxotere
___ Surgery had to be postponed due to SVT but once stabilized,
had excision (Dr. ___: poorly diff carcinoma involving the
subq and dermis wi th tumor cells present at deep margin (which
is rib). ER-/PR-/Her2neu -.
___ XRT (Dr. ___
___ New anterior chest wall pain. CT with pulmonary lesions.
___ PET (___): Large FDG-avid soft tissue mass extending
from the left pectoralis muscle to the anterior mediastinum with
associated osseous lytic destruction as detailed above
consistent with a focus of disease. 2. Multiple scattered
pulmonary nodules as detailed above measuring up to 5mm as
detailed above with a right upper lobe nodule demonstrating
increased FDG-avidity. 3. Non-specific mildly increased avidity
involving the left adrenal gland without focal associated
nodularity for which attenuation can be paid on follow-up
examinations. 4. Calcified uterine fibroid.
___ Chest wall muscle biopsy (___): poorly differentiated
carcinoma. ER-/PR-/Her2neu -.
___ - ___ Carboplatin AUC4 IV and Taxol 175mg/m2 IV q
21 days x 5 cycles.
___ Treatment holiday due to peripheral neuropathy
___ Chest CT: resolution of soft tissue mass involving
sternum and ribs. Decrease in pulmonary nodules.
___ Patient reports chest pain. Chest CT: Pumonary nodules
5mm and smaller with marginal increase. Mixed lytic and
sclerotic lesions of the sternum and rubs with increase in lytic
lesion. Minimally displaced fracture of sternum previously noted
with partial healing however new pathological fracture
inferiorally
___ radiation therapy who could
offer further radiation for symptom management. Decision made to
treat with chemotherapy initially
___ - ___ Navelbine 20mg/m2 IV day 1,8 and 15 q 21 days
___nd arm pain.
___ CT: IMPRESSION: 1. There is no significant right
foraminal stenosis. 2. There is a moderate-sized central disc
herniation at C6/7 which indents the spinal cord. 3. There is
bony stenosis of the left T2/3 foramen 4. No lesion is seen that
suggests cervical spine metastatic disease
___ Started on monthly Zometa 4mg IV
___ PET:1. Multiple subcentimeter pulmonary nodules overall
increased in size and FDG activity. 2. Lytic, FDG avid lesion of
anterior chest wall which has progressed from the prior exam. 3.
Focus of activity at the right hilum unchanged from the prior
exam and could represent a lymph node.
___ - ___ Xeloda 1500mg po bid x 14 days with 7 day rest.
S/p 3 cycles
___ CT chest/abd/pelvis: Increased number and size of
pulmonary nodules. Left upper anterior chest wall mass with soft
tissue component and mixed sclerotic lytic involvement of the
left side of the sternum and anterior left first rib. The
central low density within the soft tissue component may
represent necrosis. A small amount of abnormal soft tissue
extends into the anterior mediastinum. Enlarging solid left
upper pole renal mass. Stable right adrenal nodule
___ Cycle #1 Carboplatin and Taxol
___ Cycle #2 Carboplatin and Taxol
___ to sternum (Dr. ___ along with Xeloda
500mg BID x 14 days q 3 weeks
___ PET (___): 1. Large peripherally FDG-avid left chest
wall mass invading the soft tissues of the left chest and
sternum. Findings likely represent a combination of neoplasm
with possible necrosis, and effects of infection or
instrumentation. 2. There is a 3.0 x 3.7 cm mass arising from
the superior pole left kidney concerning for primary renal
malignancy. This is not significantly changed compared to
outside examination performed ___. 3. Upper lobe
predominant FDG-avid pulmonary nodules concerning for
metastases.
___ Started Eribulin, last dose ___, received Neulasta
___
PAST MEDICAL HISTORY:
leiomyoma
h/o thyroid cancer
HTN
spinal stenosis
sciatica
breast cancer s/p mascectomy, metastatic to bone, lung, and
chest wall
peripheral neuropathy ___ chemotherapy
cardiomyopathy with impaired left ventricular function (EF 35%)
Holter monitor with ventricular arrhythmia
Patient reports history of "palpitations" since ___
Social History:
___
Family History:
Confirmed: no history of breast cancer
Physical Exam:
Admission Physical Exam:
Vitals: T 98.3, HR 109, BP 131/83, RR 16, SvO2 95% RA
Pain: ___
HEENT: OP without lesions
Card: RR, tachycardic, no r/g/m appreciated
Pulm: left sided crackles, decreased breath sounds, otherwise
clear, speaking full sentences, no accessory muscle use, bandage
with sore on anterior chest wall, no drainage
Abd: soft, nontender, nondistended, +BS
Ext: legs without edema, LUE with edema, mild erythema, wwp
Neuro: grossly intact, limited examination
Psych: pleasant
Discharge physical exam:
Vitals: T 98.3, HR 88, BP 144/90, 18, 99% RA Pain: ___
HEENT: MMM, JVP not elevated
Card: RRR with normal S1 and S2 with S4, no murmurs
Pulm: mild left crackles, decreased breath sounds on left, no
accessory muscle use, bandage on anterior chest wallAbd: soft,
nontender, nondistended, +BS
Ext: legs without edema, LUE with edema, mild erythema, warm,
well-perfused
Neuro: CNs ___ intact, sensation and motor function grossly
intact
Psych: pleasant, appropriate
Pertinent Results:
___ 05:45PM BLOOD WBC-9.8 RBC-4.18* Hgb-11.4* Hct-35.5*
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.8* Plt ___
___ 05:45PM BLOOD Neuts-95* Bands-0 Lymphs-5* Monos-0 Eos-0
Baso-0 ___ Myelos-0
___ 05:45PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Target-OCCASIONAL
Tear Dr-OCCASIONAL
___ 05:45PM BLOOD ___ PTT-29.2 ___
___ 05:45PM BLOOD Glucose-121* UreaN-14 Creat-0.7 Na-143
K-5.8* Cl-109* HCO3-24 AnGap-16
___ 05:45PM BLOOD ALT-20 AST-58* AlkPhos-291* TotBili-0.3
___ 05:45PM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.1 Mg-2.3
___ 05:45PM BLOOD TSH-1.4
.
LABS ON DISCHARGE:
___ 06:10AM BLOOD WBC-7.4 RBC-4.11* Hgb-10.9* Hct-33.5*
MCV-82 MCH-26.4* MCHC-32.4 RDW-17.4* Plt ___
___ 06:10AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-142
K-3.8 Cl-108 HCO3-27 AnGap-11
___ 05:45PM BLOOD TSH-1.4
___ 06:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:45PM BLOOD cTropnT-<0.01
EKG: ___ clinic - SVT. Tele strip EMS - conversion to NSR.
___: Sinus tachycardia. Prominent precordial voltage. ST-T
wave abnormalities. Since the previous tracing of ___ the
rate is faster. ST-T wave abnormalities are more prominent.
There may be possible atrial flutter with 2:1 block, although
artifact precludes definitive statement. Clinical correlation
and repeat tracing are suggested.
CXR: FINDINGS: Frontal and lateral views of the chest were
obtained. Since the prior study, there has been significant
interval increase in left hemithorax opacity which involves the
left mid and lower lung fields, which may be related to
underlying metastatic disease with possible superimposed
infection/pleural effusion. Multiple pulmonary nodules are
again seen. Patchy right base opacity is also seen, which could
be due to infection and/or progression of metastatic disease.
The cardiac silhouette is not well assessed due to the
left-sided opacity. Mediastinal contours are stable.
___: LUE ultrasound:
IMPRESSION: No evidence of DVT in the left upper extremity.
___: Echocardiography
The left atrium is mildly dilated. The left atrium is elongated.
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. The left
ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 25 %) secondary to moderate-severe global hypokinesis
(based on apical views only as short axis views were not
available). The basal lateral wall contracts best. Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a very small pericardial effusion
best seen along the right ventricular free wall in subcostal
views. There is no tamponade.
IMPRESSION: Top normal left ventricular size with severe global
systolic dysfunction suggestive of non-ischemic cardiomyopathy.
Likely functional mild moderate mitral regurgitation. Very small
pericardial effusion. Left pleural effusion.
Brief Hospital Course:
___ with complicated breast cancer history with cardiomyopathy
and history of "palpitations" who presents with SVT.
# Supraventricular tachycardia: The etiology of the SVT is
unclear. The patient had received dexamethasone IV but none of
her chemotherapy at the time of her palpitations. She seems to
be prone to this as she has been getting palpitations since
___ (presumably this is the same rhythm). She also reports an
episode of palpitations for 20 minutes approximately one month
ago. Before that time, her episodes of palpitations never lasted
longer than a few minutes at most. The precipitant of her most
recent episode is unclear and could be due to infection, thyroid
function, pulmonary embolism, ischemia or other. The initial
chest X-ray showed possible pneumonia and she was given
levofloxacin in the ED. The patient did not manifest any
symptoms of pneumonia, however, so her levofloxacin was stopped.
Urine culture was contaminated, but patient was afebrile and
denies symptoms. TSH was within normal limits. Cardiac enzymes
were negative. Pulmonary embolism work-up was aborted when
patient reported that she did not want any more CTAs and that
she would not take any anticoagulants even if we found a clot,
since the anticoagulants make her sternal wound bleed. Telemetry
showed resolutaion of tachycardia within ___ hours of admission.
Because she was not tachycardic, her beta blocker was not
changed. She did undergo echocardiography, which showed LVEF of
25% (from baseline of 35%), along with mild-to-moderate mitral
regurgitation, small pericardial effusion, no thrombus in apex.
Patient's outpatient providers were made aware of these
findings.
# Left upper extremity swelling: Patient noted that she had
swelling of her entire left arm. She wanted to know if there a
clot causing the swelling, although it was unlikely that she
would accept anticoagulation. LUE ultrasound showed no evidence
of clot, so swelling likely secondary to lymphedema.
# Metastatic breast cancer: Outpatient provider ___ be kept
updated. Patient can likely restart chemotherapy next week.
# Anemia: Stable. No need for transfusion.
# Hypertension, benign: Continued home losartan, metoprolol
tartrate.
# Chest wall lesion: Wound consult was called and their
directions were used to change wound daily. Patient was
re-established with her ___ to continue dressing changes at
home.
TRANSITIONAL ISSUES:
Patient has follow-up with her Cardiologist in early ___.
Decisions about uptitrating metoprolol can be considered then.
Patient already on ___ and beta-blocker and does not appear to
need diuresis at this time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Pyridoxine 100 mg PO DAILY
3. Senna 2 TAB PO HS
4. Losartan Potassium 25 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Pyridoxine 100 mg PO DAILY
5. Senna 2 TAB PO HS
6. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Supraventricular tachycardia
Secondary diagnosis
Metastatic breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted because you had an
experience of palpitations just before you were to receive
chemotherapy. You were given a medication, adenosine, on the way
to the hospital to get your heart back in a normal rhythm. Your
heart did not go into that irregular rhythm again during your
hospitalization. You received an echocardiogram, which showed
slightly worse pumping of your heart, but nothing that would
specifically cause your palpitations. Your left arm was also
swollen, but ultrasound showed no evidence of clot.
We did not change any of your medications.
You should follow-up with your already scheduled appointments
with your oncologist and cardiologist.
Followup Instructions:
___
|
10481168-DS-10 | 10,481,168 | 22,867,017 | DS | 10 | 2152-04-26 00:00:00 | 2152-04-27 18:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Benadryl
Attending: ___
Chief Complaint:
Confusion, lethargy
Major Surgical or Invasive Procedure:
Diagnostic and Therapeutic Parcentesis ___
History of Present Illness:
___ yo F with history of breast CA (s/p chemo/XRT c/b metastases
to liver, spine, calvarium) and alcoholic
cirrhosis/pseudocirrhosis from metastases (c/b ascites requiring
weekly paracentesis)who presents with confusion and lethargy.
Patient was in USOH after recent discharge (___) for
hyponatremia/ascites and GI bleed. She then noted increased
confusion at home beginning the afternoon of ___. Her sister
visited her at home, and found the patient to be lethargic and
confused, different from her baseline. Patient was then brought
to ED by sister.
In the ED, vitals initially: 98.5 112 121/80 16 99% RA. Exam
notable for absent asterixis, A&Ox3 and ___ edema. Labs notable
for Na 127, Bicarb 18, ALT/AST 49/93, AP 558, WBC 8.3, Hgb 8.6
(close to recent baseline), Plt 130, INR 1.2. Lactate 2. She
received a CT Head with no acute intracranial process, but
notable for presence of known mixed lytic and sclerotic
metastases involving the entire calvarium.
This morning, the patient reports being less confused than
admission. She denies fevers/chills, nausea/vomiting, chest
pain, SOB, cough, abdominal pain. She has noted non-bloody,
loose stools for several days but she has been taking laxatives,
no hematochezia.
Past Medical History:
--Left breast cancer diagnosed in ___ mastectomy
with reconstruction and treated with 4 cycles of AC. Then
received radiation and on tamoxifen for ___ years
--HTN (not on meds)
--hypothyroidism
--hx of zoster
--Cirrhosis: ___ pseudocirrhosis (diffuse nodularity from liver
metastases) and/or alcoholic cirrhotic liver
Social History:
___
Family History:
Mother ___ ___ DEMENTIA, STROKES, KIDNEY CANCER
Father ___ ___ MYOCARDIAL INFARCTION
Brother Living DIABETES ___, MYOCARDIAL INFARCTION
Sister Living ___ HYPOTHYROIDISM
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 97.3 103 123/76 18 100% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, EOMI, ___. Oropharynx clear
Neck: supple, 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, moderately distended, bowel sounds present, no
TTP, +dullness to percussion, no fluid wave, no rebound or
guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses. Trace pitting edema to
knees.
Neuro: CNs2-12 intact, ___ strength in all major muscle groups.
No asterixis, no clonus.
Psych: AAOx3 (name, hospital, read date off wall calendar).
Cannot perform days of week backwards or serial 7s. Intact
long-term memory.
DISCHARGE PHYSICAL EXAM:
Vitals: T:98.3 HR: 95-105 ___ RR:18 O2:100% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, EOMI, ___. Oropharynx clear
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: tense, moderately distended, non-tender, bowel sounds
present, +dullness to percussion, no fluid wave, no rebound or
guarding
Ext: warm, well perfused, 2+ pulses. Trace pitting edema to
knees.
Neuro: CNs2-12 intact, ___ strength in all major muscle groups.
No asterixis, no clonus.
Skin: port in place R upper chest, no erythema or fluctuation
Psych: AAOx3. Can perform days of week backwards and serial 7s.
Pertinent Results:
ADMISSION LABS:
___ 11:00PM BLOOD WBC-8.3 RBC-3.02* Hgb-8.6* Hct-26.1*
MCV-86 MCH-28.5 MCHC-33.0 RDW-23.0* RDWSD-71.6* Plt ___
___ 11:00PM BLOOD Neuts-75.9* Lymphs-8.2* Monos-13.1*
Eos-2.2 Baso-0.2 Im ___ AbsNeut-6.29* AbsLymp-0.68*
AbsMono-1.09* AbsEos-0.18 AbsBaso-0.02
___ 11:00PM BLOOD ___ PTT-87.8* ___
___ 11:00PM BLOOD Glucose-120* UreaN-32* Creat-0.9 Na-127*
K-5.1 Cl-96 HCO3-18* AnGap-18
___ 11:00PM BLOOD ALT-49* AST-93* AlkPhos-558* TotBili-1.1
___ 11:00PM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.3 Mg-2.1
___ 05:49AM BLOOD Free T4-1.2
___ 10:08PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:08PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:08PM URINE Hours-RANDOM UreaN-1199 Creat-157 Na-11
K-85 Cl-13
___ 10:08PM URINE Osmolal-697
INTERVAL LABS:
___ 05:49AM BLOOD WBC-7.2 RBC-2.69* Hgb-7.6* Hct-22.9*
MCV-85 MCH-28.3 MCHC-33.2 RDW-23.0* RDWSD-71.8* Plt ___
___ 01:44PM BLOOD WBC-9.6 RBC-3.18* Hgb-8.8* Hct-27.4*
MCV-86 MCH-27.7 MCHC-32.1 RDW-22.8* RDWSD-72.2* Plt ___
___ 05:23PM BLOOD WBC-7.6 RBC-2.65* Hgb-7.6* Hct-23.0*
MCV-87 MCH-28.7 MCHC-33.0 RDW-23.1* RDWSD-72.1* Plt ___
___ 09:02PM BLOOD WBC-7.5 RBC-2.74* Hgb-7.5* Hct-24.0*
MCV-88 MCH-27.4 MCHC-31.3* RDW-22.7* RDWSD-71.9* Plt ___
___ 07:20AM BLOOD WBC-6.5 RBC-2.51* Hgb-7.0* Hct-21.5*
MCV-86 MCH-27.9 MCHC-32.6 RDW-22.7* RDWSD-71.3* Plt ___
OTHER RESULTS:
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
DISCHARGE LABS:
___ 08:20AM BLOOD WBC-7.5 RBC-2.62* Hgb-7.3* Hct-22.8*
MCV-87 MCH-27.9 MCHC-32.0 RDW-22.6* RDWSD-71.2* Plt ___
___ 08:20AM BLOOD ___ PTT-32.9 ___
___ 08:20AM BLOOD Glucose-141* UreaN-32* Creat-0.9 Na-128*
K-4.6 Cl-97 HCO3-18* AnGap-18
___ 08:20AM BLOOD ALT-60* AST-107* AlkPhos-583* TotBili-1.0
___ 08:20AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1
IMAGING:
___ MR HEAD W & W/O CONTRAS
IMPRESSION:
1. No evidence of hemorrhage, midline shift, or infarction.
2. New left frontal dural enhancement.
3. Left frontal calvarium lesion abutting the dura.
4. Diffuse heterogeneous enhancement of the calvarial bone
marrow consistent
with metastatic infiltration.
___ PARACENTESIS DIAG/THERA
IMPRESSION:
Successful ultrasound guided therapeutic and diagnostic
paracentesis with
removal of 2.0 liters of ascites.
___ CHEST (PA & LAT)
IMPRESSION:
No acute process. Diffuse osseous metastatic disease, unchanged
from prior
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial process.
2. Stable opacification of the right mastoid air cells.
3. Mixed lytic and sclerotic metastases involving the entire
calvarium,
skullbase and upper cervical spine given the history of
metastatic breast
cancer, similar in appearance to prior MRI examination ___.
Brief Hospital Course:
___ with hx of metastatic breast CA (bones, liver, spine),
cirrhosis (ascites req weekly para) and recent admission for GI
bleed with variceal banding who presents with worsening
confusion and weakness.
# Hepatic encephalopathy: Patient was admitted ___ for acute
onset of confusion and lethargy at home. She was brought to the
___ ED where a CT head showed no intracranial process. She
received an infectious workup in the ED but chest x-ray,
urinalysis and blood cultures did not show evidence of
infection. She was transferred to the medicine floor where her
exam was notable for decreased attention and orientation. She
did not have any focal neurological findings. Patient received a
diagnostic and therapeutic paracentesis (2L) on ___ that did
not show evidence of SBP. She received a brain MRI (___) that
showed her known metastatic lesions to calvarium but no new
intracranial metastases or evidence of infarct. Given her known
liver disease, we considered whether this could be delirium in
the setting of metabolic encephalopathy. Patient was started on
lactulose and rifaximin for presumed hepatic encephalopathy. Her
confusion resolved over the course of her admission and was thus
thought to be responsive to the lactulose and rifaximin. We also
considered whether this could be delirium due to thiamine
deficiency (as this was also repleted during her admission) or
medication effect (as we held her ativan and zolpidem during
admission). Patient was discharged on lactulose and rifaximin
for her hepatic encephalopathy.
# Anemia: Patient has chronic anemia with a hemoglobin of 8.5 on
admission. Her hemoglobin fluctuated throughout her admission
with a nadir of 7.0. This was concerning given her history of
prior GI bleed on her previous admission (secondary to
esophageal varices s/p banding). However the patient did not
report hematemesis or melena, and inspection of her stools did
not show melena or BRBPR, She remained asymptomatic during her
admission without any dizziness, lightheadedness or orthostatic
hypotension. She had no signs or symptoms of active bleeding.
However, her hemoglobin was 7.3 on day of discharge. She
received 1U pRBCs.
# Asymptomatic bacteriuria: Patient had no urinary symptoms,
however her urine culture grew pan-sensitive Enterococcus on
___. Given her immunocompromised state, she was started on
Augmentin 875mg BID on ___. Last day of abx course is
___.
#Cirrhosis: Patient has known felt secondary to EtOH c/b
metastatic disease. Her Plt, INR and albumin stable. She
receives weekly therapeutic paracentesis for her ascites. She
received a therapeutic paracentesis on ___ and ___ without any
evidence of infection upon fluid analysis. She had banding of
varices on last admission earlier this month. During this
admission her cirrhosis remained stable from her prior admission
other than her hepatic encephalopathy as above. Has known
varices and ascites but held nadolol for BP and diuresis for
BP/hyponatremia. Continued on SBP prophylaxis with cipro.
Continued omeprazole 40mg qD and sucralfate and discharged on
lactulose and rifaximin as above. Will follow up with liver as
outpatient.
#Hyponatremia - near baseline. Likely ___ cirrhosis. Held
diuresis given possible dehydration.
#Hypothyroidism - continue levothyroxine 200mg qD. Free T4 was
wnl
CHRONIC ISSUES:
#Tachycardia: Patient had tachycardia to 100s during her
admission that was initially thought to be secondary to
hypovolemia and dehydration given her concentrated urine osm
697. She received albumin for her dehydration however her
tachycardia persisted. Upon review with the patient, her
tachycardia appears to be a chronic issue. Her EKGs showed sinus
tachycardia that was stable from prior.
#Elevated Alk Phos: Patient has chronic elevation at baseline,
likely ___ diffuse bony mets.
# TRANSITIONAL ISSUES
- Continue rifaximin 550mg twice a day and lactulose 15mg three
times a day with goal ___ BM/day to prevent hepatic
encephalopathy
- Continue Augmentin 875mg twice a day x 5 days (last day
___
- Restart spironolactone 25mg daily given ascites and stable
sodium level.
- Repeat Chem10 and Hgb in 1 week to ensure stable K+ while on
spironolactone and stable Hgb after transfusion (pre-transfusion
Hgb 7.3).
- Consider initiation of furosemide given recurrent ascites and
nadolol given esophageal varices if BP will tolerate.
- Continue to have Ensure with meals as an outpatient.
- CODE STATUS: Full - if acute reversibility
- CONTACT: Sister ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 600 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Levothyroxine Sodium 200 mcg PO DAILY
4. Lorazepam 0.25 mg PO DAILY:PRN anxiety
5. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
6. Ciprofloxacin HCl 500 mg PO Q24H
7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
8. Omeprazole 40 mg PO DAILY
9. Sucralfate 1 gm PO QID
10. Sarna Lotion 1 Appl TP QID:PRN itchy
Discharge Medications:
1. Calcium Carbonate 600 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Levothyroxine Sodium 200 mcg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sarna Lotion 1 Appl TP QID:PRN itchy
7. Sucralfate 1 gm PO QID
8. Lorazepam 0.25 mg PO DAILY:PRN anxiety
___ cause drowsiness and confusion.
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
___ cause drowsiness and confusion.
10. Lactulose 15 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth ___ times
daily Refills:*0
11. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*28 Tablet Refills:*0
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Please take 875mg twice a day. Last day is ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*9 Tablet Refills:*0
13. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hepatic encephalopathy, anemia, asymptomatic
bacteriuria
Secondary: Metastatic breast cancer, cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were brought to the Emergency Department
because you were confused and lethargic. A CT scan and an MRI of
your head did not show any acute abnormalities. There was no
evidence of infection in the lungs. Your urine did return with
evidence of bacteria in it, and given that you have several
other medical problems, we placed you on an antibiotic called
amoxicillin-clavulanate for 5 days of treatment. We suspected
your confusion, however, was mainly due to your underlying liver
disease. You received lactulose and rifaximin for treatment of
hepatic encephalopathy (confusion related to liver disease), and
your confusion improved dramatically.
Your hospital admission was complicated by your anemia (low red
blood cell levels). We monitored your anemia and gave you 1 unit
of blood on the day of discharge.
When you are home, lease continue to take the antibiotic,
Augmentin, for 5 days ___ - ___. Please also continue
to take rifaximin and lactulose to prevent confusion caused by
liver disease.
You should have close follow up with your primary care
physician, hepatologist and oncologist.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your ___ medicine team
Followup Instructions:
___
|
10481168-DS-5 | 10,481,168 | 23,417,446 | DS | 5 | 2150-12-03 00:00:00 | 2150-12-03 20:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
leg weakness
Major Surgical or Invasive Procedure:
Radiation therapy
History of Present Illness:
___ h/o breast CA with mets to bone p/w LLE weakness. Pt reports
2 weeks of intermittent LLE weakness. Episodes last for seconds
and occur daily. She states that episodes consist of sudden
weakness in lower leg and foot though she has never fallen. She
denies f/c, numbness/tingling, bowel/bladder incontinence. CT
yesterday showed thoracic cord stenosis. Given these findings,
outpt oncology referred pt to the ED.
.
In the ED: 98.1 89 164/89 18 100% RA. wbc 8.1, hct 35, plt 200.
Lytes wnl. u/a wnl. MR full spine: "at the T3, T5 and T7 levels,
there are extensive associated epidural soft tissue components
occupying a significant portion of the left lateral aspect of
the spinal canal, with displacement and compression of the
spinal cord." Neuro evaluated and felt that exam not c/w cord
compression but given MR findings it would be reasonable to give
decadron 10 mg iv x1.
.
ROS: as above, otherwise complete ROS negative.
Past Medical History:
Overall, her past medical history is significant just for
hypothyroidism and breast cancer. HAs far as the breast cancer,
she has recently been changed over to Xeloda and has seemed to
have a significantly good response with drop in her tumor
markers
and a decrease in symptoms related to her cranial nerve
compression. Also, she has been on Zometa on a quarterly basis
now for many years probably as many as four to ___ years.
Her only surgery consists the mastectomy she had in ___.
Social History:
___
Family History:
She has cancer history, diabetes history, and heart history in
her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
t98 bp159/88 hr85 rr20 sat98%ra
NAD
eomi, perrl
neck supple
no ___
chest clear
rrr
abd benign
ext w/wp
neuro:cn ___ intact, ___ strength throughout,
DTRs intact, sensation grossly intact
no rash
DISCHARGE PHYSICAL EXAM:
Vitals - T98.0 BP 130/80 HR 87 RR 18 98RA
GENERAL: NAD. Sitting comfortably in bed.
SKIN: warm and well perfused, no rashes
HEENT: EOMI, PERRLA, MMM
NECK: nontender supple neck, no LAD
CARDIAC: RRR, no murmurs
LUNG: CTAB, no crackles or wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact. There is point tenderness along the left lateral
aspect of lower extremity in location of left fibular head known
met.
Pertinent Results:
ADMISSION LABS:
___ 12:40PM GLUCOSE-105* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
___ 12:40PM CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-2.0
___ 12:40PM URINE HOURS-RANDOM
___ 12:40PM URINE UHOLD-HOLD
___ 12:40PM WBC-8.1# RBC-3.61* HGB-11.6* HCT-35.4* MCV-98
MCH-32.1* MCHC-32.8 RDW-17.5*
___ 12:40PM NEUTS-71.9* LYMPHS-17.4* MONOS-9.6 EOS-0.5
BASOS-0.6
___ 12:40PM PLT COUNT-200
___ 12:40PM ___ PTT-33.3 ___
___ 12:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-14.9* RBC-3.69* Hgb-11.8* Hct-36.2
MCV-98 MCH-31.9 MCHC-32.6 RDW-17.7* Plt ___
___ 07:40AM BLOOD Glucose-159* UreaN-20 Creat-0.7 Na-140
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 07:40AM BLOOD ALT-98* AST-96* LD(LDH)-385* AlkPhos-412*
TotBili-0.3
MICROBIOLOGY:
# URINE CULTURE (___): No growth.
IMAGINING:
Imaging:
___: MRI:
IMPRESSION: Diffuse osseous metastatic disease throughout the
spinal column. However, at the T3, T5 and T7 levels, there are
extensive associated epidural soft tissue components occupying a
significant portion of the left lateral aspect of the spinal
canal, with displacement and compression of the spinal cord.
There is no spinal cord intrinsic signal abnormality.
___: Bone scan:
IMPRESSION: Widespread metastatic disease with a mixed pattern,
with some areas of increased activity and other areas with less
prominent activity compared to prior scan.
___: CT chest
IMPRESSION:
1. No new pulmonary nodules identified.
2. Diffuse sclerotic skeletal metastases with increased
destruction at left T5 pedicular lesion. Increased associated
soft tissue component is causing stenosis of the spinal canal,
which could be further assessed with thoracic MRI.
___: CT Abd/Pelvis:
1. Capsular retraction and increased lobulation of the liver
contour
consistent with pseudo-cirrhosis indicative of response to
chemotherapy treatment.
2. Patchy increased sclerosis throughout a background of
previous diffuse metastatic lesions in the axial skeleton likely
represents response to treatment.
3. No new areas of disease identified.
4. Cholelithiasis without evidence of acute cholecystitis.
Brief Hospital Course:
___ h/o breast CA with mets to bone p/w LLE weakness LLE
weakness/cord compression who has been evaluated by neurology
and now s/p 10 mg IV decadron.
.
ACTIVE ISSUES:
#Cord compression: MRI showed significant metastatic disease of
the spinal column. At the T3, T5 and T7 levels, there was
extensive associated epidural soft tissue components occupying a
significant portion of the left lateral aspect of the spinal
canal, with displacement and compression of the spinal cord. She
was given 10mg of IV Deacadron. Neurosurgery recommended
starting dexamethasone 4mg Q6H. She underwent emergent radiation
therapy on ___ and ___. She had formal radiation therapy
mapping on ___ followed by another round of radiation. She
was cleared to walk without a brace and did so without
difficulty. She will continue the remainder of her radiation as
an outpatient.
.
#Metastatic breast CA: Vinorelbine was held ___ for imaging
studies. Followed by Dr. ___. Chemotherapy was held during this
hospitalization. She will follow up with her outpatient
oncologist to resume her treatments.
.
#Elevated LFTs: Thought to be due to Vinorelbine (increased AST
in about 70% of pts). Looking at trend they are slightly above
baseline. Elevated of Alk phos was likely secondary to increased
bone metastasis. A slight downtrend of LFTs was noticed after
beginning radiation.
.
CHRONIC ISSUES:
#hypothyroidism: Continued home synthroid.
.
TRANSITIONAL ISSUES:
# She will follow up her radiation and medical oncologists to
receive radiation and chemotherapy respectively.
# Her LFTs should be monitored at regular intervals.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Naproxen 500 mg PO Q12H:PRN pain
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
4. Naproxen 500 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary dx:
Metastatic Breast Cancer
Thoracic spinal cord compression
Transaminitis
Secondary dx:
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to ___ due to your
left lower extremity weakness. ___ had an complete spine MRI
with changes concerning for compression of your spinal cord. ___
underwent urgent radiation therapy to your spine here in the
hospital that ___ will need to continue as an outpatient.
Followup Instructions:
___
|
10481168-DS-8 | 10,481,168 | 24,837,055 | DS | 8 | 2152-01-03 00:00:00 | 2152-01-07 08:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Benadryl
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
ultrasound-guided paracentesis ___
History of Present Illness:
___ year old female with breast cancer metastatic to bone and
liver s/p 7 cycles of paclitaxel reduced dose due to hepatic
disease (last on ___ who presents to ED worsening abdominal
distension and dyspnea. Has developed ascites and required ___
guided paracentesis x 2, ___ and ___. She did get
significant relief w/ these but after each one has had gradual
reaccumulation. She reports band of discomfort/pressure across
the abdomen, no sharp pains. No fever/chills. BM regular, no
nausea/vomiting. She is also very fatigued and getting winded w/
going to bathroom. Has been requiring
PRBC transfusions last ___. She was referred by her primary
oncologist to ___ in today, since she was too symptomatic to
wait for f/u later in the week.
In the ED, initial VS were: 5 97.7 132 22 100
Labs were notable for: Hgb of 6.3, and Na of 130
Treatments received: she was ordered for 2 units PRBCs, and got
12.5 gm of 5% albumin for volume in the setting of her
tachycardia.
CT abdomen done to eval for hemoperitoneum showed simple ascites
and cirrhosis.
On arrival to the floor, patient no longer feeling SOB. Not
currently having ab pain. Denies any bleeding, cough, chest
pain, ___ edema or orthopnea.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Left breast cancer diagnosed in ___ mastectomy w/ reconstruction and treated with 4
cycles of AC. Then received RXT & tamoxifen for ___ years.
___- rising CEA and she was on anastrozole for 18 months.
___, her markers were rising again and she was switched to
faslodex without result. Tamoxifen was added, but her
markers continue to increase. She was started on zoledronic
acid monthly and then transitioned to every-three-month therapy.
___ to the thoracic spine, T9 through L1 and in ___
received radiation therapy to the left hip and femur. She was
then placed on exemestane, which she took until ___ when
she required radiation therapy to her right femur and hip. In
___, she then started capecitabine on a 7-day on, 7-day
off schedule. Early on after starting, she had an impending
pathologic fracture of the right femur and underwent
intramedullary rodding to stabilize this.
___ restaging CT scan done because of abnormal
liver function tests and fatigue also shows innumerable small
liver metastases, which are new since ___.
___ New onset of low back pain with radiation down lt leg to lt
knee with numbness in knee. MRI of the L-spine from
___ revealed a new epidural soft tissue mass at L3 on the
left which extends from the vertebral body. Tumor markers from
___ were elevated with a CEA of 322 and a CA ___ of
6530. Decision made to change treatment to Navelbine.
___ bone mets to left leg and spine--difficulty walking
due to leg mets
___ for r/o cord compression--multiple spine mets
has completed XRT to spine and leg
___ cm lytic lesion in the proximal left fibula with new,
nondisplaced pathologic fracture.
NON-ONCOLOGICAL PAST MEDICAL HISTORY:
Hypothyroidism
PAST SURGICAL HISTORY:
Left-sided mastectomy in the past, femur
nail ___, appendectomy and tonsils as a child.
Social History:
___
Family History:
She has cancer history, diabetes history, and heart history in
her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 130/82 107 18 100%RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, mod distended and dull to percussion, no rebound or
guarding, nontender w/ deep palpation
EXT: No lower extremity pitting edema, R arm in cast
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and dry, without rashes
========================================
DISCHARGE PHYSICAL EXAM:
VS: ___ 18 99%
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, SEM, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, mod distended tender in LUQ with dullness at flanks,
no rebound or guarding,
EXT: No lower extremity pitting edema, R arm in cast
PULSES: 2+DP pulses bilaterally
NEURO: fluent speech
SKIN: Warm and dry, without rashes
Pertinent Results:
INITIAL LABS:
___ 02:00PM BLOOD WBC-7.5# RBC-2.35* Hgb-6.3*# Hct-19.8*
MCV-84 MCH-26.9* MCHC-31.9 RDW-21.7* Plt ___
___ 02:00PM BLOOD Neuts-69 Bands-2 ___ Monos-4 Eos-0
Baso-1 Atyps-1* ___ Myelos-1* NRBC-2*
___ 02:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL
Tear Dr-1+
___ 02:00PM BLOOD ___ PTT-96.8* ___
___ 02:00PM BLOOD Ret Aut-2.8
___ 02:00PM BLOOD Glucose-120* UreaN-39* Creat-0.7 Na-130*
K-4.9 Cl-102 HCO3-22 AnGap-11
___ 02:00PM BLOOD LD(LDH)-450*
___ 02:00PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6 Iron-101
___ 02:00PM BLOOD calTIBC-280 ___ Ferritn-92 TRF-215
___ 02:29PM BLOOD Lactate-1.7
=============================================================
DISCHARGE LABS:
___ 10:53AM BLOOD Hgb-9.1* Hct-26.2*
___ 04:55AM BLOOD WBC-10.7 RBC-2.48* Hgb-7.4* Hct-21.7*
MCV-87 MCH-29.9 MCHC-34.2 RDW-20.4* Plt ___
___ 12:20PM BLOOD Hgb-8.7* Hct-24.6*
___ 05:06AM BLOOD WBC-12.8* RBC-2.49* Hgb-7.6* Hct-21.2*
MCV-85 MCH-30.4 MCHC-35.7* RDW-19.1* Plt ___
___ 06:05PM BLOOD Hgb-9.2* Hct-25.9*
___ 12:03PM BLOOD Hgb-9.2*# Hct-25.2*#
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-90 UreaN-41* Creat-0.6 Na-135
K-4.4 Cl-107 HCO3-21* AnGap-11
___ 04:55AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.0
==============================================================
IMAGING:
___ CTA ABDOMEN PELVIS
1. No evidence of gastrointestinal bleed on mesenteric CTA.
2. Nodular appearance the liver compatible with pseudo
cirrhosis in the
setting of metastatic breast cancer.
3. Moderate to large amount of abdominal ascites.
4. Colonic diverticulosis.
5. Diffuse metastatic disease to the visualized skeleton.
___ ct ABDOMEN PELVIS:
IMPRESSION:
1. Large volume of simple ascites. No evidence of
hemoperitoneum.
2. Hepatic pseudocirrhosis.
3. Cholelithiasis.
4. Diverticulosis without evidence of diverticulitis.
5. Diffuse mixed lytic and sclerotic bony metastases.
6. Small left pleural effusion.
=======================================================
ASCITES STUDIES:
___ 11:15AM ASCITES WBC-106* RBC-79* Polys-12* Lymphs-9*
Monos-2* Eos-1* Macroph-76*
___ 11:15AM ASCITES TotPro-0.7 Glucose-127 Albumin-LESS
THAN
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of metastic
breast cancer s/p 7 cycles of paclitaxel presenting with dyspnea
and abdominal distention
#ASCITES: ___ pseudocirrhosis (diffuse nodularity from liver
mets) and/or malignant ascites. no signs SBP at this time.
Patient had ___ guided paracentesis during this admission with no
evidence of SBP. Could consider peritoneal drain but w/ ongoing
chemotherapy is infectious risk, she will discuss scheduled
paracenteses w/ Dr ___ at her next appointment.
#GI BLEED: found to have anemia she also reported dark stools.
Her hemoglobin level was 6.3 on admission, and remained 6.6
despite 2 units pRBC transfusion. She ultimatley recieved 5
units pRBCs during this admission. Her blood counts fluctated
but ultimatley stabalized with a hct > 24 for greater than 48
hours without transfusion. CTA was negative for brisk vascular
blled. GI was consulted and felt that endoscopy/colonoscopy was
unlikely to reveal an intervenable lesion based on symptoms. At
discharge patient denied lightheadedness and H/H was stable.
#Metastatic breast cancer - tumor markers slowly rising.
currently on paclitaxel, last CEA, Per Dr ___ clinic
note considering further paclitaxel vs eribulin. will f/u with
Dr. ___.
#Pathologic frx of right radius - post operative fixation ___,
has splint in place, on ibuprofen/tylenol prn. Stable
Transitional issues:
-Patient should have H/H monitored on ___ and faxed to
Dr. ___
-___ 40mg BID added to patients medication regimen
-Patient will likely need repeat paracentesis. This will be
evaluated by Dr. ___ at her next appointment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Spironolactone 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Hydrocortisone Acetate Suppository ___AILY PRN
constipation
6. Acetaminophen 650 mg PO Q6H
7. Ibuprofen 800 mg PO Q8H:PRN pain
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Zolpidem Tartrate 5 mg PO QHS
10. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Outpatient Lab Work
280.0 IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC)
Please draw hemoglobin and hematocrit
Please fax results to Dr. ___. Fax: ___
2. Acetaminophen 650 mg PO Q6H
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Spironolactone 50 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO EVERY OTHER DAY
9. Hydrocortisone Acetate Suppository ___AILY PRN
constipation
10. Ibuprofen 800 mg PO Q8H:PRN pain
11. Zolpidem Tartrate 5 mg PO QHS
12. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*56
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ascites
GI bleed
Secondary:
Metastatic breast cancer
Pathologic fracture of the radius
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with abdominal distension and shortness of breath, and you were
noted to have reaccumulation of ascites and anemia. You were
treated with paracentesis and blood transfusions.
We you ___ be having a slow bleed from the GI tract. You were
seen by the stomach doctors and in discussion with your primary
oncologist an EGD was deferred since it was unlikely they we
would be able to offer and endoscopic interventions to stop the
bleeding.
Because of your bleeding you should avoid NSAID medications ( ex
ibuprofen, aspirin, motrin).
At the time of discharge, you were feeling better and your blood
counts stablized. You were started on a medication called
omeprazole for the bleeding . Please follow up with your
oncologist in clinic.
Best wishes,
Your ___ Oncology Team
Followup Instructions:
___
|
10481236-DS-16 | 10,481,236 | 23,569,358 | DS | 16 | 2113-10-21 00:00:00 | 2113-10-21 12:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Macrobid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
flex sig, MRE, colonoscopy
History of Present Illness:
Ms. ___ is a ___ yo woman with history of ulcerative colitis
who presents with increased abdominal pain, rectal bleeding and
nausea.
She states six month ago she joined the military. While there
she
began to have significant amounts of rectal bleeding and
cramping. She was found to be severely anemic. She was told by
the Army doctor that she had UC. She was given canasa. She took
this for a while but didn't have any benefit. She was started on
oral iron. Due to her ongoing severe UC she was discharged from
the Military.
After discharge she did not have any insurance. The bleeding
intensified and she began to take oral iron 6 times a day. Three
days ago she had severe pain, it felt worse then her labor
pains.
She then noticed big gushes of blood. The blood was bright red
and mixed with only small amounts of stool. This is what
prompted
her to come in. Currently she is having up to 10 bloody bowel
movements a day.
She endorses ongoing cold sweats but no fevers. She denies any
sick contacts.
On arrival to the ED her vitals were T 97.3, HR 73, BP 123/71,
RR16, O2Sat 100% RA. Labs were drawn which showed hgb 11, Cr
0.6.
She was given 1l LR, IV Tylenol. GI was called who recommended
stool studies, 1g mesalamine daily, avoid all NSAIDS and
narcotics. She was subsequently admitted to medicine.
On arrival to the floor she is still having severe abdominal
pain
only slightly improved with IV Tylenol.
14 point ROS otherwise negative
.
Past Medical History:
Depression
Anxiety
PTSD
UC
.
Medications on admission:
Canasa
Iron
prenatal vitamin
Social History:
___
Family History:
Grandma with UC
Mother with frequent kidney stone
Father DM
Physical ___:
VS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy
Respiratory: multiple tattoos CTA b/l with good air movement
throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: distended , +b/s, soft, tender in all
quadrants, no masses or HSM, no rebound or guarding
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
___ 06:29AM BLOOD WBC-7.8 RBC-4.28 Hgb-11.4 Hct-35.2 MCV-82
MCH-26.6 MCHC-32.4 RDW-14.0 RDWSD-41.3 Plt ___
___ 11:30PM BLOOD WBC-7.8 RBC-4.42 Hgb-11.7 Hct-35.9
MCV-81* MCH-26.5 MCHC-32.6 RDW-14.0 RDWSD-40.8 Plt ___
___ 07:01PM BLOOD WBC-6.2 RBC-4.21 Hgb-11.3 Hct-34.7 MCV-82
MCH-26.8 MCHC-32.6 RDW-14.1 RDWSD-42.1 Plt ___
___ 05:45PM BLOOD WBC-6.4 RBC-4.03 Hgb-10.8* Hct-33.3*
MCV-83 MCH-26.8 MCHC-32.4 RDW-13.9 RDWSD-41.6 Plt ___
___ 12:55PM BLOOD WBC-6.6 RBC-4.60 Hgb-12.2 Hct-37.7 MCV-82
MCH-26.5 MCHC-32.4 RDW-14.0 RDWSD-41.0 Plt ___
___ 11:30PM BLOOD Ret Aut-2.1* Abs Ret-0.09
___ 06:29AM BLOOD Glucose-112* UreaN-8 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-25 AnGap-13
___ 12:55PM BLOOD Glucose-81 UreaN-9 Creat-0.6 Na-138 K-4.1
Cl-102 HCO3-23 AnGap-13
___ 07:15AM BLOOD ALT-14 AST-16 AlkPhos-71 TotBili-0.3
___ 12:55PM BLOOD ALT-14 AST-18 AlkPhos-74 TotBili-0.3
___ 12:55PM BLOOD Lipase-21
___ 07:15AM BLOOD calTIBC-449 Ferritn-6.7* TRF-345
___ 11:30PM BLOOD calTIBC-465 Ferritn-7.5* TRF-358
___ 07:15AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 11:30PM BLOOD CRP-1.2
KUB:
IMPRESSION:
Nonobstructive bowel gas pattern. Moderate colonic fecal load.
No free air.
Her Flex sig and colon show mild disease in very
distal rectum, without evidence of any proximal colon or small
bowel disease on colon/MRE. CRP and CBC were normal.
Brief Hospital Course:
Assessment and Plan:
Ms. ___ is a ___ yo woman with history of ulcerative colitis
who presents with increased abdominal pain, rectal bleeding and
nausea c/w UC flair.
Acute problems:
#Ulcerative proctitis exacerbation with
#abdominal pain with nausea, vomiting
#gastrointestinal bleeding
Patient with ongoing severe symptoms after recent diagnosis with
ongoing brbpr. GI consulted. Had brief steroids on admission.
Stool studies were negative. Treated with canasa, hydrocortisone
enema, IV Tylenol. Her Flex sig and colon show mild disease in
very distal rectum, without evidence of any proximal colon or
small bowel disease on colon/MRE. CRP and CBC were normal.
Therapy transitioned to ___ and budesonide foam (BID for 2
weeks then daily for 4 weeks). She will follow up with GI.
#Iron Deficiency Anemia
patient has been taking iron six times a day. Iron studies
reveal
slightly high retic and low ferritin. Continued PO iron
#Anxiety
#Depression
#PTSD
not on medications at this time.
Ms. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO Q4H
2. Mesalamine (Rectal) ___AILY
3. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. budesonide 2 mg/actuation Other BID
RX *budesonide [___] 2 mg/actuation 1 foam(s) rectally twice
daily Refills:*2
2. Lialda (mesalamine) 1.2 gram oral DAILY
RX *mesalamine [___] 1.2 gram 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*3
3. Ferrous Sulfate 325 mg PO DAILY
4. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
ulcerative proctitis
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 abdominal pain with bloody
diarrhea concerning for ulcerative colitis flare. You were seen
by the GI team and had a flex sigmoidoscopy, MRE, and
colonoscopy. These tests shows that the inflammation is limited
to the end of the colon (ulcerative procitis).
Instructions:
- Use rectal budesonide foam twice dialy for two weeks, followed
by daily for 4 weeks
- Take ___ daily
- continue Iron supplementation
- avoid NSAIDS
Followup Instructions:
___
|
10482402-DS-24 | 10,482,402 | 22,193,602 | DS | 24 | 2160-03-24 00:00:00 | 2160-03-24 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
___ CHOLECYSTECTOMY LAPAROSCOPIC
History of Present Illness:
___ year old female with history of HTN, NHL in remission, IDDM,
hyperlipidemia, systolic CHF, and remote ERCP with stent
placement in left hepatic system presents with four days of RUQ
abdomial pain.
Describes as sharp, intermittent. Dry heaves, no vomiting. Was
seen by PCP yesterday who did an US and showed gallstones.
Denies CP, SOB. Denies abdominal surgeries.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: 98 91 135/70 20 100% ra
US at ___: FINDINGS:
2 small stones are demonstrated in the gallbladder. The common
bile duct
measures 0.8 cm in AP diameter. No gallbladder wall thickening
or dilatation of the intrahepatic biliary ducts are
demonstrated. No tenderness was elicited to transducer pressure
over the gallbladder.
The liver is uniformly hyperechoic. No focal liver lesion is
identified. The posterior aspect of the liver is obscured by
overlying bowel gas. The
pancreatic tail is partially obscured by overlying bowel gas.
The visualized pancreas appears normal. The right kidney is
normal in appearance with no evidence of hydronephrosis. The
right kidney measures 9.9 cm in length. The abdominal aorta
appears normal.
Cholelithiasis. Mild dilatation of the common bile duct with an
AP diameter of 0.8 cm.
ERCP fellow - will add-on schedule for tomorrow
Past Medical History:
1. Non-Hodgkin's lymphoma, stage 1E, status post CHOP times
seven, complete response in ___.
2. DCIS, status post excision ___, XRT in ___.
3. Hypertension.
4. Diabetes mellitus.
5. Hypercholesterolemia.
6. History of systolic CHF
7. ERCP with stent placement in the left hepatic system and
endoscopic sphincterotomy
Hospitalizations:
___: CHF and CAP
___: ERCP with stent placement
Social History:
___
Family History:
Mother with diabetes and breast cancer, coronary artery disease.
Father with no known past medical history.
Physical Exam:
VS: 98.5 113/65 HR 77 RR 20 95% RA
General: pleasant, no distress
HEENT: anicteric sclera, EOMi
CV: RRR, normal S1, S2, no m,r,g
Pulm: CTA bilaterally
Abd: RUQ tenderness, no rebound or guarding
Ext: 2+ ___ pulses, no c/c/e
Neuro: CNs II-XII grossly intact
Pertinent Results:
___ 09:07PM LACTATE-1.7
___ 07:19PM GLUCOSE-271* UREA N-27* CREAT-1.6* SODIUM-138
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
___ 07:19PM estGFR-Using this
___ 07:19PM ALT(SGPT)-215* AST(SGOT)-163* ALK PHOS-135*
TOT BILI-3.2*
___ 07:19PM LIPASE-18
___ 07:19PM ALBUMIN-4.7
___ 07:19PM WBC-10.0# RBC-4.39 HGB-13.3 HCT-40.4 MCV-92
MCH-30.3 MCHC-33.0 RDW-12.6
___ 07:19PM NEUTS-90.9* LYMPHS-5.0* MONOS-3.3 EOS-0.6
BASOS-0.2
___ 07:19PM PLT COUNT-168
blood cultures pending
Brief Hospital Course:
___ year old female with history of IDDM, h/o sCHF, and HTN
presents with RUQ pain due to choledocholithiasis. She was
initially admitted to the medical service and underwent an ERCP.
Her LFT's were trended and once stabilized it was discussed with
her operative intervention. She was then consented, prepped and
taken to the operating room for laparoscopic cholecystectomy on
___. There were no complications.
Postoperatively she did well. Her diet was slowly advanced for
which she was able tolerate and her home medications restarted.
Her pain was well controlled on oral narcotics and she was given
a bowel regimen.
She was discharged to home on HD 7 with instructions for follow
up with her PCP and in ___ clinic.
Medications on Admission:
simvastatin 40 mg daily
spironolactone 50 mg daily
lisinopril 40 mg daily
furosemide 80 mg daily
gabapentin 300 mg daily
Lantus 36 units HS
SS humalog
metoprolol tartrate 50 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
please hold for loose stools
3. Furosemide 80 mg PO DAILY
4. Gabapentin 300 mg PO DAILY
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*25 Tablet Refills:*0
6. Glargine 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP < 100, HR < 55
8. Ranitidine 150 mg PO DAILY
9. Senna 1 TAB PO BID
please hold for loose stools
10. Simvastatin 40 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with an inflammation of your
gallbladder and underwent an operation to have it removed. You
are now being discharged to home with the following
instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
10482710-DS-8 | 10,482,710 | 24,927,706 | DS | 8 | 2166-03-03 00:00:00 | 2166-03-03 20:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Fevers, cough, shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy ___
History of Present Illness:
___ with history of hodgkin disease x ABVD ___ remission x ___
yrs, history of active TB as a child treated with streptomycin,
who is being admitted for fevers, cough, shortness of breath and
CT findings concerning for infection.
The patient has had a chronic cough due to post-nasal drip,
however, last ___ he states his cough changed ___ quality and
worsened ___ severity. He went to his PCP and ENT who treated him
for sinusitis, post-nasal drip, GERD and asthma without effect.
His symptoms worsened last ___, when he began experiencing
worsening cough productive of green-yellow sputum, fevers,
shortness of breath with exertion. He had chest xray and CT scan
that showed LLL consolidation. His pulmonologist gave him a 14
day course of levofloxacin ___ ___, at which time his
symptoms largely resolved. A few days after stopping abx, his
symptoms returned, and ___ ___ he was given another 14 day
course of levofloxacin. His symptoms also improved with the ___
course of antibiotics, but worsended when off. He last had
antibiotics about 10 days ago. He was referred to ___ by his
pulmonologist for further workup of his symptoms, including
induced sputums to r/o TB
The patient has had a history of TB ___ the past, when he was ___
years old. Unclear why the patient had TB; did not have any TB
exposures. Was born and raised ___ ___. His TB was diagnosd by
biopsy of a lymph node ___ his neck; he was diagnosed with
"glandular TB" and was given a series of streptomycin injections
over the course of months which treated his infection.
Recently, the patient has traveled to ___ ___,
___ ___, and ___ ___. He denies any
other exotic travel. He denies any mold/animal exposures,
besides his pet (dog) at home. Received radiation therapy to his
mediastinum ___ years ago for his lymphoma.
___ the ED intial vitals were: 97.9 94 120/62 20 100%
- Labs were significant for normal CBC, normal chem 10, normal
lactate. Patient has transaminitis with ALT 74, AST 52, Alk phos
91, t-bili 0.5.
- Patient was admitted to negative pressure room for rule out TB
with induced sputum.
On the floor, patient continues to have cough, otherwise no
complaints.
Past Medical History:
Hx of TB as a child treated with streptomycin for 6 months
IBS
History of Hodgkin's disease s/p ABVD and radiation now ___
remission x ___ years
Hx of atrial fibrillation on high dose ASA
Erectile Dysfunction
Hypothyroidism on supplementation
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 127/55 84 18 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Decreased breath sounds on L lower lobe; no
wheezing/rales/rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, no clubbing, no edema
Neuro: No focal deficits
DISCHARGE PHYSICAL EXAM:
VSS
General: thin male, NAD, breathing comfortably
HEENT: MMM, NCAT
CV: RRR, no m/r/g
Resp: CTAB
Abd: soft, non-tender, non-distended
Ext: warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
___ 04:30PM BLOOD WBC-8.7 RBC-4.87 Hgb-14.5 Hct-42.8 MCV-88
MCH-29.8 MCHC-33.9 RDW-14.0 Plt ___
___ 04:30PM BLOOD Neuts-67.0 ___ Monos-8.7 Eos-1.8
Baso-0.4
___ 04:30PM BLOOD ___ PTT-30.6 ___
___ 04:30PM BLOOD Glucose-121* UreaN-16 Creat-0.8 Na-140
K-3.9 Cl-105 HCO3-26 AnGap-13
___ 04:30PM BLOOD ALT-74* AST-52* AlkPhos-91 TotBili-0.5
___ 04:30PM BLOOD cTropnT-<0.01
___ 04:30PM BLOOD Lipase-27
___ 04:30PM BLOOD Albumin-3.6 Calcium-9.3 Phos-3.9 Mg-2.0
___ 04:42PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 06:13AM BLOOD WBC-5.0 RBC-4.47* Hgb-13.0* Hct-39.6*
MCV-89 MCH-29.0 MCHC-32.8 RDW-14.2 Plt ___
___ 06:13AM BLOOD ___
___ 06:13AM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-138
K-4.8 Cl-102 HCO3-28 AnGap-13
___ 06:13AM BLOOD ALT-221* AST-83* AlkPhos-89 TotBili-0.2
___ 06:13AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
TRANSAMINITIS WORK-UP:
___ 12:40PM BLOOD ESR-76*
___ 06:10AM BLOOD calTIBC-159* Ferritn-290 TRF-122*
___ 06:10AM BLOOD TSH-2.9
___ 03:28PM BLOOD HAV Ab-POSITIVE
___ 04:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 12:40PM BLOOD CRP-42.3*
___ 03:28PM BLOOD ___ * Titer-1:40
___ 03:10PM BLOOD IgG-1038 IgA-99 IgM-131
___ 06:10AM BLOOD HIV Ab-NEGATIVE
___ 03:28PM BLOOD Acetmnp-NEG
___ 04:30PM BLOOD HCV Ab-NEGATIVE
___ 06:13AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
___ 12:40PM BLOOD HISTOPLASMA ANTIBODY (BY CF AND ID)-PND
___ 06:15AM BLOOD QUANTIFERON-TB GOLD-PND
PENDING TESTS AT DISCHARGE:
- Quantiferon gold
- Histoplasma antibody
- EBV PCR
- CMV viral load, CMV IgM and IgG
- 7 AFB cultures ___ x2, ___ x2)
- Blood fungal and AFB culture ___
MICRO:
Blood cultures negative ___
Blood cultures pending ___
Urine legionella Ag negative
AFB smear negative ___ (2 smears), ___ AFB
cultures pending
Urine culture ___: 10,000-100,000 colonies enterococcus sp.
Urine cx ___: negative
Sputum cx: Streptococcus pneumoniae (see sensitivities below)
___
MTB Direct Amplification Negative ___
BAL results ___: see below; positive for Strep pneumo
Bronchial washings ___: see below: positive for Strep pneumo
and Moraxella catarrhalis
Rapid respiratory viral culture: negative ___
Malaria antigen test negative ___
EBV VCA IgG positive, EBV VCA IgM negative, EBV EBNA IgG
negative ___
Cryptococcal antigen ___ negative
___ 8:03 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- 1 S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
___ 8:30 am BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STREPTOCOCCUS PNEUMONIAE. ~6OOO/ML.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
WORK UP REQUESTED BY ___. ___ (___) ON ___.
This is a low yield procedure based on our ___
studies.
NO FUNGAL ELEMENTS SEEN.
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):
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.
___ 8:30 am BRONCHIAL WASHINGS
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___.
MORAXELLA CATARRHALIS. 10,000-100,000 ORGANISMS/ML..
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Brief Hospital Course:
___ with history of hodgkin disease x ABVD ___ remission x ___
yrs, history of active TB as a child treated with streptomycin,
presented with recurrent fevers, cough, shortness of breath and
CT findings concerning for infection.
ACUTE ISSUES:
# Pneumonia: The pt had a 6 month hx of worsening cough,
improved by 2 courses of levofloxacin initially but recurring
off antibiotics. Recent chest CT scan on ___ showed improvement
after abx, however, showed persistent residual patchy opacities
and enlarging pulmonary nodule. Received bronchoscopy during
admission. Several sputum cultures at ___ grew strep
pneumoniae sensitive to levofloxacin. One culture grew moraxella
catarrhalis. Unclear why these pathogens were not treated
effectively during previous treatment. Possibly due to
hyperdynamic airways that closed completely when coughing, seen
during bronchoscopy, causing trapping of infection ___ lower
lungs. AFB culture from ___ returned with prelim culture
consistent with Mycobacterium gordonae, although this is likely
a contaminant. AFB smears at ___ negative, cultures pending.
Both pulmonary and infectious disease consulted. The patient was
initially treated with IV vancomycin/cefepime and then was
transitioned to IV ceftriaxone. At discharge, ID recommended
cefpodoxime antibiotic until ___. Pulmonary recommended
repeat CXR on ___ during PCP ___.
# Transaminitis: Pt with transaminitis on admission, did not
have a history of elevated LFTs. Extensive work up for cause of
transaminitis negative. Normal HBV, HCV, HIV, TSH, ferritin, EBV
IgM. Liver ultrasound negative. Rare alcohol use. Hepatology
consulted and thought the increased LFTs may be due to prior
levofloxacin use. Per hepatology, elevated LFTs due to
medication use can take ___ weeks to resolve. They recomended
several viral studies, which are pending at discharge. They
recommended monitoring LFT levels twice weekly to ensure
resolution and to follow up with gastroenterology as an
outpatient.
# SVT: On telemetry, the patient had recurrent ___ beat runs
of SVT with heart rates ___ the 150s. Pt was asymptomatic and
hemodynamically stable during these episodes. Due to concerns
for sustained SVT during bronchoscopy, cardiology was consulted
and recommended starting a beta-blocker. Tolerated the
bronchoscopy without event. Due to low blood pressures, the beta
blocker was held at discharge. Should follow up with cardiology
as an outpatient.
CHRONIC ISSUES:
# Hypothyroidism: Continued levothyroxine
# Hx of atrial fibrillation: Patient's CHADS score is 0.
Continued aspirin 325mg daily
TRANSITIONAL ISSUES:
- Pulmonary recommends CXR during PCP visit on ___ to monitor
for interval change during antibiotics. They also recommend
repeat chest CT scan; should follow up with Dr. ___
the timing.
- Chest CT on ___ revealed a pulmonary nodule; interval follow
up is suggested to ensure it is stable
- Pt had transaminitis during admission. The hepatologists
recommended ___ labs to ensure stable or downtrending
LFTs
- The patient had asymptomatic, 15 beat runs of SVT repeatedly
during admission. Should follow up with cardiology for further
evaulation
- The patient's elevated LFTs may be caused by levofloxacin. The
patient should avoid fluoroquinolones ___ the future
- The patient has several cultures and studies pending at
discharge. At next PCP appointment, these labs should be
reviewed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
4. Aspirin 325 mg PO DAILY
5. Sildenafil 100 mg PO 1 HOUR PRIOR TO SEXUAL INTERCOURSE
6. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN wheezing
7. TraZODone 50 mg PO HS:PRN insomnia
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D Dose is Unknown PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Aspirin 325 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN wheezing
5. Levothyroxine Sodium 50 mcg PO DAILY
6. TraZODone 50 mg PO HS:PRN insomnia
7. Multivitamins 1 TAB PO DAILY
8. Sildenafil 100 mg PO 1 HOUR PRIOR TO SEXUAL INTERCOURSE
9. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
10. Vitamin D 400 UNIT PO DAILY
Please resume your home dose
11. Outpatient Lab Work
Please draw AST, ALT, Tbili, and Alkaline phoshatase on ___ and
___
ICD 9 code 790.4 Transaminitis
Please fax results to Dr. ___ at ___
12. Cefpodoxime Proxetil 400 mg PO Q12H
Please take until ___.
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Streptococcus pneumoniae pneumonia
Elevated liver enzymes
Supra-ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted with cough, shortness of breath and fevers that
persisted despite 2 treatments with levofloxacin. Your sputum
cultures grew strep pneumoniae and moraxella, two common
bacterial causes of pneumonia. ___ addition, a sputum culture
from ___ is currently positive for acid fast bacteria, with
prelim cultures growing mycobacteria gordonae. This may be a
contaminant. Pulmonology and infectious disease consulted, and
recommended continuing cefpodoxime (antibiotic) for a total of
21 days of treatment, until ___. Please follow up with your
pulmonologist as an outpatient.
___ addition, you had elevated liver function enzymes, a marker
of liver inflammation, while admitted. An extensive workup did
not reveal any obvious cause of the inflammation, however many
lab tests are pending. It is likely due to the lung infection or
the antibiotics that were given. Please follow up with your PCP
for ___ lab draws to monitor these liver enzymes.
Please see your GI physician as well. You should avoid
levofloxacin and other antibiotics from the same class ___ the
future (ciprofloxacin, moxifloxacin).
You had several episodes of high heart rates during admission.
We started a beta-blocker, but then held it at discharge due to
low blood pressures. Please follow up with a cardiologist after
discharge.
Best,
Your ___ medical team
Followup Instructions:
___
|
10482897-DS-18 | 10,482,897 | 23,499,220 | DS | 18 | 2127-12-03 00:00:00 | 2127-12-04 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hematuria, clot retention
Major Surgical or Invasive Procedure:
Diagnostic cystoscopy, clot evacuation, transurethral resection
of bladder tumor, ___ electrohydraulic lithotripsy) of bladder
stone.
History of Present Illness:
Mr. ___ is a ___ M with a h/o CAD s/p quadruple bypass, CHF
(EF 50-55% in ___, DM, and HTN, presenting to the ED with
gross
hematuria. He reports painless gross hematuria beginning ___
days
ago. This gradually worsened over the last five days,
accompanied
by weakness of stream, dribbling, frequency, urgency, and
dysuria. He denies any flank pain, fevers, chills, nausea, or
vomiting. He reports having an isolated episode of painless
gross
hematuria approximately a year ago. Workup revealed bilateral
non-obstructive renal stones. He does not recall undergoing
cystoscopy at the time.
At baseline, he reports a moderate stream, daytime frequency q 2
hours, nocturia x ___, and no hesitancy, urgency, incontinence
or
urinary tract infections.
Past Medical History:
CAD, NSTEMI
Hypertension
Dyslipidemia
Diabetes mellitus
Obesity
hearing loss w/ bilateral hearing aids
chronic low back pain
Surgical Hx:
CABG x 4
Eye surgery
Social History:
___
Family History:
No family history of GU malignancies
Physical Exam:
WDWN male, nad, AVSS
abdomen obese, soft, nt/nd
extremities w/out edema, pitting, pain
foley has been removed
UOP faint pink
Pertinent Results:
___ 07:00PM BLOOD WBC-11.0 RBC-3.24* Hgb-10.6* Hct-31.9*
MCV-99* MCH-32.8* MCHC-33.3 RDW-12.8 Plt ___
___ 07:00AM BLOOD WBC-9.6 RBC-3.30* Hgb-10.8* Hct-32.2*
MCV-98 MCH-32.8* MCHC-33.6 RDW-12.8 Plt ___
___ 10:00AM BLOOD WBC-10.3 RBC-3.49* Hgb-12.1* Hct-34.9*
MCV-100* MCH-34.5* MCHC-34.6 RDW-12.5 Plt ___
___ 10:00AM BLOOD Neuts-71.8* ___ Monos-5.4 Eos-2.1
Baso-0.5
___ 07:00AM BLOOD ___ PTT-31.3 ___
___ 07:00PM BLOOD Glucose-151* UreaN-10 Creat-0.9 Na-138
K-4.3 Cl-104 HCO3-23 AnGap-15
___ 07:00AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-136
K-4.1 Cl-102 HCO3-24 AnGap-14
___ 10:00AM BLOOD Glucose-141* UreaN-19 Creat-1.2 Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
___ 07:00PM BLOOD Mg-1.9
___ 07:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
___ 10:09AM BLOOD Lactate-1.7
Time Taken Not Noted Log-In Date/Time: ___ 7:06 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ was admitted to Urology from the emergency department
with hematuria and clot urinary retention. He was catheterized,
set up on continuous bladder irrigation and hand irrigated as
necessary. He was prepped for surgical intervention and added on
for ___. He was taken to the operating room where he
underwent diagnostic cystoscopy, clot evacuation, transurethral
resection of bladder tumor, ___ (electrohydraulic lithotripsy)
of bladder stone. No concerning intraoperative events occurred;
please see dictated operative note for details. He patient
received ___ antibiotic prophylaxis. The patient's
postoperative course was uncomplicated. He received intravenous
antibiotics and continuous bladder irrigation overnight. On POD1
the CBI was discontinued and Foley catheter was removed with an
active vodiding trial. Post void residuals were checked. His
urine was clear to faint pink and and without clots. He remained
a-febrile throughout his hospital stay. At discharge, the
patient had pain well controlled with oral pain medications, was
tolerating regular diet, ambulating without assistance, and
voiding without difficulty. He was given pyridium and oral pain
medications on discharge and a course of antibiotics along with
explicit instructions to follow up in clinic with Dr. ___ to
reveiw pathology and overall progress.
Medications on Admission:
Aspirin, Glipizide XL, Metoprolol, Simvastatin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Aspirin 81 mg PO DAILY
You may resume in three days if urine remains clear, yellow.
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
4. GlipiZIDE XL 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Phenazopyridine 200 mg PO TID Duration: 2 Doses
RX *phenazopyridine 100 mg ONE tablet(s) by mouth Q8hrs Disp
#*15 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PREOPERATIVE DIAGNOSES: Gross hematuria and bladder stone with
clot urinary retention.
POSTOPERATIVE DIAGNOSES: Papillary bladder tumor, bladder
stone, and clot in bladder.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ may be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Avoid straining on the toilet/with bowel movements. Continue
stool softener and gentle laxative if necessary.
-You may periodically have blood or pinking of your urine
output. This will gradually resolve.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment in 2 weeks AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
REPLACE the Tylenol with this narcotic pain medication if
additional pain control is needed.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-You may shower or bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
10483570-DS-21 | 10,483,570 | 29,592,147 | DS | 21 | 2182-11-23 00:00:00 | 2182-11-24 12:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Large volume paracentesis ___
History of Present Illness:
___ yo M with history of HCV cirrhosis complicated by
hepatocellular carcinoma, ascites, hepatic encephalopathy, and
esophageal varices. He is s/p TACE (transarterial
chemoembolization) & cyberknife for ___ and medical treatment
for HCV with Harvoni and ribavirin (completed ___, and his
HCV viral load has been undetectable since this time).
On discussion with wife and patient, reportedly he had a recent
hospital stay at ___ for an unknown reason. He was
sent home with Ativan to help his sleep. Since that time, his
wife states that "he does nothing more than eat, sleep, and go
to the bathroom." Over the past few days she has noticed him
being unable to use the TV remote or do other simple tasks. She
then brought him to ___ where CT head was performed
due to concerns for mets to the brain. This was negative. They
then requested transfer to ___ due to his previous care under
Dr. ___.
He denies any recent sick contacts, nausea/vomiting/diarrhea, no
dysuria, no cough, no sore throat. No hematemesis and no
melena/hematochezia. He states he is compliant with his meds,
but his wife is unsure. They have a ___ that comes ___.
Otherwise his wife had to stop helping with meds because it got
too confusing. Now she is unsure if he is taking lactulose as
frequent as he should because often he says "I'll take it
later."
In addition, it appears that Ativan is a new medication that is
currently prescribed 0.5mg po q6h prn. He says maybe he has
taken 20 pills or so in the past ___ weeks. He does also take
oxycodone 5mg ___ for shoulder pain.
He undergoes Q2 week therapeutic paras, last paracentesis on
___ drained 5L.
In the ED patient was noted to be HD stable and have asterixis
on exam. Diagnostic tap revealed no SBP. UA did not reveal
obvious sign of infection. CXR revealed new L-sided pleural
effusion, and RUQ US revealed patent portal vasculature with
cirrhotic liver. Patient was given lactulose 30mL x 2 and
admitted to ___ for hepatic encephalopathy.
On arrival to the floor patient is quite emotional, thinking
that his current illness is maybe a sign that he's dying. He
denies any abdominal pain, dysuria, cough, shortness of breath.
ROS: complete and thorough review of systems obtained and is
otherwise negative.
Past Medical History:
- Hep C (Genotype 1B) Cirrhosis: complicated by HCC, esophageal
varices w/ hx of GIB (s/p banding ___, and portal
hypertensive gastropathy
- ___ s/p failed TACE with subsequent embolization and
CyberKnife therapy
- Vitiligo
- Anemia
- Sigmoid diverticulosis
- Duodenitis
- Right shoulder arthritis
- Seasonal allergies
Social History:
___
Family History:
Family History: Denies history of hepatitis C, liver disease, or
colon cancer.
Physical Exam:
ADMISSION EXAM
VS: 98.9 142/77 66 18 99RA 68.1kg
General: covers his face with bed sheets; cachectic and somewhat
jaundiced, not grossly volume overloaded
HEENT: sclera slightly icteric, mucous membranes appear slightly
dry
CV: RRR
Lungs: decreased breath sounds on L overall, more pronounced on
L
Abdomen: distended, NABS, no TTP, + fluid wave
Ext: no peripheral edema
Neuro: + asterixis; able to say days of week backwards
Skin: vitiligo present on bilateral hands
DISCHARGE EXAM
Vitals: 98.3 ___ normotensive 18 98RA
General: cachectic and somewhat jaundiced, not grossly volume
overloaded
HEENT: sclera slightly icteric, mucous membranes appear slightly
dry
CV: RRR
Lungs: decreased breath sounds on L overall, more pronounced on
L
Abdomen: distended, NABS, no TTP, + fluid wave
Ext: no peripheral edema
Neuro: neg asterixis; able to say days of week backwards
Skin: vitiligo present on bilateral hands
Pertinent Results:
ADMISSION LABS
___ 09:30AM BLOOD WBC-4.9 RBC-3.47* Hgb-10.9* Hct-33.0*
MCV-95 MCH-31.4 MCHC-33.0 RDW-13.5 RDWSD-47.3* Plt ___
___ 09:30AM BLOOD ___ PTT-37.3* ___
___ 09:30AM BLOOD Glucose-101* UreaN-10 Creat-0.6 Na-135
K-4.2 Cl-99 HCO3-29 AnGap-11
___ 09:30AM BLOOD ALT-23 AST-40 AlkPhos-126 TotBili-2.8*
___ 09:30AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.1 Mg-2.1
___ 10:18AM BLOOD Lactate-1.9
DISCHARGE LABS
___ 05:20AM BLOOD WBC-5.1 RBC-2.91* Hgb-9.2* Hct-28.2*
MCV-97 MCH-31.6 MCHC-32.6 RDW-13.5 RDWSD-47.6* Plt ___
___ 05:20AM BLOOD ___ PTT-39.7* ___
___ 05:20AM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-133
K-4.1 Cl-100 HCO3-29 AnGap-8
___ 05:20AM BLOOD ALT-26 AST-40 AlkPhos-101 TotBili-1.9*
___ 05:20AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.3 Mg-2.0
OTHER LABS
___ 11:58AM ASCITES WBC-107* RBC-372* Polys-10* Lymphs-17*
Monos-10* Macroph-63*
___ 11:00AM ASCITES TotPro-0.9 Albumin-LESS THAN
___ 11:00AM ASCITES WBC-78* RBC-293* Polys-1* Lymphs-35*
___ Mesothe-3* Macroph-61*
UCX ___ NEGATIVE
BCX ___ PND
PERITONEAL FLUID CULTURES ___ AND ___ PND
IMAGING
CXR ___
Small to moderate left pleural effusion with adjacent
compressive atelectasis. No evidence of pneumonia.
RUQ US ___. Patent hepatic vasculature.
2. Cirrhotic liver with large ascites.
Brief Hospital Course:
___ yo M HCV cirrhosis complicated by hepatocellular carcinoma,
ascites, hepatic encephalopathy, and esophageal varices who is
s/p TACE & cyberknife for HCC and medical treatment for HCV with
Harvoni and ribavirin ___ who presents from home for
confusion. Infectious w/u negative and encephalopathy cleared
with lactulose. LVP ___ for symptomatic improvement in
abdominal distention. Visited with social work during stay for
social services support.
Investigations/Interventions:
1. Hepatic encephalopathy: patient presented with confusion at
home noticed by wife, described as being unable to use the TV
remote. Patient had asterixis on exam at presentation to the ED.
He reports compliance with his medications (self-administers)
but did have a recent hospital stay at ___ during
which Ativan was prescribed q6h prn anxiety. Likely cause of
encephalopathy is ativan use vs medication noncompliance at
home. Infectious workup including diagnostic paracentesis was
negative. Encephalopathy cleared with q2h lactulose.
2. HCV cirrhosis: complicated by hepatocellular carcinoma,
ascites, hepatic encephalopathy, and esophageal varices. Last
EGD ___ which showed 3 cords of grade I varices. On nadolol
and no diuretics at home. MELD-Na 18. Of note he has a history
of variceal bleed requiring ligation of varices in ___ and
again ___. Not a liver transplant candidate due to not
meeting ___ criteria (>3 lesions). Ascites required q2week
paracentesis. LVP performed in house on ___ draining 4L of
ascitic fluid negative for SBP. Has hepatology follow up on ___.
3. Hepatocellular carcinoma: patient was due for repeat CT
abd/pelvis for monitoring of a 7mm hepatic lesion. CT performed
in house revealed no evidence of HCC. His case will be discussed
further in the hepatology service; has follow up with heme/onc
on ___.
4. Social stressors: patient is overwhelmed by social situation
including his illness, his wife's illness (bipolar), and lack of
income. Patient was frequently tearful. Social work visited with
him and suggested using social services of oncology through his
oncologist, Dr. ___. We set up outpatient follow up with
palliative care ___ for assistance in meeting emotional
needs.
Transitional Issues:
[]Medication changes: discontinued home oxycodone use due to
concern for contribution to hepatic encephalopathy; instead
prescribed tramadol
[]Medication changes: changed Ativan to qhs prn insomnia
[]PCP follow ___
[]PAL care follow up ___
[]Heme/onc and Hepatology follow up on ___
[]F/u pending peritoneal fluid cultures
#CODE: Full
#CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Nadolol 10 mg PO BID
3. Ondansetron 4 mg PO Q6H:PRN nausea
4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
5. Pantoprazole 40 mg PO Q24H
6. Furosemide 40 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. LORazepam 0.5 mg PO Q6H:PRN anxiety
9. Lactulose 30 mL PO TID
10. Rifaximin 550 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Spironolactone 100 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Nadolol 10 mg PO BID
7. Lactulose 30 mL PO TID
8. Ferrous Sulfate 325 mg PO DAILY
9. Ondansetron 4 mg PO Q6H:PRN nausea
10. LORazepam 0.5 mg PO QHS:PRN insomnia
RX *lorazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
11. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hepatic encephalopathy
HCV cirrhosis
Hepatocellular carcinoma
Secondary:
Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were hospitalized with confusion. This was likely due to
buildup of toxins related to liver disease. We made sure you
had no infection then increased the frequency of your lactulose.
Thankfully your confusion cleared and you were discharged with
a follow up appointment with Dr. ___.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
10483818-DS-13 | 10,483,818 | 27,993,553 | DS | 13 | 2169-11-21 00:00:00 | 2169-11-21 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
___ Left craniotomy for subdural hematoma evacuation.
History of Present Illness:
___ y/o male who presents to the ED with increased confusion
over the last day. Per the daughter, he is generally sharp and
takes care of himself and his wife who has mild dementia. Per
report he fell about a week ago, unclear if + head strike or
LOC.
The patient does not take any anticoagulation. He was
transferred
to an OSH were a head CT was obtained and showed a large left
sub-acute SDH with 8mm of MLS. He was transferred here to ___
for further work up. On arrival to ___ a repeat head CT was
obtained and was stable compared to the OSH. Neurosurgery was
consulted for evaluation and recommendations. The patient
denies,
headache, n/v, dizziness, blurred vision or weakness.
Past Medical History:
HTN, HLD, Benign cerebellar tumor found ___ yrs ago, gout,
LLQ hernia with plans for surgery at the ___ and ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: T: 98.9 BP: 110/83 HR: 82 R: 18 O2Sats: 99% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place (hospital), and date
(year
and month, not day).
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ to left side, RUE: bi/tri/grip
___, delt ___. RLE IP ___, Ham 4-, o/w ___. + right upward
drift.
Sensation: Intact to light touch
DISCHARGE EXAM:
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place (hospital), and date
(year
and month).
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ other than left bicep 4+/5
(baseline). + right upward drift.
Sensation: Intact to light touch
Pertinent Results:
___ CT head without contrast:
1. Bilateral subdural collections, containing acute, subacute
and chronic
blood products, overall similar in size to recent prior exam
with persistent rightward subfalcine herniation with 8 mm
midline shift.
2. Left CP angle mass, incompletely characterized on this
examination.
Recommend MRI for further evaluation when clinically
appropriate.
___ CT c-spine without contrast:
Multilevel degenerative changes without acute fracture or
malalignment.
___ CT head without contrast:
Postoperative changes are seen with air-fluid level on the left
side in the subdural space. No acute hemorrhage seen. Subdural
drain is identified. No hydrocephalus.
___ CT head without contrast:
1. New hyperdense blood in the left subdural space, likely an
acute bleed. Similar size of air-fluid level in the left
subdural space.
2. Small right subdural fluid collection, increased in size
compared to prior. 3. Stable appearance of extra-axial a
ventricular drain placement, rightward shift and sulcal
effacement.
___ CT head without contrast:
1. Decrease in left subdural mixed density collection compare to
exam from the day before. Mild re-expansion of the left lateral
ventricle.
2. Unchanged appearance of small right subdural collection.
___. Unchanged appearance of the left subdural mixed density
collection, right subdural collection, left sulcal effacement
and midline shift compared to exam from 1 day ago.
2. Stable postsurgical changes including position of the left
subdural drain.
___ CT HEAD W/O CONTRAST
1. Status post left subdural drain removal. Increased amount of
pneumocephalus and hyper density, consistent with acute on
chronic left
subdural hematoma. Mildly increased left sulcal effacement and
midline shift. Unchanged appearance of right subdural hematoma.
___ CT HEAD W/O CONTRAST
Compared with a CT head of the prior day, no significant change.
There is
continued pneumocephalus and hyperdensity, consistent with acute
on chronic left subdural hematoma. No change in the 7 mm
rightward shift of normally midline structures, or in the size
and morphology of the ventricles. No new acute intracranial
hemorrhage identified.
___ CT HEAD W/O CONTRAST
IMPRESSION:
No significant change in left greater than right subdural
hematomas with
hyperdense components, left cerebral hemispheric effacement,
rightward midline shift, compared to the head CT from ___. No new foci of hemorrhage identified. The left
cerebellopontine angle mass (4:8) is
unchanged.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service on the day
of admission for management of his large left-sided subdural
hematoma. Due to the severity of mid-line shift, the patient
was emergently taken to the operating suite for evacuation of
his subdural. He tolerated the procedure well and there were no
intraoperative complications. An EVD catheter was placed in the
subdural space for continued drainage. Please see the operative
report for further details. Mr. ___ was extubated
___ and transferred to the PACU under ICU-level care.
A post-op head CT revealed slightly improved mid-line shift with
some remaining blood products in the resection bed. Due to a
fair amount of pneumocephalus, the patient was placed on 100%
fiO2 via non-rebreather.
On ___, Mr. ___ continued to recover well. A CT scan of
the head was repeated and was stable from prior. The patient's
diet was advanced to regular. His subdural drain remained in
place. He was transferred to the neuro step-down unit for
continued observation and management.
___, the patient remained neurologically intact. A repeat CT
of the head showed a decrease in the left subdural fluid
collection. His non-rebreather was discontinued and subdural
drain was left in place for an additional day. Mr. ___ was
tolerating his diet well. He was assisted out of bed with
nursing and evaluated by Physical Therapy.
On ___, the patients exam reamained stable. His Head CT
showed continued subdural collection and pneumocephalus. His
subdural drain remained in place and was draining minimally and
will be taken out tomorrow.
On ___, patient remains neurologically intact; JP drain was
discontined and a post-pull CT Head was completed showing
Increased amount of
pneumocephalus and hyper density, consistent with acute on
chronic left
subdural hematoma. Mildly increased left sulcal effacement and
midline shift. Unchanged appearance of right subdural hematoma.
Per physical therapy, patient needs ___ rehabilitation and
is pending transfer to ___ tomorrow.
On ___, the patient remained hemodynamically stable with a
stable neurological exam. He underwent a ___ for investigation
of possible change in pneumocephalus size. When compared with
the CT head of the prior day, no significant change. There is
continued pneumocephalus and hyperdensity, consistent with acute
on chronic left subdural hematoma. No change in the 7 mm
rightward shift of normally midline structures, or in the size
and morphology of the ventricles. No new acute intracranial
hemorrhage identified. It was decided to monitor for the patient
for one more day.
On ___, the patient remained stable, and underwent another
NCHCT for evaluation of pneumocephalus. There was no significant
change in left greater than right subdural hematomas with
hyperdense components, left cerebral hemispheric effacement,
rightward midline shift, compared to the head CT from ___. No new foci of hemorrhage identified. The left
cerebellopontine angle mass (4:8) is unchanged. The patient's
neurological exam was stable, and he was hemodynamically stable
and therefore deemed stable for discharge to ___.
Medications on Admission:
-allopurinol ___ mg tablet oral 2 tablet Daily
-amlodipine 10 mg tablet oral 1 tablet Daily
-atorvastatin 20 mg tablet oral 1 tablet Daily
-colchicine 0.6 mg capsule oral 1 capsule Every Other Day
-cyanocobalamin (vit B-12) 1,000 mcg tablet oral 1 tablet Daily
-ergocalciferol (vitamin D2) 50,000 unit capsule oral Once
Weekly
-folic acid 1 mg tablet oral 1 tablet Daily
-indomethacin 25 mg capsule oral 1 capsule TID, PRN
-lisinopril 40 mg tablet oral 1 tablet Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Colchicine 0.6 mg PO QOD
7. Docusate Sodium 100 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Heparin 5000 UNIT SC BID
10. HydrALAzine ___ mg IV Q6H:PRN for SBP > 160
11. Indomethacin 25 mg PO TID:PRN gout flare up
12. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
13. Lisinopril 40 mg PO DAILY
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Left subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures or staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
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.
Followup Instructions:
___
|
10483945-DS-6 | 10,483,945 | 20,908,047 | DS | 6 | 2174-10-23 00:00:00 | 2174-10-23 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Concern for seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old right-handed man with depression and
anxiety who presented to the emergency department because he
reports to me that he was "seizing a lot" and could not move his
extremities because of generalized weakness.
Mr. ___ reports that starting in the beginning of ___
that
he noticed that he was having episodes in which both of his eyes
were moving abnormally and his eyelids were twitching nearly
continuously for hours at a time. He reports this this abnormal
movement leads to vision blurriness. Mr. ___ thinks the
abnormal eye movement and his eyelid twitching is suppressible
for perhaps a second if he really tries, but he overall feels
that he cannot control the eyelid twitching. Mr. ___
eyelid
twitching occurs at all times of the day. He feels like being
in
a bright room or outside might make the eyelid twitching worse,
but ultimately is uncertain if he just notices the eyelid
twitching more in bright light.
==============================================================
Pertinently, Mr. ___ did not initially disclose, but when I
returned to ___ him later in the evening he revealed that
while his abnormal eye and eyelid movement is largely
involuntary
he can actually voluntarily produce the movement.
===============================================================
Mr. ___ reports that one to two weeks after the onset of
eyelid twitching he noticed that he was having twitching of both
of his hands with the right arm being more affected than the
left
arm. Mr. ___ initially was not having the hand twitching
very
often, but over the last week it has increased in frequency and
is occurring about five times per day and lasts between 10 to 30
minutes. Mr. ___ is conscious when he has the hand
twitching,
but feels that the movement is rhythmic. Mr. ___ reports
that
in addition to the hand twitching that he sometimes has abnormal
movements of his entire legs that occur with the hand twitching
or independent of the hand twitching. He feels that his whole
arms and legs have been becoming progressively weaker over the
entire weak. Mr. ___ reports because of the intermittent leg
weakness that he sometimes cannot walk.
Mr. ___, finally, reports that over the last week that he has
been having speech difficulty. Mr. ___ knows what he wants
to
say, but has difficulty getting the words out because of
slowness
of speech and stuttering.
Mr. ___ mother agreed with the patient's history but added
that she is puzzled by her sons behavior as sometimes he looks
normal and sometimes he is quite disabled by the above symptoms.
Mrs. ___ mother is perhaps most concerned about her sons
falls at home. Thankfully, Mr. ___ has not hit his head or
hurt himself as a result of the falls. Mr. ___ mother
plans
to move Mr. ___ back to home to ___ once she gets a good
idea of what might be going on.
Mr. ___ reports that he recently withdrew from ___ ___ because of mental health issues. He
had
only been in class for three weeks. Mr. ___ reports
significant mental health issues lead to his withdrawal,
including depression and anxiety. Mr. ___ felt his anxiety
and depression were getting worse because of pressure from being
in school. Mr. ___ states that his anxiety and depression
did
not improve after he left school and the pressure of such was
lifted. I asked Mr. ___ mother to leave the room so that I
could privately ask him questions and Mr. ___ did not reveal
any additional stressors. He feels safe and does not want to
hurt himself.
Mr. ___ presented to ___ ED on ___.
He had a ___ and blood work which were reported as normal. He
was not seen by a neurologist because there was not one in the
hospital. Mr. ___ has been working to schedule an
appointment
with a neurologist, but has been unable to do so.
Past Medical History:
Mr. ___ reports that he has had anxiety and depression since
age ___. Mr. ___ feels that his symptoms are secondary to
genetics and because of stress from school. Mr. ___ started
seeing a Dr. ___ in ___ about one year ago. Mr.
___ was diagnoses with major depression with anxiety and
reports that he has been on 6 different psychotropic
medications.
Mr. ___ stopped taking any medications in ___ because he
felt none of them were of any benefit. Mr. ___ has never
previously been evaluated by a neurologist.
Social History:
___
Family History:
Mr. ___ reports dense history of anxiety and depression on
both sides of his family. Mr. ___ has two maternal aunts
with
multiple sclerosis.
Physical Exam:
Admission Physical Exam:
Neurologic examination:
Mental status:
He is awake, alert, and cooperative with the exam. He is
oriented to name, place and date. He is attentive, able to say
months of the year backwards. Fund of knowledge is intact. He
is able to provide the last three presidents and is able to
detail important historical details. Language is fluent, but
speech is flat and lacks intonation. Left, right
differentiation
and calculations are intact. No evidence of ideational,
ideomotor, or limb kinetic apraxia. No frontal reflease signs,
including glabellar, palmomental, and grasp reflexes.
Cranial nerves:
Pupils are equal and reactive. Extraocular movements are full.
Patient initially had abnormal eye and eyelid movements that he
could not control and I examined him while occurring. Patient's
eyelids were fluttering rhythmically at a high frequency and on
primary gaze he was having rapid movements of his eyes in the
horizontal plane. I could not determine a fast or slow phase of
the eye movement. I asked him to look medially and laterally
and
during the saccade and the end gaze he continued to have the
abnormal horizontal eye movement. He could look upward and
downward and, again, during the pursuit and maintenance of the
upward and downward gaze he continued to have the abnormal
horizontal eye movement. I left patient and came back later to
examine him and tried to wait til he had abnormal eye/eyelid
movement, but then he disclosed to me he could perform the
abnormal movements on command. The voluntary abnormal movement
was identical to the "involuntary" abnormal movement described
above. Facial sensation and movement are intact and symmetric.
Hearing is intact to finger rub bilaterally. Patient's speech
is
slow, but not dysarthric. Palate elevates symmetrically. SCM
and trapezius are full strength bilaterally. Tongue is midline.
Motor:
Bulk and tone is normal. Patient had no abnormal arm or leg
movements. Patient has no pronator drift, orbiting, and/or
slowing of movement in one arm compared to the other. Patient
gives poor effort on confrontational motor examination. He, for
example, will provide good initial resistance and but then will
stop providing resistance and let the tested muscle go limp.
There is no pattern of weakness. I did not detect any asymmetry
in strength on his initial good efforts when testing muscles of
arms and legs.
Sensation:
Pinprick is intact in the hands and feet. Position sense is
intact in the toes bilaterally, even to small upward and
downward
excursions.
Coordination:
No rebound. No dysdiadocokinesia. Finger-nose-finger and
finger-to-nose are intact without dysmetria bilaterally.
Reflexes:
Patient's reflexes are 1 throughout. Toes are downgoing
bilaterally.
Gait:
Patient told me on first examination that he could not walk, but
when I returned to ___ him he was OK with walking and was
able to do so normally.
Discharge Physical Exam:
-Mental Status: Alert, oriented, attentive. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt. was able to name both high and
low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
He had an episode of difficulty speaking, while on EEG. This
difficulty speaking was associated with eyes rolling upwards and
shaking. He was conscious and able to follow commands during
event, and all movements were distractible.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally.
III,IV,VI: EOMI, no ptosis. No nystagmus. Patient can
voluntarily create the movement of concern when eyes are fixated
ahead. These movements do not interrupt saccades, and do not
occur spontaneously.
V: sensation intact V1-V3 to LT
VII: Symmetric forehead raise, eye closure, and smile.
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift.
Delt Bi Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 5 ___ 5 5
R 5 ___ 5 5
IP Quad ___ PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 ___
R 5 5 5 ___
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L ___ 2 ___ Flexor
R ___ 2 ___ Flexor
-Sensory: No deficits to light touch throughout.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based.
Pertinent Results:
___ 02:54PM BLOOD WBC-7.5 RBC-4.68 Hgb-13.9 Hct-42.7 MCV-91
MCH-29.7 MCHC-32.6 RDW-13.0 RDWSD-43.1 Plt ___
___ 02:54PM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-141
K-4.1 Cl-106 HCO3-25 AnGap-10
___ 02:54PM BLOOD ALT-17 AST-22 AlkPhos-69 TotBili-0.3
___ 02:54PM BLOOD Albumin-4.5
___ 02:54PM BLOOD TSH-1.2
___ 02:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
MRI ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. The ventricles and sulci are normal in caliber
and
configuration. There is no abnormal enhancement after contrast
administration.
There is mild mucosal thickening and mucous retention cyst in
the left
maxillary sinus. Mild anterior ethmoid air cell mucosal
thickening is also
present. The imaged portions of the orbits are unremarkable.
IMPRESSION:
Normal brain MRI.
Brief Hospital Course:
___ is a ___ yo RHM with depression and anxiety who
presented with several weeks of eye fluttering, bilateral
extremity shaking, speech changes and falls without injury, all
intermittent. Eye fluttering could be briefly suppressible and
was generally involuntary, though he later disclosed during the
hospitalization that he could also voluntarily produce the same
movement. In addition, he endorsed extremity twitching, speech
difficulty, and generalized weakness. Of note, he has an
extensive history of anxiety and depression, and he recently
withdrew from college due to mental health issues. He is not
currently on any psychotropic medications. He denied active PDW
or SI.
His neurological exam was normal. We observed several episodes
of rapid eyelid fluttering that was suppressible and decreased
when the patient was distracted. In addition, he was
volitionally able to produce these movements. We felt that his
symptoms were most consistent with a functional neurological
disorder, with mixed features (motor and seizure). We did an MRI
brain that was normal. EEG captured several episodes of eyelid
fluttering, as well as bilateral extremity shaking that did not
show an epileptiform correlate; his background was also normal.
He was evaluated by physical therapy who recommended outpatient
therapy. He should follow up with a psychiatrist to discuss
further psychotropic management and therapist for cognitive
behavioral therapy as an outpatient. He was counseled regarding
the diagnosis and further reliable information sources
(neurosymptoms.org). Patient and mother were agreeable to
discharge, and will be returning home to ___ in the next few
days.
Transitional issues:
If patient returns to live in ___, could consider referral to
___ as wholistic therapies have
previously been helpful for him
Outpatient psychiatry follow up
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Functional Neurological Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to eye fluttering, tremors,
twitches, and muscle weakness. In your neurological exam, you
sometimes had difficulty with strength but other times had
excellent strength. Your labs and MRI brain were normal. We did
an EEG that captured several episodes of eyelid fluttering. We
found that these events are not seizures. During your
hospitalization, we also spoke with Dr. ___ updated him
on your results and discharge plan.
You were diagnosed with a Functional Neurological Disorder. This
is a disorder where your neurological symptoms (such as the eye
fluttering and limb weakness) are due to a problem with how your
brain functions. It is not due to damage of the brain. We do not
understand precisely why functional neurological disorders occur
in certain people, but we do know that we can treat the
symptoms. We are giving you a prescription for physical therapy.
In addition, managing stress, anxiety, and depressive symptoms
is a key part of your recovery. We would like you to resume
working with a therapist for cognitive behavioral therapy and a
psychiatrist to discuss medication management.
Please schedule an appointment with your primary care provider
___ ___ days following discharge.
It was a pleasure taking care of you!
Your ___ Neurology team
Followup Instructions:
___
|
10484069-DS-5 | 10,484,069 | 27,663,358 | DS | 5 | 2158-10-08 00:00:00 | 2158-10-10 15:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Substernal chest burning
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with hx of CAD
s/p DES to LCX in ___, DM2, HTN, HLD, who presents with
nausea, vomiting, and burning retrosternal chest pain that began
about 4 days ago.
Patient reports that he had episode of nausea and vomiting last
___, also with diarrhea, but no fevers. Vomiting and diarrhea
were limited to that one day, but he has had decreased appetite
since that time with reduction in his po intake. He also notes
retrosternal chest pain ongoing since ___ that is
non-exertional. Chest pain was about ___ in ED, reduced to ___
in ED after medications, now ___ on the floor. He did not have
chest pain prior to ___. He reports lightheadedness,
but
denies LOC or palpitations. He states that he is SOB with long
walks, but this has been going on for ___ months. His breathing
has not worsened over the past few days. He reports his last BM
occurring this morning without concerning features (no blood).
He
has BMs about every 2 days.
He initially presented to ___ for his symptoms but was referred
for inpatient admission as he was scheduled for outpatient cath
in 2 days after MIBI performed ___ was concerning for new
LAD lesion.
In the ED
- Initial vitals: 98.4 78 113/55 18 97%RA
- EKG: LBBB (stable from EKG in ___, new from EKG in
___
- Labs/studies notable for: CXR without acute cardiopulmonary
process. Labs notable for: normal LFTs/lipase, H/H 10.6/32.8,
BUN/Cr 37/1.7, normal trop, normal lactate
- Patient was given: Nitro SL 0.4 x 2 doses, ASA 324 mg, 1 L NS,
GI cocktail
- Vitals on transfer: 73 144/48 18 99%RA
REVIEW OF SYSTEMS:
Positive as per HPI. 10-point ROS is otherwise negative
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
- CAD
- PVD
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: ___: DES to LCX
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Obesity
- Erectile dysfunction
- Lumbar disc disease
- OA of knee
- Amputations of toes
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 97.8PO 157 / 68 72 20 98 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple
CV: systolic murmur in RUSB, S1/S2
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
VS: ___ 0744 Temp: 97.4 PO BP: 114/58 R Sitting HR: 56 RR:
18 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
Fluid Balance (last updated ___ @ 1044)
Last 8 hours Total cumulative -71.1ml
IN: Total 503.9ml, PO Amt 420ml, IV Amt Infused 83.9ml
OUT: Total 575ml, Urine Amt 575ml
Last 24 hours Total cumulative 1424.7ml
IN: Total 2419.7ml, PO Amt 1575ml, IV Amt Infused 844.7ml
OUT: Total 995ml, Urine Amt 995ml
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, JVP < 10 cm at 90 degrees
CV: systolic murmur in RUSB that radiates to carotids, S1/S2
PULM: Bibasilar rales. No wheezes or rhonchi. Breathing
comfortably.
GI: abdomen soft, distended, nontender in all quadrants.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===============
___ 03:15PM BLOOD WBC-8.4 RBC-3.66* Hgb-10.6* Hct-32.8*
MCV-90 MCH-29.0 MCHC-32.3 RDW-13.6 RDWSD-44.5 Plt ___
___ 03:15PM BLOOD Neuts-69.0 Lymphs-15.9* Monos-12.0
Eos-2.7 Baso-0.2 Im ___ AbsNeut-5.82 AbsLymp-1.34
AbsMono-1.01* AbsEos-0.23 AbsBaso-0.02
___ 04:10PM BLOOD ___ PTT-30.3 ___
___ 03:15PM BLOOD Glucose-92 UreaN-37* Creat-1.7* Na-137
K-4.8 Cl-102 HCO3-23 AnGap-12
___ 03:15PM BLOOD ALT-28 AST-27 AlkPhos-79 TotBili-0.3
___ 03:15PM BLOOD Lipase-24
___ 03:15PM BLOOD cTropnT-<0.01
___ 09:00PM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD Albumin-4.4
___ 03:19PM BLOOD Lactate-1.1
PERTINENT INTERVAL LABS
========================
___ 02:46AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:35AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:35AM BLOOD Calcium-9.9 Phos-3.6 Mg-2.1
DISCHARGE LABS
===============
___ 06:35AM BLOOD WBC-7.3 RBC-3.30* Hgb-9.9* Hct-29.7*
MCV-90 MCH-30.0 MCHC-33.3 RDW-13.3 RDWSD-43.9 Plt ___
___ 08:30AM BLOOD ___ PTT-57.6* ___
___ 06:35AM BLOOD Glucose-85 UreaN-27* Creat-1.5* Na-144
K-4.5 Cl-105 HCO3-24 AnGap-15
___ 06:35AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9
IMAGING
========
CXR (___)
---------------
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or
edema. Cardiac
silhouette is within normal limits. No acute osseous
abnormalities,
hypertrophic changes seen in the spine.
IMPRESSION:
No acute cardiopulmonary process.
TTE (___)
---------------
CONCLUSION:
The left atrium is mildly dilated. 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 58 %.
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) are moderately
thickened. There is mild aortic valve stenosis (valve area
1.5-1.9 cm2). There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is mild [1+] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild calcific aortic stenosis. Mild mitral
regurgitation.
RENAL U/S (___)
--------------------
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally. The indeterminate hypodensities within the right
kidney described on previous CT have no correlate on today's
ultrasound.
Right kidney: 12.2 cm
Left kidney: 12.8 cm
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Normal renal ultrasound. No hydronephrosis identified.
MICROBIOLOGY
=============
None
Brief Hospital Course:
SUMMARY
========
___ year old male with hx of CAD s/p DES to LCX in ___, DM2,
HTN, HLD, who presented with retrosternal chest pain thought to
be GI-related as well as a pre-renal ___ from diarrhea and
vomiting.
ACUTE ISSUES
=============
___
Patient presented with Cr of 1.7 with a baseline of 1.0-1.2.
Thought to be pre-renal in etiology as patient had a few days of
vomiting and diarrhea prior to admission. He received IVF, which
improved his Cr to 1.5. He underwent a renal U/S which was
normal. Nephrology saw the patient; they spun his urine and saw
many hyaline and granular casts but no muddy brown casts. We
held off on doing his scheduled left heart cath as his Cr
remained above his baseline.
#Chest pain
Patient presented with substernal chest pain in the setting of
vomiting and diarrhea. His troponins on admission were negative
and remained flat. His EKG was unchanged. This chest pain was
thought to be GI in nature. He received SL nitro and a GI
cocktail in the ED as well as a full-dose aspirin; his chest
pain was gone once he hit the floor. He was started on a heparin
gtt and continued on his aspirin and rosuvastatin. We held his
lisinopril due to the ___. He had no more feelings of chest pain
or pressure. We held off on doing his scheduled coronary
angiogram given his ___ he will reschedule it as an outpatient
for another time.
CHRONIC ISSUES
===============
#Type 2 DM. Complicated by neuropathy, retinopathy,
microalbuminuria, PVD s/p amputations, and CAD.
- Held Metformin and trulicity inpatient
- Continued Lantus 40 U QHS
- Placed on ISS while inpatient
#Hypertension
- Held Lisinopril due to ___
TRANSITIONAL ISSUES
====================
[ ] ___ - Please ensure patient's Cr continues to downtrend
(baseline ___ on labs. Patient to have repeat labs done next
___ to ensure continued Cr improvement.
[ ] Chest pain - Patient needs to reschedule coronary angiogram.
CORE MEASURES:
==============
# CODE: Full code (confirmed)
# CONTACT: HCP: ___ (daughter): ___
Discharge Weight: 93.0 kg (205.03 lb)
Discharge Cr: 1.5
Discharge Hgb: 9.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Lisinopril 40 mg PO QAM
3. Glargine 40 Units Bedtime
4. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
5. Rosuvastatin Calcium 40 mg PO QPM
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Glargine 40 Units Bedtime
3. Omeprazole 20 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO QPM
5. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
6. HELD- Lisinopril 40 mg PO QAM This medication was held. Do
not restart Lisinopril until your renal function normalizes and
you are told to restart this by a doctor.
7. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until your renal
function normalizes and you are told to restart this by a
doctor.
8.Outpatient Lab Work
CHEM10
ICD-10 code: ___
___, MD
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Acute Kidney Injury
SECONDARY DIAGNOSES
====================
GERD
Type 2 Diabetes Mellitus
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 here at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you had some nausea and vomiting
that caused some dehydration that led to brief damage of your
kidneys; you were also having some chest pain.
WHAT WAS DONE WHILE I WAS HERE?
- We checked some tests to make sure you were not having a heart
attack - you did not have a heart attack, and we think the chest
pain was from indigestion.
- We held off on giving you some of your home medications and
gave you some fluids through your IV to help your kidneys
recover.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Please continue taking all of your medications as prescribed
except your lisinopril and metformin; you will resume taking
your lisinopril and metformin once your doctor tells you.
- Please keep all of your appointments.
- If you notice a significant decrease in urination, please go
to the emergency room.
- If you have symptoms of chest pain, please go to the emergency
room.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10484294-DS-3 | 10,484,294 | 27,383,048 | DS | 3 | 2110-02-26 00:00:00 | 2110-02-27 19:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Pericarditis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
___ male with past medical history of head and neck
cancer status post radiation therapy, CAD, CKD, Diabetes, HTN,
HLD, gout, recently treated pericarditis, transferred from
outside hospital for chest pain. Patient was recently treated at
___ for pericarditis only discharged on ___. He
completed his prednisone taper for the pericarditis 2 days prior
to admission and his symptoms had improved at that time. Over
the day prior to admission he noted worsening chest pain and
shortness of breath in addition to a non-productive cough. He
has not had fever or chills.
He initially represented to BI-P where he had a CT Chest
revealing pleural effusion, possible pneumonia, and pericardial
effusion. Bedside TTE obtained which did not show RV collapse.
Additionally noted to have anterior T wave inversions op EKG
however denied radiating pain to the back. On presentation to
BI-P labs notable for significant leukocytosis. Given new onset
of symptoms in addition to lab findings concern higher for
infectious process, likely pneumonia, and patient was started on
vancomycin and zosyn to cover for HAP given recent
hospitalization and relative immunosuppression with recent
prednisone use.
In the ED:
- Initial vital signs were notable for: 98.3, 91, 129/61, 18,
96% RA
- Exam notable for: Breathing comfortably with normal VS,
decreased breath sounds in lower lobes, heart sounds
appreciated, no murmur
- Labs were notable for: Leukocytosis 14.3, proBNP 974, Cr 1.74
- Studies performed include: Echo with effusion; no clinical
tamponade
- Patient was given: Morphine 4mg, Zosyn, Vancomycin, ASA 81,
metoprolol 25, insulin 4u
- Consults: None
Vitals on arrival to floor:
99.3 PO 104 / 62 L Lying 96 24 95 RA
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Head and Neck Cancer
Seizure Disorder
HTN
HLD
CAD
CKD
Diabetes
GERD
Pericarditis
Gout
Cholecystectomy
Social History:
___
Family History:
FAMILY HISTORY:
- Father with unknown heart disease
Physical Exam:
ADMISSION EXAM:
===================
VITALS:99.3 PO 104 / 62 L Lying 96 24 95 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Heart sounds distant.
Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Diminished breath sounds at bases, otherwise 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.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
DISCHARGE EXAM:
===================
24 HR Data (last updated ___ @ 352)
Temp: 97.5 (Tm 98.3), BP: 130/67 (121-135/67-82), HR: 69
(48-82) RR: 16 (___), O2 sat: 99% (93-99), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric
NECK: No JVD. no kussmaul
CARDIAC: Regular rhythm, normal rate. Heart sounds distant.
Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Diminished breath sounds at bases, otherwise clear to
auscultation bilaterally. No wheezes, rhonchi or rales. No
increased work of breathing. egophony of L base
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS
=========================
___ 05:45AM WBC-14.3* RBC-4.05* HGB-12.0* HCT-37.0*
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.9 RDWSD-46.2
___ 05:45AM NEUTS-90.8* LYMPHS-2.3* MONOS-5.6 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-12.98* AbsLymp-0.33* AbsMono-0.80
AbsEos-0.02* AbsBaso-0.01
___ 05:45AM proBNP-974*
___ 05:45AM cTropnT-<0.01
___ 05:45AM GLUCOSE-105* UREA N-24* CREAT-1.2 SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
___ 05:58AM LACTATE-0.8
___ 05:45AM estGFR-Using this
___ 05:45AM PLT COUNT-131*
___ 05:45AM ___ PTT-29.1 ___
PERTINENT LABS
=========================
___ 07:50AM BLOOD CRP-281.9*
DISCHARGE LABS
=========================
___ 02:49AM BLOOD WBC-9.0 RBC-3.76* Hgb-11.2* Hct-33.7*
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.9 RDWSD-45.1 Plt ___
___ 02:49AM BLOOD Plt ___
___ 02:49AM BLOOD ___ PTT-20.0* ___
___ 02:49AM BLOOD Glucose-219* UreaN-31* Creat-1.2 Na-133*
K-4.7 Cl-98 HCO3-23 AnGap-12
___ 02:49AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.9
STUDIES
=========================
___ TTE
IMPRESSION: Large circumferential, dense pericardial effusion
with respiratory variation in mitral and tricuspid valve inflow
velocities, septal bounce, annulus paradoxus, but no chamber
collapse suggesting ventricular interdependence suggestive of
pericardial constriction in the absence of evidence of
pericardial tamponade. Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function. Pulmonary artery diastolic hypertension.
RECOMMEND: If clinically indicated, a cardiac MR is suggested
for further evaluation of pericardial
constriction.
___ Cardiac MRI
IMPRESSION: Small to moderate organized pericardium effusion
with inflammation and mild constriction. Normal pericardium
thickness with extensive tethering. There is early and late
gadolinium enhancement in
both visceral and parietal pericardium. Normal left ventricular
wall thickness, biventricular cavity sizes, and regional/global
biventricular systolic function.
The CMR findings are c/w pericarditis with organized effusion
and mild constriction.
MICROBIOLOGY
=========================
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT
=========================
___ male with past medical history of head and neck
cancer status post radiation therapy, CAD, CKD, Diabetes, HTN,
HLD, gout, recently treated pericarditis, transferred from
outside hospital for chest pain. Patient recently completed
steroid course w/ taper for 6 days and re-presented with
pericardial effusion and left lower lobe consolidation. This is
likely in the setting of undertreated pericarditis and he was
re-initiated on steroids and continued on colchicine.
ACUTE ISSUES:
=============
#Chest Pain
#Recent pericarditis
He noted a day of worsening CP/SOB prior to admission iso
completion of prednisone taper for pericarditis. He was on
steroids and tapered over 6 days. CT Chest at OSH notable for
LLL consolidation
and L sided pleural effusion. His symptoms were felt to be
continued
pericarditis that was not completely treated given taper over 1
week. The chest pain was also similar to his prior presentation.
The left lower lobe consolidation was concerning for pneumonia
given leukocytosis on presentation as well. However, patient
remained afebrile and reported a chronic cough that had not
changed.
TTE showed large dense pericardial effusion with constriction
w/out evidence of tamponade. He also underwent a cardiac MRI
that showed a mild to moderate pericardial effusion that was
organized but no tamponade.
For the pericarditis, patient was treated with prednisone 40 mg
to take over 2 weeks and initiate a slow taper afterwards. He
should continue on prednisone 40 mg until ___ and transition to
30 mg on ___ for another week. The rest of the taper will be
managed by the outpatient cardiologist. He should also continue
colchicine for 3 months. He is to follow-up with his
cardiologist on ___. Treatment for possible pneumonia as
below.
# Leukocytosis
# c/f pneumonia
Patient presented with leukocytosis but remained afebrile. Given
CT findings from OSH, he was treated with empiric antibiotics
for possible HAP/CAP. However, antibiotics were discontinued on
the fourth day given low suspicion for bacterial pneumonia.
Strep and Legionella were negative. For his antibiotics, he
received vanc/Zosyn in ED (___), transitioned to vanc/cefepime
(___), then CTX/azithro (___) discontinued ceftriaxone (___).
Leukocytosis was resolved on discharge.
#Cough
Stable dry cough for weeks
- Benzatonate prn
===============
CHRONIC ISSUES:
===============
#Diabetes
-Continued home insulin glargine 50U qAM and SCC Humalog
-added Humalog 10u w/ meals iso elevated BGs
#HTN
-Continue home metoprolol 25mg qmorning, 50mg nightly PO
#HLD
-Continued home lovastatin 40mg PO daily
#RLL Pulmonary Nodule
6mm solitary nodule seen on CT Chest at BI-P. Recommend repeat
CT at ___ months, then consider CT at ___ months
#CKD
-Recent baseline around 1.5-1.8 per BI-P records. Cr 1.2 on
admission here and stable. Will CTM.
#Chronic Anemia
-Chronic, stable at recent baseline around ___. Likely iso CKD
#Gout
-Continued home allopurinol
#Seizure disorder
-Continued home divalproex and primidone
#GERD
-Continued home pantoprazole
TRANSITIONAL ISSUES
=====================
Hg: 11.2
Cr: 1.2
[] Discharged on a slow prednisone taper. 40mg till ___ then
down to 30mg on ___ for a week. He is scheduled to see his
cardiologist on ___ will handle the rest of the taper
[]6mm solitary nodule seen on CT Chest at BI-P. Repeat CT at
___ months, then consider CT at ___ months
[] His blood sugars were elevated in the setting of starting
steroids. Restarted mealtime Humalog at 10u TID that had been
held on admission
[] He should continue colchicine for 3 months (___)
[] Cardiac MRI pending on discharge but the preliminary results
not suggestive of tamponade
[] LLL consolidation read as effusion on subsequent imaging.
Please consider repeat imaging after completion of treatment
course
[] chothalidone held this admission and his BPs remained
normotensive. Please consider restarting at the PCP appt if BPs
stable
#CODE: DNR/DNI
#CONTACT: Son ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Divalproex (EXTended Release) 1000 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lovastatin 40 mg oral DAILY
4. Allopurinol Dose is Unknown PO DAILY
5. Chlorthalidone 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. PrimiDONE 50 mg PO DAILY
8. Colchicine 0.6 mg PO DAILY
9. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO QPM
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
2. Allopurinol ___ mg PO QPM
3. Glargine 50 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
4. Aspirin 81 mg PO DAILY
5. Colchicine 0.6 mg PO DAILY
6. Divalproex (EXTended Release) 1000 mg PO DAILY
7. Lovastatin 40 mg oral DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO QPM
10. Pantoprazole 40 mg PO Q24H
11. PrimiDONE 50 mg PO DAILY
12. HELD- Chlorthalidone 25 mg PO DAILY This medication was
held. Do not restart Chlorthalidone until your doctor tells you
to
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
===================
Pericarditis
Pericardial effusion
Secondary
===================
Leukocytosis
Diabetes
Cough
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had recurrent
pericarditis and pericardial effusion (fluid around your heart)
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were started on prednisone and colchicine
- You also underwent imaging studies of your heart to make sure
that you do not have compromised squeeze of the heart.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- Please continue taking the prednisone at 40 mg until ___ at
that point you should start taking 30 mg daily. You are also
scheduled to see your cardiologist on ___ who will manage
the rest of your steroid taper. Please make sure that you make
it to this appointment.
-Please also continue taking the colchicine to complete a
3-month course. Your last day will be ___.
- You should attend the appointments listed below.
- Please call your doctor if his symptoms recur
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10484456-DS-19 | 10,484,456 | 27,598,221 | DS | 19 | 2146-09-10 00:00:00 | 2146-09-23 17:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / daptomycin / ceftaroline fosamil
Attending: ___.
Chief Complaint:
fever, back pain
Major Surgical or Invasive Procedure:
1. Revision laminectomy, medial facetectomy and
foraminotomy of L3-4, L4-5.
2. Incision and debridement to bone of infected
postoperative wound with epidural abscess and diskitis.
3. Cultures of both soft tissue, epidural abscess and bone
sent for microbiology as well as pathology.
History of Present Illness:
Ms. ___ is a ___ year old female with history of L4/L5
decompression surgery by Dr. ___ at ___ on ___ with
post-operative course complicated by MRSA wound infection
requiring operative drainage and washout on ___ and
___. She was on vancomycin but had an allergic reaction.
SHe was then swithed to dapto, but had a reaction to this as
well as a PICC line infection with E.coli. She then completed a
course of linezolid and ciprofloxacin PO 1 week ago.
Six days ago she reported new onset headache which has lasted
until now. She has been intermitently febrile to 102.2. Her ID
doctor (___) suggested MRI to rule out osteomyelitis which
she had @ ___ on ___. The ED obtained the report
of this, which showed "posterior element edema and mild
enhancement at the L5 level."
Patient did not want to go back to ___ after complicated
course and so came here with persistant Sx. She continues to
have headache/photophobia, upper back sensitive to touch, lower
back with pain. There is no weakness, numbness, cough, chest
pain, dyspnea, dysuria, hematuria, diarrhea, blood ___ stool.
___ the ED, initial vitals were 98.6 100 109/69 18 100%
- Labs were significant for Hct 27.3 (no baseline avilable)
- Patient was given 3 doses of IV morphine, 2 doses of
ondansetron, 1650mg acetaminophen, 400mg IV cipro. Linezolid was
ordered, but she did not recieve it prior to transfer.
Past Medical History:
chronic back pain leading to surgery as above, HLD, B12
deficiency
Social History:
___
Family History:
not obtained
Physical Exam:
PHSYICAL EXAM ON PRESENTATION
T 98.2, BP ___, HR 89, RR 16, 100% RA
General- Well-appearing, NAD until she tried to change
positions, then uncomfortable ___ pain.
HEENT- MMM, anicteric
Lungs- CTAB
CV- S1, S2, RRR
Abdomen- soft, NT, ND
Ext- warn, no edema
Neuro- grossly intact
Physical Exam on Discharge:
VS: T98.0 BP120/78, HR97, RR18, O2sat:100%RA
HEENT: crusting, erythemetous lesion over central lower lip and
at the corners of the mouth
BACK: incision clean, dry, intact
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 07:15PM BLOOD WBC-7.2 RBC-2.93* Hgb-8.7* Hct-27.3*
MCV-93 MCH-29.6 MCHC-31.8 RDW-13.8 Plt ___
___ 07:15PM BLOOD Neuts-67.7 ___ Monos-8.0 Eos-1.5
Baso-0.6
___ 07:15PM BLOOD ___ PTT-28.6 ___
___ 07:15PM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-133
K-4.4 Cl-100 HCO3-25 AnGap-12
___ 09:45AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0
___ 09:45AM BLOOD CRP-63.9*
___ 07:22PM BLOOD Lactate-1.8
___ 04:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:45PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 04:45PM URINE Mucous-RARE
___ 04:45PM URINE UCG-NEGATIVE
MICROBIOLOGY:
___ 4:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 7:16 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:00 pm ABSCESS
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___ @ 1849 ON ___
- ___.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 3:00 pm TISSUE EPIDURAL TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___ @ 1849 ON ___
- ___.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 4:00 pm TISSUE EPIDURAL TISSUE #2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 382-1798R
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 5:27 pm SKIN SCRAPINGS
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
No Herpes simplex (HSV) virus isolated.
VARICELLA-ZOSTER CULTURE (Preliminary):
No Varicella-zoster (VZV) virus isolated.
PATHOLOGY:
Date of Procedure: ___ ___ #: ___
Date Specimen(s) Received: Patient Location: Discharged ___
___
Date Reported: ___ Ordering Provider: ___,
MD
Responsible Provider: ___
___, MD
Assigned Pathologist: ___
___, MD
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Epidural tissue (1A):
-Fibrous tissue with extensive chronic and focal acute
inflammation
with multiple gram-positive cocciform bacteria.
IMAGING:
Radiology Report MR ___ & W/O CONTRAST Study Date of
___ 12:24 AM
IMPRESSION:
Laminectomy at L4-5 level with enhancing soft tissues at the
laminectomy site as well as surrounding the thecal sac and also
mildly enhancing to the foramina. Small fluid collection is
seen within the enhancing soft tissues at the laminectomy site
measuring approximately 2 cm. While ___ absence of immediate
prior studies, determination of the nature of the enhancing soft
tissues is difficult, but appear to be more extensive than
expected from disc surgery and may represent underlying
inflammation or infection. Clinical correlation is recommended
as the MR appearances alone may not suggest infection or
abscess. If there are prior studies, direct comparison would be
helpful. There is no epidural abscess seen or cord compression
identified. Multilevel degenerative change is seen.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
___ 9:57 AM
IMPRESSION:
New left PICC with tip terminating at the cavoatrial junction.
For placement within the low superior vena cava, the catheter
should be pulled 1-2 cm back.
LAB RESULTS ON DISCHARGE:
___ 06:05AM BLOOD WBC-4.7 RBC-2.48* Hgb-7.2* Hct-23.1*
MCV-93 MCH-28.9 MCHC-31.1 RDW-13.9 Plt ___
___ 06:05AM BLOOD Neuts-50.3 ___ Monos-8.7 Eos-6.2*
Baso-0.5
___ 06:05AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-105* UreaN-6 Creat-0.7 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
___ 09:10AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Ms. ___ is a ___ s/p L4/L5 decompression ___ whose post-op
course has been c/b MRSA wound infection and E coli bacteremia
who presented with fever and new paraspinal abscess. She
underwent OR drainage on ___ and was treated with levofloxacin
for treatment of MRSA given prior culture data and antibiotic
intolerances.
ACUTE CARE:
# Paraspinal abscess: Ms. ___ presented with fever and back
pain and was found to have L4-L5 epidural abscess. She underwent
successful OR drainage ___. Cultures grew MRSA. She was
initially placed on linezolid as she was on this during previous
treatment. However, she developed lip and mouth lesions while
taking this, a reaction that she also had during the end portion
of her previous course. She also had previous intolerances to
vancomycin and daptomycin. For this reason she was trialed on
ceftaroline, which caused an erythemetous itching rash over the
trunk and extremities consistent with hives requiring
diphenhydramine. The medication was discontinued. Given the
multiple drug sensitivities and culture data showing MRSA
fluoroquinolone sensitivity, she was started on levofloxacin
under ID's guidance. She was referred for allergy followup on
discharge to evaluate for drug hypersensitivities given multiple
reactions to medications. She was discharged on this for a
prolonged course with ___ clinic followup. For pain control she
initially had a PCA and was transitioned to oxycodone. She was
ordered a sem-rigid brace as well with activity as tolerated.
#Mouth lesions: Ms. ___ developed mouth and lip lesions while
on linezolid therapy, a reaction that she reports when she was
previously on this therapy. Dermatology was consulted and felt
that the rash was an atypical reaction to linezolid vs. herpes
vs. angular stomatitis. Viral swab was taken of the lesions,
though after the lesions had crusted. The lesions improved on
cessation of linezolid.
CHRONIC CARE:
# Anemia: No prior value avialable. Pt is taking B12 and has
borderline macrocytosis, so B12 deficiency possible but seems
unlikely to be the only cause ___ a pt who eats animal-derived
products given long t1/2 of B12. She will followup with PCP
regarding this issue.
# HLD: Continued statin
TRANSITIONS ___ CARE:
# Emergency Contact: ___ (husband; ___
-followup is made with ID, ortho spine, and allergy
-dermatology will call the patient with results of viral swab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Fish Oil (Omega 3) 2 capsules PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Discharge Medications:
1. Levofloxacin 750 mg IV Q24H
RX *levofloxacin ___ D5W 750 mg/150 mL 750 mg IV daily Disp #*21
Bag Refills:*0
2. benzocaine 20 % topical QID:PRN mouth pain
RX *benzocaine [Pain Relieving] 20 % apply to affected area
QID:PRN Disp #*1 Tube Refills:*2
3. Simvastatin 40 mg PO DAILY
4. OxycoDONE (Immediate Release) 7.5-15 mg PO Q4H:PRN pain
RX *oxycodone 15 mg ___ tablet(s) by mouth Q4H:PRN Disp #*20
Tablet Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fish Oil (Omega 3) 2 capsules PO DAILY
10. Acetaminophen 325 mg PO Q4H:PRN pain
do not take more than 3g of acetaminophen per day
11. Petroleum Jelly (white petrolatum) 1 application topical PRN
dry lip lesions
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: MRSA Epidural Abscess
Secondary: Drug allergy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with an MRSA abscess at the
site of a lower back surgical wound. While ___ the hospital, the
orthopedic surgeons cleaned out the abscess. The infectious
disease experts worked with you to find an antibiotic that you
could tolerate, and levofloxacin was found to be well-tolerated.
You are being discharged on a course of IV levofloxacin and will
followup with Orthopedic Surgery and Infectious Disease.
You have several medication allergies that we became aware of,
which may limit your treatment choices if needed ___ the future.
For this reason, we have set up an appointment for you with the
allergist to sort out to which antibiotics you are allergic.
Regarding the mouth rash, our dermatologists are not sure
exactly what caused the lesion as it is not a typical reaction
seen with linezolid. Please seek urgent care if the rash
worsens. If it occurs again, please call dermatology and they
may be able to evaluate it quickly.
It is critically important not to miss even one dose of your
antibiotics, as the bacteria can become resistant even with one
missed dose. For this reason, please present to the ___
emergency room if you will be missing a dose for unforseen
circumstances.
Followup Instructions:
___
|
10485315-DS-4 | 10,485,315 | 21,131,281 | DS | 4 | 2118-02-14 00:00:00 | 2118-02-16 06:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of HFrEF (EF 40-45% ___, mitral valve stenosis
___ bovine MVR (___), tricuspid valve annuloplasty (___), Afib
on coumadin, biventricular AICD, COPD on oxygen ___ L) at
night, active tobacco use who was transferred from ___
with dyspnea on exertion, evaluation for mitral valve repair.
Dyspnea has been worsening over last few months, associated with
decreased mobility as well (essentially bed-bound), weight loss
of approximately ___ pounds, and increased confusion/short
term memory loss. Has been admitted to the ED ___ times over
this time period as well. Poor medication compliance, PO intake,
at home reported by hospice service.
Patient reports that he spoke with his cardiologist (Dr. ___
at ___ who reportedly told him that he requires cardiac
catheterization. Per call in referral, Dr. ___ spoke with Dr.
___ transfer for cardiac surgery evaluation/mitral valve
repair and possible catheterization.
Workup at ___, per OSH referral, with troponin of 0.03,
BNP 349, and chest x-ray with bilateral pleural effusions.
In the ED initial vitals were: 97.7 66 145/96 16 99% RA
EKG:
Labs/studies notable for:
- Troponin < 0.01 x 2
- proBNP ___
- 4.0 > 12.3/37.2 < 114
Patient was given: IV Lasix 20, PO Lasix 20, ASA 81, citalopram
20, carvedilol 3.125, venlafaxine 37.5, olanzapine 2.5
Cardiology was consulted and recommended TTE, trop x 2, IV
Lasix, and NPO for possible catheterization
Vitals on transfer: 72 127/87 18 93% NC
On the floor patient denies shortness of breath, chest pain,
palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
- Tobacco use
2. CARDIAC HISTORY
- Afib
- BiV ICD
- CABG
- Mitral valve stenosis ___ MVR (porcine, ___ y at ___
- TV annuloplasty (___)
- L sided MAZE and ___ ligation (___)
- pericardial effusion ___ post MVR, TV annuloplasty, MAZE)
3. OTHER PAST MEDICAL HISTORY
- COPD on NC at night
- GERD
- Depression/Anxiety
- Alcohol use disorder
Social History:
___
Family History:
Father MI ___, died ___ years, mother CVA died ___ years, otherwise
no family history of arrhythmia, cardiomyopathies, or sudden
cardiac death. Used to work in ___, ___
___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.6 PO 135/91 69 20 97 2L
I/Os: N/A
Weight: 59.8 kg (64.8 kg in ___
GENERAL: ill appearing, thin, no acute distress, pleasant and
conversant.
HEENT: Normocephalic atraumatic. icteric sclera. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. +JVP
CARDIAC: Distant heart sounds, egular rate and rhythm. Diastolic
murmur at apex.
LUNGS: Kyphotic, scattered wheezes bilaterally, no crackles.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: 1+ pitting edema in ankles bilaterally, trace edema
shins bilaterally, warm, well perfused, no cyanosis or clubbing.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AAOx3, attention intact able to recite months of year
backwards.
DISCHARGE PHYSICAL EXAM
========================
Weight: 62.8 kg (admit weight 59.8 kg)
VS: T 97.8 HR 62 RR 18 BP 118/62 96%RA
Gen: Cooperative, disillusioned regarding prolonged
hospitalization
HEENT: PERRLA
NECK: JVP flat.
CV: Irregular, unable to appreciate diastolic rumble
LUNGS: CTAB, rare expiratory wheeze
ABD: Soft, non-tender
EXT: Warm, well-perfused. Non-edematous
Pertinent Results:
ADMISSION LABS
===============
___ 12:13AM BLOOD WBC-4.0 RBC-3.82* Hgb-12.3* Hct-37.2*
MCV-97 MCH-32.2* MCHC-33.1 RDW-14.5 RDWSD-51.6* Plt ___
___ 12:13AM BLOOD Neuts-65.3 Lymphs-18.2* Monos-13.2*
Eos-2.0 Baso-0.8 Im ___ AbsNeut-2.58 AbsLymp-0.72*
AbsMono-0.52 AbsEos-0.08 AbsBaso-0.03
___ 05:36PM BLOOD ___ PTT-34.7 ___
___ 12:13AM BLOOD Plt ___
___ 05:36PM BLOOD Glucose-133* UreaN-18 Creat-0.8 Na-140
K-3.8 Cl-95* HCO3-33* AnGap-12
___ 12:13AM BLOOD Glucose-78 UreaN-16 Creat-0.8 Na-139
K-3.7 Cl-96 HCO3-31 AnGap-12
___ 12:13AM BLOOD ALT-48* AST-59* LD(LDH)-321* CK(CPK)-43*
AlkPhos-209* TotBili-1.2
___ 06:55AM BLOOD cTropnT-<0.01
___ 12:13AM BLOOD cTropnT-<0.01
___ 12:13AM BLOOD CK-MB-3 proBNP-___*
___ 12:13AM BLOOD Albumin-3.6
___ 05:36PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
___ 05:50PM BLOOD Lactate-1.7
INTERVAL STUDIES
=================
ECHO ___
The left atrial volume index is severely increased. Moderate to
severe spontaneous echo contrast is seen in the body of the left
atrium. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Overall left ventricular systolic
function is mildly depressed (LVEF= 40-45 %). Doppler parameters
are indeterminate for left ventricular diastolic function. Right
ventricular chamber size is normal with borderline normal free
wall function. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened (?#). There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present. Motion
of the prosthetic mitral valve leaflets/poppet is abnormal. The
gradients are higher than expected for this type of prosthesis.
There is very severe valvular mitral stenosis (MVA <1.0 cm2).
The tricuspid valve leaflets are mildly thickened. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
IMPRESSION: Severe bioprosthetic mitral valve stenosis with
severe spontaneous echo contrast consistent with stasis of flow
in the severely dilated left atrium. Mild symmetric left
ventricular hypertrophy with depressed left ventricular
function. Borderline right ventricular systolic function. Mild
aortic stenosis.
CXR ___
FINDINGS:
Left anterior chest wall ICD is in place. There is at least
moderate
cardiomegaly with unfolding of the thoracic aorta and aortic
knob
calcifications. There is pulmonary vascular congestion and mild
interstitial
edema with moderate right-sided and small left-sided pleural
effusions with adjacent right greater than left compressive
atelectasis. There is no pneumothorax. There is no acute
osseous abnormality.
IMPRESSION:
Moderate cardiomegaly, central pulmonary vascular congestion,
mild
interstitial edema and moderate right and small left pleural
effusions. No gross evidence of pneumonia, though this would be
difficult to exclude in the appropriate clinical context.
CTA Abdomen and Pelvis ___:
IMPRESSION:
1. Widely patent pelvic and proximal femoral arterial
vasculature with heavy calcifications.
2. Borderline aneurysmal dilatation of the descending abdominal
aorta, measuring up to 3 cm.
3. Mild heterogeneity of the liver is likely related to hepatic
congestion.
4. Chronic compression deformities of the T7 and T12.
CARDIAC STRUCTURE AND MORPHOLOGY ___:
FINDINGS:
EXTRACARDIAC FINDINGS:
CT CHEST WITH CONTRAST: There are bilateral, dependent,
layering,
nonhemorrhagic pleural effusions, moderate on the right and
small to moderate on the left. There is extensive ground-glass
opacities and perifissural fluid seen in the lungs, which in
combination with the pleural effusion is concerning for moderate
pulmonary edema. Incidental note is made of a left pectoral
pacemaker.
CT ABDOMEN AND PELVIS WITH CONTRAST: The CTA abdomen and pelvis
exam will be reported separately.
OSSEOUS STRUCTURES: There is no bony abnormality. Degenerative
changes are seen along the visualized spine.
CTA:
CARDIAC: The right atrium is normal. The right ventricle is
normal. The left atrium is severely enlarged, measuring up to
10 cm. The left ventricle is normal. The pericardium is normal
and there is no pericardial effusion. The aortic valve is is
tricuspid with leaflet thickening and calcification. Dominance
of the coronary artery system is right with normal origins and
course. Coronary artery calcification is moderate to severe.
Patient is status post mitral valve and tricuspid valve
replacement.
PULMONARY ARTERIES: The main, right and left pulmonary arteries
are normal and appear patent to the subsegmental level without
filling defects.
AORTA: The thoracic aorta is normal in caliber with mild
calcifications.
IMPRESSION:
1. Patient is status post mitral valve and tricuspid valve
replacement. The left atrium is severely enlarged, measuring up
to 10 cm. An addendum will be placed with final measurements
and assessment of the valves pending 3D reformats.
2. Mild-to-moderate pulmonary edema with bilateral dependent,
layering, nonhemorrhagic pleural effusion, moderate on the right
and small to moderate on the left.
3. Coronary artery calcifications are moderate to severe.
4. Please refer to the separate CTA abdomen and pelvis exam for
full
description of subdiaphragmatic findings.
DISCHARGE LABS
=================
___ Hct-35.9* Plt ___ UreaN-19 Creat-0.7 Na-140 K-4.5
Mg-2.2
___ PTT-86.9* ___
Brief Hospital Course:
___ year old man with a history of HFrEF (LVEF 40-45%), COPD (on
home O2), MVP/MR ___ bioMVR (___), TR ___ annuloplasty (___),
valvular AF, hypertension, dyslipidemia
who was transferred from ___ on ___ for evaluation for
MVR for severe mitral stenosis, being evaluated by structural
team for TMVR. He was initially followed by the Heart Failure
Service and transitioned to the ___ NP service on
___. Structural Heart service continued to follow him during
this time. Given his co-morbidities and his frail status, he had
been seen by Geriatrics who weighed in on his risk for
intervention to repair his mitral valve which was felt to be
causing some, but not all of his symptoms. Given his severe
COPD, he will continue to have symptoms of shortness of breath
and dyspnea on exertion. His Coumadin was held while his
testing was completed in the event he moved forward with an
intervention during the admission. He was maintained on a
heparin drip during that time given his history of AFIB and
porcine valve replacement. He restarted Coumadin on ___ and
his INR responded appropriately after one 5 mg dose of Coumadin
on ___ and 7.5 mg on ___. He was given 2 mg on ___ after a
repeat INR was 1.9. His hospice services were terminated by the
family prior to his admission at his daughter's request. His
PCP ___ continue to manage his INR at discharge (weekly INR
checks recommended) and ___ Services will be coordinated by Case
Management given he is no longer on hospice services at this
time.
A number of family meetings occurred where risks and benefits of
intervention with a new minimally invasive valve procedure could
be performed and provide some benefit and relief of his
symptoms. Initially, the daughter and patient declined to move
forward. On ___, the patient was again seen by Dr. ___
the ___ Service and the patient indicated he was
interested in the procedure if it could benefit his symptoms. He
is sedentary at home, and primarily uses a computer. His
daughter works during the day. The current plan is for the
Structural Team to coordinate his planned procedure with his
cardiologist, Dr. ___. Much of the preoperative workup
(imaging studies) were done while he was an in-patient here.
#) DYSPNEA ON EXERTION: Likely some contribution from severe
mitral stenosis and also his underlying lung disease (on
nighttime O2 @ home) and ongoing smoking. Management of these
issues as below. It is unknown/unclear how much incremental
benefit a mitral valve intervention would have in terms of his
dyspnea given his coexistant lung disease, however, the
Structural Team does feel there will be incremental benefit.
Further discussion will continue with his cardiologist. He was
seen by the Cardiac Surgery team and deemed high risk for
conventional surgery.
# DYSPNEA ON EXERTION, MV STENOSIS MVA 0.4 cm2 by TTE
(___): Likely some contribution from severe mitral stenosis
and also his underlying lung disease (on nighttime O2 @ home)
and ongoing smoking. Management of these issues as below. It is
unknown/unclear how much incremental benefit a mitral valve
intervention would have in terms of his dyspnea given his
co-existant lung disease.
- Family meeting held ___ and ___. Initially
felt he would not have TMVR but has since indicated he would
move forward. Dr. ___ to review imaging studies with Dr.
___. Will possibly have procedure ___
- Therapeutic INR of 2.1 today. Managed by PCP, next draw ___
- Lasix was restarted on ___ at a 40 mg dose. He was
closely monitored with dietary control on a low 2 gram sodium
diet and a 2 liter daily fluid restriction with daily weights.
- Carvedilol discontinued earlier in his stay, escripted Toprol
to his pharmacy
- Continue 2 gram low sodium diet, 2 liter fluid restriction,
daily weights
- Dr. ___ will coordinate plan with Dr. ___
#) COPD/TOBACCO USE: On nighttime O2 at home. Actively smoking.
Currently on maintenance prednisone.
- Continue bronchodilators
- Continue maintenance prednisone
- Smoking cessation was counseled. He did not utilize a nicoderm
patch or gum while here.
#) ATRIAL FIBRILLATION: Valvular. Rate controlled currently.
His Carvedilol was discontinued and he was started on Metoprolol
Tartrate 12.5 mg every 6 hours and ordered for 50 mg Toprol at
the time of discharge. He was bridged to a therapeutic INR as
described above using heparin.
He worked with Physical Therapy and was ambulatory with
supervision (see ___ note for further information). He should
continue to be out of bed for meals and ambulate as tolerated at
home. He was voiding without difficulty and moving his bowels as
normal. His LFTs were elevated and was seen to have hepatic
congestion, and these values improved somewhat during his stay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Amoxicillin 500 mg PO PREOP
3. Atorvastatin 10 mg PO QPM
4. Mirtazapine 15 mg PO QHS
5. Carvedilol 3.125 mg PO BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
7. Warfarin 2 mg PO DAILY16
8. Venlafaxine XR 75 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
Hold for systolic blood pressure less than 95 or heart rate less
than 50
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Furosemide 40 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing or SOB
5. Amoxicillin 500 mg PO PREOP
6. Atorvastatin 10 mg PO QPM
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
9. Mirtazapine 15 mg PO QHS
10. PredniSONE 10 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Venlafaxine XR 75 mg PO DAILY
13. Warfarin 2 mg PO DAILY16
Dose per PCP ___ (next INR ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
severe mitral stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for shortness of breath and dyspnea on
exertion. This was related to your existing porcine mitral valve
replacement and your underlying severe COPD. Your Coumadin was
held and multiple studies were done to assess your valve and
whether this could be repaired by conventional means versus a
newer less invasive procedure. Extra fluid was removed from your
body using Lasix. Your shortness of breath improved and you
continued with your home inhalers. You were seen by the
Electrophysiology Team who adjusted your device to improve
filling time of blood in your heart. Your home inhalers were
restarted on ___. You resumed Coumadin on ___ and
because your INR was not therapeutic and you were at risk of a
stroke, you were continued on a Heparin drip and then bridged
back to a therapeutic INR level on Coumadin. You were seen by
the Cardiac Surgery Service and risk stratified given your
co-morbidities for the less invasive repair of your valve. Once
you were therapeutic with your INR you were discharged to home
with ___ services so that your Coumadin could be managed as it
was prior to admission. New ___ services were established for
you by Case Management since you were no longer on ___
___ prior to your admission to ___.
You eventually decided to pursue a mitral valve replacement
under less invasive means with the Structural Heart team. Many
of these studies were completed during your stay. The Structural
Team will be contacting Dr. ___ to discuss planning for your
new mitral valve replacement. Your procedure may be completed as
early as ___. ___ and Dr. ___ will be in contact with
you to plan for your procedure.
Continue all of your home medications, including your daily
Lasix and Coumadin. Your Carvedilol was discontinued and you
were started on a new medication called Toprol or Metoprolol
which helps your heart beat more effectively and also helps with
blood pressure. This has been sent to your pharmacy and can be
picked up on your way home from the hospital. Your home Lasix
dose of 20 mg Daily was increased to 40 mg Daily. A new
prescription for the 40 mg dose was sent to your pharmacy.
Your INR should continue to be monitored and you should take
your Coumadin as you had prior to your admission. Your PCP, ___.
___ continue to manage your INR. These checks can be
done once per week or as ordered by her office. Your first INR
check will be ___ since your INR ws checked prior to your
discharge from ___.
Continue to follow a low sodium diet (2 grams) and limit fluids
to 2 liters daily, you should include anything that melts at
room temperature (popsicles, jello, etc.). Weigh your self
daily. If your weight increases by ___ lbs. in ___ hours,
contact your Cardiologist as your Lasix may need to be adjusted
to prevent worsening fluid overload and admission to the
hospital. Contact your PCP if any symptoms worsen.
Followup Instructions:
___
|
10485425-DS-14 | 10,485,425 | 27,469,101 | DS | 14 | 2200-04-24 00:00:00 | 2200-04-24 14:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Chief Complaint:
ABD Distention, Dyspnea
Major Surgical or Invasive Procedure:
___ Incision and drainage of R necrotic foot ulcer
___ R hallux and partial ___ metatarsal amputation
History of Present Illness:
___ with a PMH of CAD (known fixed inferior defect), mild OSA,
diastolic CHF, DM2, COPD and HTN who p/w one week of onset ___
edema, abdominal distension, SOB and right necrotic toe ulcer.
At baseline, pt is able to dress herself, do chores, walk
several blocks without getting SOB. She gets SOB walking up
stairs. She uses 2 pillow at night. She is on 2L home O2 at
night.
Approximately 1.___eveloped increasing edema ___
her thighs, legs and abdomen. She reports difficulty putting her
pants on. She had increasing DOE, being unable to walk ___ steps
without getting SOB. She has positive sick contact,
granddaughter developed a cold 2 weeks ago. Since seeing her
granddaughter she developed congestion and a "junky" cough with
yellow sputum. She saw her pulmonologist ___ where she was
diagnosed with a COPD exacerbation and prescribed 10D of 10 mg
prednisone, to be followed by 5D course of azithromycin. Her
last day of prednisone is ___. She states that her breathing
has improved since starting the course of steroids. Of note, she
missed two Lasix doses. She has had increasing weight gain. She
was discharged ___ at 190 lbs, presents now at 210 lbs.
Reports decreased PO intake, mild constipation (last BM ___,
she has been using Colace) and decreased UOP. She denies
worsening orthopnea, denies PND. Denies fevers/chills, HA/vision
changes, diarrhea, CP/palpitations, abdominal pain,
dysuria/urinary frequency.
Of note, pt has large right toe necrotic ulcer that developed
over the past few days.
___ the ED, initial vital signs were: ___ pain 98.1 84 148/96
20 93% RA
Exam notable for: Lungs with decreased air movement, faint
expiratory wheezes bilateral lower extremities with edema up to
thighs, and stasis related changes on shins.
Labs were notable for:
1) CBC: WBC 21.7, Hb 12.9, plt 192, 80% PMN
2) BNP: 3607
3) BMP: Na 144, K 4.3, Cl 96, HCO3 33, BUN 22, Cr 0.7, glucose
244, AG 15
4) Troponin 0.04
5) Lactate 3.3
6) pH 7.41/57/40
Studies performed include:
1) CXR: Mild left basal atelectasis. Otherwise unremarkable.
2) EKG: SR, normal axis/intervals, sub- 1mm STD V4-V6, J-point
elevated V2-V3
Patient was given:
___ 18:56 IV Magnesium Sulfate Started
___ 20:06 IV Magnesium Sulfate 2 gm Stopped (1h ___
___ 20:07 IV Magnesium Sulfate Restarted
Consults: None
Vitals on transfer: 99.4 106 126/69 25 97% RA
Upon arrival to the floor, the patient reports that her
breathing feels "70%" of normal, and has been improving.
Past Medical History:
L sensorineural hearing loss
DM2 - poorly controlled, with Hgb A1c 14
Hypertension
Hyperlipidemia
CAD- fixed inferior defect on nuclear imaging
COPD with active smoking
Social History:
___
Family History:
Mother died ___ ___ of colon cancer. Father died ___ years ago
from prostate cancer and also had lung disease. Family history
of diabetes mellitus. No siblings. Both children had childhood
asthma when young, but have outgrown it.
Physical Exam:
ADMISSION
Vitals: 99.4 PO 134 / 87 L Sitting ___ 2l
GEN: NAD, sitting up ___ bed
HEENT: PERRL, EOMI, MM dry, OP clear, neck supple, JVD elevated
to jaw-line
CARD: RRR, S1 + S2 present, no mrg
RESP: CTAB, sporadic expiratory wheezes, no crackles at bases
ABD: Soft, non-tender, distended, no rebound/guarding, +BS
EXT: WWP, 2+ pitting edema b/l, nonpitting edema thighs
NEURO: CNII-XII intact, motor function grossly intact
SKIN: Lateral right toe with large necrotic ulcer, all toes WWP
DISCHARGE
GEN: alert, awake, NAD, currently breathing comfortably on RA
NECK: JVP with prominent v-waves to mandible when sitting at
30degrees
CV: RRR, no m/r/g
PULM: CTAB
ABD: Distended abdomen, Soft, NT.
EXT: R foot ___ bandage with wound vac ___ place. L foot ___
bandage, no wound vac
NEURO: alert, interactive, moving all extremities with purpose
against gravity
Pertinent Results:
ADMISSION
___ 04:38PM BLOOD WBC-21.7*# RBC-5.02 Hgb-12.9 Hct-47.2*
MCV-94 MCH-25.7* MCHC-27.3* RDW-17.2* RDWSD-59.0* Plt ___
___ 04:38PM BLOOD Neuts-80* Bands-15* Lymphs-2* Monos-2*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-20.62*
AbsLymp-0.43* AbsMono-0.43 AbsEos-0.22 AbsBaso-0.00*
___ 04:38PM BLOOD Glucose-244* UreaN-22* Creat-0.7 Na-144
K-4.3 Cl-96 HCO3-33* AnGap-15
___ 04:38PM BLOOD Calcium-8.9 Phos-3.3 Mg-1.1*
___ 04:51PM BLOOD ___ pO2-40* pCO2-57* pH-7.41
calTCO2-37* Base XS-8
___ 04:51PM BLOOD Lactate-3.3*
PERTINENT INTERVAL AND DISCHARGE LABS
___ 05:44AM BLOOD WBC-7.9 RBC-3.49* Hgb-9.1* Hct-33.1*
MCV-95 MCH-26.1 MCHC-27.5* RDW-17.9* RDWSD-61.3* Plt ___
___ 05:44AM BLOOD Glucose-96 UreaN-15 Creat-0.7 Na-144
K-4.3 Cl-101 HCO3-32 AnGap-11
___ 05:47AM BLOOD ALT-29 AST-23 LD(LDH)-331* AlkPhos-138*
TotBili-0.4
___ 04:38PM BLOOD proBNP-3607*
___ 04:38PM BLOOD cTropnT-0.04*
___ 09:25PM BLOOD CK-MB-4 cTropnT-0.05*
___ 03:06PM BLOOD cTropnT-0.05*
___ 03:30AM BLOOD CK-MB-3 cTropnT-0.05*
___ 09:56AM BLOOD CK-MB-3 cTropnT-0.04*
___ 02:30PM BLOOD CK-MB-3 cTropnT-0.05* proBNP-2849*
___ 05:44AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.2*
___ 09:20PM BLOOD CRP->300*
___ 04:56AM BLOOD Vanco-19.6
___ 07:36AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:36AM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 07:36AM URINE RBC-133* WBC-10* Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:31PM URINE CastHy-11*
___ 10:02PM URINE Hours-RANDOM Na-31
___ 10:02PM URINE Osmolal-849
___ 06:19AM BLOOD Glucose-82 UreaN-16 Creat-0.6 Na-143
K-4.2 Cl-103 HCO3-30 AnGap-10
MICROBIOLOGY
___ 10:02 pm URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 4:00 pm SWAB Source: right foot abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringens, and C.septicum.
None of
these species was found.
___ 6:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Time Taken Not Noted ___ Date/Time: ___ 2:50 pm
SWAB RIGHT FOOT WOUND .
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 7:36 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:05 am TISSUE Site: TOE RIGHT BIG TOE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
Susceptibility testing requested by ___. ___ ___) ON
___.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
IMAGING
IMPRESSION:
Status post amputation of the first digit at the level the mid
first
metatarsal with postoperative changes.
PATH REPORT
GROSS DESCRIPTION:
The specimen is received ___ 3 parts labeled with the patient's
name and medical record number.
Part 1 is received fresh ___ a container additionally labeled
"right big toe." It consists of a toe that
measures 7.0 x 5.0 x 3.5 cm. The entire surface of the toe is
involved with black/brown firm necrotic
tissue that abuts the soft tissue margin. The bone at the bony
margin is firm and yellow. The bone marrow throughout the distal
portion of the toe is red tan and friable. The toenail is
enlarged. The
specimen is represented as follows: 1A = bony margin, 1B =
black/brown necrotic tissue with
underlying friable bone marrow.
1A1B submitted for decal
Part 2 is additionally labeled "right first metatarsal." It
consists of a bone fragment that measures 2.5
x 2.5 x 1.7 cm. The specimen is serially sectioned to reveal
firm yellow bone marrow. The specimen
is represented ___ cassette 2A.
2A submitted for decal
Part 3 is additionally labeled "right first metatarsal margin."
It consists of a ring shaped piece of
bone that measures 1.5 x 1.3 cm x 0.5 cm. The specimen is
submitted whole ___ cassette 3A.
3A submitted for decal.
Brief Hospital Course:
========
Summary
========
Ms. ___ is a ___ year old woman with a past medical history of
CAD (known fixed inferior defect), mild OSA on 2 L oxygen at
home, diastolic CHF, DM2, COPD and HTN who presented with one
week of lower extremity edema, abdominal distension, shortness
of breath found to have heart failure exacerbation, as well as
right toe necrotic ulcer s/p I&D on ___, course complicated by
hypoxemia requiring ICU transfer for bipap now s/p aggressive
diuresis with improvement ___ respiratory status.
=============================
Acute Medical/Surgical Issues
=============================
#Acute hypoxemic respiratory failure
#Acute on Chronic CHF with Preserved EF
On admission, patient had signs and symptoms of volume overload
___ the context of elevated BNP, increase ___ weight (dry weight
likely 190 lbs, admission weight 226 lbs) consistent with CHF
exacerbation further evidenced by her diffuse crackles and
elevated JVP. Likely became decompensated ___ the setting of
smoldering right foot necrotic infection. TTE performed showing
EF 45-50% with elevated right sided pressures and more TR than
previous. Patient was initially diuresed then held off on
diuresis on the day of amputation as below while she was treated
for her infection. Patient subsequently diuresed with Lasix gtt,
followed by BID bolus dose Lasix 160mg then transitioned to
torsemide 40mg daily for maintenance. Lisinopril was decreased
to 20mg daily. Spironolactone 25mg was started on ___. On
___, switched from diltiazem to metoprolol XL given heart
failure diagnosis with reduced EF and inferior WMA. She
tolerated the metoprolol without shortness of breath.
Discharge regimen:
- Lisinopril 20 mg PO/NG DAILY
- Spironolactone 25 mg PO/NG DAILY
- Torsemide 40mg daily
- Metoprolol XL 50mg daily
Discharge weight: 84.78 kg 186.9 lb
#Right Hallux Necrotic Ulcer:
Patient presented with right toe necrotic ulcer of the the first
digit. This is most likely ___ the setting of her underlying
diabetes. Podiatry evaluated her and X-rays showed right bone
abnormality concerning for Osteo vs. gas forming bug infection
based on the sub cutaneous gas seen on X-day. Treated broadly
with vancomycin and Zosyn started on ___. Taken to the OR on
___ by podiatry for open incision and drainage. Would cultures
from I&D grew mixed bacterial flora with sparse group B strep.
Given necrotic infection and likely osteo, consulted ID ___.
On ___ stopped Vanc/zosyn and started on IV ceftriaxone 2g IV
q24hrs, PO Flagyl 500mg q8hrs. Per ID, patient will need abx for
at least 6 weeks given likely tendon and bone involvement. S/p R
hallux and partial first metatarsal amputation with wound VAC
application ___ need further amputation to clear
infection depending on whether tissue margins are clear.
Plastics consulted for possible skin graft or flap closure of
wound, but decided to not pursue further intervention during
this admission. The patient will follow up with plastics (Dr.
___ as an outpatient. Wound cultures from amputation growing
coag neg staph and started on IV vancomycin 1g q12 hrs. To
continue IV ceftriaxone 2g IV q24hrs, PO Flagyl 500mg q8hrs, IV
vanc 1g q12hr for at least 6 weeks (___) for
osteomyelitis treatment.
- strictly non-weightbearing on right foot
- f/u appointment with ID to determine length of treatment (to
be scheduled by ID)
- f/u appointment with podiatry ___, Dr. ___
- f/u appointment with plastics (Dr. ___ as above
===================================================
Chronic Medical Issues Pertinent to hospitalization
===================================================
#COPD:
Long standing COPD with recent exacerbation treated with
Prednisone 80mg daily for 5 days and then 40mg daily for 5
dayslast dose ___. No wheezes, picture not consistent with
COPD exacerbation, but treated with azithromycin and IV
solumedrol 1x mainly for anti-inflammatory effect.
#OSA
Recently diagnosed, not yet on home CPAP. patient had been
refusing CPAP overnight as she felt she did not need it. We
re-explained her need for it and she states she will now try.
MEDICATION CHANGES
==================
*** STOPPED Medications/Orders ***
Diltiazem Extended-Release 360 mg PO DAILY This medication was
stopped it is being replaced with metoprolol
Furosemide 40 mg PO DAILY This medication was stopped it is
being replaced with Torsemide
*** NEW Medications/Orders ***
Acetaminophen 1000 mg PO Q8H This is a new medication to treat
your pain
CefTRIAXone 2 gm IV Q24H This is a new medication to treat your
infection
Metoprolol Succinate XL 50 mg PO DAILY This is a new medication
to treat your heart failure
MetroNIDAZOLE 500 mg PO Q8H This is a new medication to treat
your infection
Spironolactone 25 mg PO DAILY This is a new medication to treat
your heart failure
Torsemide 40 mg PO DAILY This is a new medication to remove
excess fluid
Vancomycin 1250 mg IV Q 12H This is a new medication to treat
your infection
*** CHANGED Medications/Orders ***
Humalog ___ 30 Units Breakfast Humalog ___ 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin You were taking this
medication at home but there has been a change ___ frequency
and/or dose
Lisinopril 20 mg PO DAILY You were taking this medication at
home but there has been a change ___ dose (how much)
=====================
Transitional Issues
=====================
[] Strictly non-weightbearing right foot
[] Will need 6 weeks antibiotics from ___. IV
ceftriaxone 2 g q24h, PO flagyl 500 mg PO q8h, IV vanc 1g q12hrs
[] needs weekly lab draws given ongoing treatment with
antibiotics (see below)
[] to be seen by ID as an outpatient to determine length of ABX
treatment (to be scheduled by ID)
[] to by seen by podiatry after discharge to determine further
treatment wound ulcer ___, Dr. ___
[] to be seen by plastic surgery (Dr. ___ ___ weeks after
discharge
[] Switched from diltiazem to metoprolol XL given heart failure
diagnosis with reduced EF and inferior WMA.
[] Switched from Furosemide 40mg daily to Torsemide 40mg daily.
Weight on discharge as below. Monitor weight, respiratory
symptoms and adjust torsemide dose accordingly.
[] Lisinopril decreased to 20mg daily
[] Discharge weight: 84.78 kg 186.9 lb
[] Fluid restriction 2L, daily weights as outpatient.
[] Has newly diagnosed OSA but does not have CPAP machine at
home. Recommend fitting for CPAP mask.
[] Wound vac to be placed at ___ - medium sponge
- Please have VAC placed at rehab, medium sponge, change every
3
days.
- Operative intervention will be discussed when the patient
follows up with Dr. ___ as an outpatient.
INFECTIOUS DISEASE OPAT PLAN:
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed ___ the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough
CEFTRIAXONE: WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS
OTHER MEDICATIONS: Flagyl 500mg q8h
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY CRP for patients with bone/joint
infections
and endocarditis or endovascular infections
FOLLOW UP APPOINTMENTS:
TBD
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
#CODE: Full
#CONTACT: ___ (daughter) c: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
2. Atorvastatin 80 mg PO QPM
3. Diltiazem Extended-Release 360 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Furosemide 40 mg PO DAILY
6. Humalog ___ 40 Units Breakfast
Humalog ___ 40 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
7. Lisinopril 40 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
9. Tiotropium Bromide 1 CAP IH DAILY
10. Aspirin 81 mg PO DAILY
11. MagBid ER (magnesium L-lactate) 168 mg oral BID
12. Nicotine Polacrilex 2 mg PO Q4H:PRN craving nicotine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CefTRIAXone 2 gm IV Q24H
3. Metoprolol Succinate XL 50 mg PO DAILY
4. MetroNIDAZOLE 500 mg PO Q8H
5. Spironolactone 25 mg PO DAILY
6. Torsemide 40 mg PO DAILY
7. Vancomycin 1250 mg IV Q 12H
8. Humalog ___ 30 Units Breakfast
Humalog ___ 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Lisinopril 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. MagBid ER (magnesium L-lactate) 168 mg oral BID
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Nicotine Polacrilex 2 mg PO Q4H:PRN craving nicotine
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
17. Tiotropium Bromide 1 CAP IH DAILY
18.Outpatient Lab Work
Diabetic foot infection - E11.621
Date: weekly
Labs: CBC with differential, BUN, Cr, Vancomycin trough, AST,
ALT, Total Bili, ALK PHOS, CRP
Please send results to: ATTN: ___ CLINIC - FAX:
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
==================
Primary Diagnosis
==================
R hallux necrotic infection
Acute decomprnsated heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I ___ the hospital?
- You were found to have a severe foot infection and had a lot
of extra fluid ___ your legs and lungs.
What was done while I was ___ the hospital?
- X-rays were taken that showed a severe infection ___ your
right foot that includes your bones
- You were started on antibiotics through your IV and taken to
surgery to clean out the infection
- You were given a medication called Lasix through your IV to
held get the extra fluid out of your legs and lungs
- You had a surgery to remove your right big toe to prevent the
infection from spreading up your leg.
- plastic surgery saw you but did not want to perform any
additional surgery while you were ___ the hospital. They will see
you ___ clinic one to two weeks after discharge.
What should I do when I go home?
- It is very important that you take your medication called
torsemide and spironolactone to prevent fluid from building up
___ your legs again
- It is very important that you have your antibiotics given
through your IV every day to prevent the infection ___ your right
foot from getting worse.
- Weigh yourself everyday and call your doctor if your weight
increases by 3 lbs ___ one day or 5 pounds ___ one week. The
discharge weight was 187 lb
- Please go to your scheduled appointment with your primary
doctor, infectious disease doctor, and cardiologist
- please go to your appointments with podiatry and plastic
surgery
- If you have worsening swelling ___ your legs, trouble
breathing, or notice new drainage or swelling ___ your right
foot, please tell your primary doctor or go to the emergency
room.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10485425-DS-17 | 10,485,425 | 21,579,521 | DS | 17 | 2201-03-26 00:00:00 | 2201-03-27 17:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o COPD on 2L O2, HFrEF, CVAs, CAD, OSA, HTN, IDDM,
initially presented with slurred speech/word finding
difficulties for which she was concerned so came to the
hospital. She says this ffelt similar to her previous strokes.
She also notes significant weight gain since her last discharge
and overall increasing DOE and ___ swelling over that time. Also
has had increased cough with sputum production over the last 2
weeks. Recently had podiatry debridement of her ___ ulcers. She
reports that because of lab abnormalities her spironolactone was
recently stopped, and her torsemide was changed to 40 qam and 20
qpm. She is on home O2 2L but reportedly has not been wearing
it. she also has not yet startied using CPAP at night. She
denies any chest pain or current SOB.
Per last d/c summary from ___ stay, her admission
weight was 248 lb and her goal weight is 196 lb. Cr was 1.0 on
discharge. Her most recent recorded weight at her PCP office was
215 lbs.
In ED,
she was afebrile, saturating well on RA initially then 95% on
2L, eventually put on bipap for hypercarbia, BP ___
NIHSS 2 for mild dysarthria, LUE and LLE decreased sensation to
light touch. No code stroke as LKW >6hrs PTA.
Labs:
CBC normal, K 4.7, Cr 2.1, trop 0.10, AST 74, pBNP 3655, VBG
___
lactate 1.8.
Imaging: CT head negative, CXR cardiomegaly without overt edema.
Given: Azithro 500mg IV, duonebs, albuterol nebs.
Consults: Neuro, podiatry
REVIEW OF SYSTEMS: 10 point ROS negative except per HPI
Past Medical History:
-Heart failure with reduced EF (35-40% ECHO ___ with PDA
WMAs)
-Left parietal stroke ___
-Coronary artery disease with history of inferior MI ___
nuc stress with fixed, small, moderate severity perfusion defect
involving RCA territory)
-Cerebrovascular disease (right 2mm PCOM aneurysm, mild M1/M2
disease)
-COPD (very severe obstruction on ___ PFTs)
-Obstructive sleep apnea with hypersomnia (2L home O2, CPAP
pending)
-Hypertension
-Diabetes
-Tobacco use disorder
Social History:
___
Family History:
Mother died in ___ of colon cancer.
Father died ___ years ago from prostate cancer and also had lung
disease.
Family history of diabetes mellitus. No siblings.
Both children had childhood asthma when young, but have outgrown
it.
Physical Exam:
===============================
ADMISSION PHYSICAL EXAM
===============================
VITALS: T 98 HR 56 BP 109/95 RR 13 SaO2 93% 4L via BiPAP mask at
___
GENERAL: Alert, oriented, no acute distress, comfortable on
BIPAP
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated to upper neck
LUNGS: Bibasilar crackles, end expiratory wheezing
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: bilateral dressings on chronic ___ ulcers. 2+ edema to the
knee bilaterally. warm.
SKIN: ___ wounds as above
NEURO: AAOx3, grossly intact
===============================
DISCHARGE PHYSICAL EXAM
===============================
Pertinent Results:
=============================
ADMISSION LABS
=============================
___ 06:50AM BLOOD WBC-4.8 RBC-4.88 Hgb-11.2 Hct-43.1 MCV-88
MCH-23.0* MCHC-26.0* RDW-20.7* RDWSD-64.4* Plt ___
___ 06:50AM BLOOD Neuts-59.5 ___ Monos-12.9 Eos-1.7
Baso-0.2 Im ___ AbsNeut-2.85 AbsLymp-1.22 AbsMono-0.62
AbsEos-0.08 AbsBaso-0.01
___ 06:50AM BLOOD Glucose-164* UreaN-73* Creat-2.1* Na-136
K-8.3* Cl-96 HCO3-24 AnGap-16
___ 06:50AM BLOOD ALT-22 AST-74* CK(CPK)-210* AlkPhos-75
TotBili-0.5
___ 06:50AM BLOOD Lipase-95*
___ 06:50AM BLOOD CK-MB-7 cTropnT-0.10* proBNP-3655*
___ 12:27PM BLOOD Calcium-9.1 Phos-4.5 Mg-1.9
___ 06:50AM BLOOD %HbA1c-9.2* eAG-217*
___ 04:09AM BLOOD Triglyc-46 HDL-52 CHOL/HD-1.5 LDLcalc-18
___ 12:27PM BLOOD TSH-1.6
___ 06:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:53AM BLOOD ___ pO2-39* pCO2-75* pH-7.23*
calTCO2-33* Base XS-0
=============================
DISCHARGE LABS
=============================
=============================
IMAGING/STUDIES/PROCEDURES
=============================
___ TTE
Severe pulmonary hypertension. Dilated and hypokinetic right
ventricle with pressure/volume overload. Severe functional
tricuspid regurgitation. Mild mitral regurgitation. Normal left
ventricular systolic function.
___ CXR
Mild enlargement of cardiac silhouette is stable. Lungs clear.
Normal pulmonary and mediastinal vascular caliber. No pleural
abnormality.
___ Head CT
No acute intracranial findings
Brief Hospital Course:
================================
BRIEF SUMMARY
================================
___ is a ___ year old women with a complicated
cardiopulmonary history notable for severe COPD with ongoing
tobacco use, obstructive sleep apnea, coronary artery disease
with ischemic HFrEF, recent L parietal stroke (unknown source,
no AF with ZioPatch, on aspirin and apixaban), and poorly
controlled diabetes who presented from home with worsening of
her residual stroke symptoms ultimately felt to be recrudescence
in the setting of subacute decompensated heart failure.
She was admitted to the MICU initially given a respiratory
acidosis in the ED (VBG pH 7.23 CO2 75). BiPAP did not improve
her blood gas, likely because of minimal settings used, and on
arrival to the MICU the BiPAP was removed and her blood gas did
not worsen nor did she have any encephalopathy from the elevated
CO2. The etiology of her respiratory failure was felt to be
multi-factorial including baseline severe COPD with an
additional component of likely OSA/OHS superimposed on a heart
failure flare that increased work of breathing (ultimately
increasing her CO2) and also caused a cardio-renal ___
(preventing appropriate metabolic compensation). The plan was to
diurese her to a dry weight and then reassess her needs, only
placing her on BiPAP for a clinical change.
Her heart failure exacerbation was subacute in nature, with
around a 30 pound weight gain over the several months since she
was last discharged (weight at that time was 196 pounds with a
SCr of 1.0) that correlated with a gradual worsening of her
functional status. She ultimately required a Lasix drip at
7.5mg/hr to achieve active diuresis, with improvement in her
creatinine and increase in her bicarbonate levels (unclear if
this represented a regained ability for metabolic compensation
for the respiratory acidosis vs. contraction alkalosis from
aggressive diuresis).
Following improvement of oxygenation status, she was
transitioned to the floor where diuresis was continued with IV
Lasix boluses. During this time, her O2 requirements ultimately
decreased to her home requirements of 2L. She did intermittently
develop a significant contraction alkalosis with bicarb in the
low ___ for which diuretics were briefly held pending
resolution. She was then transitioned to oral torsemide,
initially BID then daily. In this setting, she did develop
another ___, most likely prerenal, which resolved with more
judicious diuresis. She will be discharge on torsemide 80mg
daily (increased from 60mg daily).
================================
TRANSITIONAL ISSUES
================================
[]Will need to clarify her day time oxygen requirement and night
time positive pressure requirement
[]Discharge weight/dry weight: 206 lb
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Apixaban 5 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 25 mg PO BID
5. fluticasone-salmeterol 232-14 mcg/actuation inhalation BID
6. Glargine 39 Units Breakfast
7. Lisinopril 5 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Torsemide 40 mg PO QAM
10. Acetaminophen 650 mg PO Q8H
11. Magnesium Oxide 500 mg PO DAILY
12. Torsemide 20 mg PO QPM
Discharge Medications:
1. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth Once a day Disp #*120
Tablet Refills:*0
2. Acetaminophen 650 mg PO Q8H
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. Apixaban 5 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Carvedilol 25 mg PO BID
7. fluticasone-salmeterol 232-14 mcg/actuation inhalation BID
8. Glargine 39 Units Breakfast
9. Lisinopril 5 mg PO DAILY
10. Magnesium Oxide 500 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12.Outpatient Lab Work
Please draw chem 10, ICD 10: I50.3
Please fax results to Dr ___ office, fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Acute decompensated systolic heart failure
#hypoxic and hypercarbic respiratory failure, resolved
___
SECONDARY DIAGNOSES:
#COPD
#OSA
#h/o CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for weight gain and fluid in your lungs and
legs because of worsening heart failure.
What was done for me while I was in the hospital?
- You were given medications similar to your home torsemide to
help remove the extra fluid from your body.
What should I do when I leave the hospital?
- Continue to take torsemide daily
- Please have your blood drawn on ___. You
were given a prescription for this - you can bring this to any
local blood draw ___ and they will fax the results to your
doctors.
- Please weigh yourself every day in the morning, immediately
after waking up and emptying your bladder but before eating or
drinking anything. If your weight goes up by more than 3 pounds
in 24 hours or 5 pounds in a week, please call Dr ___
cardiologist) office at ___ to let them know as they
may want to change your medications.
- If you notice that your weight goes down by more than 3 lbs,
please decrease your torsemide from 80mg a day (4 pills per day)
to 60mg a day (3 pills per day) and call Dr ___
cardiologist) office at ___ to let them know, as they
may want to change your medications.
- Please limit your fluid intake to less than 2L.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10486056-DS-23 | 10,486,056 | 29,743,355 | DS | 23 | 2174-01-16 00:00:00 | 2174-01-16 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with COPD, HTN, paroxysmal afib, and HFpEF who presented
from ___ with shortness of breath and abdominal pain. She
states she has been increasingly short of breath over the past
few days with increased work of breathing. She also notes ankle
swelling over the past 2 weeks. She has gained 20 pounds over
the
past 2 months, with 10 pound weight gain in the past week. She
denies fever, cough, chest pain, dysuria, constipation, N/V. Of
note, she was hospitalized in ___ for acute hypoxemic and
hypercarbic respiratory failure.
In the ED, initial vitals were notable for BP 148/68, RR 24,
with
SpO2 of 95% on 4L NC. Since arrival to the ED, she has had
increasing oxygen requirement to 5L NC. Exam was notable for
increased work of breathing with use of accessory muscles,
wheezing and congestion bilaterally, as well as 2+ pitting edema
of bilateral lower extremities. EKG was unchanged from prior.
Labs were notable for troponin 0.04, proBNP 7289, WBC 11.1, Hgb
7.9 (baseline 8). CXR notable for moderate pulmonary edema with
moderate left and small right pleural effusions. She was given
40mg IV Lasix while in the ED without improvement in ___
oxygenation, but with significant improvement in symptoms.
On arrival to the floor, she reports feeling "terrible." She
notes that ___ abdomen is painful, primarily in the upper
abdomen
and that she is nauseous. On further questioning, she notes that
she has felt nauseous for the past month, since being discharged
from the hospital.
Past Medical History:
-Hypertension
-hx of C. difficile
-COPD
-cheilitis
-constipation
-facial bone fx
-hyponatremia
-osteoporosis
-PAD
-recurrent UTI
-trigger middle finger or right hand
-vbaginal atrophy
-L hip fx
-rectal abscess
-hypocalcemia
Social History:
___
Family History:
Father and brother with MIs. Negative for
arrhythmias, heart failure, cardiomyopathy, sudden or unexpected
death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:
___ 1818 Temp: 97.6 PO BP: 102/70 HR: 97 RR: 17 O2 sat: 94%
O2 delivery: 5L
GENERAL: elderly woman, lying in bed, appears uncomfortable,
with
nasal cannula in place
HEENT: PERRL, crusting around mouth
NECK: difficult to appreciate JVP
CARDIAC: RRR, no murmurs/gallops/rubs
LUNGS: crackles in bilateral lung bases, mild increase in work
of
breathing with some use of abdominal muscles
ABDOMEN: obese abdomen, BS+, soft, mild tenderness to palpation
throughout
EXTREMITIES: warm, 2+ pitting edema to hip bilaterally
PULSES: distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAMINATION:
VITALS:
24 HR Data (last updated ___ @ 800)
Temp: 97.8 (Tm 98.1), BP: 121/68 (115-144/67-76), HR: 68
(68-76), RR: 18 (___), O2 sat: 93% (92-94), O2 delivery: Ra,
Wt: 132.5 lb/60.1 kg
Fluid Balance (last updated ___ @ 800)
Last 8 hours Total cumulative 481ml
IN: Total 781ml, PO Amt 320ml, TF/Flush Amt 461ml
OUT: Total 300ml, Urine Amt 300ml
Last 24 hours Total cumulative 1071ml
IN: Total 2621ml, PO Amt 1420ml, TF/Flush Amt 1201ml
OUT: Total 1550ml, Urine Amt 1550ml
GENERAL: elderly woman, lying in bed, alert
HEENT: crusting around mouth
NECK: JVP at clavicle at 30 degrees
CARDIAC: irregular rhythm, no murmurs/gallops/rubs
LUNGS: moderate air movement, no increased work of breathing, no
wheezes, mild bibasilar crackles (decreasing with continued
inspiration)
ABDOMEN: obese abdomen, BS+, soft, PEG in place in left upper
quadrant
Back: 3x3cm area of redness on the coccyx without skin breakdown
covered with mepiplex
EXTREMITIES: warm, no edema
Pertinent Results:
ADMISSION LABS:
___ 10:15AM BLOOD WBC-11.1* RBC-2.45* Hgb-7.9* Hct-26.1*
MCV-107* MCH-32.2* MCHC-30.3* RDW-15.2 RDWSD-59.5* Plt ___
___ 10:15AM BLOOD Neuts-88.2* Lymphs-2.4* Monos-8.6
Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.81* AbsLymp-0.27*
AbsMono-0.96* AbsEos-0.01* AbsBaso-0.01
___ 10:15AM BLOOD Plt ___
___ 10:15AM BLOOD ___ PTT-27.4 ___
___ 10:15AM BLOOD Glucose-110* UreaN-35* Creat-0.7 Na-136
K-7.3* Cl-90* HCO3-34* AnGap-12
TTE ___:
The left atrial volume index is mildly increased. The right
atrium is moderately enlarged. The estimated right atrial
pressure is >15mmHg. There is normal left ventricular wall
thickness with a small cavity. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
Quantitative biplane left ventricular ejection fraction is 68 %
(normal 54-73%). There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with depressed free wall motion. 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 no aortic
regurgitation. The mitral valve leaflets
are mildly thickened with no mitral valve prolapse. There is
moderate to severe [3+] 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. A left
pleural effusion is present.
Compared with the prior TTE (images reviewed) of ___ ,
mitral regurgitation appears markedly increased for unclear
reason, but the suboptimal image quality of the studies
precludes definitive comparison.
TTE ___
The left atrium is elongated. The right atrium is moderately
enlarged. There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional left
ventricular function. The visually estimated left ventricular
ejection fraction is >=55%. Normal right
ventricular cavity size with normal free wall motion. The aortic
valve is not well seen. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild
[1+] mitral regurgitation. The pulmonic valve leaflets are not
well seen. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Focused study. Mild mitral regurgitation. Normal
left ventricular wall thickness,
cavity size, and global systolic function. Normal estimated
pulmonary artery systolic pressure.
Compared with the prior TTE ___ , the findings are
similar. The degree of mitral regurgitation
was OVERestimated on the prior study.
___
Pharmacological Stress Test
FINDINGS:
The image quality is adequate but limited due to soft tissue,
breast, and left
arm attenuation.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a predominantly fixed,
mild reduction in
photon counts involving the mid and distal anterior wall in a
pattern most
consistent with attenuation.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 67% with an
EDV of 44 ml.
IMPRESSION:
1. Probably normal myocardial perfusion. Anterior wall defect
most consistent
with attenuation.
2. Normal left ventricular cavity size and systolic function.
INTERPRETATION: ___ yo woman with new PAF and HFpEF was referred
to
evaluate an atypical chest discomfort and shortness of breath.
The
patient was administered 0.4 mg Regadenoson IV bolus over 20
seconds. No
chest, back, neck or arm discomforts were reported. The patient
reported
nausea with the infusion. The nausea resolved with the
administration of
60 mg Caffeine IV. No significant ST segment changes were noted.
The
rhythm was sinus with rare isolated APBs, one atrial couplet.
The
hemodynamic response to the infusion was appropriate.
IMPRESSION: Atypical symptoms with no ischemic ST segment
changes.
Nuclear report sent separately.
DISCHARGE LABS:
___ 06:47AM BLOOD WBC-7.3 RBC-2.94* Hgb-9.4* Hct-29.7*
MCV-101* MCH-32.0 MCHC-31.6* RDW-15.4 RDWSD-57.2* Plt ___
___ 06:47AM BLOOD Glucose-110* UreaN-46* Creat-1.0 Na-133*
K-4.2 Cl-88* HCO3-28 AnGap-17
___ 06:47AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Please ensure cardiology f/u at ___
[] Consider adding spironolactone for both blood pressure
control and diuresis.
[] Initially digoxin was held at admission given concern for dig
toxicity. Given good rate response with metoprolol, will
continue
metoprolol at this time and defer re-initiating digoxin during
admission.
DISCHARGE WEIGHT: 60.1 kg (132.5 lb)
DISCHARGE CREATININE: 1.0
DISCHARGE DIURETIC: Torsemide 80 mg BID
[] Increased metoprolol to 100 XL qd for rate control of AF,
stopped dig
[] Patient started on lisinopril for additional blood pressure
control, adjust prn
[] required intermittent straight caths. Please continue to
monitor for urinary obstruction, cont with intermittent straight
caths.
[] underwent repeat speech and swallow study which showed
continued aspirations; recommendation for moderate means to
reduce aspiration risk: eat pureed solids with honey-thick
liquids. Swallow 3x per bite/sip. With this option, the patient
may be at risk for aspiration after the swallow ___ residue
spillover into the airway.
[] Recommend aspiration precautions:
- 1:1 feeding assistance/supervision
- Small bites/sips
- Swallow x3 for each bite/sip
- Eat slowly and carefully
[] recommend ongoing SLP evaluation
SUMMARY:
========
___ yo F with COPD, HTN, paroxysmal afib, and HFpEF who presented
from ___ with shortness of breath and abdominal pain, found
to be in acute decompensated heart failure.
CORONARIES: unknown
PUMP: EF 55-60% (echo ___
RHYTHM: sinus, pAfib
ACTIVE ISSUES:
==============
#Acute on chronic HFpEF
#Mitral Regurgitation
Original TTE with 3+ MR which was significantly worsened from
baseline likely occurring in the setting of fluid overload as it
improved significantly following diuresis on repeat TTE. Given
initial concern for possible ischemic MR, patient also underwent
pharmacological stress test which showed no evidence of ischemic
changes or wall motion abnormalities. Patient was diuresed with
boluses of IV Lasix, before transitioning to torsemide 80 mg
bid. Following diuresis, repeat TTE showed mild (eccentric) MR.
___ metoprolol was also increased to 100mg XL per day. Continues
to have preserved EF.
#pAfib
Initially digoxin was held at admission given concern for dig
toxicity. Given good rate response with metoprolol, will
continue metoprolol at this time and defer re-initiating digoxin
during admission. Continued home apixiban.
#Abdominal pain
#Nausea
Has had persistent nausea and abdominal pain for the past month,
since ___ last admission at OSH per daughter. Still unclear
etiology and in the outpatient setting they are treating
symptomatically. Certainly could have component of GERD.
Abdominal discomfort appears to be mostly in ___ upper abdomen,
which was thought to be worse in the setting of diaphragmatic
irritation from pleural effusions due to volume overload.
Improved with diuresis. Continued simethicone, omeprazole,
zofran, lidocaine patch.
#Dyshagia
Patient last had formal video swallow testing in ___ and has
been unable to advance ___ diet since. SLP was reconsulted and
did a repeat formal video swallow that showed ongoing
aspiration. "Moderate means to reduce aspiration risk: Eat
pureed solids with honey-thick liquids. Swallow 3x per bite/sip.
With this option, the patient may be at risk for aspiration
after the swallow ___ residue spillover into the airway";
moderate means to reduce aspiration risk with nectar thick
liquids: "Eat pureed solids with nectar-thick liquids via
TEASPOON ONLY." Findings were discussed with patient. Given ___
preference to avoid complications, decision was made to follow
recommendations to reduce aspiration risk. Ongoing SLP
evaluation is recommended. Further aspiration precautions per
SLP:
- Meds: via non-oral means
- Oral care: Q2 oral care
- Aspiration precautions (should patient decide to continue PO
intake):
- 1:1 feeding assistance/supervision
- Small bites/sips
- Swallow x3 for each bite/sip
- Eat slowly and carefully
#COPD
Continued home tiotropium, albuterol.
#HTN
Continued home amlodipine.
#Urinary retention
Continued home Tamsulosin, however patient refusing on multiple
occasions.
#Constipation
Continued home senna, bisacodyl, fleet enema, milk of mag.
CHRONIC ISSUES:
===============
#IDDM
Continued home lantus 12U Qdinner, ISS with meals.
#Insomnia
Continued home trazodone. Held home melatonin.
#Pain
Continued home tramadol, APAP.
#Depression
Continued home escitalopram.
CORE MEASURES:
==============
# CODE STATUS:
# CONTACT:
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
>30 minutes on discharge planning/coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simethicone 40 mg PO TID
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Metoprolol Tartrate 25 mg PO TID
4. Digoxin 0.0625 mg PO 2X/WEEK (___)
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Glargine 12 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
7. Furosemide 40 mg PO DAILY
8. melatonin 10 mg oral QHS
9. TraZODone 12.5 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
11. Albuterol 0.083% Neb Soln 1 NEB IH BID
12. omeprazole magnesium 40 mg oral DAILY
13. Escitalopram Oxalate 10 mg PO DAILY
14. amLODIPine 5 mg PO DAILY
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Tamsulosin 0.4 mg PO QHS
18. ___ Antacid (calcium carbonate) 200 mg calcium (500 mg)
oral DAILY
19. TraMADol 50 mg PO BID
20. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
21. Apixaban 2.5 mg PO BID
22. Senna 17.2 mg PO QHS
23. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
24. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
25. Fleet Enema (Saline) ___AILY:PRN constipation
26. Milk of Magnesia 15 mL PO DAILY:PRN Constipation - Third
Line
27. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
28. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 50 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*3
3. Torsemide 80 mg PO BID
4. Glargine 12 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Albuterol 0.083% Neb Soln 1 NEB IH BID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
8. amLODIPine 5 mg PO DAILY
9. Apixaban 2.5 mg PO BID
10. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
11. ___ Antacid (calcium carbonate) 200 mg calcium (500
mg) oral DAILY
12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
13. Escitalopram Oxalate 10 mg PO DAILY
14. Fleet Enema (Saline) ___AILY:PRN constipation
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. melatonin 10 mg oral QHS
17. Milk of Magnesia 15 mL PO DAILY:PRN Constipation - Third
Line
18. Multivitamins W/minerals 1 TAB PO DAILY
19. omeprazole magnesium 40 mg oral DAILY
20. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
21. Senna 17.2 mg PO QHS
22. Simethicone 40 mg PO TID
23. Tiotropium Bromide 1 CAP IH DAILY
24. TraMADol 50 mg PO BID
25. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
26. TraZODone 12.5 mg PO QHS
27. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Acute decompensated heart failure with preserved ejection
fraction
Mitral regurgitation
SECONDARY:
==========
GERD
COPD
HYPERTENSION
PAROXYSMAL ATRIAL FIBRILLATION
INSULIN DEPENDENT DIABETES MELLITUS
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. ___,
It was a pleasure participating in your care. Please read
through the following information.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had been feeling
short of breath and you were found to have fluid on your lungs.
This was felt to be due to a condition called heart failure,
where your heart does not function well enough and fluid backs
up into your lungs.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given a diuretic medication through the IV to help
get the fluid out.
- You improved considerably and were ready to leave the
hospital.
- We also did an ultrasound of your heart that showed one of
your heart valves wasn't working properly. We gave you the
diuretic and once we got the fluid out, we repeated the
ultrasound and your valve was working well again.
- You had a stress test that showed that your heart was pumping
well.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Please follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is ###
lbs. Call your doctor or seek medical attention if your weight
goes up more than 3 lbs in one day (### lbs) or 5 lbs total (###
lbs).
- Call your doctor or seek medical attention if you have new or
concerning symptoms or you develop swelling in your legs,
abdominal distention, or shortness of breath at night.
- Any questions, call ___ Cardiology ___
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10486130-DS-15 | 10,486,130 | 25,382,870 | DS | 15 | 2148-09-18 00:00:00 | 2148-09-18 08:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / iodine
Attending: ___.
Chief Complaint:
Recurrent disc herniation at L4-L5 with cauda equina syndrome
Major Surgical or Invasive Procedure:
L4-L5 laminectomy and discectomy
History of Present Illness:
ORTHOPAEDIC SURGERY CONSULT NOTE
NAME: ___
MRN: BID ___
DATE: ___
RESIDENT: ___ ___, MD
ATTENDING: Dr. ___ SERVICE: Emergency Department
REASON FOR CONSULT: increasing back pain with urinary
incontinence
HPI: Ms. ___ is a ___ year old women who is two months out
from L4-5 microdiscetomy for disc herniation that was leading to
sciatic like symptoms. Patient's states she was doing well up
until approximately two weeks ago when the pain returned, has
progressively worsened, and over the past week she has had
several episodes of urinary incontinence while sleeping. She
called Dr. ___ and she was advised to come to the ED
today. At time of examination, she denies numbness/tingling
distally. She denies weakness. She denies bowel
incontinence/saddle anesthesia. She has not had urinary
retention.
ROS: Denies CP/SOB/F/C/N/V
PMH/PSH:
HTN, diabetes, anxiety, asthma
Cholecystectomy ___
L4/5 microdiscectomy ___
MEDS:
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
ALPRAZOLAM - alprazolam 0.5 mg tablet. 1 tablet(s) by mouth at
night as needed - (Prescribed by Other Provider)
ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth
every night - (Prescribed by Other Provider)
CITALOPRAM [CELEXA] - Celexa 20 mg tablet. 1 tablet(s) by mouth
every night - (Prescribed by Other Provider)
GABAPENTIN - gabapentin 600 mg tablet. 1 tablet(s) by mouth
three
times a day
HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 300
mg
tablet. 1 tablet(s) by mouth q6 hours as needed for pain
INSULIN LISPRO PROTAMIN-LISPRO [HUMALOG MIX 75-25] - Humalog Mix
___ 100 unit/mL subcutaneous suspension. 72 units sc in am and
36 units at night - (Prescribed by Other Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth every
night - (Prescribed by Other Provider)
METFORMIN - metformin 1,000 mg tablet. 1 tablet(s) by mouth
every
night - (Prescribed by Other Provider)
MUPIROCIN - mupirocin 2 % topical ointment. Apply to the inside
of each nostril with cotton swab twice daily Apply, pinch nose,
and massage for 60 seconds. Use ___
POTASSIUM CHLORIDE [KLOR-CON M20] - Klor-Con M20 mEq
tablet,extended release. 1 tablet(s) by mouth every night -
(Prescribed by Other Provider)
SITAGLIPTIN [JANUVIA] - Januvia 100 mg tablet. 1 tablet(s) by
mouth every night - (Prescribed by Other Provider)
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 1,000
unit
capsule. 2 capsule(s) by mouth once a day - (Prescribed by
Other
Provider)
FLUTICASONE [FLONASE ALLERGY RELIEF] - Flonase Allergy Relief 50
mcg/actuation nasal spray,suspension. 2 sprays each nare as
needed - (Prescribed by Other Provider)
--------------- --------------- --------------- ---------------
ALL:
Allergies (Last Verified ___ by ___:
iodine
Penicillins
Sulfa (Sulfonamide Antibiotics)
SH: denies tobacco, alcohol, illicit drug use.
PHYSICAL EXAMINATION:
Vitals:
General: Well-appearing female in no acute distress.
Spine exam:
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 4+ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 ___
R 2 2 2 2 ___
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
POSITIVE Straight leg raise on left
LABS:
___: WBC: 7.1
___: HCT: 38.8
___: INR: 1.0
IMAGING:
MRI Lumbar Spine: Pending
ASSESSMENT/RECOMMENDATIONS:
Ms. ___ is a ___ year old women who is two months out from
L4-5
microdiscetomy for disc herniation. Patient's states she was
doing well up until approximately two weeks ago when the pain
returned, has progressively worsened, and over the past week she
has had several episodes of urinary incontinence while sleeping.
At time of examination denies numbness, tingling, weakness
(other
than from pain), urinary retention, saddle anesthesia, bowel
incontinence. On exam, she is neuro intact throughout, no long
tract signs, normal perianal sensation, and intact rectal tone.
She did have a positive straight leg raise. At this point, given
her return of symptoms along with several episodes of urinary
incontinence would recommend the following:
- MRI of L spine
- please keep NPO for now
- please obtain CBC, BMP, T&S, ___, EKG if not already done.
- final recommendations pending MRI results
Past Medical History:
HTN
Diabetes
Anxiety
Asthma
Social History:
___
Family History:
NC
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BLE: SILT L1-S1 dermatomal distributions
BLE: 4+/5 ___
All toes WWP, brisk capillary refill
Pertinent Results:
___ 02:30PM WBC-7.1 RBC-4.47 HGB-13.7 HCT-38.8 MCV-87
MCH-30.6 MCHC-35.3 RDW-12.3 RDWSD-38.6
___ 02:30PM GLUCOSE-124* UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#1. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.Hospital course was otherwise unremarkable.On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
5. sitaGLIPtin 100 mg oral DAILY
6. Atorvastatin 40 mg PO QPM
7. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Citalopram 20 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Lisinopril 20 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
7. Humalog ___ 72 Units Breakfast
Humalog ___ 36 Units Dinner
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6hrs Disp #*80
Tablet Refills:*0
9. Senna 8.6 mg PO BID
10. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
11. sitaGLIPtin 100 mg oral DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L4-L5 recurrent disc herniation, cauda equina syndrome
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:
Lumbar Decompression Without Fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace, this brace is to be worn when you are
walking.You may take it off when sitting in a chair or lying in
bed.
Wound Care: Remove the dressing in 2 days.If
the incision is draining cover it with a new sterile dressing.If
it is dry then you can leave the incision open to the air.Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___ 2.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions.We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
___
|
10486513-DS-16 | 10,486,513 | 23,013,617 | DS | 16 | 2185-08-24 00:00:00 | 2185-08-31 20:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal/thigh pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ Y/o M presents to ED with right thigh pain as a transfer from
___. The patient is a ___ and was pinned and
knocked over by a horse and hit the back of her head. She denies
LOC. The horse then stepped on her right thigh. She was brought
to OSH where ___ showed a 7x5.5x2cm hematoma with some active
extravasation on OSH imaging. CT Head, CT C-spine, right humerus
x-ray, left ankle x-ray, and CXR were negative. She had a
laceration on the back of
her head that was stitched close and her tetanus was updated.
Patient was given Tylenol, Zofran, and Morphine for pain
control, and was transferred here for trauma evaluation. Trauma
basic activated.
Timing: Sudden Onset
Quality: Sharp
Duration: Hours
Location: right leg
Context/Circumstances: Transfer
Mod.Factors: ___. with time
Associated Signs/Symptoms: +head strike
Past Medical History:
Past Medical History: None
Social History:
___
Family History:
Family History: noncontributory
Physical Exam:
Physical Exam at Admissions:
Temp: 97 HR: 86 BP: 119/54 Resp: 18 O(2)Sat: 97 Normal
General: Constitutional: No acute distress
HEENT: pupils 4 to 3 mm bilaterally, small forehead hematoma,
stapled laceration on left posterior occiput, Pupils equal,
round and reactive to light, Extraocular muscles intact
Airway intact
Chest: Bilateral breath sounds, chest wall is stable
Cardiovascular: intact pulses in all extremities, Regular
Rate and Rhythm, Normal first and second heart sounds
Abdominal: Hematoma under RLQ, Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: large hematoma under right forearm, hematoma on
right thigh, abrasion on left anterior shin
Skin: Warm and dry
Neuro: Speech fluent, awake and alert, GCS=15. Intact
sensation to light touch in all extremities
Psych: Normal mentation
PE at dc:
Vitals: 97.7, 141/78, 78, 18, 96%Ra
HEENT: EOMI, small forehead hematoma resolving, stapled
laceration over occiput intact
CV: Regular Rate and Rhythm
Pulm: Clear to Auscultation b/l
Abdomen: soft, + BS, tender to palpation RUQ and RLQ over
hematomas
Ext: Stable hematoma R thigh
Neuro: using all limbs spontaneously
Pertinent Results:
___ 08:25AM BLOOD WBC-6.1# RBC-3.82* Hgb-11.0* Hct-33.0*
MCV-86 MCH-28.8 MCHC-33.3 RDW-13.3 RDWSD-41.2 Plt ___
___ 12:18AM BLOOD Glucose-152* UreaN-13 Creat-0.6 Na-138
K-4.2 Cl-105 HCO3-18* AnGap-19
CT Chest ___:
IMPRESSION: The there is mild soft tissue stranding involving
anterior right chest wall, right arm, likely posttraumatic. No
hematoma. No fracture.
Few small lung nodules, indeterminate, largest measures 0.3 cm.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules smaller than 6mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT follow-up
in 12 months is recommended in a high-risk patient.
CT Abd/ Pelvis ___:
IMPRESSION:
1. No evidence of intra-abdominal or pelvic acute injury, no
free air, or
fluid.
2. Fatty liver. Indeterminate 1.5 cm lesion left hepatic lobe,
possibly
hemangioma, suboptimally evaluated.
3. Soft tissue contusion right lateral abdominal wall, right
flank, no
evidence of organized hematoma.
Brief Hospital Course:
Mrs. ___ was admitted to ___ as ___
transfer
from ___ after she was trampled by a horse. She was
managed conservatively in the hospital with pain control
medications. She remained hemodynamically stable, had pain well
controlled, and was tolerating good PO intake. At the time of
discharge, her CT findings were reviewed and including lung
nodules and liver nodules. These incidental findings were
discussed with Mrs. ___ and she was recommended to
follow-up with her primary care physician in ___ to
determine the appropriate additional imaging.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Please do not exceed 4000mg in 24 hours.
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Please do not drive or operate machinery while taking this
medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
trauma- thigh hematoma
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 actue care surgery-trauma service for
management of your thigh hematoma and general symptoms after you
were trampled on by your horses. You did well in house and were
discharged in stable condition with pain medications.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience ___ chest pain, pressure, squeezing or
tightness.
___ 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 ___ symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any ___ 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
*Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
*If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
Thank you so much for letting us participate in your care! We
wish you a speedy recovery!
Followup Instructions:
___
|
10486632-DS-16 | 10,486,632 | 28,892,134 | DS | 16 | 2141-01-05 00:00:00 | 2141-01-05 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___: Bronch with transbronchial bx
___: Radiation therapy
___: Chest tube placement for drainage of right pleural
effusion
___: Chest tube removed
___: Chest tube placement for re-drainage of right pleural
effusion
History of Present Illness:
___, h/o HTN, HLD and worsening back pain thought to be
attributable to AS, who presented to ___ with severe
back pain, CP and SOB and was transfered here for spine MR and
possible neurosurgical intervention. At OSH he was in rapid afib
and hypotensive, started on diltiazem gtt. CTA of chest was done
that shows large RUL mass extending to pleural surface at least
5.7 x 5 cm, with nodules and numerous osteolytic lesions in T
spine and left 7th rib, and endplate compression fractures at
T12 and T5. No PE.
In the ED Patient was seen by Neurology due to c/f cord
compression. Per Neurology note, his symptoms began in ___,
when he started having low back pain, which spread to his hips,
left worse
than right. He was evaluated by his PCP in ___ and had been
treated as outpatient by a rheumatologist after MRIs in ___
(lumbar and possibly T spine) showed ankylosing spondylitis
(although HLA-B27 neg). was initially taking tramadol and aleve
for this pain, without effect. He was given an unknown
immunomodulator injection (does not remember what it was called)
after labs such as TB, etc were checked.
His pain continued to worsen and in the last ___ days was
placed on a fentanyl patch with percoset for breakthrough, also
without effect. Possible weakness of LLE though may be pain
related (severe hip pain). In addition, since starting these
medications, he has been constipated and had a weak stream of
urine/intermittent urinary retention. Over the last week, he has
had difficulty getting out of bed, he is unsure if there is any
weakness or if it is just pain. He also reported an occasional
band-like sensation around his abdomen.
While in the ED, he could not tolerate MRI, and required
intubation. Following this, his blood pressures dropped to ___,
and was started on neo. He was also given one dose of azithro
and ceftriaxone as CXR for a possible CAP. He was also given one
dose of digoxin. His exam by Neurology was notable for weakness
in the left IP and quadriceps, an L2-3/femoral nerve
distribution, with a dropped patellar reflex.
In the ED, initial vitals: 98.6 137 118/70 16 98% 4L
On transfer, vitals were:88 99/67 14 99% RA
On arrival to the MICU, Patient was intubated and sedated. Per
Patient's wife, Patient had been in good health. His only
complaint prior to the onset of back/hip pain, had been
intermittent left groin pain. He had a normal colonoscopy at age
___. He has had prostate exams, but unsure whether he has had PSA
checked. Smoked tobacco in grade school, but quit by age ___.
In ___ he developed low back/hip pain, saw his PCP, had ___
normal xray and was referred to Rheum. He received one dose of
Simpony biologic from his rheumatologist on ___. He has
had constipation for the past month, since starting tramadol,
relieved by Miralax/dulcolax, but no BM in 4 days. He has had
decreased urinary stream, but no urinary retention for the past
week. No urinary or bowel incontinence. He has been able to get
up from bed, but has been most comfortable lying flat on the
firm sofa. To her knowledge, no other symptoms.
OMED HPI:
========
Mr. ___ is a ___ who was in his usual state of health when
he presented with progressive back and hip pain resulting in
difficulty ambulating. He initially presented to ___
___ and was found to be hypotensive and have Afib with RVR.
He was then transferred to ___ for further management on
___. Prior to this admission, he had been treated as an
outpatient by a rheumatologist for ankylosing spondylitis, after
prior MRIS (___) showed findings consistent with
Ankylosing Spondylitis. However his back pain persisted and
worsened. He then developed urinary retention, LLE weakness and
left hip pain. Work-up at ___ was then revealing for a CXR
showing a R-sided mass. A CTA that showed RUL mass extending to
pleural surface that was at least 5.7 x 5 cm with nodules and
numerous osteolytic lesions in T spine, left 7th rib, and an
endplate compression fractures at T12 and T5. The CTA showed no
PE. He was then transferred to ___ for further care.
Since his admission to ___, he has been managed for his AFib
and has undergone subsequent imaging including: head CT that
showed ___ to the skull, spinal MRI showing multiple ___
in the vertebra, and chest CT that confirms lung mass. There was
no radiographic evidence of cord compression on spinal MRI. For
the imaging studies, he had to be intubated so that he could lie
flat given the severity of his pain. He has now been extubated
as
of ___. His ICU course was complicated with start of afib with
RVR, which did not convert to SR but was rate controlled with
digoxin and metoprolol. ASA was held due to planning for
subsequent bronchoscopy (see below).
He had been evaluated by neurosurgery and neuro-onc. He has now
undergone bronchoscopy on ___ with biopsy and prelim path is
revealing for likely adenocarcinoma. Given the imaging and
cytology, he is staged as non-small cell lung carcinoma, likely
adenocarcinoma, Clinical Stage IV (cT4N2M1), with a large L4
metastasis with epidural extension and nerve root compression.
As such, he was seen by ___ radiation oncology team, with
planning for 5 treatmetns to L3-S3 spine field starting on
___
He now presents to the OMED floor for further care.
Review of Systems:
(+) Per HPI
Past Medical History:
- HTN
- HLD
Social History:
___
Family History:
Father with CAD s/p CABG in ___, mother with questionable
pancreatic lesion s/p partial whipple, but no dx of CA
Physical Exam:
ADMISSION PHYSICAL (FICU)
GENERAL: intubated, sedated, no acute distress
HEENT: PERRLA, Sclera anicteric, MMM, intubated
NECK: supple
LUNGS: Coarse, breath sounds on ventillator, no wheezes
CV: irreg irreg rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, +distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: heavily sedated
ADMISSION PHYSICAL (OMED):
VS: T 98.6 BP 122/67 HR 99 RR 20 96 % on 4L.
GEN: AOx3, NAD
HEENT: PERRLA; however slightly miotic baselione. Dry tongue,
moist buccal gutters. . no LAD. no JVD. neck supple. No
cervical, supraclavicular, or axillary LAD
Cards: irregularly irregular, tachy, no m/r/g over aortic,
pulmonic, tricuspid, mitral valves
Pulm: No dullness to percussion, CTAB no crackles or wheezes
over anterior chest, posterior chest not assessed
Abd: BS+, soft, NT, visibly distended, no fluid wave.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising. Tattoo over RUE
Neuro: ___ strength on handgrip and B/L dorsiflexion/plantar
flexion. CN XX-XII intact. No
Labs: See below
DISCHARGE PHYSICAL EXAM:
===================
VS: 98.3, 98/42, 89, 12, 100% on 3L NC
GEN: AOx3, NAD, sitting up in bed, comfortable appearing.
HEENT: PERRLA, EOMI.
Cards: Irregularly irregular
Pulm: Decreased breath sounds over right lung base. Chest tube
in place draining serosanguinous
Abd: BS+, soft, NT, no rebound/guarding
Extremities: Anasarcic with 2+ pitting edema.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. ___ strength in U/L extremities.
Pertinent Results:
ADMISSION LABS
___ 12:30AM BLOOD WBC-9.8 RBC-3.84* Hgb-11.5* Hct-34.7*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.0 Plt ___
___ 12:30AM BLOOD ___ PTT-27.2 ___
___ 11:30AM BLOOD Glucose-88 UreaN-24* Creat-0.9 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
___ 11:30AM BLOOD Calcium-9.1 Phos-5.2* Mg-1.9
___ 04:18AM BLOOD LD(LDH)-689*
___ 04:18AM BLOOD Calcium-9.7 Phos-4.4 Mg-1.7 UricAcd-2.2*
OTHER PERTINENT LABS:
===============
___ 04:20AM BLOOD WBC-9.8 RBC-3.56* Hgb-10.3* Hct-31.4*
MCV-88 MCH-28.9 MCHC-32.7 RDW-14.2 Plt ___
___ 03:12AM BLOOD WBC-9.4 RBC-3.49* Hgb-10.4* Hct-30.7*
MCV-88 MCH-29.9 MCHC-34.0 RDW-14.0 Plt ___
___ 03:22AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.8* Hct-29.2*
MCV-88 MCH-29.4 MCHC-33.6 RDW-13.9 Plt ___
___ 04:20AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-136
K-3.9 Cl-95* HCO3-31 AnGap-14
___ 03:12AM BLOOD Glucose-109* UreaN-24* Creat-0.7 Na-136
K-4.0 Cl-94* HCO3-31 AnGap-15
___ 03:22AM BLOOD Glucose-102* UreaN-25* Creat-0.7 Na-140
K-3.9 Cl-99 HCO3-30 AnGap-15
DISCHARGE LABS
===========
___ 05:28AM BLOOD WBC-11.8* RBC-3.25* Hgb-9.1* Hct-28.9*
MCV-89 MCH-28.0 MCHC-31.5 RDW-17.2* Plt Ct-79*
___ 06:35AM BLOOD Neuts-89.5* Lymphs-7.6* Monos-2.7 Eos-0.1
Baso-0.1
___ 05:28AM BLOOD ___ PTT-42.3* ___
___ 05:28AM BLOOD Glucose-103* UreaN-31* Creat-0.5 Na-135
K-4.3 Cl-101 HCO3-26 AnGap-12
___ 06:35AM BLOOD ALT-36 AST-24 AlkPhos-114 TotBili-0.3
___ 06:35AM BLOOD WBC-8.3 RBC-2.61* Hgb-7.3* Hct-23.4*
MCV-90 MCH-27.9 MCHC-31.0 RDW-16.5* Plt Ct-75*
___ 05:28AM BLOOD WBC-11.8* RBC-3.25* Hgb-9.1* Hct-28.9*
MCV-89 MCH-28.0 MCHC-31.5 RDW-17.2* Plt Ct-79*
___ 05:28AM BLOOD ___ PTT-42.3* ___
___ 05:28AM BLOOD Plt Ct-79*
___ 06:35AM BLOOD Glucose-80 UreaN-25* Creat-0.3* Na-140
K-4.0 Cl-110* HCO3-22 AnGap-12
___ 05:28AM BLOOD Glucose-103* UreaN-31* Creat-0.5 Na-135
K-4.3 Cl-101 HCO3-26 AnGap-12
___ 01:38PM BLOOD ALT-44* AST-31 AlkPhos-140* TotBili-0.4
___ 06:35AM BLOOD ALT-36 AST-24 AlkPhos-114 TotBili-0.3
___ 06:35AM BLOOD Albumin-1.6* Calcium-5.5* Phos-2.3*
Mg-1.8
___ 05:28AM BLOOD Calcium-6.9* Phos-3.2 Mg-2.5
___ 09:30PM BLOOD Type-ART Temp-36.7 FiO2-96 O2 Flow-2
pO2-95 pCO2-36 pH-7.47* calTCO2-27 Base XS-2 AADO2-558 REQ O2-92
Intubat-NOT INTUBA Comment-NASAL ___
MICRO
___ UCX negative
___ BCx x2 pending
___ BCx x2 pending
___ Sputum contaminated
___ BRONCHOALVEOLAR LAVAGE: negative
IMAGING
___ CXR
Multiple parenchymal masses including a large pleural-based
right lung apex mass.
___ MRI SPINE
1. Diffuse osseous metastases throughout the skeleton with
pathologic fracture of L4 and epidural extension of tumor
compressing the left L4 and bilateral L5 nerve roots. Focus of
contrast enhancement along the right L4 nerve root (series 16,
image 12) suggestive of leptomeningeal disease in this patient
with diffuse metastases. Alternatively, this enhancing focus
could be benign such as a nerve sheath tumor.
2. Additional diffuse osseous metastases throughout the
cervical and thoracic spine but without epidural tumor at these
levels.
3. Multilevel degenerative disc disease of the cervical spine
with cord
flattening at C3-4 through C6-7. There is increased cord signal
at C5-6 on sagittal images, but this is not definitely confirmed
on axial images. If real, it appears to be due to compression
from degenerative disc disease.
4. Large right lung mass highly concerning for primary
malignancy.
___ CT CHEST
Extensive involvement of the chest by malignancy including
dominant right
upper lobe mass as described attenuating right upper lobe a
bronchus and
bronchus intermedius, extensive mediastinal lymphadenopathy,
local
lymphangitic spread of the tumor and multiple pulmonary nodules
as well as
extensive metastatic involvement of the skeleton as described in
details in the body of the report
___ MR HEAD
1. No evidence of parenchymal, leptomeningeal or pachymeningeal
intracranial metastases.
2. Osseous metastases involving the left occipital condyle and
visualized
cervical spine.
___ TTE
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Symmetric LVH with normal global and regional left
ventricular systolic function. Mildly dilated right ventricle
with normal global systolic function. Mild mitral regurgitation.
___ Abd XR
Distended air-filled loops of small and large bowel. No evidence
of
obstruction or ileus.
___ ___
No evidence of deep vein thrombosis in right or left lower
extremity.
PATHOLOGY
___ Cytology
Right upper lobe, transbronchial fine need aspiration:
POSITIVE FOR MALIGNANT CELLS.
Consistent with non-small cell carcinoma.
___ Transbronchial Bx Pathology
Lung, right upper lobe, biopsy:
Adenocarcinoma. See note.
Note: By immunohistochemistry, tumor cells are positive for
cytokeratin 7 and negative for
cytokeratin 20, TTF-1, and napsin. The immunohistochemical
profile and morphologic findings are non-specific but could
represent a primary lung malignancy. Upper gastrointestinal,
breast, or other sites of origin cannot be entirely excluded;
clinical correlation is needed. Dr. ___
reviewed the case and concurs.
Head CT NON - CON ___:
No acute intracranial abnormalities are identified.
CXR ___:
As compared to the previous radiograph, the right pleural drain
was removed. There is reaccumulation of pleural fluid at the
right lateral lung bases, causing increased radiodensity in this
region. The size of the cardiac silhouette, the known extensive
consolidations on the right as well as the left hemi thorax are
of unchanged appearance.
CT Chest ___:
IMPRESSION:
1. Diffuse pleural metastatic disease with bilateral malignant
loculated pleural effusions and interval increase in multiple
mediastinal, epicardial, and subcarinal lymph nodes, consistent
with disease progression. Limited assessment for superinfection
due to absence of IV contrast.
2. Stable trace pericardial effusion.
3. Right upper and lower lobes ground-glass opacities with
septal thickening is most consistent with lymphangitic spread of
tumor or less likely postobstructive pneumonia.
5. Mild increase in large right apical mass causing compression
of bronchus intermedius, similar to previous examination.
6. Interval progression of lytic bone metastases with new
compression fracture of T3 vertebral body. No retropulsion.
7. Right adrenal metastases with multiple enlarged
retroperitoneal lymph nodes, similar to previous examination.
Brief Hospital Course:
Pt is a ___ M who was in his usual state of health until this
early ___. Prior to this admission, he had been treated as an
outpatient by a rheumatologist for ankylosing spondylitis, after
prior MRIS (___) showed findings consistent with
Ankylosing Spondylitis. However his back pain persisted and
worsened. He then developed urinary retention, LLE weakness and
left hip pain. Work-up at ___ was then revealing for a CXR
showing a R-sided mass. A CTA that showed RUL mass extending to
pleural surface that was at least 5.7 x 5 cm with nodules and
numerous osteolytic lesions in T spine, left 7th rib, and an
endplate compression fractures at T12 and T5. The CTA showed no
PE. He was then transferred to ___ for further care.
Since his admission to ___, he has been managed for his AFib
and has undergone subsequent imaging including: head CT that
showed ___ to the skull, spinal MRI showing multiple ___
in the vertebra, and chest CT that confirms lung mass. There was
no radiographic evidence of cord compression on spinal MRI. For
the imaging studies, he had to be intubated so that he could lie
flat given the severity of his pain. He was extubated as of of
___. His ICU course was complicated with start of afib with
RVR, which did not convert to SR but was rate controlled with
digoxin and metoprolol.
On the solid oncology service, his stay was noted for several
pain crises secondary to osseous metastases. He was seen by
palliative care, and was initally kept on a PCA, later titrated
to longacting oxycontin and morphine elixir for breakthrough
pain. With physical therapy on the solid oncology floor, patient
was able to begin to take some steps, for the first time in his
hospital stay.
A family meeting was held with patient, his wife and daughter,
oncology and palliative care teams to discuss his overall
prognosis. It was discussed that the prognosis of his metastatic
cancer was poor and given his current functional status, he
would likely be a poor candidate for palliative chemotherapy.
Patient and family expressed his ultimate goal was to go home so
he was discharged with hospice services. He will follow up with
oncologist Dr. ___ to discuss further treatment options.
# Lung Cancer: Since admission, imaging was consistent with
metastatic lung cancer with metastases to the spine and skull.
Biopsy of lung mass revealed adenocarcinoma, positive for
cytokeratin 7 and negative forcytokeratin 20, TTF-1, and napsin.
Patient was admitted to the solid oncology service and had ___
XRT treatments from ___ for the osteous metastases in
his lumbr-thoracic spine and hips. He was seen by oncology and
palliative care, with a plan put in place for outpatient follow
up with Dr. ___ Dr. ___. To definitively identify
whether his cancer was a primary lung cancer, molecular marker
studies including ALK were sent for testing. In addition, cells
obtained from his R lung pleural effusion drain were sent for
cytological block testing. Ultimately the patient was not deemed
a poor candidate for palliative chemotherapy given his poor
functional status. This was discussed in depth with the family
in particular during a family meeting on ___. He will
follow up with Dr. ___ to go over pending molecular
studies to see if further treatment options would be available
to him.
# Pain control: Patient was in significant pain secondary to
osteous metastases from lung cancer in lumbar-thoracic spine and
pelvis. Patient was initially kept on PCA; with titration to 150
mg oxycontin q8 and ___ mg oxycodone and gabapentin 600 q8 per
palliative care. Given somnolence and reduction in pain, the
patient was downtitrated to 60mg oxycontin q8h and his oxycodone
and gabapentin doses further lowered. He is also on morphine
elixir for breakthrough pain and dyspnea.
# Afib with RVR: On the floor, the patient was noted to have new
onset of atrial fibrillation with RVR with HR 140-160s. The
patient was initially started on metoprolol tartrate and digoxin
with continued atrial fibrillation. Cardiology was consulted and
recommended that the patient be transferred to the ___ for
management with diltiazem drip. In the FICU, the patient was
started on a diltizaem drip with improvement of rates to
90-110s. The patient was subsequently transitioned to PO
metoprolol and diltiazem. The patient was received IV fluid
boluses and electrolytes were repleted to maintain K>4, Mg >2.
Initially, a TEE and synchronized cardioversion was planned, but
cardiology decided to not further pursue cardioversion given
rates were better controlled. The patient was transferred back
to the OMED service on Metoprolol succinate 100 mg PO BID and
Diltiazem 120 mg PO QPM. Of note, the patient's CHADS score was
1 and did not warrant systemic anticoagulation. However, the
patient was on agatroban for ongoing treatment of HIT. On the
OMED floor, his medications were adjusted to metoprolol 50mg
q6h, diltiazem 30mg q6h, and digoxin .25mg qd. Due to persistent
afib w/RVR into the 150-170s on this regimen, however,
cardiology service was consulte. Pt was asymptomatic during his
spikes into the 150-170s. Cardiology recommended transferring pt
back to the FICU to initiate diltiazem drip. Pt remained in the
FICU for 2 nights on diltiazem gtt and was transitioned back
onto his prior oral regimen with better HR control. Pt returned
to OMED floor and remained relatively stable on this regimen.
When a chest tube was placed on ___ to drain his large R
pleural effusion, his evening metoprolol dose was held. The next
morning his HR was persistently in the 150s with SBP 90-100s,
otherwise pt was asymptomatic. He was administered 250cc 5%
albumin and given 5mg IV metoprolol with good results.
Ultimately he was transitioned to long acting metoprolol and
diltiazem with good rate control.
# Gram positive cocci bacteremia/Enterococcus UTI: The patient's
blood cultures from ___ grew GPC in clusters and the patient
was continued on IV Vancomycin. The blood cultures speciated to
Coagulase negative Staph aureus, likely representing
contamination from skin flora. Of note, the patient's urine
cultures grew enterococcus. The patient was thus continued on IV
Vancomycin. Sensitivity results showed it was E.coli sensitive
to vancomycin. These antibiotics were stopped after completing a
full course.
#HCAP
Pt spiked an isolated fever and received an infection workup.
CXR on ___ revealed a large R pleural effusion. Pt otherwise
denied a cough and was asymptomatic. Given his long stay in the
hospital and potential to rapidly decompensate if truly infected
however, he was empirically started on an abx course of
vanco/cefepime. Blood cultures eventually only grew coag
negative staph in one bottle, likely representing contamination.
His R pleural effusion was drained and pleural fluid analysis
revealed it to be malignant effusion, not infectious.
#Pleural Effusion: In the FICU, CXR from ___ was notable for
right-sided pleural effusion thought to be from either malignant
pleural effusion versus parapneumonic pleural effusion vs
hemothorax. Hemothorax was unlikely in the setting of stable
H/H. The patient was continued on IV Vancomycin and Cefepime for
HCAP coverage vs concern for post-obstructive pneumonia.
Interventional Pulmonology was consulted and a diagnostic
paracentesis was offered, but the patient initially declined.
Upon return the OMED floor, pt was noted to have worsening
decrease in breath sounds on exam, although his respiratory
status remained stable without an increase in oxygen
requirement. Need for IP thoracentesis was reassessed and pt
received a thoracentesis with chest tube left in. 2L of fluid
were removed upon initial drain placement. Drain fluid was sent
for cytological and pleural fluid analysis, with results
consistent with malignant effusion. Patient will require daily
chest tube drainages for about 250cc out per day.
#HIT: Patient was noted to have a platelet drop from 213 on
___ to 104 on ___. As a result, subcutaneous heparin was
held and heparin antibodies were sent out, which came back
positive. Patient's platelet count hit a nadir of 56 on ___,
and argatroban was started on ___. At time of discharge
patient's platelet count had climbed to 86. Pt's plt count
continued to trend down despite being on argatroban drip. Pt was
subsequently transitioned to ___ SC and his plt count
subsequently nadired at 43 before trending upwards. He was found
to be HIT positive, and was continued on fondaparinux.
# Bilateral PE: Patient desatted on night on ___ and was
transferred to ICU and found to have bilateral PEs. Respiratory
status stabilized. He will be on lifelong fondaparinux given
HITT.
TRANSITIONAL ISSUES
-COMPREHENSIVE ___ PREDICITIVE PANEL and RET-FISH are pending
from biopsy; will be followed up by Dr. ___ in clinic but
patient likely poor palliative chemo candidate given poor
functional status
-Radiation Therapy: Patient had XRT in house
-HIT: Patient found to have bilateral PEs so will be on lifelong
fondaparinux.
-Afib: patient d/ced in stable condition on metropolol succinate
200mg daily and diltiazem ER 180mg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO DAILY
3. lisinopril-hydrochlorothiazide ___ mg oral qdaily
4. Aspirin 81 mg PO DAILY
5. Lorazepam 0.5 mg PO Q6H:PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply 1 patch once a
day Disp #*30 Patch Refills:*0
6. Polyethylene Glycol 17 g PO BID
7. Senna 8.6 mg PO DAILY
8. Fondaparinux 7.5 mg SC DAILY
RX *fondaparinux 7.5 mg/0.6 mL 7.5 mg SubQ once a day Disp #*90
Syringe Refills:*0
9. TraZODone 50 mg PO HS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*60 Tablet Refills:*0
11. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
12. Gabapentin 300 mg PO Q8H
RX *gabapentin 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*30 Capsule Refills:*0
13. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
14. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO
Q2H:PRN pain/dyspnea/cough
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 2 mL by mouth
Q2H Refills:*0
15. Dexamethasone 3 mg PO Q12H
RX *dexamethasone 1 mg 3 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO
Q1H:PRN pain, dyspnea
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by
mouth Q1H Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Metastatic lung Cancer
Heparin Induced Thrombocytopenia
Bilateral pulmonary embolism
Right sided pleural effusion
Anasarca
Severe Pain
Constipation
Hypotension
Secondary:
Hyperlipidemia
Hypercholesteremia
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You have had an extended stay in the hospital due to the
discovery that you have metastatic lung cancer. You made clear
that your goal was to get home to be with your family, and so
you received multiple procedures to stabilize you. You will be
going home with home hospice, and they will work closely with
you to assist you with your breathing and pain.
It has been a pleasure caring for you, and we wish you all the
best.
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10486955-DS-19 | 10,486,955 | 29,029,690 | DS | 19 | 2141-02-19 00:00:00 | 2141-02-19 20:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / lisinopril
Attending: ___.
Chief Complaint:
Lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of alcohol abuse recently admitted with
hypokalemia, hyponatremia and LFT abnormalities thought to be
secondary to EtOH abuse and possible cirrhosis representing with
bilateral lower extremity edema.
Mr. ___ was recently admitted with electrolyte abnormalities,
pancytopenia discharged on ___. His chlorthalidone was stopped
and electrolytes recovered with repletion and fluids and patient
was discharged off of chlorthalidone, on KCl, folate, thiamine,
vitamin, vit D and asa. Pt had CT chest and abdomen/pelvis
post-discharge for w/u of weight loss and eval of liver with
worsening liver disease but no e/o metastatic disease.
Since discharge, he reports 6 days of new, worsening b/l edema
and TTP of his ___ distal to the knees. He denies history of
blood clots, heart failure, pulmonary insufficiency or renal
insufficiency. Given worsening edema and pain, patient presented
to ED for evaluation.
In the ED initial vitals were: 99.3 ___ 18 100% RA
- Labs were significant for WBC 5.1, hct 25.9 (stable), plts
214, Na 135, K 5.1, Cr 0.7, ALT 38, AST 82, tbili 0.4, alb 3.2,
lipase 164, bnp 299, lactate 1.4, UA unremarkable.
- Patient had RUQ US without evidence of PVT or ascites.
Vitals prior to transfer were: 98.9 88 113/75 16 97% RA
On the floor, pt with pain on standing but otherwise well,
vitals as below. Eager to start treatment as he doesn't want to
stay in hospital for long.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Alcohol use
HTN
Seizure (? related to EtOH withdrawal in ___ of this year)
? Cirrhosis
Social History:
___
Family History:
Unremarkable for any relatives with seizure disorder or any
other neurologic conditions. He does have a history of
hypertension in multiple members of his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T 98.7 132/76 98 18 100% RA, Weight 64.9kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: 2+ pitting edema with warmth bilaterally to knees
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, A&Ox3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
As above with decreased lower extremity swelling and warmth
Pertinent Results:
ADMISSION LABS
==============
___ 10:29PM LACTATE-1.4
___ 10:15PM GLUCOSE-111* UREA N-12 CREAT-0.7 SODIUM-135
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
___ 10:15PM ALT(SGPT)-38 AST(SGOT)-82* ALK PHOS-75 TOT
BILI-0.4
___ 10:15PM LIPASE-164*
___ 10:15PM proBNP-299*
___ 10:15PM ALBUMIN-3.2*
___ 10:15PM WBC-5.1# RBC-2.37* HGB-8.3* HCT-25.9*
MCV-110* MCH-35.1* MCHC-32.1 RDW-16.2*
___ 10:15PM NEUTS-72.8* ___ MONOS-5.4 EOS-0.7
BASOS-0.2
___ 08:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 08:45PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
DISCHARGE LABS
==============
___ 08:22AM BLOOD WBC-4.7 RBC-2.29* Hgb-8.2* Hct-24.8*
MCV-108* MCH-35.7* MCHC-33.0 RDW-16.0* Plt ___
___ 08:22AM BLOOD ___ PTT-27.4 ___
___ 08:22AM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-137
K-3.5 Cl-99 HCO3-30 AnGap-12
___ 08:22AM BLOOD ALT-30 AST-37 AlkPhos-77 TotBili-0.5
___ 08:22AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.6
RADIOLOGY
=========
___ 10:46 ___ LIVER OR GALLBLADDER US (SINGL; DUPLEX DOP
ABD/PEL LIMITED
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study. No focal lesion detected.
2. Patent portal veins.
3. Punctate echogenic focus within the right renal cortex,
compatible with a tiny stone or AML.
Brief Hospital Course:
___ with history of alcohol abuse recently admitted with
hypokalemia, hyponatremia, and LFT abnormalities thought to be
secondary to EtOH abuse and possible cirrhosis represented with
bilateral lower extremity edema, thought to be due to a
combination of fluid overload, hypoalbuminemia, and refeeding
retention.
ACTIVE ISSUES
# Bilateral Lower Extremity Edema
The patient presented with edema in the setting of stopping
chlorthalidone from prior admission. On further history
gathering, it appeared that the swelling occurred over the
course a day suddenly 2 days after discharge. Interval studies
and imaging including ultrasound from this admission ruled out
acute thrombosis of the portal system. The patient did not have
any signs or history to suggest acute liver or heart failure.
The cause was likely a combination of receiving fluids from
previous admission along with stopping chlorthalidone,
hypoalbuminemia, and improved nutritional status leading to
insulin-induced retention of sodium. The patient was given
furosemide 20 mg IV and was discharged with a short course of PO
furosemide. He was given compression stockings and instructed to
keep legs elevated. The swelling should self-resolve.
CHRONIC ISSUES
# Alcohol Abuse
Patient reported much improved alcohol abuse with a reduction in
drinking from 0.5 pint of hard liquor with ___ beers once per
day to once per week since discharge.
# Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 20 mEq PO DAILY
2. Aspirin 81 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. FoLIC Acid 0.5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 0.5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
7. Furosemide 20 mg PO EVERY OTHER DAY:PRN LEG SWELLING leg
swelling Duration: 6 Days
Only take if your leg swelling hasn't improved
RX *furosemide 20 mg 1 tablet(s) by mouth every other day Disp
#*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lower Extremity Edema
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 ___ after presenting to your PCP's office
a week of acute onset leg swelling and bilateral leg pain. We
gave you a medication to help you increase your urine output. We
think the swelling is temporary and should get better with time.
You should follow up with your PCP within the next week.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10487400-DS-22 | 10,487,400 | 21,428,509 | DS | 22 | 2181-10-24 00:00:00 | 2181-10-24 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abscess
Major Surgical or Invasive Procedure:
___: US-guided placement of ___ pigtail catheter into
intra-abdominal abscess
History of Present Illness:
Per admitting resident: ___ with a-fib on Xarelto and recent
history of diverticulitis with abscess in ___ treated with
percutaneous drainage and antibiotics who presented to
___ with recurrent and persistent RLQ pain found to have
recurrent abscess on CT and transferred to ___ for further
care. Following drain removal on ___ ___
reports he had felt better but that his abdominal pain never
completely resolved. He finished a course of antibiotics. About
___ weeks ago, pain started to re-escalate and remained
persistent thus prompting his presentation to the ER. CT scan
showed diverticulitis with increased size of right lateral
pericolonic abscess (now 4.7 x 4.8 x 5.4-cm) extending to the
right anterior abdominal wall, and he had a WBC of 27.
On evaluation, patient recounts history as above. Pain is in the
RLQ (same location as prior), "gnawing", and worsens with
positional changes. He denies fever, chills, nausea, and
vomiting. His appetite has, in general, been poor, and he has
not been drinking as much. He has been passing small amounts of
flatus and his last bowel movement was 4 days ago. He reports
his last colonoscopy was ___ years ago. Last dose of Xarelto was
yesterday.
Past Medical History:
PMH:
-Atrial fibrillation
-Renal cell carcinoma
-Diverticulitis
-Obesity
-Gout
-Hypertension
PSH:
-Robot assisted left partial nephrectomy
-Right nephrectomy
-Hip surgeries
-Umbilical hernia repair
Social History:
___
Family History:
No history of malignancy.
Physical Exam:
T 97.7 BP 105/63 P 90 02 93%RA
GEN: no acute distress, alert and oriented x 3
CARDIAC: regular rate, irregular rhythm, no murmurs appreciated
RESP: clear to auscultation, bilaterally; no respiratory
distress
ABD: soft, non-tender to palpation, non-distended, pigtail drain
to bulb suction in right lower abdomen, insertion site without
erythema or drainage, drainage in bulb serosanguinous
EXT: no lower extremity edema or tenderness, bilaterally
Pertinent Results:
LABS:
___ 09:30PM BLOOD WBC-27.3* RBC-4.04* Hgb-12.7* Hct-39.6*
MCV-98 MCH-31.4 MCHC-32.1 RDW-14.5 RDWSD-52.1* Plt ___
Neuts-36 Bands-0 Lymphs-58* Monos-5 Eos-1 Baso-0 ___ Metas-0
Myelos-0 AbsNeut-9.83* AbsLymp-15.83* AbsMono-1.37* AbsEos-0.27
AbsBaso-0.00* Glucose-81 UreaN-21* Creat-1.3* Na-132* K-4.6
Cl-97 HCO3-18* AnGap-17 ___ 09:34PM BLOOD Lactate-1.9
11:48PM BLOOD ___ PTT-42.5* ___
___ 05:00AM BLOOD WBC-17.0* RBC-5.02 Hgb-15.7 Hct-49.1
MCV-98 MCH-31.3 MCHC-32.0 RDW-14.6 RDWSD-52.3* Plt ___
Neuts-41.1 ___ Monos-5.2 Eos-0.9* Baso-0.2 Im ___
AbsNeut-7.00* AbsLymp-8.88* AbsMono-0.88* AbsEos-0.16
AbsBaso-0.04 ___ PTT-24.9* ___
___ 10:00AM BLOOD ___ PTT-30.4 ___
___ 10:03AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 WBC-15.3*
RBC-3.57* Hgb-11.2* Hct-35.7* MCV-100* MCH-31.4 MCHC-31.4*
RDW-14.6 RDWSD-53.9* Plt ___
___ 07:18AM BLOOD WBC-18.6* RBC-3.69* Hgb-11.7* Hct-36.3*
MCV-98 MCH-31.7 MCHC-32.2 RDW-14.4 RDWSD-51.9* Plt ___
Glucose-90 UreaN-15 Creat-1.0 Na-136 K-4.9 Cl-98 HCO3-25
AnGap-13 Calcium-9.0 Phos-3.3 Mg-1.9
01:20PM BLOOD WBC-17.3*
IMAGING:
___
PERC IMAGE GUID FLUID COLLECT DRAIN W
CATH(ABSC,HEMA/SEROMA;LYMPHOCELE,CYST);PERIT/RETROPERITONEAL
FINDINGS:Successful US-guided placement of ___ pigtail
catheter into the collection. Samples sent for microbiology
evaluation.
IMPRESSION: Successful US-guided placement of ___ pigtail
catheter into the collection. Samples sent for microbiology
evaluation.
Brief Hospital Course:
Mr. ___ is a ___ with a-fib on Xarelto and recent history
of diverticulitis with abscess in ___ treated with
percutaneous drainage and antibiotics who presented to
___ with recurrent and persistent RLQ pain found to have
a leukocytosis and recurrent abscess on CT, thus, he transferred
to ___ for further care. Upon arrival to ___, given CT
findings, the patient was treated with intravenous Zosyn and
underwent repeat percutaneous drainage of the intra-abdominal
abscess after receiving a total of 4 units FFP due to an
elevated admission INR.
Post-procedure, the patient remained afebrile and
hemodynamically stable; pain was well controlled and Xarelto was
resumed. Intravenous ciprofloxacin and metronidazole were
administered through HD2, but then transitioned to an oral
regimen for discharge; of note, previous culture data was
consistent with pseudomonas growth, therefore a higher dose of
ciprofloxacin was prescribed. Current cultures pending at the
time of discharge.
The patient was discharged to home on HD3 with the drain in
place. He will continue antibiotics for 14 days and receive
drain care via visiting nursing services. He will follow-up
with Dr. ___ in the next one to two weeks.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Rivaroxaban 20 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY:PRN gout flare
3. sodium chloride 0.9 % (flush) injection DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Ciprofloxacin HCl 750 mg PO BID
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Colchicine 0.6 mg PO DAILY:PRN gout flare
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
9. sodium chloride 0.9 % (flush) injection DAILY
RX *sodium chloride 0.9 % (flush) 0.9 % 1 Flush Drain once a day
Disp #*30 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intra-abdominal abscess
Perforated diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You have undergone placement of a drain into your abdominal
abscess, recovered in the hospital and are now preparing for
discharge to home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*Return of your abdominal pain, fevers, chills, change in
character of drain output.
*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 review the handout provided to you "Wound and Drain Care
Following Surgery" for drain care instructions.
Followup Instructions:
___
|
10487400-DS-23 | 10,487,400 | 27,903,299 | DS | 23 | 2182-01-10 00:00:00 | 2182-01-10 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
___: CT guided placement of ___ pigtail catheter
History of Present Illness:
Per admitting resident:
Mr ___ is a ___ male, patient of Dr. ___, with PMHx of
Afib on Xaralto and hx of complicated diverticulitis s/p perc
drainage x2, who presented at ___ for RLQ abdominal
pain and imaging findings consistent with complicated
diverticulitis. Patient began having RLQ pain 1 month ago, which
persists today. He states this pain is similar to his previous
diverticulitis episodes. Over the last 1.5 weeks, patient
describes chills, intermittent fevers, and night sweats. Over
the last ___ days, patient has endorsed nausea, but no emesis.
His appetite has decreased during this time, but tolerates PO,
having non-bloody BMs. Because of his ongoing symptoms, he
decided to go the ___. There he was found to have an
elevated WBC 27.46 and CT scan demonstrating a large pericolonic
abscess and extension into the anterior abdominal wall. Patient
was transferred to ___ for higher level of care. In ___ ___,
patient was mildly tachycardic at 102, other vitals WNL. His WBC
is 24.2, lactate 1.1. ___ surgery consulted. Of note,
patient has had 4 episodes of diverticulitis. On ___ and
___, patient was drained percutaneously for pericolonic
abscess. He was scheduled to have surgery on ___ to address
recurrent diverticulitis
Past Medical History:
PMH:
-Atrial fibrillation
-Renal cell carcinoma
-Diverticulitis
-Obesity
-Gout
-Hypertension
PSH:
-Robot assisted left partial nephrectomy
-Right nephrectomy
-Hip surgeries
-Umbilical hernia repair
Social History:
___
Family History:
No history of malignancy.
Physical Exam:
GEN: A&Ox3, NAD, resting comfortably
HEENT: NCAT, EOMI, sclera anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, NT, ND, no rebound, no guarding
EXT: warm, well-perfused, no edema
PSYCH: normal insight, memory, and mood
DRAIN(S): JP drain x2 to RLQ, scant purulent bloody output
Pertinent Results:
LABS:
___ 08:01PM BLOOD WBC-24.2* RBC-3.50* Hgb-10.5* Hct-32.6*
MCV-93 MCH-30.0 MCHC-32.2 RDW-13.9 RDWSD-47.6* Plt ___
Neuts-73* ___ Monos-3* Eos-0* Baso-0 AbsNeut-17.67*
AbsLymp-5.81* AbsMono-0.73 AbsEos-0.00* AbsBaso-0.00* Glucose-99
UreaN-19 Creat-1.2 Na-130* K-4.4 Cl-97 HCO3-21* AnGap-12 08:20PM
BLOOD Lactate-1.1
___ 05:24AM BLOOD WBC-12.6* RBC-3.77* Hgb-11.2* Hct-35.8*
MCV-95 MCH-29.7 MCHC-31.3* RDW-14.0 RDWSD-48.7* Plt ___
Glucose-96 UreaN-16 Creat-1.3* Na-140 K-4.7 Cl-102 HCO3-25
AnGap-13
___ 04:49AM BLOOD Vanco-19.1
___ 04:49AM BLOOD ALT-9 AST-13 LD(LDH)-118 AlkPhos-77
TotBili-0.7
IMAGING:
___ IMAGE CATH FLUID ___
Successful CT-guided placement of 10 ___ pigtail catheters
into the
superficial and deep collections in the right lower quadrant.
Sample was sent for microbiology evaluation.
Brief Hospital Course:
The patient presented to an OSH on ___ with
several days of right lower quadrant pain, fevers and chills.
After a CT scan suggested recurrent perforated diverticulitis
with an intra-abdominal abscess, the a patient was transferred
to ___. Upon arrival, the patient was placed on bowel rest,
given intravenous fluids and antibiotics and admitted the
general surgical service. On HD2, the patient underwent CT
guided placement of two ___ pigtail drains and was also managed
with intravenous vancomycin and Zosyn. Over the next several
days, the patient's leukocytosis resolved. Wound cultures were
consistent with pseudomonas strep viridians; ID recommended
treatment with intravenous Zosyn until two days after the
patient's planned colonic resection on ___. A midline IV
catheter was placed and the patient was discharged to home with
drains and IV antibiotics until his planned surgery date on
___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Colchicine 0.6 mg PO ASDIR
2. Metoprolol Succinate XL 37.5 mg PO QHS
3. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 mg IV every eight (8)
hours Disp #*26 Vial Refills:*0
3. Colchicine 0.6 mg PO ASDIR
4. Metoprolol Succinate XL 37.5 mg PO QHS
5. Rivaroxaban 15 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intra-abdominal abscess
Complicated diverticulitis
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 an intra-abdominal
abscess that was managed with intravenous antibiotics and
drainage. You have recovered in the hospital and are now
preparing for discharge with the following 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.
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).
*Maintain suction of the bulb.
*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.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10487580-DS-10 | 10,487,580 | 20,865,682 | DS | 10 | 2169-12-04 00:00:00 | 2169-12-04 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cc: abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female in the emergency department for
evaluation of epigastric pain radiates to her back x 1 day.
Patient first developed abdominal pain afte eating dinner two
days. She alid down and then it dissipated. She then developed
abdominal pain again after breakfast on the day of presentation
along with reflux that was not improved with OTC. She also then
vomited x 2 with no relief of the pain which prompted her to
present to the hospital. (NBNB emesis - undigested food) She
describes the pain as sharp, ___ L epigastric pain, worsened
with inspiration and moving. She threw up approximately 5x in
the
ED. This is the first time that she has ever had these sx. Last
BM ___ which was slightly hard which is normal for her as it
is normal for her to not have a bm every day.
No fevers or chills. No weight loss. No dysuria. No CP. Pain
took her breath away but no shortness of breath. She does not
report neuro sx, HA, easy brusing/bleeding. No recent foreign
travel. No pets. Her roomate had a cold and felt under the
weather. No strange raw or under cooked foods
In ER: (Triage Vitals:98, 115/66, 63, 18, 100% on RA )
Meds Given: zofran/maalox/donnatal elixir/viscous
lidocaine/PPI/morphine IV 5 mg x 2
Fluids given:1020cc
Radiology Studies: ___ US
consults called: None
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
[X]all other systems negative except as noted above
Past Medical History:
PMH:
- H/o elevated liver enzymes- hepatitis serologies negative
She was being followed by a GI specialist in ___.
- Mid ___ she had a stomach virus with n/v/d amd fever x 2
days
- GERD - not helped by medications and her doctors have wanted
to
an upper GI
- Genital herpes
- she has never tested positive for any other sexually
transmitted disease.
Social History:
___
Family History:
Grandmother:HTN
Both of her parents have elevated liver enzymes
Physical Exam:
VITAL SIGNS:
GLUCOSE:
PAIN SCORE
1. VS: T = 98.3 P = 61 BP 136/80 RR 16 O2Sat on _97% on RA
GENERAL: Young female laying in bed
Nourishment:OK
Grooming:OK
Mentation: alert, oriented, fluent speech a little sleepy.
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
no lesions noted in OP
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[X] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[] Regular [X] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
2+ DPP b/l
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X]WNL
[X] CTA bilaterally [ ] Rales [ ] Diminshed
6. Gastrointestinal [ ] WNL
soft, non-tender,
[x] Soft[-] Rebound [] No hepatomegaly [] Non-tender [X] Tender
[] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac:
positive/negative
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[
] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
[X Warm [X]Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[X] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [+] Anxious- understandably
anxious
[] Manic [] Intoxicated [] Pleasant [] Depressed [] Agitated []
Psychotic
Discharge exam:
VS:98.1 BP: 107/59 HR: 60 R: 18 O2: 100% RA
Well appearing young woman, laying in bed in NAD.
HEENT: MMM. No scleral icterus.
Lungs: Clear B/L on auscultation
Abd: Soft, Slightly tender on palpation of epigastrium, RUQ. No
rebound or guarding
EXT: No edema, no rashes
Pertinent Results:
LABS: 0n admission:
138 ___ AGap=18
--------------
3.8 23 0.7
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
estGFR: >75 (click for details)
ALT: 245 AP: 349 Tbili: 2.1 Alb: 4.5
AST: 182 LDH: Dbili: TProt:
___: Lip: 24
97
9.0 13.8 334
/41.2 \
N:81.6 L:13.7 M:2.9 E:1.2 Bas:0.6
Labs on discharge:
___ 06:50AM BLOOD WBC-6.8 RBC-4.40 Hgb-14.1 Hct-42.0 MCV-96
MCH-32.2* MCHC-33.7 RDW-12.8 Plt ___
___ 10:20PM BLOOD Neuts-81.6* Lymphs-13.7* Monos-2.9
Eos-1.2 Baso-0.6
___ 06:50AM BLOOD Glucose-94 UreaN-6 Creat-0.6 Na-139 K-3.9
Cl-105 HCO3-30 AnGap-8
___ 06:50AM BLOOD ALT-309* AST-150* AlkPhos-440*
TotBili-1.5
___ 06:50AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.9
___ 05:40PM BLOOD HBcAb-NEGATIVE
___ 10:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE IgM HAV-NEGATIVE
___ 06:39AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 10:20PM BLOOD ___
___ 10:20PM BLOOD PEP-AWAITING F IgG-1137 IgA-189 IgM-242*
IFE-PND
___ 10:20PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 06:39AM BLOOD tTG-IgA-3
___ 10:20PM BLOOD HCV Ab-NEGATIVE
RUQ Ultrasound ___
FINDINGS: There is increased echogenicity of the portal triad
walls relative to the hepatic parenchyma. No intra- or
extra-hepatic biliary ductal dilatation with the common bile
duct measuring 3 mm. The gallbladder is contracted, consistent
with patient's reported recent meal. Within this limitation,
there is a suggestion of thickening of the gallbladder wall.
Overall, findings are suspicious for hepatitis,particularly in
setting of elevated liver function tests.
A 1.4 cm hyperechoic lesion within the left lateral lobe without
increased vascularity, likely represents a hemangioma. Pancreas
is unremarkable. Limited assessment of the right kidney, aorta,
and inferior vena cava are unremarkable.
Doppler assessment of the main portal vein demonstrates patency
and
hepatopetal flow.
IMPRESSION:
Findings suggestive of hepatitis. Please correlate clinically.
No evidence of cholecystitis.
1.4 cm hyperechoic lesion within the left hepatic lobe likely
represents
hemangioma.
Brief Hospital Course:
This is a ___ y/o female with history of mildly elevated
transaminases who presented with epigastric abdominal pain and
found to have elevated LFTs and positive Monospot.
#Acute hepatitis
#Epigastric abdominal pain
The patient presented with abdominal pain and both laboratory
and imaging suggestive of hepatitis. The patient was seen by
hepatology and had a number of laboratory studies sent including
___, AMA, viral hepatitis serologies, immunoglobulin levels,
TTG, Anti-smooth muscle antibodies, APAP, CMV IgM all of which
were negative. Monospot was positive but the patient had no
additional symptoms of infectious mononucleosis. Hepatology
recommended a liver biopsy to evaluate cause of hepatitis. After
discussion with the patient and her parents, the patient
deferred biopsy and preferred to follow up with her providers
closer to home. She is graduating from college in a week. Her
bilirubin was trending down and was 1.5 on discharge. Her
transaminases and alkaline phosphatase remain elevated on
discharge. The etiology of her hepatis remains unclear. It may
have been autoimmune, drug induced (the patient is taking an
herbal supplement) or less likely ___ disease or infectious
mononucleosis. She will need to follow up with her PCP and with
hepatology on discharge. She was counseled to avoid alcohol,
NSAIDs, contact sports.
Transitional issues:
- it is very important that the patient follow up with a liver
specialist for further evaluation of her liver abnormalities and
discussion of liver biopsy
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. This patient is not taking any preadmission medications
Discharge Medications:
No medications prescribed on discharge
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatitis- unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with abdominal pain and
were found to have elevated liver function tests. You had an
abdominal ultrasound which showed inflammation in your liver.
You were seen by the liver doctors who recommended a liver
biopsy. After discussing the biopsy with you and your family,
you decided you wanted to wait for a liver biopsy and see your
primary care physician.
It is important that you do not drink ANY alcohol. Do not take
any medicaitons from the class called NSAIDs. Do not take any
herbal medications.
If you notice that your eyes or skin are turning yellow, you
have worsening or changing abdominal pain you should return to
the hospital. It is very important that you follow up with a
liver doctor when you return home.
Followup Instructions:
___
|
10487877-DS-18 | 10,487,877 | 23,882,092 | DS | 18 | 2174-04-07 00:00:00 | 2174-04-07 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
aspirin / Motrin
Attending: ___.
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ F w/ PMH meningioma s/p XRT, resection, seizures.
Patient was in her usual state of health until yesterday. She
states with that when she woke up in the morning she felt tired
and she went back to sleep. She states that when she woke up at
1 point she walked to the bathroom and felt a bit off balance
she
then went back to bed for beds. She states that around 3 ___ she
began to notice a Novocain-like feeling on the left side of her
face, she called her husband to tell him about this. Prior to 3
___ she had felt relatively normal otherwise. Today around 10 AM
she noticed that her face on the left was drooping. Her husband
suggested that she go to the PCPs office. PCP recommended that
she come to the ED for evaluation. The patient states that in
the last few hours she feels like the facial droop is more
noticeable than it initially was. She reports she has a dull
headache. She feels like sounds are softer in the left ear.
She
denies any jaw pain. She denies any taste changes. She denies
any rash. She states that she feels like she is moving the left
side of her body more slowly, but denies clear focal weakness.
She notes that she did have facial droop for a few days in
___ of last year, which was attributed to her radiation
therapy. She states that this had recovered. She denies any
current infectious symptoms. No fevers, chills, cough, dysuria,
diarrhea. She notes at some point she felt like her speech was
becoming more slurred.
Regarding her meningioma history, this is limited, as she
receives most of her care at ___, and some at ___. She tells me
that she was diagnosed with a meningioma after having seizures
starting in ___. She said she had episodes where she
had a feeling of coldness that spread down from her head to her
toes on the left side followed by numbness of the left hemibody.
She felt like the arms and legs were weak. There was no jerking
or myoclonic movements. She felt lightheaded was not able to
speak and had slurred speech during these she had a few episodes
and work-up showed a right frontal meningioma. She underwent
radiation in ___ at ___. She states that she was on Keppra
1000 mg twice daily. She continued to have seizures so,
resolving ultimately decided that she would go undergo resection
of the meningioma. This was done in ___ at ___. She
states following this resection she no longer had seizures. She
states that her keppra was reduced to 750 mg BID a few weeks
ago.
It appears she is followed in resident clinic at ___ by Dr.
___. She says she thinks her meningioma was stage "1.5"
because it had more mitoses than a stage I meningioma.
ROS:
On neurological review of systems, the patient denies headache,
confusion, difficulties producing or comprehending speech, loss
of vision, blurred vision, diplopia, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
meningioma s/p XRT, resection
seizures
Social History:
___
Family History:
Father with CHF
sister with seizures
Physical Exam:
ADMISSION EXAMINATION:
======================
Vitals: T97.0 HR 80 BP 134/79 RR 16 SpO2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. Able to follow both midline and
appendicular
commands. Able to register 3 objects and recall ___ at 5
minutes.
There was no evidence of apraxia or neglect.
Speech is somewhat slurred
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: sensation decreased to pin, mostly around V3
VII: L NLFF, slight lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 ___ 5 5 5 5
R 5 5 5 5 5 ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception throughout. No extinction to DSS.
Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE EXAMINATION:
======================
General: well-appearing woman, sitting in bed
HEENT: MMM
Pulm: no increased WOB
Neurologic:
MS: Alert, oriented x 3. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. Slight dysarthria. There were no
paraphasic errors.
CN: PERRL, EOMI without nystagmus, decreased sensation in a L V3
distribution, slight L lower facial weakness with symmetric
emotional smile, symmetric eye closure/cheek puff, slight weak
lip closure, sweeter taste on left side of tongue.
Motor: No pronator drift. Slower movements with left hand and
slightly less coordinated (since surgery). Strength full
throughout.
Sensory: Intact to light touch throughout.
Coordination: See motor.
DTRs: ___.
Gait: Deferred.
Pertinent Results:
ADMISSION LABS:
___ 02:44PM BLOOD WBC-5.5 RBC-4.96 Hgb-12.5 Hct-41.1 MCV-83
MCH-25.2* MCHC-30.4* RDW-14.3 RDWSD-42.9 Plt ___
___ 02:44PM BLOOD Neuts-57.9 ___ Monos-9.5 Eos-2.0
Baso-0.5 Im ___ AbsNeut-3.16 AbsLymp-1.62 AbsMono-0.52
AbsEos-0.11 AbsBaso-0.03
___ 02:44PM BLOOD ___ PTT-31.1 ___
___ 02:44PM BLOOD Plt ___
___ 02:44PM BLOOD Glucose-99 UreaN-17 Creat-0.8 Na-141
K-3.5 Cl-103 HCO3-27 AnGap-11
___ 02:44PM BLOOD ALT-34 AST-25 AlkPhos-74 TotBili-<0.2
___ 02:44PM BLOOD cTropnT-<0.01
___ 02:44PM BLOOD Albumin-4.4
___ 06:05AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
___ 02:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 02:52PM BLOOD Glucose-98 Creat-0.8 Na-144 K-3.2* Cl-104
calHCO3-28
MR BRAIN:
1. No acute intracranial abnormality is identified.
2. Postsurgical changes following biparietal craniotomy for
meningioma
resection.
3. Predominantly pachymeningeal enhancement without nodular
enhancement at the surgical site could be postoperative in
nature. However, comparison with prior study if any would be
helpful.
CTA H/N:
1. No acute intracranial process. Specifically, there is no
evidence acute large territory infarction or hemorrhage. Please
note that MRI is more sensitive for the detection acute infarct.
2. Postsurgical changes status post frontal craniotomy an area
of
hypoattenuation in the right frontal lobe most likely
representing
posttreatment changes, grossly there is no evidence of residual
mass lesion.
3. Patent circle of ___ without evidence of stenosis,
occlusion, or
aneurysm.
4. Patent bilateral cervical carotid and vertebral arteries
without evidence of stenosis, occlusion, or dissection.
5. Left thyroid nodule measuring 6 mm with small foci of
internal
calcification. Ultrasound follow up recommended. See
recommendations below.
6. Asymmetric fullness of the left fossa of ___ with
central
hypoattenuation. No evidence of surrounding lymphadenopathy or
extension into the adjacent parapharyngeal, retropharyngeal or
masticator spaces. Recommend direct visualization.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] She is being uptitrated on Trileptal and downtitrated on
Keppra as below:
- START taking Trileptal with a plan to INCREASE the dose over
the next few weeks.
TAKE 300mg two times per day for 1 week ___
TAKE 600mg two times per day for 1 week ___
TAKE 900mg two times per day for 1 week ___
- Start to DECREASE the dose of Keppra after optimal Trileptal
dose
TAKE ___ pill of Keppra for 3 days ___
STOP Keppra starting ___ and only take Trileptal moving
forward
[ ] She has a left thyroid nodule measuring 6mm with small foci
of internal
calcification found incidentally on CTA. Ultrasound follow up
recommended.
SUMMARY:
========
Ms. ___ is a ___ year old woman with history of right frontal
meningioma complicated by epilepsy s/p resection and radiation
therapy who presented to ___ with left facial numbness, droop,
altered taste, and decreased hearing associated with a feeling
of unwell and subjective decreased strength on her left side.
Her symptoms had nearly completely resolved by the morning
following admission with just a slight left lower facial droop
with symmetric emotional smile. Given her history of epilepsy as
well as a recent decrease in Keppra dose in the setting of
psychiatric side effects, this episode was attributed to focal
seizure. After speaking with her outpatient neurologist, Dr.
___, the decision was made to initiate oxcarbazepine
with a plan to uptitrate and then titrate off Keppra. She will
follow-up with her outpatient neurologist as scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 750 mg PO BID
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. OXcarbazepine 300 mg PO BID
RX *oxcarbazepine 300 mg 1 tablet(s) by mouth twice a day Disp
#*168 Tablet Refills:*1
2. LevETIRAcetam 750 mg PO BID
Decrease your dose as noted in the discharge instructions.
3. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Focal seizure
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 had a weird feeling on the left side of your body,
drooping of the left side of your face, and a weird feeling on
the left side of your body.
WHAT HAPPENED WHILE YOU WERE HERE?
- You had an MRI of your brain that did not show anything new to
be causing your symptoms.
- We think that the symptoms you had at home and when you came
to the hospital were related to a seizure since you've had
similar symptoms in the past and have been coming down on your
seizure medicine.
- We started you on a new seizure medicine called Trileptal
(oxcarbazepine) and discussed this plan with your neurologist,
Dr. ___.
WHAT TO DO WHEN YOU LEAVE?
- START taking Trileptal (oxcarbazepine) with a plan to INCREASE
the dose over the next few weeks.
TAKE 300mg two times per day (1 pill two times per day) for 1
week ___
TAKE 600mg two times per day (2 pills two times per day) for
1 week ___
TAKE 900mg two times per day (3 pills two times per day)
___
- Start to DECREASE the dose of your Keppra after you reach 3
pills two times per day of Trileptal (oxcarbazepine).
TAKE ___ pill of Keppra for 3 days ___
STOP Keppra starting ___ and only take Trileptal
- Follow-up with your outpatient doctors as ___ (see
below).
Best wishes,
Your ___ Neurology Team
Followup Instructions:
___
|
10488066-DS-5 | 10,488,066 | 26,937,521 | DS | 5 | 2167-03-03 00:00:00 | 2167-03-03 12:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / lisinopril / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
right reverse obliquity hip fracture with subtrochanteric
extension
Major Surgical or Invasive Procedure:
s/p R TFN ___, ___
History of Present Illness:
___ female with PMH of dementia with behavioral disturbances
and HTN who presents with the above fracture s/p mechanical
fall.
She is unable to give much of a history as she is very demented.
However, per records, she had a widnessed fall yesterday
(___)
evening onto her right hip. She was noticed to be in significant
pain on the right hip and found to have a short, externally
rotated hip. She was sent to the ED for further evaluation.
Past Medical History:
Dementia with ?behavioral disturbances
HTN
Social History:
___
Family History:
Unable due to patients mental status
Physical Exam:
Right lower exam
-dressing c/d/I
-does not follow commands ___ dementia, but grossly moves foot
-foot WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R reverse obliquity ITFx w/ subtroch extension and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for surgical fixation of
the right femur fracture, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. She
received 2U of PRBC for Hct <24 on POD1 and 2. Her Hct
stabilized to 26.9 on POD3. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
The patient was co-managed with the ___ service. Please
see below for further assessment and recommendations.
===============================
Ms. ___ is a ___ female with PMH of dementia with behavioral
disturbances, HTN, and HLD who presents to the ED after a fall
of
unclear etiology with subsequent RLE pain and swelling. Found to
have comminuted right intertrochanteric fracture and is now s/p
ORIF.
#Hypoactive delirium
#Dementia with behavioral disturbances
She is at high risk for post-operative delirium given age and
history of dementia. While admitted, has had waxing and waning
course of hypo and hyperactive delirium. Would recommend:
- Continue home Lexapro 5mg QD and 2.5mg QD
- Continue home Seroquel 25mg daily and 50mg at 1700
- Limit trazodone to 25mg PO QHS PRN agitation. Would try to
avoid if possible given increased sedation with this medication
during admission.
- Consider taper or reduced dose of home Seroquel once she is
back in familiar environment at rehab
- Continue delirium precautions including minimizing overnight
vitals if able, night time interruptions
- Would also continue non-pharmacologic interventions including
accompaniment (especially by familiar people like her husband),
reinforcement of sleep/wake cycle (e.g., having window shades up
during the day, minimizing overnight VS checks), frequent
reorientation
#R intertrochanteric fracture - Presented with R hip fracture,
now s/p ORIF.
- Management per primary ortho team
- On lovenox 30mg SC QD
- Continue standing Tylenol ___ mg Q8H for pain control
- ___ consult - plan for discharge to rehab ___
#Microcytic anemia
Has known baseline anemia from review of ___ records.
S/p 3u pRBC since admission. Likely a combination of
phlebotomization well as intra-operative blood loss, +/-
hematoma
at surgical site. No signs of overt bleeding. Hemolysis labs
within normal limits.
- Monitor CBC daily while inpatient, and q48 hours at rehab
until
stable
- Continue to tranfuse for Hgb <7 or greater than 2 unit drop
- Recommend checking stool guaiac to r/o occult GIB
#Thrombocytopenia:
Likely post-operative sequestration as well as a dilutional
component. Low suspicion for a consumptive process other than
possibility of a hematoma, given stable coags/fibrinogen.
Suspicion for HIT also low (4T score <2).
- Continue to trend daily while inpatient and q48 hours at rehab
until stabilized
#Urinary tract infection - UA consistent with UTI, culture
positive for E.Coli. Unable to determine if patient symptomatic
iso dementia. Has completed 3 day course of CTX.
#HTN - Continue home HCTZ.
#Constipation - Continue home bowel regimen senna 17.2mg QHS,
Miralax 17mg daily, can also add Colace 100mg BID.
#Lung lesions - Incidentally found to have upper lobe lung
lesions concerning for a neoplastic process. Recommend
non-urgently obtaining a CT chest w/o contrast for further
elucidation. PCP has been sent a letter re: these findings.
#GOC: Per MOLST and confirmation with husband, patient is
DNR/DNI. Patient is a resident of ___.
Thank you for the consultation. This is a preliminary note and
should not be considered final until it is cosigned by the
attending physician ___.
___, MD
___ Resident
Medications on Admission:
Hydrochlorothiazide 12.5 mg PO DAILY
Escitalopram Oxalate 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. QUEtiapine Fumarate 25 mg PO QAM
5. QUEtiapine Fumarate 50 mg PO QPM
6. TraZODone 25 mg PO Q6H:PRN as needed for agitation
7. TraZODone 25 mg PO QHS
8. Escitalopram Oxalate 5 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right hip fx
Discharge Condition:
Mental Status: dementia
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Weightbearing as tolerated right lower extremity
Treatment Frequency:
Staples to be removed at 2-week follow-up appointment
Followup Instructions:
___
|
10488151-DS-11 | 10,488,151 | 25,662,244 | DS | 11 | 2131-07-25 00:00:00 | 2131-07-25 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
joint pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male with reported past medical history significant
for an poly-arthritis (unknown etiology) on daily prednisone and
sulfasalazine here with worsening joint and bone pain.
To summarize the patient's symptom history, he is originally
from ___ and first began experiencing back pain ___ years
ago. Since that time, he has had gradually worsening back pain
and involvement of other joints (swelling and pain). His knees
were the next to be involved and at this point, he has had
involvement of the majority of his joints. He has significant
morning stiffness with difficulty sitting in one position for a
long time. He endorses intermittent swelling and pain. He also
has experienced intermittent mouth ulcers and difficulty
urinating. In addition, he has had "jerking" that is involuntary
over the past year; these episodes come in short spasms. No skin
rashes that he has noticed.
As he has been in the ___ officially for the past 2.5 months, he
just established care with Dr. ___
___. Dr. ___ via phone conversation) sent a
CBC (normal), lytes (normal), LFT's and hepatitis panel (normal,
not Hep B vaccinated), as well as RF (<8.6), CCP (<16), and
HLAB27 (negative). UA bland. He was referred to Dr. ___
(rheumatology) at ___.
Dr. ___ him in clinic on ___, at which time he was
taking diclofenac 75 mg bid for pain, omeprazole, and
sertraline. On physical exam: "No significant nail changes that
may suggest psoriatic arthritis. . . no evidence of skin
psoriasis anywhere... There is mild swelling of all the DIPs,
tenderness ofall the DIP joints. . . significant enthesitis at
the insertion of the quadriceps tendon at the patella. . .
tenderness of the common extensor and flexor regions of the
elbow.". Modified ___ test showed 3 cm of expansion. Based
on his history and exam, the conclusion was that he likely has
an inflammatory arthritis with a ddx of psoriatic arthritis, IBD
associated arthritis, and ankylosing spondylitis. Psoriatic was
considered the most likely given his family history and
presentation.
He was subsequently ordered for several imaging studies (MRI
spine/pelvis, hand X-rays, pelvis X-rays) which were normal and
showed no sacroileitis. He was then started on sulfasalazine
(1000 mg bid) and prednisone 40 mg daily. He briefly tried
celebrex with omeprazole but then was switched back to
diclofenac. This was complicated by blood in the stools, for
which he underwent a normal ___ and diclofenac was stopped.
He remains on prednisone currently.
He states that the pain in his joints and bones has been
worsening over the past 2 weeks and has gotten acutely worse in
the past 24 hours. He is now in "agony" over his entire body and
is unable to climb stairs. Every joint in his body hurts. He
also is having increasing difficulty urinating. He is unable to
work (is a ___). Therefore, he presented to the ED due to
intractable pain.
In the ED, initial vitals were: 99.1 94 134/83 16 99%
- Labs were significant for CRP 5.8 and hypokalemia
- The patient was given tylenol, ketorolac, diazepam and
pantoprazole.
Upon arrival to the floor, the patient was in significant pain
with any movement. He gave the above history on interview.
Past Medical History:
Arthritis (unclear etiology)
Depression
Occasional chest pain (non-cardiac per prior cardiologist)
Ocular migraines
Social History:
___
Family History:
Father with psoriasis.
Mother with heart condition, s/p stent.
Sister with unknown heart condition, still undergoing work-up.
Physical Exam:
Admission physical:
Vitals: 97.2 118/79 88 18 99 ra
General: Alert, pleasant, in severe distress upon any movement.
Frequent twitching/jerking movements of the entire body,
amplified by discomfort (and improved after pain medication
administration).
HEENT: Normalocephalic/atraumatic, no oral lesions
NECK: supple but patient with neck pain
Heart: RRR no M/G/R
Lungs: CTAB, no wheezes or crackles
Abdomen: soft/nontender/nondistended, + bs
Genitourinary: no foley
Extremities: no edema. Significant pain of almost every joint in
the body including hands and feet.
Neurological: Alert and conversing well. Neuro exam extremely
limited by pain and patient able to walk only short distances
due to pain.
.
Discharge physical:
Vitals: afebrile, 100-120s/60-70s, 85-101, 96% RA
General: young male, lying in bed flat, does not appear to be in
pain or any distress, moving around intermitently in bed
NECK: supple
Heart: RRR, no murmurs
Lungs: CTAB, anterolaterally with minimal effort
Abdomen: soft, ND, no significant TTP
Genitourinary: +foley
Extremities: no edema.
MSK: TTP anywhere that is palpated
Neurological: Alert and conversing, no movements of arms or
legs, no tremor
Pertinent Results:
Admission labs:
___ 11:54PM BLOOD WBC-7.1 RBC-4.24* Hgb-13.2* Hct-37.1*
MCV-88 MCH-31.2 MCHC-35.7* RDW-13.2 Plt ___
___ 11:54PM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-143
K-3.2* Cl-101 HCO3-23 AnGap-22*
___ 10:55AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.0
.
>> Pertinent labs:
___ 07:45AM BLOOD TSH-2.3
___ 11:54AM BLOOD ANCA-NEGATIVE B
___ 11:54PM BLOOD CRP-5.8*
___ 11:54AM BLOOD ___
.
>> Imaging:
___: MRI head
1. Few scattered T2 hyperintense foci in the supratentorial
white matter are nonspecific. Similar findings may be seen in
asymptomatic patients. Diagnostic considerations include
demyelinating disease, sequela of prior inflammation/ infection,
including Lyme disease and sarcoidosis, and sequela of
vasculitis.
2. The small linear signal abnormality in the right occipital
subcortical
white matter with faint thin linear contrast enhancement in the
same location may relate to a developmental venous anomaly, or
the same process as the other T2 hyperintense foci.
.
>> Micro:
urine cx negative
.
>> Discharge labs:
___ 07:00AM BLOOD WBC-6.3 RBC-3.84* Hgb-12.0* Hct-34.5*
MCV-90 MCH-31.3 MCHC-34.9 RDW-12.7 Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-11 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
___ 07:00AM BLOOD ALT-96* AST-45* CK(CPK)-28* AlkPhos-78
TotBili-0.5
___ 07:00AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ y/o M with reported past medical history
significant for an arthritis (unknown etiology) on daily
prednisone and sulfasalazine here with worsening pain.
# Chronic pain syndrome related to Secondary Fibromyalgia: His
diagnosis is somewhat unclear as his diffuse pain in both joints
and muscles does not easily fit into a clear pattern. He has
been on prednisone and sulfasalazine without improvement.
Outpatient records were obtained and his PCP was contacted. Most
likely diagnosis at this point is that pain is from fibromyalgia
based on rheum eval, exam, normal labs and non-focal findings on
imaging. He meets all tender point criteria. TSH normal and
___ negative. MRI brain was ordered to r/o MS and showed
non-specific ___ matter changes. Of note, patient reports he
has been tested multiple times for Lyme. ESR and CK unrevealing.
He was maintained on Tylenol/tramadol/toradol PRN; morphine was
not effective and was held. Rheumatology fully assessed the
patient and spoke with his outpatient rheumatologist regarding
his fibromyalgia diagnosis. Medication options and support
options for fibromyalgia were discussed with the patient and his
family. He was started on lyrica given persistent total body
pain. His prednisone was stopped during his hospital stay via a
quick taper (was only on it for about a week previously) but his
sulfasalazine was continued for now pending outpatient ___.
Given rheumatology suggestion of secondary fibromyalgia, suggest
___ clinic follow-up and consideration for EMG testing
to evaluate for a possible noninflammatory (metabolic) myopathy
that could be a cause secondary fibromyalgia [this rheum
recommendation was in part related to subjective history of
intermitent gait instability and diplopia].
___ consult was placed and recommended rehab. Social work also
saw the patient to discuss current coping. Limited ambualtory
abilities are related to pain. There is no clear treatment
options for his pain and do NOT suggest addition of opiates.
Rheumatologist can consider other fibromyalgia treatment options
in close ___.
Of note on further questioning he does report some sleep
disturbances, and frequent lucid dreams (including sometimes
during daytime). The wife also notes that he does sometimes have
the apparent myclonic jerking after either exhausting himself by
walking or after having the disturbed sleep pattern. I do wonder
about variant narcolepsy.
# Urinary retention/difficulty urinating: unclear etiology but
patient having to strain significantly to urinate. Retained 900
cc's on ___ and straight cath was difficult to pass, suggesting
possibility of an anatomical process rather than neurological.
It is also possible that retention related to morphine use. Now
with an indwelling foley. Will have urology ___ for voiding
trial 1wk after discharge and consideration for urodyn studies.
# Tremor/jerking motions: also unclear etiology but seemed more
pronounced when patient is in discomfort or "fatigued". Mainly
visible on the day of admission, no significant jerking for
subsequent 4 days. Pt then began to have recurrent movements on
___ that were difficult to interpret as some motions resembling
tremor in legs, myoclonus in arms/neck and resemblence of
choreiform movements at times as well. Given somewhat
intermitent nature and no clear pattern of movements, recommend
neuro evaluation and if no etiology evident to consider
possibility of somatization as cause of these movements.
# Mild transaminitis: patient with ALT/AST of 55/31 on ___
and was also negative for hepB/HepC on ___. On ___, ALT/AST
was 96/45. He has had a prior MRI spine/pelvis at ___ but
these studies were not specifically protocoled for liver
windows. Should ___ as an outpatient.
# Diaphoresis: patient and family report increased sweating
recently. TSH normal.
>> Transitional issues:
-PCP and rheumatology ___ to discuss further medical/supportive
management.
-Per ___ report, is supposed to have a capsule endoscopy
-Will need to trend CBC intermitently as an outpatient given
recent GI bleed from diclofenac.
-Suggest repeat LFT's as an outpatient in ___
-Patient already follows with a therapist and will need ongoing
support after discharge for coping.
-Urology ___ for voiding trial and consideration for urodyn
studies. Discharged with foley until uro ___
-___ clinic ___ and consideration EMG testing
reasonable to evaluate for ? of noninflammatory myopathy as a
cause of secondary fibromyalgia per rheum recs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. SulfaSALAzine ___ 1000 mg PO BID
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Omeprazole 20 mg PO DAILY
4. PredniSONE 40 mg PO DAILY
5. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Omeprazole 20 mg PO DAILY
3. Sertraline 50 mg PO DAILY
4. SulfaSALAzine ___ 1000 mg PO BID
5. Acetaminophen 650 mg PO Q6H pain
6. Docusate Sodium 100 mg PO BID
7. Pregabalin 75 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. TraMADOL (Ultram) 100 mg PO TID
RX *tramadol 50 mg 2 tablet(s) by mouth three times daily Disp
#*30 Tablet Refills:*0
10. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 tab by mouth twice daily Disp #*10 Tablet
Refills:*0
11. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Chronic pain syndrome related to Secondary
Fibromyalgia, acute urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
worsening body pains and were seen by our Rheumatology team. We
ran a number of laboratory tests and imaging studies. Your
symptoms are most consistent with fibromyalgia, which we have
discussed with you in detail. It will be important for you to
have good follow-up with your primary care physician and
outpatient rheumatologist and therapist after your discharge.
We have also set you up to see the urologists for your urinary
retention and the ___ clinic to see if the
fibromyalgia could be related to a muscle disorder.
Sincerely,
Your ___ medicine team.
Followup Instructions:
___
|
10488182-DS-10 | 10,488,182 | 29,073,668 | DS | 10 | 2206-10-19 00:00:00 | 2206-10-19 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Demerol / Nitroglycerin / Morphine / Clindamycin
/ Benzonatate / eucalyptus / Iodinated Contrast Media - IV Dye /
scents / Toprol XL / Ranexa / Hydromorphone / codeine / Naprosyn
Attending: ___.
Chief Complaint:
Dyspnea on exertion, hypoxia, palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMH significant for severe COPD,
NSCLC in LLL s/p cyberknife, tracheobronchomalacia w/failed
stent trial in ___, Mycobacterium Avium Complex, CAD s/p
stenting, Afib (not anticoagulated), and immunoglobulin
deficiency on IVIg who presents with dyspnea on exertion and
palpitations. The patient reports that for the past 2 weeks she
has needed more O2 than her baseline requirement. At baseline,
she requires 2L NC at nighttime and during exercise; however,
when walking to the bathroom at home she has noted hypoxia to
the ___. She has required continuous O2. She has a mild cough at
baseline.
Of note, she saw her urologist on ___ due to worsening
nocturia from her interstitial cystitis. She was prescribed
oxybutynin. She noted ___ edema and took some furosemide she had
at home. She then had her regular bimonthly IVIg infusion. She
had worsening edema, palpitations, and SOB that woke her. She
went to the ED in ___ on ___. She was discharged the
next day with a 3 wk course of furosemide.
Then the patient states her pulmonologist (Dr. ___
advised her to start prednisone and azithromycin in ___
for continuing SOB. She completed a 5-day course of azithromycin
and prednisone 20mg. Afterwards, she took prednisone 40mg for 1
wk due to continued symptoms. She then tapered to 30mg for 3
days, then 20mg for 3 days. Her last prednisone 20mg was on ___.
She also had had mild intermittent epigastric pain and some
palpitations. She took 20 mg PO Lasix ___, as requested by her
MD. ___ has noted numbness/cramping down her legs for the past
few days as well as tingling in her fingers.
Ms. ___ has a documented history of dCHF and states that she
had a TTE at ___ in ___, notable for "thick RV". She was seen
in cardiology clinic ___ where she was considered to have
chronic stable angina and stable dCHF.
She was seen by thoracic surgery ___ for progressively
worsening dyspnea, thought to be a combination of her dCHF, CAD,
and TBM. She reported having 8 episodes of bronchitis this year,
treated with azithromycin and prednisone by Dr. ___. She has
also been hospitalized for CHF. She had a CT trachea ___
which showed TBM with worsening tracheal collapse. Thoracics
thought surgery was not indicated at this time. She also saw IP
that same day for re-consideration of TBM. She was deemed to not
be a surgical candidate due to her multiple medical
comorbidities. At that time, TTE was ordered, and ___ rehab
with CPAP use was recommended.
Past Medical History:
PAST MEDICAL HISTORY:
1. NSCLC of LLL
- completion of CyberKnife therapy.
- received 20 Gy x3 fractions to the left lower lobe nodule,
which was biopsy proven non-small cell lung cancer.
- completed her treatment on ___.
- Last seen for follow-up in ___ no evidence of recurrent
disease
2. COPD, emphysema: on home O2 2L
3. GERD
4. OSA on CPAP
5. Tracheobronchomalacia
6. Fibromyalgia
7. Chronic Fatigue Syndrome
8. Atrial Fibrillation
9. MAC
10. CAD s/p 2 stents to the LAD
11. Immunoglobulin deficiency, on immunoglobulin injections
(2x/mo)
12. Interstitial Cystitis (___)
13. Left Adrenal Gland 10x7mm nodule (PET attenuated, biopsy
benign)
14. Constipation on Glycerin suppository 2x/wk and Bisacodyl
1x/wk
15. Oral Thrush
PAST SURGICAL HISTORY:
1. s/p post-tonsillectomy
2. appendectomy
3. hysterectomy
4. Tracheobronchial stent placement and removal
5. Cystocele repair
6. Rectocele repair
7. Cataract surgery
Social History:
___
Family History:
Mother: dementia late in life, died in her ___
Father died ___ CAD
Brother died ___ CAD, malignant HTN
Sister alive with mitral valve prolapse and GI bleeding issue
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals- T97.6 139/83 90 20 95% 3L NC
General- AOx3, no acute distress
HEENT- PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear, no
LAD, JVP no appreciated
Tongue smooth with some ~3mm nodules in posterior. No
leukoplakia.
Lungs- mildly decreased breath sounds worse in upper lobes, soft
inspiratory crackles at bases (L>R)
CV- RRR, 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, no clubbing or cyanosis. 1+ ___ edema.
Neuro- CNs2-12 intact: sensation to touch, symmetric muscle
activation, hearing to finger rub, tongue midline, uvula
midline. Motor and sensation grossly normal.
DISCHARGE PHYSICAL EXAM
========================
Vitals- Tmax 98.4/Tcurr 97.4 121/65 82 18 97% 2L NC
General- AOx3, no acute distress
HEENT- PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear, no
LAD, JVP not appreciated
Tongue smooth with some ~3mm nodules in posterior. No
leukoplakia.
Lungs- mildly decreased breath sounds worse in upper lobes, soft
inspiratory crackles at bases (L>R)
CV- RRR, 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, no clubbing or cyanosis. 1+ ___ edema.
Neuro- CNs2-12 intact: sensation to touch, symmetric muscle
activation, hearing to finger rub, tongue midline, uvula
midline. Motor and sensation grossly normal.
Pertinent Results:
ADMISSION LABS
==============
___ 08:35PM BLOOD WBC-11.6* RBC-5.09 Hgb-14.7 Hct-46.9*
MCV-92 MCH-28.9 MCHC-31.3* RDW-13.0 RDWSD-44.1 Plt ___
___ 08:35PM BLOOD Neuts-95.8* Lymphs-2.0* Monos-1.6*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.09* AbsLymp-0.23*
AbsMono-0.19* AbsEos-0.01* AbsBaso-0.02
___ 08:35PM BLOOD ___ PTT-29.4 ___
___ 08:35PM BLOOD Plt ___
___ 08:35PM BLOOD Glucose-132* UreaN-12 Creat-0.7 Na-137
K-3.9 Cl-93* HCO3-33* AnGap-15
___ 08:35PM BLOOD proBNP-151
___ 08:35PM BLOOD cTropnT-<0.01
___ 08:35PM BLOOD Calcium-9.5 Phos-3.1 Mg-1.9
___ 11:19PM BLOOD D-Dimer-298
IMAGES
======
___ LENIS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ CXR
Lungs remain hyperinflated. Bibasilar atelectasis/scarring is
again seen. No definite new focal consolidation. Biapical
pleural thickening is seen. No large pleural effusion or
pneumothorax. The cardiac and mediastinal silhouettes are
stable. Brachytherapy clip is again seen projecting over the
left lower hemi thorax. IMPRESSION: Re- demonstrated COPD and
bibasilar atelectasis/ scarring.
___ TTE
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Vigorous biventricular systolic function. Normal
estimated intracardiac filling pressures.
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-9.6 RBC-4.91 Hgb-14.0 Hct-46.1*
MCV-94 MCH-28.5 MCHC-30.4* RDW-13.1 RDWSD-45.0 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-141
K-3.6 Cl-98 HCO3-34* AnGap-13
___ 06:10AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ with a PMH significant for severe COPD
w/multiple recent exacerbations, NSCLC in LLL s/p cyberknife,
tracheobronchomalacia w/failed stent trial in ___,
Mycobacterium Avium Complex, CAD s/p stenting, Afib (not
anticoagulated), and immunoglobulin deficiency on IVIg who
presents with dyspnea on exertion, hypoxia, and palpitations
concerning for worsening COPD with possibly complicated by TBM
and CHF.
# Chronic Respiratory Failure: Patient has a hx of TBM, COPD,
MAC, NSCLC, and OSA. DDx: COPD v TBM v CHF v PNA v malignancy v
ACS. Hypoxia may be multifactorial, likely from chronic and
progressively worsening COPD complicated by TBM and CHF given
recent leg edema. CXR is clear without mass concerning for
tumor, effusion, or infection. Recent PET ___ shows no
pulmonary enhancement. Recent PFTs show very severe obstructive
ventilatory defect with evidence of gas trapping and emphysema.
She is afebrile without cough and on amoxicillin for PNA
prophylaxis. Normal echo, BNP, and absence of fluid in the lungs
makes CHF less likely. Troponin negative and EKG shows no signs
of ischemia. PE unlikely given negative D-dimer and LENIs.
Venous gas shows hypoxia, hypercapnia, and normal pH. Bicarb is
elevated. Labs show a primary respiratory acidosis with
metabolic compensation. Pt may be a candidate for lung
transplant or lung volume reduction surgery in the future,
though this is complicated by multiple pulmonary co-morbidities
including on-going malignancy rule-out. Continue prednisone 20
mg, taper to be managed by outpatient pulmonologist Dr. ___.
Consider need for PCP prophylaxis given prednisone. Recommend
pulmonary rehab upon discharge, limited by patient living far
from ___.
# TBM: Pt w/known TBM s/p failed stent trial in past; not a
surgical candidate given multiple medical comorbidities.
Medically managed with CPAP, prednisone, Acapella valve, Mucinex
at home. Pt takes her PPI only intermittently. Continue acapella
flutter valve, continue guaifenesin. Follow up with IP as
outpatient regarding candidacy for second stent trial.
# COPD: hx severe COPD (FEV1 36%, on home 2L O2). Recent PFTs
___ show stable severe COPD. Continue home medications:
albuterol/ipratropium nebs PRN,fluticasone-salmeterol and
tiotropium bromide
# MAC: Pt w/hx colonization of MAC; during previous OSH
admission had sputum w/Stenotrophomonas maltophilia. Induced
sputum ___ contaminated, low c/f infection. Antibiotics were
held given low c/f infection.
# ___ edema: She reports ___ edema improved w/Lasix. Normal
pro-BNP on admission, no ___ edema, and unremarkable TTE with no
signs of CHF.
# CAD s/p LAD stents x2 (___): Pt w/negative troponin on
admission with non-ischemic EKG. Patient reports diaphoresis
since ___. She noted she became sweaty when she got up to use
the restroom. Possible worsening angina. Continue home ASA,
Plavix, statin
# Afib: Pt has never been on warfarin or NOACs. Normal sinus
rhythm. CHADS2Vasc score 3. Stroke risk was 3.2% per year.
Recent holter ___ showed: sinus rhythm, normal intervals, no
pauses with small amount of atrial ectopy and a large amount
(3%) of ventricular ectopy (VPBs, couplets/triplets). Continue
home verapamil. Consider restartin home ASA.
# NSCLC: Patient with biopsy proven neoplasm in left lower lung.
She is s/p CyberKnife therapy (___). Pt reports increased
diaphoresis but no recent weight changes per OMR review. Recent
PET shows no increased pulmonary avidity. Consider CT chest if
sx don't improve (last ___
# Immunoglobulin deficiency: Pt receives 2x/month IVIG as well
as daily amoxicillin for prophylaxis. Pt is scheduled for
outpatient IVIG therapy upon discharge. Discuss utility of home
amoxicillin 500 mg daily.
# Thrush: Pt diagnosed by outpt provider with thrush and started
on Nystatin. Likely ___ chronic prednisone use. No leukoplakia
on exam today. Continue nystatin.
# Interstitial cystitis: Pt on amitriptyline. Previously on
oxybutynin for nocturia but pt stopped it. Continued on home
amitriptyline.
# GERD. Continue home omeprazole.
TRANSITIONAL ISSUES
===================
[]F/up IVIG rescheduled to ___
[]Please discuss utility of pneumococcal vaccination in setting
of immunoglobulin deficiency
[]Patient was provided with information regarding Pulmonary
Rehabilitation which was recommended.
[]Please consider initiating PCP prophylaxis with ___ given
prolonged steroid course.
[]Please assess continued need for amoxicillin
[]Ms. ___ is being discharged on 20mg of Prednisone daily
with a plan to taper. Please assess prednisone dosage/tapering
at the next outpatient pulmonology appointment.
[] Should follow up with PCP ___: apparent sensation of reduced
proprioception in BLE.
CODE: Full (confirmed)
CONTACT: ___ (boyfriend/HCP) ___
___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Amitriptyline 50 mg PO QHS
4. Verapamil SR 120 mg PO BID
5. Rosuvastatin Calcium 20 mg PO QPM
6. Bisacodyl 10 mg PR Q6H
7. Gammagard Liquid (immun glob G (IgG)-gly-IgA 50+) unknown
unknown injection 2x/month
8. LORazepam 1 mg PO QHS
9. GuaiFENesin ER 1200 mg PO Q12H
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN
11. Tiotropium Bromide 1 CAP IH DAILY
12. Amoxicillin 500 mg PO DAILY
13. Azithromycin 250 mg PO 3X/WEEK (___)
14. Clopidogrel 75 mg PO EVERY OTHER DAY
15. Vitamin D ___ UNIT PO EVERY TWO WEEKS
16. Nystatin Oral Suspension 5 mL PO TID
17. Omeprazole 20 mg PO BID
18. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
19. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
Discharge Medications:
1. Amitriptyline 50 mg PO QHS
2. Amoxicillin 500 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Azithromycin 250 mg PO 3X/WEEK (___)
5. Bisacodyl 10 mg PR Q6H
6. Clopidogrel 75 mg PO EVERY OTHER DAY
7. Estradiol 0.01 % (0.1 mg/gram) VAGINAL 2X/WEEK (MO,FR)
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Gammagard Liquid (immun glob G (IgG)-gly-IgA 50+) unknown
INJECTION 2X/MONTH
10. GuaiFENesin ER 1200 mg PO Q12H
11. LORazepam 1 mg PO QHS
12. Nystatin Oral Suspension 5 mL PO TID
13. Omeprazole 20 mg PO BID
14. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4-6H:PRN dyspnea
16. Rosuvastatin Calcium 20 mg PO QPM
17. Tiotropium Bromide 1 CAP IH DAILY
18. Verapamil SR 120 mg PO BID
19. Vitamin D ___ UNIT PO EVERY TWO WEEKS
20.Pulmonary Rehab
DIAGNOSIS: COPD
ICD-10 CODE: ___
PULMONARY REHABILITATION
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-worsening COPD
Secondary Diagnoses:
-Tracheobronchomalacia
-Mycobacterium avium complex
-Coronary artery disease
-Atrial fibrillation
-Chronic interstitial cystitis
-Oral thrush
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 part of your care.
You were admitted to the hospital because you were experiencing
shortness of breath, palpitations and sweating. We performed a
work up for pulmonary or cardiac reasons that you could be
feeling more short of breath. After reviewing all of your tests,
the most likely explanation is that you are experiencing
progression of your chronic COPD. You should follow up with your
outpatient pulmonologist Dr. ___ further adjustments
to your treatment.
If you experience any worsening shortness of breath please
contact your doctor.
Thank you for letting us take part in your medical care.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10488182-DS-12 | 10,488,182 | 22,816,705 | DS | 12 | 2207-07-19 00:00:00 | 2207-07-20 22:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Demerol / Nitroglycerin / Morphine / Clindamycin
/ Benzonatate / eucalyptus / Iodinated Contrast Media - IV Dye /
scents / Toprol XL / Ranexa / Hydromorphone / codeine / Naprosyn
/ Tessalon Perles / Ditropan / Cephalosporins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ w/ GOLD 4 COPD (on ___ home O2), TBM,
IgG deficiency, HFpEF, and CAD, who presented with worsening
dyspnea on exertion, hypoxia, and ongoing productive cough and
worsening leukocytosis c/f ongoing parainfluenza virus vs
overlying bacterial infection.
Ms. ___ had been discharged from ___ on ___ after being
treated with doxycycline and methylprednisolone. She reports
that she never felt well after her discharge. She has had
increasing increasing malaise, SOB, and headache severe enough
that she cannot ambulate to the bathroom. She says that at
baseline her O2 sats will be 89 without oxygen and in the low
___ with. The past few weeks her O2 sats have been 81 when
ambulating and she saw them go down to 72 once.
She endorses an ongoing cough and postnasal drip, however these
are long term issues, related to her tracheomalacea. She
endorses night sweats and the subjective feeling of having a
fever but says that she did not have a temperature when she took
it. She had additionally experienced a 3.5 lb weight gain over
the past month for which she has been taking Lasix. She stopped
taking her Lasix on ___, due to hypotension (systolic in
the ___, associated with lightheadedness. She restarted it
___ night when she had worsening chest tightness, and
swelling in her legs, which she says she typically experiences
with a CHF exacerbation. She additionally endorses heart
palpitations when exerting herself.
She finished her course of doxy on ___ and had been undergoing
an ongoing taper of methylprednisolone. She is still currently
taking 20 mg daily.
In the ED: HR of 108, BP 132/80, RR16, O2sat: 93% RA. Her exam
was notable for mild respiratory distress with poor air
movement. Her WBC of 23.1 with 95% PMNs, normal H/H and a
normal chem 7 aside from a bicarb of 32. She had a negative
troponin and a BNP of 218. D-dimer was 679. UA was
unremarkable. Her chest xray showed bibasilar opacities
reflecting atelectasis vs. infection. EKG showed sinus rhythm
with a RBBB but no ischemic changes. She was given albuterol,
ipratropium, dexamethasone, Pip/Tazo and Guiafenesine in the ED
and was transferred to the floor.
Past Medical History:
GOLD 4 COPD (on ___ home O2)
Tracheobronchomalacia (on CPAP; s/p failed stent trial)
NSCLC of LLL (s/p CyberKnife ___
Colonized with MAC
CAD (s/p stents to LAD)
HFpEF
IgG deficiency (on IVIG and chronic amoxicillin)
GERD
Fibromyalgia
Paroxysmal a-fib (appears on her problem list but cannot find
any objective documentation)
Interstitial Cystitis
Oral Thrush
s/p appendectomy
s/p hysterectomy
s/p cystocele repair
s/p rectocele repair
Social History:
___
Family History:
Father died ___ CAD
Brother died ___ CAD, malignant HTN
Physical Exam:
ADMISSION EXAM
===============
PHYSICAL EXAM:
Vital Signs: 97.9PO 151/78 108 18 93 3L
General: Alert, oriented, no acute distress; uncomfortable with
movement due to right sided chest pain
HEENT: Sclerae anicteric, MMM, oropharynx clear, no thrush.
Neck: Supple. JVP not elevated. no LAD
CV: Tachycardic. Normal S1+S2, no murmurs
Lungs: Poor air movement throughout; prolonged expiratory
phase; scattered right sided rhonchi
Abdomen: Tenderness elicited over the right ribs, under right
breast with palpation. Abdomen soft, non-tender, non-distended,
bowel sounds present
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper
DISCHARGE EXAM
===============
PHYSICAL EXAM:
VS: T/Tmax: 97.4/98.0 BP: 118-138/63-83 HR:80-105 RR:18 O2sat:
84-95% on 3L Weight
GENERAL: tachypnic, but alert and talkative
HEENT: sclera anicterica, EOMI, MMM
CARDIAC: Heart sounds difficult to appreciate ___ transmitted
upper airway shounds
LUNGS: Decreased airmovement bilaterally, no crackles
appreciated
ABDOMEN: nondistended with significant bruising at heparin
injection sites, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis or clubbing, trace edema in the lower
extremities.
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===============
___ 05:22PM ___ PO2-71* PCO2-61* PH-7.40 TOTAL
CO2-39* BASE XS-9
___ 02:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:55PM GLUCOSE-120* UREA N-11 CREAT-0.7 SODIUM-134
POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-32 ANION GAP-16
___ 01:55PM cTropnT-<0.01 proBNP-218
___ 01:55PM D-DIMER-679*
___ 01:55PM WBC-23.1*# RBC-4.76 HGB-14.8 HCT-44.9 MCV-94
MCH-31.1 MCHC-33.0 RDW-13.2 RDWSD-45.6
IMAGING
===============
CXR ___
IMPRESSION:
Patchy bibasilar opacities may reflect atelectasis, though
infection is not excluded in the correct clinical setting.
Moderate emphysema. Unchanged fiducial marker in the left lower
lobe.
Rib Xray: ___
IMPRESSION:
Frontal and oblique views show no evidence of rib fracture or
pneumothorax.
CXR: ___
FINDINGS:
Compared with ___, no definite change.
Upper zone redistribution may be very slightly greater. However,
doubt overt CHF
Bibasilar patchy opacities with minimal blunting of the
costophrenic angles is similar to prior. Background
hyperinflation compatible with COPD, cardiomegaly, upper zone
redistribution, and biapical pleural thickening are also similar
to the prior study. . No new infiltrate identified.
___: ___
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. ___ cyst in the left popliteal fossa measuring 2.8 x 1.0
x 1.1 cm.
MICRO
===============
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
MRSA SCREEN (Final ___: POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS. (Nasal Swab)
DISCHARGE/INTERVAL LABS
========================
___ 06:40AM BLOOD WBC-14.5* RBC-4.60 Hgb-13.7 Hct-43.1
MCV-94 MCH-29.8 MCHC-31.8* RDW-13.2 RDWSD-44.3 Plt ___
___ 07:15AM BLOOD Neuts-87.9* Lymphs-4.6* Monos-6.1
Eos-0.0* Baso-0.1 Im ___ AbsNeut-14.24* AbsLymp-0.74*
AbsMono-0.99* AbsEos-0.00* AbsBaso-0.02
___ 06:40AM BLOOD Glucose-86 UreaN-24* Creat-0.8 Na-135
K-3.7 Cl-87* HCO3-36* AnGap-16
___ 07:35AM BLOOD proBNP-255
___ 07:00AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.9
Weight at discharge (dry weight): 172.62
Brief Hospital Course:
___ COURSE
======================
Ms. ___ presented to the ___ emergency room on ___
complaining of worsened dyspnea and chronic right sided chest
pain. Upon arrival to the ED she was found to have a
leukocytosis of 23.1 and an xray with patchy bibasilar opacities
(representing infection or atelectasis). Given recent
parainfluenza there was concern for a new pneumonia. Troponin x
2 was <0.01, BNP was 218, and D-dimer was 679.
Given the concern for pneumonia she was started on Vancomycin
and Piperacillin-Tazobactam in the ED and switched to Vancomycin
and Aztreonam (due to concern for reaction to Zosyn) when she
arrived to the floor on ___. Blood cultures and urine
cultures were sent and showed no growth.
Her symptoms were additionally treated with duonebs, albuterol,
her home COPD and CHF medications, as well as chest ___. Her pain
was treated with lidocaine patches, heating pads, and APAP. Out
of concern for a PE given continued chest pain, LENIs and a CXR
were sent on ___ which were both unremarkable. She was
given supplemental oxygen throughout her hospitalization with a
goal O2sat>88%. On ___ her steroid dose was increased to 40
mg/day of Methylprednisone due to a likely overlying COPD
exacerbation.
At the time of discharge she reported significant symptomatic
improvement, especially after increasing steroid dose. She was
able to ambulate with a walker and oxygen and maintain her
saturations in the ___. She remained hemodynamically stable and
afebrile throughout her hospitalization. She will be
transitioned to PO antibiotics for 5 more days after discharge
(Augmentin and Doxycycline). She will complete a steroid taper.
BY PROBLEM HOSPITAL COURSE
=======================
# Dyspnea
Most likely etiology was considered PNA given leukocytosis with
95% PMNs, night sweats, increasing SOB, concerning chest xray
and recent parainfluenza. Other etiologies that were considered
were COPD exacerbation or CHF exacerbation. There was low
suspicion for PE (patient had right sided pleuritic pain) given
slow onset of SOB, however it could not be ruled out with CTA
given the patient's contrast allergy.
She was treated with a 6 day course of vancomycin and aztreonam
(allergic to cephalosporins, had a reaction to Zosyn in the ED
which we later determined was not an allergic reaction) for HAP
and transitioned to Augmentin and Doxycycline meds on day 7 in
preparation for discharge home. On day 1 of her
hospitalization, she was given a 1 time 500 mg dose of
Azithromycin and then restarted on her home 250 daily
Azithromycin dose. MRSA swab came back positive. As the patient
was not producing sputum, a sputum culture could not be checked.
She was additionally treated with chest ___ and her home
medications (nocturnal CPAP, Lasix 40 mg BID, guaifenasen,
albuterol, and methylprednisone). On ___ her methylpredisone
dose with increased to 40 BID with the plan for a 5 day steroid
burst to address an overlying COPD exacerbation. She was
maintained on supplemental O2 throughout her hospitalization
with a goal O2>88%. Her blood and urine cultures were sent and
were negative at her time of discharge.
# Right chest pain: She presented to the hospital with a right
sided chest pain likely etiology was MSK given that she reports
it started when coughing, and she had tenderness to palpation on
exam. It was reproducible on exam and worse with movement and
coughing. Her xray did not show evidence of rib fracture.
Other items on the differential included PE (given hypoxia and
tachycardia, though no leg swelling on exam) as well as
pleuritic pain from her pneumonia. Her pain was treated with
Ibuprofen, APAP, heating pads, and lidocaine patches as needed.
On ___, there was continued concern for PE given continued chest
pain and SOB, so bilateral LENIs and a new CXR were done and
where unremarkable.
# IgG Deficiency / Fibromyalgia
Presented with a history of IgG deficiency. At her last
admission her quantitative IgG was normal. She gets q2week IgG
infusions as prophylaxis against other conditions with her last
infusion on ___. She did not require an additional infusion
while in house. Her home amoxicillin was held while she was
being treated for pneumonia.
# WHO Group III pHTN
Evaluated by pulm at prior admission, thought due to hypoxemia
and/or intrinsic lung disease. She was given oxygen support
throughout the hospitalization, and no other interventions were
necessary at this time.
TRANSITIONAL ISSUES:
===========================
#CODE STATUS: full (confirmed); would not want any prolonged
treatment if no chance for recovery to current baseline
#CONTACT: ___ (boyfriend/HCP) ___, ___
___ (daughter) ___.
- DRY WEIGHT: 78.3 kg / 172.62 lb
- DISCHARGE O2 REQUIREMENT: Ambulating on 4L with sats in the
high ___
[ ] Will complete 5 more days of PO Antibiotics after discharge.
Doxycycline BID and Augmentin BID. After that, resume home
suppressive Amoxicillin and Azithromycin.
[ ] Will complete a Methylprednisolone taper as an outpatient.
Being discharged on 40mg daily x3 days, then will go down to
32mg daily x3 days, then 24mg daily x3 days, and then back to
home dose of 20mg methylprednisolone daily. Further taper from
there to be determined by her outpatient Pulmonologist.
[ ] History of afib but not currently on anticoagulation,
consider revisiting as an outpatient if patient is reporting
symptoms. No afib on telemetry here
[ ] Prescription written for pulmonary rehab, as well as a
walker per patient request
[ ] ___ CT Chest showed pulmonary nodule. Follow up CT
scan scheduled for ___.
[ ] FYI: Patient noted that she has anaphylaxis to
cephalosporins, which was not in our system and was added to OMR
during this admission
[ ] Patient is NOT allergic to Zosyn. Her reaction was a "funny
feeling, tingling of the neck and throat" which is why she was
on aztreonam in the meantime while those symptoms were sorted
out. She was improving, which is why she was not switched back
to Zosyn before transition to PO antibiotics.
[ ] Recently was being titrated down on Lasix outpatient.
However, patient was given Lasix 40 mg BID on admission and
continued on this dose, and appeared euvolemic with stable daily
weights and stable labs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 50 mg PO QHS
2. Amoxicillin 500 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Clopidogrel 75 mg PO EVERY OTHER DAY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Furosemide 40 mg PO BID
8. GuaiFENesin ER 1200 mg PO Q12H
9. Loratadine 10 mg PO DAILY
10. LORazepam 1 mg PO QHS
11. Methylprednisolone 20 mg PO DAILY
Tapered dose - DOWN
12. Nystatin Oral Suspension 5 mL PO TID
13. Rosuvastatin Calcium 20 mg PO QPM
14. Senna 8.6 mg PO BID:PRN constipation
15. Verapamil SR 120 mg PO BID
16. Estradiol 0.01 % (0.1 mg/gram) VAGINAL 2X/WEEK (MO,FR)
17. Gammagard Liquid (immun glob G (IgG)-gly-IgA 50+) Dose is
Unknown INJECTION 2X/MONTH
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4-6H:PRN dyspnea
19. Tiotropium Bromide 1 CAP IH DAILY
20. Vitamin D ___ UNIT PO EVERY TWO WEEKS
21. Potassium Chloride (Powder) 20 mEq PO DAILY
22. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days
Take with food
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 2 sprays each nostril daily
Disp #*1 Spray Refills:*0
4. Methylprednisolone 32 mg PO DAILY Duration: 3 Days
Take on ___ and ___
Tapered dose - DOWN
RX *methylprednisolone 8 mg 4 tablet(s) by mouth once a day Disp
#*12 Tablet Refills:*0
5. Methylprednisolone 24 mg PO DAILY Duration: 3 Days
Take on ___ and ___
Tapered dose - DOWN
RX *methylprednisolone 8 mg 3 tablet(s) by mouth once a day Disp
#*9 Tablet Refills:*0
6. Methylprednisolone 20 mg PO DAILY
Start on ___ and keep taking until your doctor tells you to
change the dose
Tapered dose - DOWN
RX *methylprednisolone 8 mg 2.5 tablet(s) by mouth once a day
Disp #*75 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
RX *sodium chloride [Saline Nasal] 0.65 % 2 sprays each nostril
as need for dry nose Disp #*1 Spray Refills:*0
9. Furosemide 40 mg PO BID
10. Methylprednisolone 40 mg PO DAILY
RX *methylprednisolone 8 mg 5 tablet(s) by mouth once a day Disp
#*10 Tablet Refills:*0
11. Amitriptyline 50 mg PO QHS
12. Aspirin 81 mg PO DAILY
13. Azithromycin 250 mg PO Q24H
14. Clopidogrel 75 mg PO EVERY OTHER DAY
15. Estradiol 0.01 % (0.1 mg/gram) VAGINAL 2X/WEEK (MO,FR)
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. Gammagard Liquid (immun glob G (IgG)-gly-IgA 50+) Dose is
Unknown INJECTION 2X/MONTH
18. GuaiFENesin ER 1200 mg PO Q12H
19. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
20. Loratadine 10 mg PO DAILY
21. LORazepam 1 mg PO QHS
22. Nystatin Oral Suspension 5 mL PO TID
23. Potassium Chloride (Powder) 20 mEq PO DAILY
24. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4-6H:PRN dyspnea
25. Rosuvastatin Calcium 20 mg PO QPM
26. Senna 8.6 mg PO BID:PRN constipation
27. Tiotropium Bromide 1 CAP IH DAILY
28. Verapamil SR 120 mg PO BID
29. Vitamin D ___ UNIT PO EVERY TWO WEEKS
30. HELD- Amoxicillin 500 mg PO DAILY This medication was held.
Do not restart Amoxicillin until you finish taking Augmentin
31.Walker
Dx: Weakness | ICD10: ___
32.Pulmonary Rehab
Dx: COPD | ICD10: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) and supplemental oxygen.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for your shortness of breath. We
thought that this was mostly due to a pneumonia and exacerbation
of your chronic obstructive pulmonary disease. We put you on IV
antibiotics for your pneumonia and treated you with them for 6
days total. We have now switched you to oral antibiotics which
you should continue for 4 more days.
We additionally increased your dose of prednisone to 40 mg a day
to help treat the COPD exacerbation. You are currently on your
___ day of this dose. You should continue this dose for 2 more
days (5 days total) and then taper to your original dose of 20
mg. You should continue to wear your oxygen to keep your oxygen
saturations in the high ___ or low ___ and follow up with your
physicians as indicated below.
We finally took some images of the chest to make sure that your
chest pain was not due to a fracture or a blood clot in your
lung. We did not find anything to suggest that it was. You
should continue to treat this pain as needed.
It was our pleasure to take care of you. If you have any
questions or concerns, please do not hesitate to contact us,
Your ___ care team
Followup Instructions:
___
|
10488182-DS-18 | 10,488,182 | 27,840,909 | DS | 18 | 2208-01-19 00:00:00 | 2208-01-20 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Demerol / Nitroglycerin / Morphine / Clindamycin
/ Benzonatate / eucalyptus / Iodinated Contrast Media - IV Dye /
scents / Toprol XL / Ranexa / Hydromorphone / codeine / Naprosyn
/ Tessalon Perles / Ditropan / Cephalosporins / gabapentin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Vertebroplasty ___
History of Present Illness:
Ms. ___ is a ___ with h/o COPD on home O2 and
tracheobronchomalacia with tracheal stents, remote history of
NSCLC of LLL status post CyberKnife, HFpEF, paroxysmal a fib,
IgG
deficiency, and CAD s/p PCI to LAD who presents for worsening
abdominal pain. She notes that for the past few weeks, she has
been having worsening abdominal pain. It starts at her upper
stomach and radiates to the back frequently. She feels food
sometimes helps it feel better. She notes a history of a peptic
ulcer and states this may feel similar in nature to this. She
has
been taking Tylenol, which helps somewhat with the pain. She
describes the pain as a "rubber band" around her waist, and
notes
the pain is worst on the right side. On further history, notes a
fall out of bed recently. She also has been having loose bowel
movements, with multiple watery stools per day. She attributes
this to an aggressive bowel regimen and notes a negative c. diff
test both at ___ and her rehab within the past week. This is
reportedly improving. She also has had urinary retention
requiring foley catheter placement but stated when she was
having
urinary retention and being straight cathed, the distention of
her bladder would often make the pain worse. The most concerning
this to her about the abdominal pain is the fact that it hurts
when she takes a deep breath. She otherwise denies any changes
in
her respiratory symptoms including worsening SOB, DOE, cough,
sputum production. She also denies fevers, chills. She endorses
a
25 lb weight loss over the past year, but feels it's due to
recurrent hospitalizations. She presented today because of
worsening overall symptoms and was noted to have crackles on
lung
exam at her gynecology appointment.
In the ED:
- Initial vital signs were: 96.5 87 145/72 18 99% 3L NC
- Exam notable for: uncomfortable, splinting forward due to back
pain and SOB, tachypnic, lungs with rales in b/l lower lobes
abd, mildly distended, TTP in epigastrum on deep palpation, no
r/g
HR irregularly irregular, diffuse ecchymoses throughout arms and
legs
1+ edema to knees in legs
- Labs were notable for: WBC 16.7 with neutrophilic
predominance,
H&H 10.3/31.9, proBNP 362, Na 127, K 5.4 (4.4 on repeat), Cl 76,
Bicarb 35, Cr 1.1, Mg 1.5, lactate 2.1, VBG 7.37/82, urine
chemistry: cr 33, Na 67;
- Studies performed include: CXR Fiducial marker within region
of
fibrosis at the left lung base. No superimposed acute
cardiopulmonary process. No edema.
- EKG showed: Sinus at 87, poor baseline in I, II, V1, though no
STe or STd
- Patient was given:
___ 12:04 PO Acetaminophen 1000 mg ___
___ 13:39 IV LORazepam 0.5 mg ___
___ 13:39 IV Furosemide 20 mg ___
___ 14:45 IV Magnesium Sulfate 2 gm ___
- Consults:
Respiratory therapy: Pt with TBM on CPAP at home, currently
comfortable on NP and cool aerosol. Does not feel she needs the
CPAP at this time.
IP: Continue bipap at night, IVIG, home inhalers and nebs,
guifensaine, and flutter valve
- Vitals on transfer: 102 146/73 22 100% humidified O2
Upon arrival to the floor, the patient endorses the above story.
She continues to have significant epigastric abdominal pain that
radiates to her right flank. Unsure of what brings it on,
although notes movement, particularly laying flat makes it
worse.
Denies CP, worsening SOB, DOE (actually states it's improved
from
her baseline), N/V, cough, sputum production, hemoptysis. Notes
her legs are more swollen and red from what they are before. Her
arms have been bruised, but her feet are worse than they have
been recently in terms of the "rash."
Review of Systems:
==================
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
hematuria.
Past Medical History:
- Gold stage IV COPD on 2 3 L of home O2
- tracheobronchomalacia with tracheal stents
- remote history of NSCLC of LLL status post CyberKnife
- MAC colonized
- CAD s/p PCI to LAD
- heart failure with preserved ejection fraction
- paroxysmal A fib
- IgG deficiency
- GERD
- fibromyalgia
- interstitial cystitis
- respiratory pseudomonas colonization
- s/p kyphoplasty at L2, T9 and T10
Social History:
___
Family History:
Father died ___ CAD
Brother died ___ CAD, malignant HTN
Sister with ___ prolapse
Mom w/o cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7 130 / 79 98 16 93%2L
GENERAL: Alert and interactive. Visibly uncomfortable when
moving
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Soft S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Occasional crackle. overall, poor air movement. Not using
accessory muscles. Can speak full sentences comfortably
CHEST: Pain to palpation of R ribs
ABDOMEN: Soft. Tender to palpation in RUQ and epigastrum without
rebound tenderness or guarding. Normal bowels sounds. **Note
exam
was done with patient sitting up in bed, as she refused to lay
down for exam due to discomfort
EXTREMITIES: Toes and fingers cool. 2+ pitting edema of LEs,
symmetric. No cyanosis or clubbing. Radial pulses 2+
bilaterally,
unable to palpate DP or ___ pulses.
SKIN: Diffuse ecchymoses on all four extremities. ___ reticular
rash on LEs. No rash on abdomen. Cap refill 5s in LEs, 2s in
UEs.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation x4. AOx3.
DISCHARGE PHYSICAL EXAM:
Physical Exam
VITALS:
___ 0744 Temp: 97.7 PO BP: 150/81 HR: 99 RR: 18 O2 sat: 97%
O2 delivery: 2L
GENERAL: Alert and interactive. NAD.
HEENT: Normocephalic, atraumatic. PERRL. EOMI. Sclera anicteric
and without injection. MMM.
NECK: No JVD.
CARDIAC: RRR, mildly tachycardic. Soft S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Poor air movement throughout. Bilateral basilar crackles.
ABDOMEN: Soft. Non-tender to palpation diffusely. Mildly
distended in the epigastrium. No rebound or guarding.
EXTREMITIES: 2+ pitting edema of LEs, symmetric. No cyanosis or
clubbing. Pressure dressing over B/L elbow.
SKIN: Diffuse ecchymoses on all four extremities. No rash on
abdomen.
NEUROLOGIC: CN2-12 intact. AOx3.
Pertinent Results:
ADMISSION LABS:
==================
___ 11:58AM BLOOD WBC-16.7*# RBC-3.59* Hgb-10.3* Hct-31.9*
MCV-89 MCH-28.7 MCHC-32.3 RDW-14.6 RDWSD-47.4* Plt ___
___ 11:58AM BLOOD Neuts-95.5* Lymphs-1.6* Monos-2.2*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.92* AbsLymp-0.27*
AbsMono-0.37 AbsEos-0.00* AbsBaso-0.01
___ 11:58AM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-127*
K-5.4* Cl-76* HCO3-35* AnGap-15
___ 11:58AM BLOOD ALT-40 AST-44* AlkPhos-96 TotBili-0.2
___ 11:58AM BLOOD proBNP-362*
___ 11:58AM BLOOD cTropnT-<0.01
___ 11:58AM BLOOD Albumin-3.8 Calcium-9.9 Phos-4.0 Mg-1.5*
___ 11:41PM BLOOD ___ pO2-44* pCO2-69* pH-7.39
calTCO2-43* Base XS-12
DISCHARGE LABS:
=================
___ 07:00AM BLOOD WBC-8.6 RBC-3.22* Hgb-9.4* Hct-30.2*
MCV-94 MCH-29.2 MCHC-31.1* RDW-14.8 RDWSD-51.1* Plt ___
___ 07:00AM BLOOD Glucose-83 UreaN-12 Creat-0.9 Na-136
K-3.6 Cl-83* HCO3-40* AnGap-13
MICROBIOLOGY:
=================
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING/RESULTS:
=================
CXR ___:
IMPRESSION:
Fiducial marker within region of fibrosis at the left lung base.
No
superimposed acute cardiopulmonary process. No edema.
RENAL ULTRASOUND ___:
IMPRESSION:
No evidence of hydronephrosis.
CT ABD/PELVIS W/ PO CONTRAST ___:
IMPRESSION:
1. Substantial stool burden in the ascending and transverse
colon. No acute abdominopelvic abnormality.
2. Since prior there has been a kyphoplasty of L2 however there
is also a new superior endplate deformity of L3, new since the
MRI of the lumbar spine dated ___.
TTE ___:
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is ___ 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. The estimated cardiac index is high
(>4.0L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Very suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No definite valvular pathology or pathologic flow
identified. Compared with the prior study (images reviewed) of
___, the overall findings are similar.
MRI THORACIC AND LUMBAR ___:
IMPRESSION:
1. Evidence of multiple acute to subacute compression
deformities involving
the T4, T7, T8 and possibly T11 vertebral bodies as described
above.
2. Subacute compression deformities of the lumbar spine at the
L2 and L3 with
the L3 compression deformity new from the prior study. Both of
these
fractures demonstrate mild retropulsion of the posterior
superior endplates
resulting in mild spinal canal narrowing and no cord injury.
3. Multilevel degenerative changes of the lumbar spine most
significant at
L4-5 where there is moderate spinal canal narrowing.
ABDOMINAL FILM ___:
FINDINGS:
There is marked distention of the ascending colon secondary to
large amount of
fecal material. There is no free air. There is no evidence of
bowel
obstruction. The oral contrast on prior CT has passed into the
distal colon.
Patient is status post vertebroplasty.
IMPRESSION:
Marked distention of the ascending colon secondary to large
amount of fecal
material.
CXR ___:
FINDINGS:
There are small bilateral pleural effusions with subjacent
atelectasis. No
pneumothorax is identified. Emphysematous changes are seen
within the lungs.
The size of the cardiac silhouette is within normal limits. The
bones are
diffusely osteopenic with prior vertebroplasties performed in
the mid thoracic
spine.
IMPRESSION:
No significant interval change since the prior chest radiograph.
ABDOMINAL FILM ___:
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Mild to
moderate fecal content in the large bowel. There is radiopaque
areas of
vertebral body compatible with vertebroplasty. There is no free
intraperitoneal air.
IMPRESSION:
There is no abnormally dilated loops of large or small bowel.
Mild-to-moderate fecal content in the large bowel.
Brief Hospital Course:
___ with h/o end-stage COPD on home O2 and tracheobronchomalacia
with tracheal stents, remote history of NSCLC of LLL status post
CyberKnife, HFpEF, paroxysmal a fib, IgG deficiency, and CAD s/p
PCI to LAD who presents with worsening abdominal/rib pain over
the past week, concerning for rib fracture. She was found to
have severe constipation and treated with an aggressive bowel
regimen, including Moviprep. Her course was complicated by heart
failure exacerbation, acute vertebral compression fractures s/p
vertebroplasty.
ACUTE ISSUES:
=============
# Abdominal/rib pain
Presenting with RUQ abdominal pain radiation around ribs to
back. Renal US without signs of hydronephrosis or
nephrolithiasis. CT A/P demonstrating healing right eighth rib
fracture and large stool burden in ascending and transverse
colon, either of which could be contributing to abdominal pain.
Patient was treated with pantoprazole 40mg Q12H and APAP 1000mg
q8h prn. Her bowel regimen was increased resulting in patient
having a BM. She had a KUB that showed significant stool burden
despite loose stools and an aggressive bowel regimen. She was
trialed on moviprep which significantly improved her pain and
distention and follow up KUB demonstrated NO dilated loops of
bowel and only mild/moderate stool. She was counseled to
maintain an aggressive bowel regimen with her Colace, senna,
bisacodyl, miralax, and lactulose PRN. Plan for repeat moviprep
if significant constipation/abdominal distension arises again.
# Hyponatremia
# Acute HFpEF exacerbation
Patient mildly hypervolemic on exam at time of presentation.
Urine Na 67, consistent with volume overload from heart failure.
proBNP mildly elevated at 362 from baseline 200s. CXR without
volume overload. TTE on ___ demonstrated EF > 55% and normal
biventricular cavity sizes with preserved global biventricular
systolic function. Patient was intermittently diuresed with IV
Lasix 20mg with good UOP. Her lower extremity edema improved.
She remained on home verapamil. Her spironolactone was initially
held due to hyperkalemia. Her diuretics were returned to her
reported home dose of Lasix 20 BID and spironolactone 25 BID
once there was improvement in her hyponatremia. Her discharge
weight is 66.2 kg. She should follow up with her cardiologist,
Dr. ___ continued management of her diastolic heart
failure.
# Vertebral Compression Fracture
# Fibromyalgia
Had thoracic spine MRI ___ which showed T4 and T10
compression fractures secondary to chronic steroid use appear
new from ___, with T5, T6, and T9 unchanged. L spine
MRI showed L2 acute fracture 1 week later. She underwent
kyphoplasty by ___, where she had successful kyphoplasty of the
T9, T10, and L2 vertebral bodies. She was scheduled to follow up
with ___ in ___, and had an outpatient T spine MRI ordered
from her prior admission for back pain. MRI T/L spine showed
acute fx T7, T8, L3. s/p successful T7, T8 vertebroplasty by ___
___. She should continue her alendronate 70 mg every ___
and follow up with ___ in clinic. Her pain was managed with
Tylenol and lidocaine patches.
# Chronic hypoxic/hypercarbic respiratory failure
# COPD
# Tracheobronchomalacia
Patient presenting with worsening shortness of breath, which she
attributes to abdominal pain/distention. CXR without acute
process or pulmonary edema. Patient felt subjective dyspnea
often during hospitalization. She also was concerned about
possible recurrence of underlying infection. IP was consulted
and felt that patient's respiratory status was at baseline and
did not feel that antibiotics were warranted. Her O2 saturations
remained in mid to upper ___ while on ___ NC. Her VBGs
demonstrated that the patient was retaining CO2. Her nebulizer
treatments were increased which helped with CO2 retention. Her
methylprednisolone was weaned from 20mg to 16mg daily. She
remained on home Advair, Spiriva, Mucomyst, and Guafenesis. Her
albuterol nebulizer frequency was increased. She remained on
Bactrim for PCP ___. She was kept on BiPAP overnight
with goal O2 of 92-94%. She was ordered for BiPAP but patient
intermittently refuses to wear and thinks it makes her breathing
worse. She should follow up with her pulmonologist and
interventional pulmonology for planning of her tracheopexy. Her
bipap setting are 10 over 5. She should continue her methylpred
16 mg, advair, Spiriva, albuterol PRN, guaifenesin 1200 mg BID,
and Bactrim for PCP ppx on steroids, and flutter valve.
# Urinary retention
# Interstitial cystitis
# Complicated urinary tract infection
Foley placed at last hospitalization for urinary retention. Saw
Gyn as outpatient who felt this was functional (urogenic
bladder) vs mechanical obstruction. Foley removed during
hospitalization and patient was monitored with bladder scan Q6H.
She required intermittent straight catheterization but was also
able to void on her own. Her home amitriptyline was continued.
Later in her hospital course she complained of dysuria and
retention again and grew E Coli, treated with zosyn then
narrowed to nitrofurantoin. Her last day of nitrofurantoin is
___ (treated from ___ to ___ for a 10 day course)
CHRONIC ISSUES:
===============
# Fibromyalgia
Continued on home Lidocaine 5% Patch 3 PTCH TD QAM and
Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild.
# Anxiety
Continued on home LORazepam 0.5 mg PO qAM prn anxiety
# IgG deficiency
Attempted to contact outpatient allergist about IVIg schedule
but was unable to determine schedule. She was continued on home
Amoxicillin 500 mg PO Q24H for prophylaxis. Her IgG level ___
was 598, which was close to her goal trough of 600-800. She was
given 20 g IVIG slowly on ___, she should receive IVIG 20
gram every 2 weeks and follow up with her outpt allergist Dr.
___ (___).
# CAD s/p PCI to LAD
Continued on home Aspirin 81 mg PO DAILY and Rosuvastatin
Calcium 20 mg PO QPM. Her Plavix was held during prior
hospitalization due to episode of hemoptysis and was not
restarted.
# Chronic steroid use
Remained on home Bactrim, Calcium Carbonate 500 mg PO TID
# Thrush
No evidence of active ___ on exam, but on steroids and
multiple inhalers. Remained on home Nystatin Oral Suspension 5
mL PO TID
TRANSITIONAL ISSUES:
====================
[ ] please ensure patient completes her course of nitrofurantoin
on ___ - ___
[ ] Patient discharged on reduced dose of solumedrol 16 mg
daily; further titration per outpatient pulmonologist.
[ ] please ensure patient is compliant with bowel regimen and
having regular bowel movements
[ ] If no BM for two days and patient with abdominal distension,
then recommend trial of moviprep as this yielded substantial
improvement when last given.
[ ] please ensure patient follows up with ___ ___ for
post-procedure f/u for her vertebroplasty
[ ] Please weight patient (discharge weight 66 kg) and monitor
volume status. Adjust diuretics as clinically indicated.
[ ] Please check CBC, Basic metabolic panel to monitor for
hyponatremia. Recommend checking again on ___.
[ ] Gyn planning for multichannel urodynamic test as well as a
cystoscopy to rule out neurogenic versus obstructive causes of
urinary retention.
[ ] Patient will need IVIg every two weeks as per her outpatient
allergist Dr. ___.
[ ] Patient will required BiPAP settings ___ for OSA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN shortness of
breath
3. Amitriptyline 50 mg PO QHS
4. Aspirin 81 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. GuaiFENesin ER 1200 mg PO Q12H
7. Lidocaine 5% Patch 3 PTCH TD QAM
8. LORazepam 0.5 mg PO BID:PRN anxiety
9. Nystatin Oral Suspension 5 mL PO TID
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY
12. Rosuvastatin Calcium 20 mg PO QPM
13. Spironolactone 25 mg PO BID
14. Verapamil SR 120 mg PO BID
15. Acetylcysteine 20% ___ mL NEB Q8H:PRN secretion
16. Alendronate Sodium 10 mg PO DAILY
17. Calcium Carbonate 500 mg PO QID
18. Potassium Chloride (Powder) 20 mEq PO DAILY
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4-6H:PRN dyspnea
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. Amoxicillin 500 mg PO Q24H
23. Furosemide 20 mg PO DAILY
24. Bisacodyl ___AILY:PRN constipation
25. Tiotropium Bromide 1 CAP IH DAILY
26. Methylprednisolone 20 mg PO DAILY
27. Levalbuterol Neb 0.63 mg NEB BID:PRN dyspnea
28. Senna 8.6 mg PO DAILY:PRN constipation
29. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown oral
DAILY
30. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Docusate Sodium 200 mg PO BID
2. Lactulose 30 mL PO BID until pt has bm
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
last day of your antibiotics is ___. Simethicone 40-80 mg PO QID heartburn/gas
5. Alendronate Sodium 70 mg PO QTUES
6. Amoxicillin 500 mg PO DAILY
7. Bisacodyl ___AILY constipation
8. Furosemide 20 mg PO BID
9. Methylprednisolone 16 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Senna 17.2 mg PO BID constipation
12. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
13. Acetylcysteine 20% ___ mL NEB Q8H:PRN secretion
14. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN shortness of
breath
15. Amitriptyline 50 mg PO QHS
16. Aspirin 81 mg PO DAILY
17. Calcium Carbonate 500 mg PO QID
18. Fluticasone Propionate NASAL 2 SPRY NU BID
19. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
20. GuaiFENesin ER 1200 mg PO Q12H
21. Levalbuterol Neb 0.63 mg NEB BID:PRN dyspnea
22. Lidocaine 5% Patch 3 PTCH TD QAM
23. LORazepam 0.5 mg PO BID:PRN anxiety
24. Nystatin Oral Suspension 5 mL PO TID
25. Polyethylene Glycol 17 g PO DAILY
26. Potassium Chloride (Powder) 20 mEq PO DAILY
Hold for K > 4.6
27. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4-6H:PRN dyspnea
28. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown oral
DAILY
29. Rosuvastatin Calcium 20 mg PO QPM
30. Spironolactone 25 mg PO BID
31. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
32. Tiotropium Bromide 1 CAP IH DAILY
33. Verapamil SR 120 mg PO BID
34. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
=================
ABDOMINAL PAIN
CONSTIPATION
VERTEBRAL COMPRESSION FRACTURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
TRACHEOBRONCHOMALACIA
CHRONIC HYPOXIC/HYPERCARBIC RESPIRATORY FAILURE
ACUTE DIASTOLIC HEART FAILURE EXACERBATION
HYPONATREMIA
URINARY RETENTION
URINARY TRACT INFECTION
SECONDARY DIAGNOSIS
===================
FIBROMYALGIA
INTERSTITIAL CYSTITIS
ANXIETY
IGG DEFICIENCY
CORONARY ARTERY DISEASE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___.
Why you were admitted?
-You were admitted because you were having abdominal pain.
What was done for you while you were in the hospital?
-You had imaging done which showed that you had a healing right
rib fracture and a large amount of stool in the area of your
abdominal pain.
-You were given medications to help you have a bowel movement.
Your abdominal pain improved after this.
-Your breathing was monitored and you were given medications to
help you breath easier.
-You also had a kyphoplasty to repair the fractures in your
spine.
-You were treated with antibiotics for a urinary tract infection
What to do when you leave the hospital?
-Please take all of your medications as prescribed.
-Please follow-up with all of your appointments as listed below.
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
10488182-DS-20 | 10,488,182 | 21,912,022 | DS | 20 | 2208-03-07 00:00:00 | 2208-03-07 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Demerol / Nitroglycerin / Morphine / Clindamycin
/ Benzonatate / eucalyptus / Iodinated Contrast Media - IV Dye /
scents / Toprol XL / Ranexa / Hydromorphone / codeine / Naprosyn
/ Tessalon Perles / Ditropan / Cephalosporins / gabapentin
Attending: ___.
Chief Complaint:
O2 desaturations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o COPD (home ___, OSA, HFpEF, PAD, remote ___ s/p
cyberknife, IgG deficiency on IVIG, TBM on chronic
Methylprednisone who p/w intermittent SOB. She was recently
admitted to the hospital from ___ for SOB and
nocturnal hypoxia to ___. She was treated for COPD flare with
steroid burst (completed ___ and for pseudomonas PNA
(___). Of note, during admission pt was breathless with
minimal activity/talking which was attributed to deconditioning
on top of multifactorial pulmonary conditions. She experienced
intermittent episodes of SOB and "tracheal collapse" attributed
to TBM flares and associated w/ hypoxia to 70-70s and
occasionally w/ tachycardia to 120s. These episodes resolved
with positive pressure, Ativan, and deep breathing. She had
nocturnal episodes of hypoxia to ___, but refused sleep
medicines' attempt to titrate BiPAP. Of note, during admission
she underwent RHC which showed low filling pressures.
Since discharge, the patient has been doing well at home. On
___ she started having increasing amount of bouts of shortness
of breath. These were short-lived. She was monitoring her oxygen
during this time that would go down to as low as 80%. She would
rebound from these episoes and feel tired. Did not have any
chest pain, nausea, or vomiting. No fevers or chills or cough.
No history of blood clots. Has mild lower extremity edema
bilaterally and a small skin tear on the right anterior shin
from prior EKG lead with some surrounding erythema.
Pulmonary consult: Do not increase steroids, admit to ICU for
intermittent BiPAP use
On arrival to the MICU, the patient was resting in the bed
comfortably. Her SpO2 was >95% on 2L NC, but during the course
of the conversation she would periodically drop to the low ___.
These episodes were brief (<5 minutes) and would spontaneously
resolve with slow, deep breaths. The patient confirmed that she
did not have any lightheadedness, dizziness, headache, double
vision, chest pain, cough, N&V, new abdominal pain,
melena/BRBPR, or dysuria. She did c/o low back pain that
radiates down her leg which she called "sciatica" but denied any
bladder/bowel incontinence, urinary retention, saddle
anesthesia, or leg weakness.
Past Medical History:
- Gold stage IV COPD on ___ L of home O2
- tracheobronchomalacia with tracheal stents
- remote history of NSCLC of LLL status post CyberKnife
- MAC colonized
- CAD s/p PCI to LAD
- heart failure with preserved ejection fraction
- paroxysmal A fib
- IgG deficiency
- GERD
- fibromyalgia
- interstitial cystitis
- respiratory pseudomonas colonization
- s/p kyphoplasty at L2, T9 and T10
Social History:
___
Family History:
Father died ___ CAD. Brother died ___ CAD, malignant HTN.
Sister with ___ prolapse.
Mom w/o cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.0F HR-102 BP-133/72 RR-21 SpO2-100% 2L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, oropharynx clear
NECK: Supple, no appreciable JVP
LUNGS: Decreased breath sounds bilaterally, no appreciable
wheezing or rhonchi
CV: Regular rate and rhythm, no appreciable murmur
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Right elbow has large protuberant, fluctuant mass that is
warm to touch but with no spontaneous drainage; Right anterior
shin has small wound that is closed and dry but with surrounding
erythema; Left foot has area of bright erythema extending up
anterior shin that is warm to touch; Pulses 2+, Mild bilateral
___ edema
NEURO: No focal deficits
DISCHARGE PHYSICAL EXAM:
VS: 97.4 PO 105 / 69 R Sitting ___ 3L NC
GEN: Alert, sitting up, no acute distress
HEENT: NCAT, NC in place, no icterus
NECK: No JVD noted
PULM: few crackles at bases L>R. No wheezes
COR: borderline tachy, regular, no MRG
ABD: Soft, non-tender, moderately distended
EXTREM: no ___ edema, ___, L olecranon bursa with no
active drainage
NEURO: Alert, oriented, answers questions appropriately
Pertinent Results:
ADMISSION LABS:
___ 10:11AM BLOOD WBC-10.0 RBC-3.42* Hgb-8.9* Hct-30.2*
MCV-88 MCH-26.0 MCHC-29.5* RDW-15.9* RDWSD-50.5* Plt ___
___ 10:11AM BLOOD Neuts-79.6* Lymphs-8.7* Monos-10.6
Eos-0.3* Baso-0.4 Im ___ AbsNeut-8.00* AbsLymp-0.87*
AbsMono-1.06* AbsEos-0.03* AbsBaso-0.04
___ 03:46AM BLOOD ___ PTT-26.9 ___
___ 10:11AM BLOOD Glucose-104* UreaN-14 Creat-0.8 Na-138
K-4.3 Cl-89* HCO3-37* AnGap-12
___ 03:46AM BLOOD ALT-43* AST-29 LD(LDH)-230 AlkPhos-126*
TotBili-0.2
___ 10:11AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
___ 10:26AM BLOOD Lactate-1.6
___ 12:48PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-15.7* RBC-3.19* Hgb-8.0* Hct-27.3*
MCV-86 MCH-25.1* MCHC-29.3* RDW-15.8* RDWSD-49.4* Plt ___
___ 06:50AM BLOOD Glucose-91 UreaN-28* Creat-1.1 Na-138
K-4.5 Cl-90* HCO3-40* AnGap-8*
IMAGING REPORTS:
===============
CT Trachea with contrast ___: No evidence of tracheomalacia,
collapsibility of the upper and lower trachea is 52 at 48%
respectively, in prior studies 74 and 50% respectively, this
apparent improvement is likely due to mild variation in patient
compression as current collapsibility is similar to ___
when measured 51 and 50% respectively. Collapsibility of the
main and lobar bronchi is significant with almost complete
effacement and is unchanged.
___ ___: The left peroneal veins were not well
visualized. Otherwise no evidence of
deep venous thrombosis in the left lower extremity veins.
L ELBOW XR ___: No evidence of fracture or dislocation.
Soft tissue swelling in the posterior
aspect of the left elbow
CXR ___:
1. Linear opacities at the bilateral lung bases appear more
suggestive of atelectasis than an infectious source. 2. Vague
opacity projecting over right lateral chest wall appears similar
to prior exams and may represent sequela of healed rib fractures
or post surgical changes. If no history of trauma or surgery on
the right-side, CT could be considered for further evaluation.
Brief Hospital Course:
___ h/o COPD (home ___, OSA, HFpEF, PAD, remote ___ s/p
cyberknife, IgG deficiency on IVIG, and TBM on chronic
Methylprednisolone who presents with worsening episodes of SOB
requiring BiPAP.
ACUTE ISSUES:
=============
# TBM:
# COPD on home O2:
# Obstructive Sleep Apnea:
# Acute on chronic hypoxic hypercapnic respiratory failure
She presented with increased frequency of exacerbations of SOB
which responded to deep/slow breathing, Ativan, and BiPAP. She
had similar to CXR to prior without signs of pneumonia and she
had no evidence of COPD exacerbation on exam. She had an
unexplained leukocytosis that downtrended spontaneously without
any clinical or lab evidence of infection. She had improvement
in the frequency of events to her baseline ___ per day. She was
seen by IP and thoracics in house and a repeat dynamic trachea
CT was done. Thoracics discussed surgery with her and plan was
made to pursue minimally invasive tracheobronchopexy ___.
Cardiology and pulmonology were consulted for pre-op risk
stratification and medical optimization with recommendation of
tapering off methylprednisolone. Decreased methylprednisolone to
12 mg daily ___ with plan to taper by 4 mg weekly. Cardiology
did not recommend stress test due to metop anaphylaxis. No
changes were made to Non-invasive ventilation she receives at
night: InsP 4 cm/H2O, ExP 6 cm/H2O, IPAP 10, O2 4L/min. Plan for
sleep titration study after her tracheobronchopexy, which is
planned for ___. In the meantime she will continue with her
current nighttime non-invasive ventilation. Continued home
Advair, tiotropium, albuterol and levalbuterol PRN, NAC PRN,
Flonase, and prophylactic Bactrim/pantoprazole/nystatin while on
steroids.
# ___ swelling and erythema:
Erythema and dorsum of left foot tracking up anterior shin and
mild ___ edema L>R. DVT ruled out with ___. Improved within 1
day making cellulitis less likely and she was transitioned back
to her home antibiotics (amox, Bactrim) without worsening in the
erythema.
# Left elbow chronic bursitis
There was no erythema or evidence of infection/acute
inflammation. Wound care was consulted and placed wick in
draining area. This was eventually removed and OT was consulted
for brace/sleeve for elbow to prevent further accumulation of
damage and fluid build up.
# Back Pain: s/p kyphoplasty ___. No change in resp status
while getting prn tramadol here so will continue at rehab, but
counseled patient to minimize given her underlying sleep apnea.
CHRONIC ISSUES:
===============
# HFpEF: Continued lasix 20 mg BID and spironolactone 25 mg
BID
# pAF: NSR on admission, CHADSVASC2 =3. Continued verapamil SR
120 mg PO BID
# IgG Deficiency: IgG ___ was 647,s/p 20 g IVIG on ___ and
again on ___. Followed by allergist Dr. ___ (___).
continued amoxicillin 500 mg PO QD prophylaxis as above
# Back pain: Continued APAP 1g Q8H:PRN, lidocaine patch, and
was given tramadol as needed for pain
# Depression/Insomnia: Continued Ativan 0.5 mg BID:PRN, 1 mg
QHS:PRN, amitriptyline 50 mg PO QHS
# CAD: Continued aspirin 81 mg QD, Continued rosuvastatin 20 mg
QHS
TRANSITIONAL ISSUES:
- discharge to rehab with planned stay <30 days
- Thoracic surgery scheduled for ___, for which she
will be admitted
- Patient on methylprednisolone taper per pulmonology- taper by
4 mg every week. Please taper to 8 mg on ___. DO NOT LOWER
METHYLPREDNISOLONE LOWER THAN 8 MG UNTIL SEEN AT OUTPATIENT
PULMONOLOGY VISIT on ___.
- Needs outpatient sleep study for titration of non invasive
ventilation surgery
- Please ensure patient has regular BMs. Has baseline mild
abdominal distention.
#Code: full
#Contact: ___ ___
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Florastor (Saccharomyces boulardii) 250 mg oral BID
5. Simethicone 40-80 mg PO QID:PRN gas
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Tiotropium Bromide 1 CAP IH DAILY
9. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/wheeze
10. Acetylcysteine 20% ___ mL NEB Q8H:PRN sob/wheeze
11. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN sob
12. Alendronate Sodium 70 mg PO QTUES
13. Amitriptyline 50 mg PO QHS
14. Amoxicillin 500 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Fluticasone Propionate NASAL 1 SPRY NU DAILY
19. Furosemide 20 mg PO BID
20. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob/wheeze
21. LORazepam 0.5 mg PO BID:PRN anxiety
22. LORazepam 1 mg PO QHS:PRN insomnia
23. Methylprednisolone 16 mg PO DAILY
24. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
25. Pantoprazole 40 mg PO Q12H
26. Potassium Chloride 20 mEq PO DAILY
27. Rosuvastatin Calcium 20 mg PO QPM
28. Senna 8.6 mg PO BID:PRN cosntipation
29. Spironolactone 25 mg PO BID
30. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
31. Verapamil SR 120 mg PO BID
32. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. GuaiFENesin ER 1200 mg PO Q12H
2. Methylprednisolone 8 mg PO DAILY
3. TraMADol 25 mg PO Q12H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Q12H PRN
Disp #*30 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Acetylcysteine 20% ___ mL NEB Q8H:PRN sob/wheeze
6. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN sob
7. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/wheeze
8. Alendronate Sodium 70 mg PO QTUES
9. Amitriptyline 50 mg PO QHS
10. Amoxicillin 500 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
13. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
14. Docusate Sodium 100 mg PO BID
15. Florastor (Saccharomyces boulardii) 250 mg oral BID
16. Fluticasone Propionate NASAL 1 SPRY NU DAILY
17. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
18. Furosemide 20 mg PO BID
19. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob/wheeze
20. Lidocaine 5% Patch 1 PTCH TD QAM
21. LORazepam 0.5 mg PO BID:PRN anxiety
22. LORazepam 1 mg PO QHS:PRN insomnia
23. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
24. Pantoprazole 40 mg PO Q12H
25. Polyethylene Glycol 17 g PO DAILY:PRN constipation
26. Potassium Chloride 20 mEq PO DAILY
Hold for K >
27. Rosuvastatin Calcium 20 mg PO QPM
28. Senna 8.6 mg PO BID:PRN cosntipation
29. Simethicone 40-80 mg PO QID:PRN gas
30. Spironolactone 25 mg PO BID
31. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
32. Tiotropium Bromide 1 CAP IH DAILY
33. Verapamil SR 120 mg PO BID
34. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Exacerbation of tracheobronchomalacia
Secondary: Chronic olecranon bursitis
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 has been a pleasure taking care of you at ___.
Why was I here?
- You were admitted for more frequent shortness of breath
episodes.
What was done for me here?
- You were monitored closely.
- You had evaluation for infection or COPD exacerbation but you
were not found to have either of these.
- You were seen by the pulmonology, cardiology, interventional
pulmonology, and thoracic surgery teams.
- You were seen by wound consult to evaluate your elbow and you
were given protective gear to wear over the elbow.
What should I do when I leave here?
- It is important that you work with physical therapy to
increase your strength.
- You will need a sleep titration for your nighttime ventilator
settings after your surgery in ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10488182-DS-21 | 10,488,182 | 29,498,300 | DS | 21 | 2208-03-30 00:00:00 | 2208-03-30 17:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Demerol / Nitroglycerin / Morphine / Clindamycin
/ Benzonatate / eucalyptus / Iodinated Contrast Media - IV Dye /
scents / Toprol XL / Ranexa / Hydromorphone / codeine / Naprosyn
/ Tessalon Perles / Ditropan / Cephalosporins / gabapentin
Attending: ___
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
History of Present Illness:
___ with PMH of COPD (home ___, OSA, HFpEF, PAD, remote ___
s/p cyberknife, IgG deficiency on IVIG, TBM on chronic
Methylprednisone who presents with respiratory distress.
She was recently admitted to the hospital from ___
for SOB and nocturnal hypoxia to ___. She was treated for COPD
flare with steroid burst (completed ___ and for pseudomonas
PNA (___). She had another admission from ___
for increased frequency of exacerbations of SOB which responded
to deep/slow breathing, Ativan, and BiPAP. She was seen by
thoracics and IP at that time and plan was to pursue minimally
invasive tracheobronchopexy ___. On ___, she was started on
a course of azithromycin by her pulmonologist due to several
days of increasing yellow sputum, ___ addition to the daily
amoxicillin and SS Bactrim she was already taking. Sputum
cultures at the time were taken. Preliminary results show G-
Rods and G+ cocci ___ pairs. On day prior to presentation, she
had a follow up appointment ___ clinic with Dr. ___
(___), where her temp was 99.8 crackles on exam,
continued yellow sputum, and decreased PFTs. Plan was for her to
be started on Tobramcycin via PICC line since it is likely that
she was developing a recurrent Pseudomonal pneumonia with an
organism that is now becoming resistant to Zosyn.
Per husband, on the night prior to presentation, she was upset
about the postponement of her pulmonary procedure. Soon later,
she had worsening of her respiratory status and was given Ativan
at her nursing home. She was then brought to OSH where she was
found to be hypoxic to low ___. pH 7.28 and CO2 94. She was
given DuoNebs x 2, 2g Mg, 125mg solumedrol, and 100mg
doxycycline as well as more Ativan (1mg x2) and placed on BiPAP.
She was transported to ___ ED for further care.
On arrival to the ___ ED, she was on BiPAP. Exam was notable
for altered mental status and somnolence with GCS of
approximately 8 along with Diffuse wheezing. VBG was significant
for pH 7.28 and CO2 93. Due to significant hypercarbia despite
being on BiPAP and somnolence/AMS, patient was intubated.
On arrival to the MICU, patient was intubated and sedated with
Propofol drip. She was on CMV.
Past Medical History:
- Gold stage IV COPD on ___ L of home O2
- tracheobronchomalacia with tracheal stents
- remote history of NSCLC of LLL status post CyberKnife
- MAC colonized
- CAD s/p PCI to LAD
- heart failure with preserved ejection fraction
- paroxysmal A fib
- IgG deficiency
- GERD
- fibromyalgia
- interstitial cystitis
- respiratory pseudomonas colonization
- s/p kyphoplasty at L2, T9 and T10
Social History:
___
Family History:
Father died ___ CAD. Brother died ___ CAD, malignant HTN.
Sister with ___ prolapse.
Mom w/o cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Reviewed ___ metavision
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm and dry, no rashes
NEURO: Sedated, not following commands. PERRL.
DISCHARGE PHYSICAL EXAM
VS: T 97.3, BP 123/71, HR 97, RR 18, O2 94%4L
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: NR,RR. Nl S1/S2, no murmurs, gallops, or rubs
LUNGS: Slightly improved air movement throughout. Minimal
crackles ___ bases. No wheezes.
ABDOMEN: Nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
MSK: Point tenderness on R side at 10th rib, no cyanosis,
clubbing or edema, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 06:02AM ___ PTT-26.8 ___
___ 06:02AM PLT COUNT-338
___ 06:02AM NEUTS-97.3* LYMPHS-0.8* MONOS-1.1* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-14.42* AbsLymp-0.12*
AbsMono-0.17* AbsEos-0.00* AbsBaso-0.02
___ 06:02AM WBC-14.8* RBC-3.34* HGB-8.2* HCT-28.7* MCV-86
MCH-24.6* MCHC-28.6* RDW-17.3* RDWSD-53.9*
___ 06:02AM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-2.6
___ 06:02AM proBNP-625*
___ 06:02AM cTropnT-<0.01
___ 06:02AM LIPASE-31
___ 06:02AM ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-81 TOT
BILI-<0.2
___ 06:02AM GLUCOSE-156* UREA N-15 CREAT-0.8 SODIUM-135
POTASSIUM-5.2* CHLORIDE-89* TOTAL CO2-38* ANION GAP-8*
___ 06:15AM O2 SAT-44
___ 06:15AM LACTATE-1.1
___ 06:15AM ___ PO2-30* PCO2-93* PH-7.28* TOTAL
CO2-46* BASE XS-11
___ 07:54AM ___ TEMP-38.7 TIDAL VOL-400 PEEP-8 O2-35
PO2-46* PCO2-60* PH-7.43 TOTAL CO2-41* BASE XS-12
INTUBATED-INTUBATED VENT-CONTROLLED
___ 08:23AM URINE MUCOUS-FEW*
___ 08:23AM URINE HYALINE-54*
___ 08:23AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:23AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 11:52AM LACTATE-1.3
___ 07:36PM ___
___ 07:36PM ___ PTT-25.0 ___
___ 07:36PM PLT COUNT-303
___ 07:36PM WBC-12.9* RBC-3.08* HGB-7.7* HCT-25.8* MCV-84
MCH-25.0* MCHC-29.8* RDW-17.6* RDWSD-53.6*
___ 07:36PM CALCIUM-8.3* PHOSPHATE-2.9 MAGNESIUM-2.5
___ 07:36PM GLUCOSE-93 UREA N-20 CREAT-0.9 SODIUM-134*
POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-33* ANION GAP-10
___ 07:46PM LACTATE-1.4
___ 07:46PM LACTATE-1.4
___ 07:46PM ___ TEMP-36.9 PO2-29* PCO2-58* PH-7.39
TOTAL CO2-36* BASE XS-6
PERTINENT LABS
==============
___ 06:05AM BLOOD Ret Aut-1.2 Abs Ret-0.04
___ 06:05AM BLOOD calTIBC-282 Ferritn-124 TRF-217
___ 06:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9 Iron-20*
___ 06:05AM BLOOD IgG-707
DISCHARGE LABS
==============
___ 04:49AM BLOOD WBC-10.1* RBC-3.18* Hgb-7.7* Hct-26.6*
MCV-84 MCH-24.2* MCHC-28.9* RDW-17.2* RDWSD-52.7* Plt ___
___ 04:49AM BLOOD Glucose-87 UreaN-15 Creat-0.8 Na-134*
K-4.3 Cl-84* HCO3-41* AnGap-8*
___ 06:06AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.4
MICRO
=====
___ 3:20 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 6:02 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set ___ the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Reported to and read back by ___ ___ ___ 340PM.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 5:55 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 480-4533M
(___).
STUDIES
=======
CXR ___
ET tube terminates 5.4 cm above the carina.
CXR ___
___ comparison with the study of ___, oblique views show
what appears to be callus formation about remote healed
fractures of several lower ribs on the right. However, on one
view there is a displaced acute rib fracture of what appears to
be the tenth rib on this side. No evidence of pneumothorax. The
endotracheal and nasogastric tubes have been removed. Continued
opacification at the right base which could represent merely
atelectasis and effusion. However, ___ the appropriate clinical
setting, it would be difficult to exclude superimposed
consolidation ___ the region of the cardiophrenic angle.
Brief Hospital Course:
Ms. ___ is a ___ year-old lady with COPD (home ___, OSA,
HFpEF, PAD, remote NSCLC s/p cyberknife, IgG deficiency on IVIG,
and TBM on chronic Methylprednisolone with recent admissions for
respiratory failure and pseudomonal pneumonia presented on
___ with respiratory distress and altered mental status
requiring intubation.
# TBM
# COPD on home O2
# Obstructive Sleep Apnea
# Acute on chronic hypoxic hypercapnic respiratory failure
At OSH, patient was hypoxic to ___ and was initiated on BiPAP.
Intubated ___ the ED for AMS with GCS 8 and persistent
hypercarbia. Per report, patient was given 2mg Ativan ___ nursing
facility prior to respiratory distress. Sedation weaned and
extubated on ___ to BiPap then to ___. Episode of tachycardia
and anxiety leading to desat; improved with Ativan and deep
breathing. Restarted on home Advair and started on chest ___ and
transferred to the floor. Breathing became more comfortable and
satting ___ mid to high ___ on home 4L O2.
# Pneumonia
Reported yellow sputum ___ days prior to admission and sputum
culture with GNR and GPCs ___ pairs. T 99.8 and crackles day
prior to admission. CXR ___ ED with multifocal pneumonia. Started
on Zosyn and briefly on Tobramycin for double-coverage, then
continued on Zosyn for 8 day course.
# GPC ___ Blood Culture, presumed contaminant
___ bottles with GPCs ___ clusters. Started on Vancomycin which
was discontinued when speciation showed coag negative staph.
# 10th Rib fracture
No trauma. Noted flank pain. XR with 10th rib fracture but no
pneumothorax. Responded well to Tylenol and lidocaine patch.
# Normocytic Anemia
Baseline Hb ___ and previously treated with iron. Studies
obtained here c/w combination of iron deficiency and anemia of
chronic disease. Gave 1 dose of 125mg IV iron due to report of
poor tolerance of po iron.
CHRONIC ISSUES
==============
# HFpEF
Continued home Lasix and Spironolactone.
# Questionable H/o pAF
NSR on admission, CHADSVASC2=3. Continued on home verapamil. NSR
on telemetry and EKG here. On chart review it appears the
diagnosis of A fib was unclear and as such she has never been
started on anticoagulation. Given no signs of AF here, no
indication to start anticoagulation.
# IgG Deficiency
IgG ___ was 647, s/p 20 g IVIG on ___. Followed by allergist
Dr. ___ (___). Patient reported she usually gets
infusions q2weeks and with infection. IgG on ___. Spoke
with Dr. ___ recommended ok for IVIG dose. Received
roughly ___ of 20g dose and developed chest tightness. Infusion
held and gave no further dose during admission.
# Depression/Insomnia
Takes Ativan 0.5 mg BID prn and 1mg QHS prn as well as
amitriptyline 50 mg QHS at home. Amitriptyline was held given
patient's AMS and somnolence on admission. Ativan was initially
held but restarted at small doses (.25 mg) only as needed for
anxiety to good effect.
# CAD
Continued home ASA and Statin.
TRANSITIONAL ISSUES
===================
[ ] Continue Zosyn for three more doses (should be finished by
___
[ ] Anemia due to combination of iron deficiency and chronic
disease. s/p 125mg IV Ferric Gluconate. Please re-assess iron
studies ___ ___ weeks.
[ ] Frequent, recurrent pseudomonal infections. Recommend ID
outpatient consult for consideration of eradication therapy.
[ ] Please avoid excess anxiolytics due to concern that Ativan
may have contributed to initial respiratory distress. Anxiety
well-controlled ___ house on reduced doses of Ativan prn.
[ ] Unclear history of atrial fibrillation. If truly no
documentation of fibrillation, consider removing from problem
list. No indication for starting anticoagulation seen at this
time.
[ ] Received roughly one-half of planned 20g IVIG infusion this
admission which was halted due to chest tightness. Should follow
up with allergist Dr. ___ further dosing.
[ ] Missed planned tracheopexy due to admission. Appointments
set up with pulmonary and thoracic surgery to assess for
rescheduling surgery.
#CODE: Full
#CONTACT:
Name of health care proxy: ___
Relationship: Partner
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q8H:PRN sob/wheeze
3. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN sob
4. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/wheeze
5. Amitriptyline 50 mg PO QHS
6. Amoxicillin 500 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Furosemide 20 mg PO BID
13. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob/wheeze
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. LORazepam 0.5 mg PO BID:PRN anxiety
16. LORazepam 1 mg PO QHS:PRN insomnia
17. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Rosuvastatin Calcium 20 mg PO QPM
20. Senna 8.6 mg PO BID:PRN cosntipation
21. Simethicone 40-80 mg PO QID:PRN gas
22. Spironolactone 25 mg PO BID
23. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
24. Tiotropium Bromide 1 CAP IH DAILY
25. Verapamil SR 120 mg PO BID
26. Vitamin D 1000 UNIT PO DAILY
27. Alendronate Sodium 70 mg PO QTUES
28. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
29. Florastor (Saccharomyces boulardii) 250 mg oral BID
30. Potassium Chloride 20 mEq PO DAILY
31. Methylprednisolone 8 mg PO DAILY
32. GuaiFENesin ER 1200 mg PO Q12H
33. TraMADol 25 mg PO Q12H:PRN Pain - Moderate
34. Ranitidine 150 mg PO QHS:PRN reflux
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 3 Doses
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*3 Vial Refills:*0
4. LORazepam 0.25 mg PO BID:PRN anxiety
5. LORazepam 0.5 mg PO QHS:PRN insomnia
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Acetylcysteine 20% ___ mL NEB Q8H:PRN sob/wheeze
8. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN sob
9. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB/wheeze
10. Alendronate Sodium 70 mg PO QTUES
11. Amitriptyline 50 mg PO QHS
12. Amoxicillin 500 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
15. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
16. Docusate Sodium 100 mg PO BID
17. Florastor (Saccharomyces boulardii) 250 mg oral BID
18. Fluticasone Propionate NASAL 1 SPRY NU DAILY
19. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
20. Furosemide 20 mg PO BID
21. GuaiFENesin ER 1200 mg PO Q12H
22. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob/wheeze
23. Lidocaine 5% Patch 1 PTCH TD QAM
24. Methylprednisolone 8 mg PO DAILY
25. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
26. Polyethylene Glycol 17 g PO DAILY:PRN constipation
27. Potassium Chloride 20 mEq PO DAILY
Hold for K >
28. Rosuvastatin Calcium 20 mg PO QPM
29. Senna 8.6 mg PO BID:PRN cosntipation
30. Simethicone 40-80 mg PO QID:PRN gas
31. Spironolactone 25 mg PO BID
32. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
33. Tiotropium Bromide 1 CAP IH DAILY
34. Verapamil SR 120 mg PO BID
35. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Respiratory Failure, resolved
Pseudomonal Pneumonia
SECONDARY DIAGNOSES
===================
Anxiety
Rib Fracture
Anemia
IgG Deficiency
Heart Failure with preserved Ejection Fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
- You came to the hospital because of difficulty breathing.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- We had to put a breathing tube ___ to help you breathe, but
then we were able to get you back to your normal levels of
oxygen.
- We treated you for a pneumonia.
- We gave you some IV iron for your anemia.
- We gave you IVIG; you had some chest tightness so we stopped
it halfway and your symptoms resolved.
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:
___
|
10488677-DS-3 | 10,488,677 | 25,296,400 | DS | 3 | 2172-08-29 00:00:00 | 2172-09-01 21:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived / dust mites / oxycodone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
___ male with ESRD due to FSGS on HD ___, DM type 2
(since age ___, HTN, OSA not on CPAP, presents with dyspnea.
Patient reports 1.5 months of progressively worsening dyspnea on
exertion and fatigue. Associated dry cough. Endorses orthopnea
and weight gain from reported dry weight of 201kg but no
increase in pedal edema. Unable to sleep at night due to dyspnea
and often uses father's CPAP machine in morning with minimal
improvement(patient was previously on CPAP as a child but
self-discontinued it). Thinks his shortness of breath is due to
worsening kidney function as he notes decreased urination in
last few months. Additionally reports poor compliance with his
medications, taking them about 3 time per a week. Endorses
fevers reportedly noted at HD but denies chills, dysuria,
abdominal pain. Does endorse slight chest discomfort/tightness
with exertion and coughing fits but none at rest.
Of note, patient presented to ED one week prior with shortness
of breath and was diagnosed with URI. Presented to ED again for
this admission due to continued shortness of breath and dry
heaving resulting in emesis of blood tinged mucous.
In the ED, initial vitals were: Temperature 98.8 HR 110
BP196/128 R28 O2 saturation 85% RA. Exam notable for clear
lungs, no JVD or pitting edema, and protuberant abdomen but
without tenderness to palpation. Labs notable for absence of
leukocytosis, K 6.0 not hemolyzed, creatinine 12.6, BUN 77,
troponin 0.06, BNP greater than assay, and lactate 1.1. UA with
proteinuria, glucosuria, few bacteria, 8 WBC, and neg
luek/nitrites. EKG without peaked t waves or signs of acute
ischemia. CXR with cardiomegaly, mild congestion, but no
evidence of pneumonia. Peak flow measured at 200 with minimal
response to ipratroprium and albuterol nebulizers. Blood and
urine cultures were sent. Received insulin regular 10 units,
Dextrose 50% 25 gm, Sodium Polystyrene Sulfonate 30 gm for
hyperkalemia. Home lantus held due to low BS and placed on q6h
ISS. Underwent dialysis with UF of 3L in ED on ___ evening and
full HD session on ___. Creatinine subsequently improved to
10.0, BUN to 56, and K to 4.5. Received amlodipine 10mg,
metoprolol succinate 50mg and losartan potassium 25mg on ___
AM and metoprolol succinate 50mg and amlodipine 10mg on ___ at
8AM.
Patient was evaluated by nephrology and cardiology in the
emergency
room who recommended inpatient HD, trend troponin, and TTE in
AM.
Vitals on transfer: T97.8 HR81 BP146/95 R18 O2 saturation 100%
Nasal Cannula
On the floor, patient feeling slightly better with HD but
endorses continued DOE and dry cough. Abdominal discomfort
thinks due to gas. Prior diarrhea with bright red blood per
rectum but since resolved. Denies headache, chest pain, dysuria,
new numbness or tingling sensation, or hematochezia. Pruritus
after HD.
Past Medical History:
Hypertension
OSA
Adenoidectomy
AV fistula placement (superficialization ___
Social History:
___
Family History:
Per OMR, both his mother and father have diabetes mellitus and
hypertension. Father uses CPAP.
Physical Exam:
========================
Admission Physical Exam:
========================
Vital Signs: 98.8 145/85 79 18 98%4L
General: Alert, oriented, no acute distress. Obese, pleasant
male. Getting short of breath with conversation and occasionally
with dry cough.
HEENT: Sclera anicteric. PERRL. JVP difficult to assess given
body/neck habitus.
CV: Regular rate and rhythm, no murmurs appreciated.
Lungs: Clear to auscultation bilaterally, no wheezes, crackles
appreciated.
Abdomen: Protuberant abdomen. Soft, nontender to palpation. +BS,
no guarding.
GU: No foley
Ext: Warm, well perfused, no edema or asymmetry. L arm with
fistula, palpable thrill.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred. No flapping tremor. No
tongue fasciculations.
========================
Discharge Physical Exam:
========================
Vitals: 97.9 136/67 (136-154/67-80) 61 (61-75) 18 97 CPAP
post HD VS T 88.2 136/48 80 18 100%RA
Wt post HD 176.7kg
Exam in AM pre HD
General: NAD, pleasant male
HEENT: Sclera anicteric, MMM, PERRL.
Neck: JVP difficult to assess given neck size.
Lungs: Clear to auscultation with no wheezes or crackles
CV: Distant heart sounds. Regular rate and rhythm, no murmurs.
Abdomen: Protuberant abdomen, soft, nontender to palpation. BS
present.
Ext: Warm, well perfused, 1+ nonpitting edema bilaterally. LUE
with palpable thrill.
Neuro: CN2-12 grossly intact. Grossly moving upper and lower
extremities appropriately.
Pertinent Results:
===============
Admission Labs:
===============
___ 03:25PM BLOOD WBC-9.9 RBC-2.90* Hgb-8.1* Hct-27.0*
MCV-93 MCH-27.9 MCHC-30.0* RDW-17.2* RDWSD-57.9* Plt ___
___ 03:25PM BLOOD Neuts-81.7* Lymphs-10.8* Monos-4.5*
Eos-1.9 Baso-0.6 Im ___ AbsNeut-8.12* AbsLymp-1.07*
AbsMono-0.45 AbsEos-0.19 AbsBaso-0.06
___ 03:25PM BLOOD Plt ___
___ 03:25PM BLOOD ___ PTT-30.4 ___
___ 03:25PM BLOOD Glucose-101* UreaN-77* Creat-12.6*#
Na-137 K-6.0* Cl-101 HCO3-22 AnGap-20
___ 03:25PM BLOOD CK(CPK)-127
___ 03:25PM BLOOD CK-MB-2 proBNP-GREATER TH
___ 03:25PM BLOOD cTropnT-0.06*
___ 03:25PM BLOOD Calcium-9.3 Phos-8.0*# Mg-2.5
___ 09:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 09:00PM BLOOD HCV Ab-NEGATIVE
___ 03:39PM BLOOD ___ pO2-92 pCO2-44 pH-7.39
calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 03:39PM BLOOD Lactate-1.1
___ 03:39PM BLOOD O2 Sat-95
====================================
Pertinent Labs During Hospital Stay:
====================================
___ 03:25PM BLOOD cTropnT-0.06*
___ 02:05AM BLOOD CK-MB-2 cTropnT-0.08*
___ 06:20AM BLOOD cTropnT-0.07*
===============
Discharge Labs:
===============
___ 06:30AM BLOOD WBC-7.9 RBC-3.53* Hgb-9.6* Hct-32.6*
MCV-92 MCH-27.2 MCHC-29.4* RDW-15.7* RDWSD-53.4* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-97 UreaN-55* Creat-10.4*# Na-136
K-4.7 Cl-97 HCO3-24 AnGap-20
___ 11:00AM BLOOD ALT-66* AST-23 AlkPhos-78 TotBili-0.7
___ 06:30AM BLOOD Calcium-9.9 Phos-6.6* Mg-2.8*
========
Imaging:
========
ECG Study Date of ___ 3:17:20 ___
Baseline artifact. Sinus tachycardia. Compared to the previous
tracing
of ___ artifact persists and probably no significant change.
Clinical
correlation is suggested.
TRACING #1
Rate 101 PR 169 QRS 97 QT384 QTc455/498
ECGStudy Date of ___ 10:07:13 ___
Sinus rhythm at the upper limits of normal rate. Since the
previous tracing
there is less artifact. Mild Q-T interval prolongation persists.
TRACING #2
Rate 97PR172QRS99QT391QTc455/497
CHEST (PORTABLE AP)Study Date of ___ 3:03 ___
Little interval change from prior with continued moderate
cardiomegaly, small
bilateral pleural effusions and mild pulmonary vascular
congestion.
Portable TTE (Complete) Done ___ at 12:17:10 ___ FINAL
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). 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 leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global systolic function.Mild-moderate
mitral regurgitation. Moderate pulmonary artery systolic
hypertension.
CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of ___
6:35 ___
1. No evidence of pulmonary embolism or aortic abnormality.
Portions of
subsegmental upper lobe pulmonary arteries not included in
imaged volume.
2. 3 mm left lower lobe pulmonary nodule. As per ___
guidelines no
follow-up needed in low-risk patients. For high risk patients,
recommend
follow-up at 12 months and if no change, no further imaging
needed. Possible
minimal patchy air trapping suggestive of small airways disease.
3. Mild cardiomegaly. No pleural effusion.
==========
Microbiology:
==========
___ 2:05 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
========
Summary:
========
___ male with ESRD due to FSGS on HD ___, DM type 2
(since age ___, HTN, OSA not on CPAP, presented with dyspnea.
============
ACUTE ISSUES:
============
# Dyspnea:
Patient presented with 1.5 months of dyspnea with associated
weight gain and orthopnea. Dyspnea was felt to be multifactorial
in origin including volume overload, OSA (not on CPAP as
outpatient), obesity hypoventilation, and anemia. BNP was
elevated on admission and patient with evidence of volume
overload on admission CXR. CTA was negative for PE. While there
was concern for cardiac dysfunction contributing to the
patient's dyspnea as well given cardiomegaly on CXR,
uncontrolled HTN and untreated CPAP. TTE performed that showed
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%) and
evidence of increased left ventricular filling pressure
(PCWP>18mmHg). EKG without evidence of acute ischemic changes,
patient without chest pain, and troponins stable. Weight at
admission was ~201kg and weight at discharge was 176.7 kg after
undergoing multiple sessions of HD. Per renal, dry weight
estimated to be about 175kg.
# Hypertension:
Patient reported poor compliance with medications, taking them
about three times per week. Hypertensive to 196/112 in ED which
improved with administration of home antihypertensive regimen
and removal of fluid via HD. TTE with mild symmetric LVH.
Amlodipine was discontinued from antihypertensive regimen give
improved blood pressure control after fluid removal with HD.
# End stage renal disease:
Stage 5 CKD secondary to FSGS. Patient first diagnosed with CKD
s/p biopsy ___ that showed advanced segmental and global
glomerulosclerosis though to be either primary or secondary to
obesity. No evidence of immune complex GN and no diabetic
changes noted. AV fistula placed ___, superficialization
___ and started on HD on ___. Currently on ___
schedule. Dry weight 201 kg per patient. Per renal, challenging
dry weight, with weight post ___ HD 176.7kg.
# Type 2 Diabetes Mellitus:
Present since age ___. Initially managed with oral hypoglycemic
but on insulin for past ___ years. On glargine 10 units nightly
with no mealtime insulin. Seen by ___ ___ who would like to
see patient in outpatient follow up.
===============
CHRONIC ISSUES:
===============
# Anemia:
Hgb on admission 8.1. Iron studies from ___ consistent with
AOCD. Continued on EPO ___ Units qHD
and Ferrous Sulfate 325 mg PO/NG BID.
# Sleep Apnea:
Patient non-compliant with CPAP as outpatient, stating that he
uses father's CPAP machine on occasion. Previously required 2L
at night with CPAP in ___ admission. CPAP was continued
during his hospital stay qhs.
====================
Transitional Issues:
====================
- Please ensure follow-up with sleep medicine doctor and sleep
study as patient has untreated sleep apnea.
- Please acquire euvolemic TTE as outpatient to assess for
pulmonary hypertension. If evidence of pulmonary hypertension is
present, patient will need follow up with pulmonary hypertension
physisican such as Dr. ___.
- Please emphasize importance of medication compliance for blood
pressure control.
- Home amlodipine was discontinued due to improved blood
pressure control status post fluid removal using HD. Please
further titrate blood pressure medications as clinically
warranted.
- Patient to continue previous dialysis on ___,
and ___.
- Weight at discharge 176.7 kg. Estimated dry weight per renal
175 kg.
- Please ensure follow-up with ___ diabetes team.
- CTA with 3 mm left lower lobe pulmonary nodule. As per
___ guidelines no follow-up needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if
no change, no further imaging needed.
# CODE: Full code, confirmed
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Acetate 1334 mg PO TID W/MEALS
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
6. Amlodipine 10 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Glargine 10 Units Bedtime
11. Calcium Acetate 1334 mg PO TID:PRN snacks
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg Take 1 capsule by mouth daily. Disp #*30
Capsule Refills:*0
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Calcium Acetate 1334 mg PO TID:PRN snacks
5. Ferrous Sulfate 325 mg PO BID
6. Glargine 10 Units Bedtime
7. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg Take 1 tablet by mouth daily. Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg Take 1 tablet by mouth daily.
Disp #*30 Tablet Refills:*0
9. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg Take 1
capsule by mouth daily. Disp #*30 Capsule Refills:*0
10. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- End Stage Renal Disease on Hemodialysis
- Obstructive Sleep Apnea
- Hypertension
Secondary:
- Type 2 Diabetes Mellitus
- Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital due to shortness of breath. We think
that this was likely due to a number of factors including
increased fluid in your body, poor control of your blood
pressure, and because you were unable to use your CPAP machine
at home overnight.
We took off a significant amount of fluid from your body using
hemodialysis and you felt better. Your blood pressures improved
after this fluid was removed so we were able to discontinue one
of your hypertension medications, amlodipine. You also felt
better after using a CPAP machine overnight. We also performed
imaging of your chest to assess for a clot to see if that was
making you short of breath. We did not find any clots in your
lung.
Please make sure you use a CPAP overnight each night. Please
also make sure that you take ALL of your medications,
particularly all of your blood pressure medications. Also make
sure that you come to all of your dialysis sessions.
You will need to follow up with your primary care doctor and
your endocrinologist from your ___ diabetes team after you
leave the hospital. Please make sure to discuss with your
primary care doctor about seeing a sleep medicine doctor to have
a repeat sleep study so that you can get a sleep apnea machine
at home.
We wish you the best. It was a pleasure caring for you.
Your ___ Care Team
Followup Instructions:
___
|
10488677-DS-6 | 10,488,677 | 20,133,578 | DS | 6 | 2175-03-15 00:00:00 | 2175-03-15 19:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
shellfish derived / dust mites / oxycodone
Attending: ___.
Chief Complaint:
L quad tendon rupture
Major Surgical or Invasive Procedure:
Left quadriceps rupture repair
History of Present Illness:
___ male with ESRD on dialysis presents with inability to
extend his left leg after a fall at a diner yesterday morning.
He reports that he heard a snap as he tried to maintain balance
when his chair fell out from underneath him. He was unable to
walk or bear weight on the leg nor extend the leg. Today he
reports being able to limp around on the knee and it is less
painful, but he was concerned enough to report to the emergency
department. He was brought in by a friend and wheeled to the
emergency department. He also reports that he stubbed his Right
5ht toe one week ago and that it has been hurting as well.
Past Medical History:
-Hypertension (dx age ___
-OSA (untreated)
-Adenoidectomy
-AV fistula placement (superficialization ___
-Cardiomegaly/LVH
-End-Stage Renal Disease (started dialysis ___
-Insulin-Dependent DM (dx age ___
Social History:
___
Family History:
Mother, d.___ (deceased): DM, HTN, ESRD/HD, died from
complications from a hip fracture.
Father (living): DM, HTN, OSA on CPAP.
Brothers x2, ages ___ & ___: ?HTN.
Physical Exam:
Vitals:
Temp: 99.0 PO BP: 115/62 R Lying HR: 79 RR: ___ O2
sat: 100% O2 delivery: Cpap
General: Well-appearing, breathing comfortably
MSK:
LLE:
In long leg cast
Fires ___, FHL, TA, GSC
SILT s/s/t/sp/dp
WWP
Pertinent Results:
For relevant labs and imaging, see OMR.
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 quadriceps tendon restaurant and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for left quadriceps tendon repair, 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 outpatient ___ following cast removal was appropriate.
During hospitalization the patient underwent regular dialysis
for his ESRD. He was noted to require transfusions with dialysis
every other day six days following surgery. He was seen by
medicine who determined he was not hemolyzing and not bleeding
given negative CT of the leg. By discharge his H/H was stable
and he was cleared for home. Per medicine there is no medical
contraindication to discharge with close follow-up and serial
CBC, which should be feasible at dialysis. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left extremity, and will be
discharged on aspirin 325 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:
Active Medication list as of ___:
Medications - Prescription
CALCIUM ACETATE - calcium acetate 667 mg capsule. 1 capsule(s)
by
mouth twice a day with meals - (Prescribed by Other Provider)
INSULIN GLARGINE [LANTUS SOLOSTAR U-100 INSULIN] - Lantus
Solostar U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen. 70
twice a day will take 35 units preop night before and dos as
directed by MD - (Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider)
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit capsule. capsule(s) by mouth once a day - (Prescribed by
Other Provider)
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth twice a day - (Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*25 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Out of PACU
5. Senna 17.2 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. amLODIPine 10 mg PO DAILY
8. Calcium Acetate 1334 mg PO TID W/MEALS
9. Cinacalcet 60 mg PO DAILY
10. Glargine 10 Units Bedtime
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left quadriceps tendon rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity in cylinder
cast
MEDICATIONS:
- Continue pre-operative medications unless otherwise instructed
by surgeon or medical team at discharge
- You may take Tylenol ___ every 6 hours around the clock.
This is an over the counter medication.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 3 wks
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.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Physical Therapy:
WBAT LLE in cylinder cast
Progress mobility including transfers, gait and
stairs as tolerated
crutch training
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
Followup Instructions:
___
|
10488906-DS-2 | 10,488,906 | 25,817,228 | DS | 2 | 2161-11-29 00:00:00 | 2161-11-30 12:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: lethargy, gingival bleeding
REASON FOR MICU: shock, DIC
Major Surgical or Invasive Procedure:
Endotracheal intubation
Left Internal Jugular Central Venous Catheter
(insertion/removal)
Right Internal Jugular Temporary Hemodialysis Catheter
(insertion/removal)
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
hypertension,
hyperlipidemia, asthma, OA, depression, and anxiety presenting
as a transfer from ___, where she presented
with the chief complaints of gingival bleeding after teeth
cleaning, hemoptysis, and diarrhea. She was found to be in shock
with multiple lab abnormalities concerning for DIC.
On the day of presentation, she went to a dental appointment for
teeth cleaning at 1pm. She reports feeling fine prior to this.
After her appointment around 2pm-3pm, she complained of feeling
cold and not feeling . Later in the afternoon, she was lethargic
and had moderate oozing of blood from her mouth/was swallowing
blood, with resultant hemoptysis and hematemesis. Denied ETOH
abuse. Admitted to taking aspirin but no other anticoagulants.
She presented to ___, where she was febrile to 102.5,
hypotensive to 70/40s, had significant leukocytosis to 15.9 (10%
bands), lactic acidosis (3.5), and floridly positive urinalysis
indicative of UTI. INR was 1.9, PTT 21.2, plts 73, Hgb 12.1. UA
showed 3+ blood, 2+ glucose, 3+ protein, >150RBCs/hpf, 109
WBC/hpf, and few bacteria. CXR showed clear lungs, noncontrast
___ CT showed no abnormalities, CT abd/pelvis showed
perinephric stranding greater on the left (nonspecific, maybe
chronic), no hydronephrosis, hydroureter, renal/ureteral stones.
She was treated with vancomycin and Zosyn, given 4L of normal
saline, and started on peripheral levophed prior to transfer to
___.
In the ED, initial vitals: T 99.7. HR 72, BP 92/48 (low 78/46),
RR ___, SPO2 90-98% on RA. She was awake, interactive, and
fully oriented.
Exam notable for dried blood in the mouth, but no active
bleeding, bilateral CVAT.
Labs showed:
--WBC 23.6 (22% bands), Hgb 11.2 (stable compared to
presentation at OSH), plt 76
--fibrinogen 70
-- INR 1.7, PTT 39
--lactate 2.3
--VBG 7.3/___
--Ca 7.5, Mg 1.2, Phos 1.6
While in the ED, the patient became more hypotensive, more
confused, and tachypneic, and out of concern for impending
respiratory collapse, she was intubated urgently in the ED. On
arrival to the MICU, patient is intubated and unable to provide
history.
Past Medical History:
-Hypertension
-CAD
-Hyperlipidemia
-Asthma
-Osteoarthritis
-Depression
-Morbid Obesity
-GERD
-Varicose veins
-Chronic low back pain
-Anxiety
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
GENERAL: intubated and sedated on fentanyl and midazolam.
Intermittently moves all 4 extremities when sedation is
lightened.
HEENT: Sclera anicteric. Dark dried blood in mouth and on lips.
No active oral bleeding
NECK: supple, unable to assess JVP
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, distended, no masses. No reaction to palpation.
Decreased bowel sounds
EXT: Lukewarm, no edema.
SKIN: dry, no rashes or petechiae
NEURO: sedated on midazolam and fentanyl. Pupils 1mm sluggishly
reactive to light. Gaze conjugate, no roving eye movements.
Opens eyes and squeezes hands to command. No tremor, clonus, or
rigidity.
DISCHARGE PHYSICAL EXAM
===============================
98.2, 127/55, pulse 80, rr18, 98% on RA
General: Pleasant, well-appearing. NAD.
HEENT: EOMI. MMM.
Neck: Supple. No LAD appreciated. HD line in place on Right IJ.
CV: II/IV crescendo-decrescendo murmur at base
Lungs: Expiratory wheezes bilaterally; no crackles
Abdomen: Prominent adipose tissue. Non-distended. Soft,
non-tender to palpation.
Ext: WWP with good pulses. 2+ pitting edema to mid thigh.
Neuro: Alert and oriented, CNII-XII grossly intact. Grossly
non-focal.
Skin: Stage 2 sacral ulcer, pre-existing
Pertinent Results:
ADMISSION LABS:
___ 03:10AM BLOOD WBC-23.6* RBC-3.80* Hgb-11.2 Hct-35.1
MCV-92 MCH-29.5 MCHC-31.9* RDW-15.2 RDWSD-51.2* Plt Ct-76*
___ 03:10AM BLOOD Neuts-75* Bands-22* Lymphs-1* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-22.89*
AbsLymp-0.24* AbsMono-0.47 AbsEos-0.00* AbsBaso-0.00*
___ 03:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 03:10AM BLOOD Plt Smr-VERY LOW Plt Ct-76*
___ 03:11AM BLOOD Fibrino-70*
___ 07:45AM BLOOD Parst S-NEGATIVE
___ 07:45AM BLOOD Ret Aut-1.9 Abs Ret-0.07
___ 03:11AM BLOOD Glucose-115* UreaN-29* Creat-2.0* Na-144
K-3.2* Cl-113* HCO3-14* AnGap-20
___ 03:11AM BLOOD ALT-15 AST-40 LD(LDH)-538* AlkPhos-59
TotBili-1.5
___ 03:11AM BLOOD Calcium-7.5* Phos-1.6* Mg-1.2*
___ 03:21AM BLOOD D-Dimer-GREATER TH
___ 07:45AM BLOOD Hapto-49
___ 04:33AM BLOOD Type-CENTRAL VE pO2-44* pCO2-38 pH-7.30*
calTCO2-19* Base XS--6
___ 03:20AM BLOOD Lactate-2.3*
___ 07:49AM BLOOD Type-ART Temp-36.9 Rates-16/ Tidal V-450
PEEP-10 FiO2-50 pO2-187* pCO2-33* pH-7.24* calTCO2-15* Base
XS--12 Intubat-INTUBATED Vent-CONTROLLED
___ 04:33AM BLOOD freeCa-1.01*
RELEVANT TRENDS
================
___ 07:20 1.6*
___ 09:25 2.1*
___ 07:20 2.4*
___ 21:59 2.6*
___ 05:49 2.9*
___ 08:15 3.6*
___ 12:07 3.8*
___ 05:17 3.6*
___ 05:55 2.9*
___ 05:35 4.8* ---Last day of HD
___ 08:52 3.9*
___ 04:30 2.2*
___ 04:15 2.8*
___ 20:54 2.2*--- HD started
___ 04:01 1.1
___ 21:44 0.9
___ 15:05 0.9
___ 08:41 1.0
___ 03:56 1.0
___ 22:00 1.0
___ 15:45 1.0
___ 09:55 1.1
___ 03:52 1.2*
___ 22:30 1.3*
___ 09:38 1.0
___ 03:11 0.9
___ 21:52 0.9
___ 15:41 1.0
___ 03:05 1.2*
___ 20:09 1.2*
___ 08:30 1.8*
___ 01:57 2.2*
___ 20:30 2.7*---CRRT started
___ 16:30 2.6*
___ 10:44 2.4*
___ 07:45 2.2*
___ 03:11 2.0*
DISCHARGE LABS:
___ 09:25AM BLOOD WBC-5.2 RBC-2.73* Hgb-7.9* Hct-25.4*
MCV-93 MCH-28.9 MCHC-31.1* RDW-16.0* RDWSD-54.8* Plt ___
___ 07:20AM BLOOD Glucose-92 UreaN-36* Creat-1.6* Na-143
K-4.4 Cl-107 HCO3-26 AnGap-14
IMAGING:
ECHO ___: IMPRESSIONS: Normal left ventricular cavity size
with moderate global left ventricular systolic dysfunction and
relative preservation of apical contractile function. Mild to
moderate mitral regurgitation. Mild aortic regurgitation.
CXR ___: IMPRESSION: Left basilar pleural effusion and
atelectasis. Pulmonary vascular congestion and minimal
interstitial edema.
RENAL U/S ___: IMPRESSION: Limited Doppler evaluation.
Within these limitations, normal intrarenal artery and main
renal vein waveforms are identified with moderately elevated
resistive indices. Symmetric renal size. No hydronephrosis.
CT ___ w/o Contrast ___: IMPRESSION: No acute intracranial
abnormalities are identified. Chronic right thalamic lacunar
infarct.
CT Abdomen w/o Contrast ___: IMPRESSION: Extensive
nonspecific perinephric stranding may represent an infectious or
inflammatory process and could correspond to the clinical
suspicion for urosepsis / pyelonephritis. Evaluation is limited
without the use of IV contrast. There is no perinephric
abscess, hydronephrosis, or nephrolithiasis.
Age-indeterminate L2 compression fracture. Moderate hiatal
hernia with a fluid-filled intrathoracic esophagus, which may
predispose to aspiration.
2 mm pulmonary nodules.
BILAT LOWER EXT VEINS PORT ___: IMPRESSION: No evidence of
deep venous thrombosis in the right or left lower extremity
veins. 1.9 cm left popliteal ___ cyst.
UNILAT UP EXT VEINS US LEFT ___: IMPRESSION: Technically
limited exam due to multiple factors as described above. No
evidence of deep vein thrombosis in the left upper extremity.
Portable Abdomen ___: IMPRESSION: Nonobstructive bowel gas
pattern.
CXR ___: IMPRESSION: Increase right lower lobe infiltrate
CT ___ w/o Contrast ___: IMPRESSION: No acute intracranial
process. If there is concern for acute stroke, consider MRI for
further evaluation.
MR ___ w/o Contrast ___: 1. No evidence of acute infarction.
Chronic small vessel ischemic disease.
EEG ___: This is an abnormal continuous ICU EEG monitoring
study because of moderate to severe diffuse background slowing
and abundant triphasic waves. These findings are indicative of
moderate to severe diffuse cerebral dysfunction, which is
nonspecific as to etiology. The frequency of triphasic waves
decreases in the second half of the study. No epileptiform
discharges or electrographic seizures are present.
Carotid Ultrasound ___:
Minimal heterogeneous plaque in the left internal carotid artery
causing less than 40% stenosis.
Brief Hospital Course:
___ year old woman with a history of hypertension, CAD,
hyperlipidemia, asthma, OA, depression, anxiety presenting as a
transfer from ___, where she presented with
the chief complaints of gingival bleeding after teeth cleaning,
hemoptysis, and diarrhea, found to be in shock with likely
pyelonephritis (abnormal UA, perinephric stranding on imaging)
as source, with multiple lab abnormalities concerning for DIC.
She is transferred to the MICU for management of shock and DIC.
Received broad spectum antibiotics which were narrowed
empirically to meropenem in setting of culture negative sepsis.
Required intense pressor support, CRRT for renal failure, blood
products for DIC and intubation for respiratory support. She was
able to be liberated of pressors and ventilation in the MICU,
upon call-out to the floor she remained on intermittent HD for
renal failure. Her renal function progressively recovered on the
floor and was taken off HD, discharge creatinine of 1.6.
#Shock: Patient came in with severe septic shock and refractory
acidosis. Presumed to be urinary source, she was started on
broad spectrum antibiotics vancomycin, Meropenem, doxycycline,
and one dose of tobramycin. Most likely primary infectious
insult is pyelonephritis (abnormal UA, perinephric stranding on
imaging). She was intubated and placed on the vent. She was
started on CRRT day one for refractory acidosis. She was given
stress dose steroids empirically. She required blood pressure
support with pressors maxing out on norepinephrine, vasopressin,
and epinephrine. Over the course of several days she was
gradually weaned off pressors with some changes in agents based
on perceived need for positive inotropy, although formal TTE
revealed that cardiogenic shock was not the primary underlying
problem. Cultures of urine and blood returned negative giving
the diagnosis of culture negative sepsis. She was taken off of
pressors and bridged with midrodine on ___, upon call-out from
MICU midodrine was discontinued. Due to the low concern for MRSA
sepsis, vancomycin was discontinued on day 6 of treatment and
she continued to improve. She completed a 14 day course of
Meropenem for culture negative sepsis. Doxycycline was
discontinued on ___ as Anaplasma phagocyticum antibodies
returned negative.
#DIC: Patient presented with prolonged bleeding after dental
cleaning, with septic shock, thrombocytopenia, prolonged ___,
low plasma fibrinogen, elevated D-Dimer, schistocytes on smear,
all consistent with DIC, likely provoked by culture negative
sepsis. Hematology consult felt that given her clinical picture,
other causes of DIC such as TTP or APML were unlikely.
She got FFP and cryoprecipitate x2 on ___. Hematology
recommended FFP if fibrinogen < 100. Her ___ PTT plt and
fibrinogen was trended and she did not require any further
products. Her coagulation studies remained normal on the floor.
#Acute renal failure: Patient was anuric since arrival. She was
started on CRRT early in her course for refractory acidosis in
the face of a normalizing lactate. Basline creatinine was
unknown, but she has a h/o CKD per records. She was continued on
CRRT until ___ where it was discontinued with her 1 L positive
for admission. Her HD line in her R IJ was kept in after
stopping CRRT due to concern that patient would need
intermittent HD going forward. She remained nearly anuric as she
was being called out from the ICU. She received intermittent HD
on the floor as she began having little then brisk urine output,
likely reflecting post-ATN diuresis. Her last HD session was on
___, since then her renal function has steadily improved. Her
temporary HD line was pulled on ___. Creatinine on discharge
was 1.6.
#Hepatic injury: Transaminases peaked in the 1300-1500s on ___
which is time most intense need for pressor support.
Hepatocellular (ALT>AST pattern) without cholestasis (normal ALP
and Tbili) are atypical for ischemic hepatopathy though. ALT
continued trending down and nearly normalized as her infectious
injury resolved. HBV and HCV have been ruled out. Leptospira and
anaplasma were ruled out.
#Respiratory Failure: Intubated initially due to concerns for
worsening mental status and inability to protect her airway. Was
put on the ARDSnet protocol. She was Extubated on ___.
# L visual field deficit (resolved): This was transient noticed
on ___ and resolved by ___. Workup with MRI, carotid ultrasound
and EEG was all reassuring that this patient did not have CVA,
seizure, or mass effect.
#Antibiotic Associated Diarrhea: Developed multiple loose bowel
movements on the floor. Was negative for C.difficile NAAT.
Likely secondary to antibiotic therapy. Was kept on yogurt 1 cup
tid with progressive improvement and resolution at the time of
discharge.
TRANSITIONAL ISSUES:
===========================
#Renal function: Creatinine on discharge is 1.6. Unclear
baseline but will need repeat Chem-10 4 days in rehab to assess
creatinine trend. PCP to determine based on plateau whether
patient will have some degree of CKD which may or may not
require her to be followed by a nephrologist.
#Pulmonary nodules: Multiple small pulmonary nodules are noted
in the lung bases, including a 5 mm perifissural nodule (2:1),
and a 2 mm right middle lobe pulmonary nodule (2:1). The 5mm
nodule needs f/u with repeat non-con chest CT scan in 12 months
(___).
#Osteoporosis: Age-indeterminate L2 compression fracture
incidentally found on CT Torso. Consider management of
osteoporosis with bisphosphonates or RANKL inhibitors.
#Congestive heart failure: Please consider starting low dose ACE
inhibitor as outpatient if continuing improvement in renal
function. In addition, would repeat TTE as outpatient.
#Code Status: DNR, OK to intubate
#Contact: ___
Relationship:Son
Cell ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN indigestion
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Atorvastatin 80 mg PO QPM
8. Lisinopril 10 mg PO DAILY
9. GuaiFENesin ER Dose is Unknown PO Frequency is Unknown
10. Gabapentin 300 mg PO DAILY
11. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
12. Pulmicort (budesonide) unknown inhalation BID
13. Sertraline 50 mg PO DAILY
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
15. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
16. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
3. Alendronate Sodium 70 mg PO QMON
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q4h:prn
Disp #*20 Tablet Refills:*0
8. Pulmicort (budesonide) 1 puff INHALATION BID
9. Sertraline 50 mg PO DAILY
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Presumed Pyelonephritis, due to presumed multi-drug resistant
gram negative rods
Culture negative Septic Shock
Acute Kidney Failure
Acute Disseminated Intravascular Coagulation
Acute Hypoventilatory Respiratory Failiure
Acute Liver Impairment
SECONDARY
Antibiotic associated diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were transferred to the hospital due to a very severe
infection that impaired your circulation, clotting, lungs, liver
and kidneys. You recovered with antibiotics and aggressive
support in the ICU. Your kidneys took longer to recover and you
needed dialysis for a while. Your kidneys recovered and you no
longer need dialysis. You are going to rehab to work on getting
you stronger to go back home. We wish you a continued recovery.
Your ___ Team
Followup Instructions:
___
|
10489424-DS-12 | 10,489,424 | 29,639,595 | DS | 12 | 2131-05-11 00:00:00 | 2131-05-12 17:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH dCHF, diabetes, HTN/HLD, ESRD (on HD TuThSa, not
anuric), CAD s/p silent MI, paroxysmal Afib (not on warfarin),
Hx of syncope and resulting fall w/ head trama in ___ and other
issues who presented with generalized weakness, dizziness, and
nausea/vomiting. He is ___ only and accompanied
by his daughter who provides the history. He had a recent
likely viral URI which resolved without intervention. Since
then, he reports that he began feeling dizzy this morning. The
symptoms are intermittent, not provoked by any particular action
or position changes and last a few seconds at a time. He does
not feel as though the room is spinning but is unable to further
articulate what he means by feeling dizzy. There is associated
nausea and has had one episode of vomiting thus far. He was seen
in the emergency department and admitted approximately 1 month
ago with identical symptoms. During that visit he was evaluated
by neurology, who felt that his symptoms were consistent with
BPPV, although he had a negative ___ at that time. He
performed the prescribed particle repositioning exercises at
home without relief. He denies any recent fever, chills, chest
pain, shortness of breath, abdominal pain, dysuria, bowel
changes.
In the ED, initial vitals: 97.5 51 151/61 18 99% RA.
___ reportedly negative in the ED. Labs were
significant for WBC and diff WNL, Hgb 12.7 w/ MCV 102 (baseline
Hgb ___, proBNP 2800, HCO3 27, lytes WNL (except for BUN/Cr,
elevated, on HD) Trop 0.03, Lactate 1.9, UA w/ 2 WBCs, no
bacteria, 100 protein, 150 glucose. CT head showed no acute
abnormality, CXR showed no focal consolidation, mild pulm edema,
and small R pleural effusion. ECG showed no ischemic changes.
Patient received IV Metaclopramide and IV Diphenhydramine, which
led to significant symptom relief. Neurology evaluated him and
felt that his Sx were "consistent with peripheral vertigo but
since there is no association with head movement and several
episodes were witnessed when the patient was not moving, this is
unlikely to be BPPV. This is possibly a perilymphatic fistula
given the prior trauma and possibly vestibular paroxysmia. It is
unlikely to be vesibular neuronitis/laberynthitis given lack of
prodrome and brief spells, Meniere's given patient's age and
intact sensorineural hearing, otitis media given normal tympanic
membranes bilaterally." They recommended admission to medicine
for treatment of nausea/vomiting, dialysis, and fluid
management. Vitals prior to transfer: 98.0 64 132/46 14 96%
RA.
Currently, the patient denies pain and does not feel dizzy if he
is not moving his head. He is reporting blurry vision for the
past several days but not other changes.
Past Medical History:
1) coronary artery disease with subclinical MI in the past (LVEF
45% with basal/mid inferior/inferolateral hypokinesis, ___
pathologic Q waves inferiorly on ECG)
2) longstanding diastolic heart failure
3) paroxysmal atrial fibrillation, documented after large AV
graft bleed in ___ and most recently on transtelephonic
monitoring (ventricular rates ___ bpm) in ___
4) hypertension, on carvedilol, imdur, and furosemide
5) hyperlipidemia, with TC 92, TG180 HDL 57 in ___
6) peripheral vascular disease on ABI testing in ___, b/l
tibial
7) diabetes, insulin dependent, with HbA1c 6.6% on ___ c/b
retinopathy
8) chronic kidney disease (stage V), followed at ___,
vascular graft placed LUE in ___ but no dialysis prior to this
admission (___)
dialysis
9) BPH on tamulosin
10) open angle glaucoma and dry eyes
11) pulmonary nodules
12) vitamin D deficiency
13) syncope w/ SAH, SDH, IVH in ___
Surgeries:
- AV Graft, LUE ___ with revision and thrombectomy
___
- cholecystectomy
- cataract surgery, b/l
Social History:
___
Family History:
No known premature CAD, arrhythmia, or SCD but family history is
largely unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.0 140-168/48-56 61-64 16 96% RA
GENERAL: NAD, well appearing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNG: Mildly decreased breath sounds bilaterally, R>L. no
wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, LUE fistula w/ thrill
PULSES: 2+ DP pulses bilaterally
NEURO: Moving all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: 97.9 108-147/41-59 64-69 16 97% RA
GENERAL: NAD, well appearing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNG: Mildly decreased breath sounds bilaterally, R>L. no
wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, LUE fistula w/ thrill
PULSES: 2+ DP pulses bilaterally
NEURO: Moving all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
PERTINENT LABS:
===============
___ 09:29AM BLOOD WBC-5.4 RBC-3.87* Hgb-12.7* Hct-39.6*
MCV-102* MCH-32.8* MCHC-32.1 RDW-14.7 RDWSD-54.8* Plt ___
___ 09:29AM BLOOD Neuts-63.4 ___ Monos-8.5 Eos-2.0
Baso-0.7 Im ___ AbsNeut-3.45 AbsLymp-1.37 AbsMono-0.46
AbsEos-0.11 AbsBaso-0.04
___ 08:06AM BLOOD WBC-4.1 RBC-3.64* Hgb-12.1* Hct-36.7*
MCV-101* MCH-33.2* MCHC-33.0 RDW-14.5 RDWSD-53.3* Plt ___
___ 09:29AM BLOOD Glucose-152* UreaN-53* Creat-6.8*# Na-140
K-4.7 Cl-99 HCO3-27 AnGap-19
___ 07:04AM BLOOD Glucose-104* UreaN-39* Creat-5.4*# Na-138
K-4.0 Cl-96 HCO3-28 AnGap-18
___ 09:29AM BLOOD proBNP-2863*
___ 09:29AM BLOOD cTropnT-0.03*
___ 07:04AM BLOOD Calcium-8.1* Phos-5.5* Mg-2.1
___ 09:37AM BLOOD Lactate-1.9
___ 11:14AM URINE Color-Straw Appear-Clear Sp ___
___ 11:14AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
___ 11:14AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 11:14AM URINE CastHy-1*
PERTINENT MICRO:
================
___ CULTUREBlood Culture, Routine-PENDING
___ CULTUREBlood Culture, Routine-PENDING
PERTINENT IMAGING:
==================
CXR ___:
IMPRESSION:
1. No focal consolidation.
2. Mild pulmonary edema.
3. Small right pleural effusion
CT HEAD ___:
IMPRESSION:
No acute intracranial abnormality.
Brief Hospital Course:
___ PMH dCHF, diabetes, HTN/HLD, ESRD (on HD TuThSa, not
anuric), CAD s/p silent MI, paroxysmal Afib (not on warfarin),
Hx of syncope and resulting fall w/ head trama in ___ and other
issues admitted for symptom control of vertigo.
ACTIVE ISSUES:
==============
# Vertigo / nausea & vomiting:
Associated with nystagmus on exam, though patient with negative
___ in ED. Per initial neuro assessment, given that
several episodes were witnessed when the patient was not moving,
this was unlikely to represent BPPV. History of head trauma
raises possibly of perilymphatic fistula and possibly vestibular
paroxysmia or superior semicircular canal dehisence. It was felt
to be unlikely to be vesibular neuronitis/laberynthitis given
lack of prodrome and brief spells, Meniere's disease also
unlikely given intact sensorineural hearing. However, upon
reassessment, patient reported that his worst symptoms occurred
with head movement, making the diagnosis of BPPV most likely.
His symptoms of nausea/vomiting improved rapidly with
administration of meclizine, which he tolerated well. He was
discharged home with ENT follow-up for further evaluation of
possible structural contributor to dizziness given history of
head trauma.
CHRONIC ISSUES:
===============
# CAD/HTN/HLD:
The patient was continued on his home ASA 325, Carvedilol 6.25
mg PO BID, Rosuvastatin, Isosorbide Mononitrate (Extended
Release) 60 mg PO DAILY, Amlodipine, and Fenofibrate 54 mg PO
DAILY.
# Glaucoma
Continued Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
and Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
# ESRD:
CKD stage V, receives HD through LUE graft, though not anuric.
Continued on Calcitriol 0.25 mcg PO DAILY, Furosemide 100 mg PO
DAILY, Nephrocaps 1 CAP PO DAILY, and calcium acetate 667 mg
oral TID W/MEALS.
# DM2:
Continued Humalog ___ 10 Units Breakfast, Humalog ___ 7
Units Bedtime
# BPH:
Continued Tamsulosin 0.4 mg PO QHS.
# CODE STATUS: Full
# CONTACT: ___ (Daughter) ___. Also daughter
___ (___)
___ ISSUES:
====================
- Given patient's history of head trauma, he should be evaluated
for structural vestibular etiologies of dizziness, including
perilymphatic fistula and superior semicircular canal
dehiscence. Dedicated imaging of the temporal bone should be
performed as an outpatient with either MRI or high-resolution
CT.
- Patient's home medication list has him recorded as being on
Carvedilol 25 mg PO BID; however, his most recent OMR notes
record him as being on 6.25 mg PO BID. As this could have
contributed to his dizziness, he was trialed on 6.25 mg PO BID
here and was normotensive. He should continue on 6.25 mg PO BID
until his next cardiology follow-up appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 325 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Calcitriol 0.25 mcg PO DAILY
5. Carvedilol 25 mg PO BID
6. Fenofibrate 54 mg PO DAILY
7. Furosemide 100 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. econazole 1 % topical DAILY:PRN fungus
14. Humalog ___ 10 Units Breakfast
Humalog ___ 7 Units Bedtime
15. Amlodipine 5 mg PO DAILY
16. Co Q-10 (coenzyme Q10) 100 mg oral TID
17. PhosLo (calcium acetate) 667 mg oral TID W/MEALS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Calcitriol 0.25 mcg PO DAILY
5. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Furosemide 100 mg PO DAILY
7. Humalog ___ 10 Units Breakfast
Humalog ___ 7 Units Bedtime
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Ascorbic Acid ___ mg PO BID
14. Co Q-10 (coenzyme Q10) 100 mg oral TID
15. econazole 1 % topical DAILY:PRN fungus
16. Fenofibrate 54 mg PO DAILY
17. PhosLo (calcium acetate) 667 mg ORAL TID W/MEALS
18. Meclizine 12.5 mg PO TID
RX *meclizine 12.5 mg 1 tablet(s) by mouth three times daily
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Benign Paroxysmal Positional Vertigo
Secondary: End-stage renal disease on hemodialysis, diastolic
congestive heart failure, hypertension, coronary artery disease,
paroxysmal 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 our pleasure caring for you at ___
___. You were admitted to the hospital with
dizziness. Our neurologists evaluated you and felt that your
dizziness was most consistent with a diagnosis called Benign
Paroxysmal Positional Vertigo (BPPV). We gave you medications
to control the symptoms, and your symptoms improved. You also
received one session of hemodialysis here, which you tolerated
well. When you were feeling better, you were discharged home.
You should weigh yourself every morning, and call MD if your
weight goes up more than 3 lbs in 1 day or more than 5 lbs in
one week.
Finally, we have arranged ENT follow-up for you to further
investigate why you are feeling dizzy. You should continue to
perform the particle repositioning exercises you were prescribed
by neurology.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10489424-DS-17 | 10,489,424 | 26,691,779 | DS | 17 | 2134-04-27 00:00:00 | 2134-04-27 19:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ w/ T2DM (7.8 in ___ complicated by
nephropathy requiring HD ___, CAD, diastolic CHF (EF 51% in
___, atrial fibrillation not on AC, HTN, HLD, and PVD s/p
bilateral tibial stent and R femoral stent who presents with
dyspnea and was found to have pulmonary edema by PCP. His last
dialysis was on ___ but he continues to have persistent
dyspnea.
He can walk up to 6 steps before having to stop. He and his
daughter have also noticed abdominal distention. Patient is not
very reliable with weighing himself and is still making urine.
Of
note, per PCP referral, patient has been having shortness of
breath for 1.5 months concurrent with bilateral leg weakness.
Recently, he has had increased blood sugars and has had his
insulin increased from 25 U to 27U by his endocrinologist.
He denies chest pain, fever.
He is a former smoker but is not on inhalers and has no history
of COPD. He has no recent travel, cancer, history of clots, leg
swelling or surgeries.
In the ED, initial vitals:
T 97.6 HR 84 BP 156/54 HR 18 O2 Sat 95% RA
- Exam notable for:
Bilateral inspiratory crackles up to mid-lung base and JVD 5cm
above the sternal angle. Mildly distended abdomen. Breathing
comfortably and able to speak complete sentences on room air. He
has trace pedal edema and AVF on L arm
- Labs notable for:
CBC: Hgb 11.3 with MCV 101
ALT 43 and Alk Phos 148; remainder of LFTs within normal limits
Trop 0.07 -> 0.08, MB ___NP 2550
Chem panel: K 4.9, BUN 68, Cr 8.1, anion gap 19
Mg 2.8, P 5.2
Lactate 1.2
Urine: 100 protein, 300 glucose, trace blood, few bacteria
ECG: NSR, RR, HR 82, RBBB
- Imaging notable for:
CXR ___
Small partially loculated left-sided pleural effusion.
Mild pulmonary edema.
- Pt given:
IV Lasix 200mg
Rosuvastatin 20mg
Tamsulosin 0.4mg
2U SC Insulin
Sevelamer 1600mg
Nephrology evaluated patient and felt there was no urgent need
for dialysis and recommended aggressive diuresis. They will set
up for inpatient HD.
- Vitals prior to transfer:
T 98.1 HR 85 BP 126/74 RR 14 O2 Sat 94% RA
Upon arrival to the floor, the patient reports that his
breathing
is improved compared to admission. He denies any chest
discomfort
or pain. He does not have significant edema.
Past Medical History:
Type 2 diabetes complicated by nephropathy and retinopathy
CKD on HD ___- AV Graft in LUE ___ with revision and
thrombectomy in ___
CHF
Hypertension
Hyperlipidemia
Coronary artery disease c/b silent MI
PVD sp bilateral tibial artery and R femoral artery stent
Atrial fibrillation not on AC
Syncope with subarachnoid hemorrhage, subdural hemorrhage and
intraventricular hemorrhage in ___
BPH
Cataract sp bilateral cataract surgery
Pulmonary nodules
Vitamin D deficiency
Open angle glaucoma
Macular degeneration
Cholecystectomy
Social History:
___
Family History:
No known premature CAD, arrhythmia, or SCD but family history is
largely unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.4 BP 142 / 60 HR 84 RR 22 O2 Sat 92 2L NC
General: Alert, oriented, no acute distress, speaks ___
with a touch of ___.
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
Lungs: inspiratory crackles throughout
Abdomen: Soft, non-tender, distended abdomen. Bowel sounds
present.
GU: No foley
Ext: LUE thrill is palpable and with bruit, with good distal
pulses although slightly diminished radial pulse. Other
extremities are warm but ___ bilaterally are non-palpable and
require Doppler. Left elbow with psoriasis plaque. He has good
capillary refill. He has no clubbing, cyanosis or edema.
Skin: Warm and dry. No lower extremity edema. No xanthalasma or
stasis dermatitis. He has some Scaling along feet and between
his
toes. Some areas of hyperpigmentation along legs.
Neuro: CNII-XII intact, normal sensation in upper extremities,
diminished sensation in lower extremities.
Psych: Mood and affect appropriate.
DISCHARGE PHYSICAL EXAM:
___ 1554 Temp: 97.9 PO BP: 133/48 R Lying HR: 92 O2 sat:
94% O2 delivery: RA
General: No acute distress, comfortable, on nasal cannula
HEENT: No pallor or icterus, OP is clear
CV: Irregular rhythm, normal rate, no murmurs
Lungs: Faint bibasilar crackles, no wheezes or rhonchi,
non-labored
Abdomen: Soft, nontender, nondistended, NABS
Ext: Warm, no edema
Neuro: Alert, oriented, non focal deficit
Access: LUE AV graft with bruit
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-6.5 RBC-3.59* Hgb-11.3* Hct-36.3*
MCV-101* MCH-31.5 MCHC-31.1* RDW-13.3 RDWSD-49.4* Plt ___
___ 05:30PM BLOOD Neuts-57.6 ___ Monos-13.6*
Eos-4.3 Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-1.46
AbsMono-0.85* AbsEos-0.27 AbsBaso-0.05
___ 05:30PM BLOOD Glucose-193* UreaN-68* Creat-8.1* Na-140
K-4.9 Cl-95* HCO3-26 AnGap-19*
___ 05:30PM BLOOD Albumin-4.1 Calcium-9.4 Phos-5.2* Mg-2.8*
___ 02:10PM BLOOD ALT-43* AlkPhos-148*
___ 02:10PM BLOOD cTropnT-0.07*
___ 05:30PM BLOOD CK-MB-2 proBNP-2550*
___ 02:10PM BLOOD TSH-2.0
___ 05:48PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-6.3 RBC-3.00* Hgb-9.7* Hct-28.6*
MCV-95 MCH-32.3* MCHC-33.9 RDW-13.2 RDWSD-45.8 Plt ___
___ 07:05AM BLOOD Glucose-318* UreaN-79* Creat-9.8*# Na-136
K-4.1 Cl-88* HCO3-24 AnGap-24*
___ 07:05AM BLOOD Calcium-8.3* Phos-7.4* Mg-2.5
IMAGING:
====================
___ CXR
IMPRESSION:
Small partially loculated left-sided pleural effusion.
Mild pulmonary edema.
___ TTE
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional LV systolic
dysfunction c/w CAD, with borderline low ejection fraction.
Normal right ventricular free wall
systolic function.
Compared with the prior TTE (images not available for review) of
___ , the findings are probably
similar.
___ Stress Test
INTERPRETATION: This ___ year old IDDM man with h/o ESRD, PVD,
dCHF,
and silent MI was referred to the lab for evaluation of dyspnea
and
chest pain. The patient was administered 0.4 mg of Regadenoson
IV bolus
over 20 seconds. No chest, neck, back, or arm discomforts were
reported
by the patient throughout the study. In the presence of RBBB,
there was
0.5 mm of upsloping ST segment depression in leads V4-6,
resolving as
recovery continued. The rhythm was sinus with one VPB.
Appropriate
hemodynamic response to the infusion. Post-MIBI, the Regadenoson
was
reversed with 60 mg of IV Caffeine.
IMPRESSION: No anginal type symptoms. Non-specific EKG changes
in the
setting of RBBB. Nuclear report sent separately.
For pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was
infused
intravenously over 20 seconds followed by a saline flush.
FINDINGS: Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a moderate to severe
fixed defect along
the inferior wall, although there is adjacent soft tissue
attenuation, this is
likely a true abnormal finding.
Gated images reveal a mildly hypokinetic inferior wall.
The calculated left ventricular ejection fraction is 49% with an
EDV of 75 mL.
IMPRESSION: 1. Fixed perfusion defect in RCA territory with
associated inferior
wall motion abnormality. 2. Normal left ventricular cavity size
with an EF of
49%.
___ V/Q scan
FINDINGS: Ventilation and perfusion images demonstrate a large
matched defect
at the right apex as well as small, irregular defect at the left
base. There is
matched heterogeneity elsewhere. There are no mismatched
defects.
Chest x-ray shows moderate loculated left-sided pleural
effusion. No
abnormality seen at the right apex.
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
___ CXR
IMPRESSION:
Interval growth of a partially loculated left-sided pleural
effusion, now moderate.
Unchanged mild pulmonary edema and small right pleural effusion.
Brief Hospital Course:
P - Patient summary statement for admission
===================================
Mr. ___ is a ___ w/ T2DM (7.8 in ___ complicated by
nephropathy requiring HD ___, CAD, CHF (Ef 51% in ___,
atrial fibrillation not on AC, HTN, HLD, and PVD s/p bilateral
tibial stent and R femoral stent who presents with subacute
dyspnea, found to have pulmonary edema.
A - Acute medical/surgical issues addressed
===================================
# Dyspnea
# Pleural effusion
# New oxygen requirement
# Volume overload
Patient presents with dyspnea and 2L O2 requirement likely ___
volume overload due to renal disease or heart failure. Admission
CXR revealed mild pulmonary edema and small partially loculated
left-sided pleural effusion. TTE similar to most recent TTE in
___, as below. pMIBI negative for new perfusion defects, as
below. V/Q scan negative for PE. Loculated pleural effusion
could represent infection, however he does not have any clinical
or lab findings consistent with infection. While he may have
emphysema and has a significant tobacco history, no sputum or
history of COPD. Treated volume overload with 200mg IV lasix
then continued home torsemide 100mg QD. He was maintained on his
regular home HD schedule (___). He was noted to be
very responsive to fluid shifts during HD. At time of discharge
he was euvolemic, satting well on RA, ambulatory O2 sats 88-93%
on RA. Discharge weight 54.3 kg (119.71 lb).
# Left-sided loculated pleural effusion
Small sized loculated pleural effusion was noted on admission
chest x-ray. On repeat chest x-ray prior to admission, effusion
had increased in size and now moderate in size. We did not feel
this effusion is responsible for patient's dyspnea and shortness
of breath, however, given the loculated appearance it should
still be sampled for diagnostic purposes. IP was consulted and
recommended outpatient follow-up for possible thoracentesis.
# End stage renal disease
Pt of Dr. ___ underwent angiogram of fistula on
___ after finding pulsatility on exam with very low flow.
Continued HD as above, and home sevelamer 1600mg with meals.
# Heart failure, diastolic, chronic
Stage C, NYHA functional class II-III. EF 51% in ___. Has been
noted to have chronic bilateral crackles on past exams.
Previously on home Lasix and now recently torsemide (100mg) and
still makes urine. He has been noted to be overly indulgent with
sodium intake in the past but denies recent dietary
indiscretion. Normal dry standing weight is around 120lb,
admission wt 118lb. Admission BNP only mildly elevated at 2550.
___ TTE demonstrating mild symmetric LV hypertrophy with mild
regional LV systolic dysfunction c/w CAD, LVEF 55%, overall
similar to prior TTE in ___. pMIBI without new perfusion
defect, as above. Diuresis and HD, as above. Pt noted to be
highly responsive to fluid shifts and went into afib (HR
100s-120s) during HD, so transitioned from home carvedilol
(6.25mg BID on non-dialysis days, 6.25mg QHS on dialysis days)
to metoprolol XL 25mg QD.
# CAD
# RBBB
Patient has been having "pinches" in his chest with exertion
that accompany his dyspnea and resolve with rest. He sees Dr.
___ cardiology. Silent MI in past with mildly reduced
left ventricular function. Last ischemic testing was in ___.
pMIBI this admission demonstrated fixed perfusion defect in RCA
territory with associated inferior WMA, consistent with
distribution of known prior silent MI. In ___, his EKGs were
noted to have right bundle branch block and inferior infarct.
This was noted again in ___ hospital admissions. More recently,
in early ___, he did not have a pronounced RBBB morphology
although his present ED EKG does show a significant RBBB.
Trended trops reveal stable troponin 0.07 and 0.08 likely in the
setting of CKD and normal stable CK-MB. Chest pain free during
this admission. He takes full dose aspirin daily and is on beta
blocker. His nitrate has been on hold given blood pressure
readings. Continued home aspirin, crestor. Transitioned from
carvedilol to metoprolol, as above.
# Paroxysmal atrial fibrillation
Documented after large AV graft bleed in ___. CHA2DS2VASC
score of 6 and HASBLED score of 6. He was previously on systemic
anticoagulation but suffered from a subarachnoid and a subdural
bleed in ___. Not on anticoagulation at present due to history
of fistula bleed and subdural hematoma and also due to logistics
(difficult to monitor INR, wife has dementia and is blind).
Continued home ASA 325. Transitioned from carvedilol to
metoprolol, as above.
# Dysphagia
PCP ordered ___ swallowing study for an evaluation. Bedside SLP
evaluation found patient to have functional oropharyngeal
swallowing abilities and low concern for aspiration, although
cannot rule out silent aspiration without video swallow study.
# Elevated anion gap
To 19 on admission, likely related to renal failure. Lactate
normal, no history of ingestions, and no evidence of
ketoacidosis.
- Continue to monitor
# Elevated ALT and alkaline phosphatase
Patient has had elevated ALT in the past, new alkaline
phosphatase elevation. No abdominal pain and abdominal exam
benign during this admission. ___ hepatitis B labs revealed
prior hepatitis B infection which was cleared. HCV negative.
Although he has mildly distended abdomen, it is more likely that
his abdominal distension is related to general volume overload.
- Continue to monitor
C - Chronic issues pertinent to admission
===================================
# Diabetes, Type 2
Diagnosed in ___. Hbg A1c 7.8 in ___. Complicated by
diabetic retinopathy, chronic kidney disease. He is following
with Dr ___ at the ___. He is seeing Dr. ___
___ his retinal exams for diabetic retinopathy. He is currently
on insulin ___ at home, recently increased from 25U to 27U.
Treatment of ESRD, as above. Continued gabapentin 300mg daily
with extra 100mg three times per week on dialysis days, and home
nortriptyline for neuropathy. Received 20U ___ insulin with SS
while in house.
# Hypertension
On home ___ 6.25 mg PO BID on non-dialysis days and
6.25mg QHS on dialysis days. Transitioned to metoprolol, as
above. He is also on torsemide. He was previously on imdur, held
for hypotension (especially diastolic hypotension).
# Peripheral vascular disease
Diagnosed with ABI measurement in ___, no progression in
claudication symptoms. On aspirin and statin as above. This is
followed by Dr. ___. Of note, he had a nonhealing right ulcer
noted over the last year, underwent Superficial femoral artery
angioplasty on ___. Per prior notes, given stent and
extensive vascular disease, he should remain on full dose
aspirin unless further bleeding complications occur.
# Anemia
Hgb 11, borderline macrocytic. At baseline. Likely anemia of
chronic disease with chronic kidney disease. Unclear if on EPO
at HD normally. B12 was 1254 one year prior and folate,
last checked in ___, was normal.
# BPH
Continued home tamsulosin.
# Psoriasis
On betamethasone ointment PRN up to 14 days per month. Has had
small scalp plaque psoriasis and on back. Last seen by derm on
___. Held betamethasone while admitted.
# Tinea pedis
On econazole 1% daily.
# Glaucoma
Continued home Brimonidine Tartrate 0.15% and Timolol Maleate
0.5%
# Concern for MGUS
Positive for increased free kappa and lambda in ___, with free
kappa 165, free lambda 78.2, and ratio 1.85 but per prior notes,
will not work up due to other comorbidities.
# Pulmonary nodules
Most recent CT chest was ___ at which point the pulmonary
nodules were stable dating back to ___ except for
minimal interval increase between ___ and ___
of the left lingular nodule. Although reassessment in ___ year was
recommended, per family, no more follow-up will be done due to
his age and other medical problems.
T - Transitional Issues
===================================
[] F/u partially loculated left pleural effusion noted on CXR.
Patient to follow-up with Dr. ___ in IP as outpatient for
possible thoracentesis.
[] F/u BP, rate control on metoprolol (switched from carvedilol
this admission due to hypotension with HD)
[] F/u volume status, dyspnea. If not improved or worsening,
could repeat CXR to see if effusion worsening.
[] F/u dysphagia noted by PCP, SLP evaluated this admission and
deferred video swallow study to outpatient setting given no
overt aspiration on bedside evaluation.
#CODE: Full, presumed
#CONTACT:
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
Date on form: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Carvedilol 6.25 mg PO BID
3. Gabapentin 300 mg PO QHS
4. Nortriptyline 25 mg PO QHS
5. sevelamer CARBONATE 1600 mg PO TID W/MEALS
6. Tamsulosin 0.4 mg PO QHS
7. Torsemide 100 mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
9. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
11. Gabapentin 100 mg PO 3X/WEEK (___) Additional dose at
night after dialysis
12. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID ear
itching
13. econazole 1 % topical DAILY
14. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
15. Humalog ___ 27 Units Bedtime
16. Calcitriol 1.25 mcg PO 3X/WEEK (___)
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO QPM
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
2. Humalog ___ 27 Units Bedtime
3. sevelamer CARBONATE 2400 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 3 tablet(s) by mouth
three times a day with meals Disp #*270 Tablet Refills:*0
4. Aspirin 325 mg PO DAILY
5. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
7. Calcitriol 1.25 mcg PO 3X/WEEK (___)
8. econazole 1 % topical DAILY
9. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID ear
itching
10. Gabapentin 300 mg PO QHS
11. Gabapentin 100 mg PO 3X/WEEK (___) Additional dose at
night after dialysis
12. Nortriptyline 25 mg PO QHS
13. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
14. Rosuvastatin Calcium 20 mg PO QPM
15. Tamsulosin 0.4 mg PO QHS
16. Torsemide 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Volume overload
SECONDARY DIAGNOSES
===================
Left-sided loculated pleural effusion
End stage renal disease
Chronic diastolic heart failure
Right bundle branch block
Paroxysmal atrial fibrillation
Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having shortness of breath
and chest pain with exertion.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were admitted to the hospital because you had been feeling
short of breath and you were found to have fluid on your lungs.
- The fluid on your lungs is likely due to your renal failure.
- You were given a diuretic medication through the IV to help
get the fluid out. You also received hemodialysis on your
regular home schedule (___).
- You had testing of your heart including an echocardiogram and
a stress test which showed less perfusion of the inferior wall
of your heart, which was caused by your heart attack in the
past. There is no evidence of more recent damage to the heart.
- You had a scan of your lung that showed no evidence of
pulmonary embolism (clot in the lungs).
- You improved considerably and were ready to leave the
hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Your weight at discharge is 54.3 kg (119.71 lb). Please weigh
yourself today at home and use this as your new baseline.
- You have some fluid around your left lung that will likely
need to be sampled in the future. We will set up an appointment
with the lung doctors (___), please be sure to attend that
appointment.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
10489424-DS-18 | 10,489,424 | 20,736,554 | DS | 18 | 2134-12-05 00:00:00 | 2134-12-06 21:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
___ - Left heart catheterization, coronary angiogram, and
balloon angioplasty of the circumflex artery
History of Present Illness:
Mr. ___ is a ___ with H/O type 2 diabetes mellitus (HbA1c 7.8
in ___ complicated by nephropathy requiring hemodialysis on
___, CAD with prior silent IMI (basal to mid
inferior/inferolateral hypokinesis), HFpEF (LVEF >55% in ___,
paroxysmal atrial fibrillation not on anticoagluation (H/O
subarachnoid, subdural, intraventricular hemorrhage ___,
hypertension, hyperlipidemia, and PAD s/p bilateral tibial stent
and right femoral artery stent who presents with chest pain and
shortness of breath that started around 3 in the morning.
Patient states he woke up because of pain located in
left-sternal anterior chest. The pain did not radiate. He
described it as a "pressure on my chest" of severity ___ and
was associated with sweating and shortness of breath. The pain
was not made worse by anything. The pain was relieved with
nitroglycerin x1 given by EMS around 2.5 hours after onset. EMS
also gave him aspirin 325 mg. The patient denied any nausea,
sweating, cough, fever, chills, abdominal pain, increased leg
swelling. He has been NPO since midnight.
Past Medical History:
-Type 2 diabetes complicated by nephropathy and retinopathy
-CKD on HD ___ AV Graft in LUE ___ with revision and
thrombectomy in ___
-Coronary artery disease c/b silent MI
-CHF
-Hypertension
-Hyperlipidemia
-PAD, s/p bilateral tibial artery and right femoral artery stent
-Atrial fibrillation not on anticoagulation
-Syncope with subarachnoid hemorrhage, subdural hemorrhage and
intraventricular hemorrhage in ___
-BPH
-Cataracts, s/p bilateral cataract surgery
-Pulmonary nodules
-Vitamin D deficiency
-Open angle glaucoma
-Macular degeneration
-S/P Cholecystectomy
Social History:
___
Family History:
No known family H/O premature CAD, arrhythmia, or SCD but family
history is largely unknown
Physical Exam:
On admission
GENERAL: Well developed, well nourished elderly East Asian man
in NAD. Oriented x3. Mood, affect appropriate.
VS: 97.5 PO BP 140/68 Right arm seated HR 84 RR 16 SpO2 97% on
O2 2 LPM via NC
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: JVP of 12-13 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. +S4, no rubs. No
thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Diffuse crackles
bilaterally encompassing the posterior lobes. End expiratory
wheeze audible without auscultation.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace,
mildly pitting peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses 1+ on RLE but otherwise palpable and
symmetric, 2+.
At discharge
Temp: 97.3 (Tm 98.3), BP: 153/56 (119-164/56-74), HR: 73
(73-102), RR: 17 (___), O2 sat: 95% (88% ambulatory-96), O2
delivery: RA,
Wt: 106.26 lb/48.2 kg
Last 24 hours Total cumulative -75ml
IN: Total 750ml, PO Amt 750ml
OUT: Total 825ml, Urine Amt 125ml, HD 700ml
HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva
were pink. No pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2, S4, no rubs. No
thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Diffuse crackles
bilaterally encompassing the posterior lobes.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing,
cyanosis. Trace, mildly pitting peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses 1+ on RLE but otherwise palpable and
symmetric, 2+.
Pertinent Results:
___ 06:55AM WBC-5.2 RBC-3.13* HGB-10.8* HCT-33.7*
MCV-108* MCH-34.5* MCHC-32.0 RDW-13.4 RDWSD-51.4*
___ 06:55AM NEUTS-63.2 ___ MONOS-11.4 EOS-2.7
BASOS-1.0 IM ___ AbsNeut-3.27 AbsLymp-1.08* AbsMono-0.59
AbsEos-0.14 AbsBaso-0.05
___ 06:55AM PLT COUNT-232
___ 06:55AM ___ PTT-34.2 ___
___ 06:55AM GLUCOSE-85 UREA N-50* CREAT-8.3* SODIUM-141
POTASSIUM-5.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
___ 06:55AM ALT(SGPT)-23 AST(SGOT)-32 CK(CPK)-222 ALK
PHOS-131* TOT BILI-0.3
___ 06:55AM ALBUMIN-3.5 CALCIUM-9.5 PHOSPHATE-3.9
MAGNESIUM-2.6
___ 06:55AM cTropnT-1.39*
___ 06:55AM CK-MB-3 ___
___ 01:40PM CK(CPK)-192
___ 01:40PM CK-MB-3 cTropnT-1.62*
ECG ___ 06:31:22
Normal sinus rhythm. Probable left atrial enlargement. Right
bundle branch block. Left posterior hemiblock/fascicular block.
T wave abnormality, consider inferior ischemia
___ CXR
Moderate cardiac silhouette size enlargement is unchanged. The
aorta is diffusely calcified. Mild to moderate interstitial
pulmonary edema is new in the interval, with small bilateral
pleural effusions demonstrated. A loculated posterior component
is also re-demonstrated, similar to prior exam. Linear opacities
in the lung bases likely reflect areas of subsegmental
atelectasis or scarring. No pneumothorax. No acute osseous
abnormality. Cholecystectomy clips are seen in the right upper
quadrant of the abdomen. Vascular stent is seen projecting over
the left axillary region.
IMPRESSION: Mild to moderate pulmonary edema and small bilateral
pleural effusions, one of which appears similarly posteriorly
loculated. Bibasilar atelectasis.
___ Cardiac catheterization
LV 128/22
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a 40% stenosis in the
proximal segment. The Diagonal, arising from the proximal
segment, is a medium caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a medium
caliber vessel. This vessel's TIMI flow grade is 2. There is
severe calcification in the proximal segment. There is a 60%
eccentric stenosis in the proximal segment. There is a 90%
ulcerated plaque in the mid segment. There are severe
irregularities in the mid and distal segments. The ___ Obtuse
Marginal, arising from the proximal segment, is a medium caliber
vessel. The ___ Obtuse Marginal, arising from the mid segment,
is a small caliber vessel. This vessel's TIMI flow grade is 2.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is severe calcification in the
proximal and mid segments. There is a 95% stenosis in the
proximal segment. There is a 100% stenosis in the proximal, mid,
and distal segments. Faint collaterals from the distal segment
of the LAD connect to the distal segment. The Right Posterior
Descending Artery, arising from the distal segment, is a medium
caliber vessel. The Right Posterolateral Artery, arising from
the distal segment, is a medium caliber vessel.
Interventional Details
Percutaneous Coronary Intervention: Percutaneous coronary
intervention (PCI) was performed on an ad hoc basis based on the
coronary angiographic findings from the diagnostic portion of
this procedure. Heparin was used for anticoagulation to maintain
ACT > 250. An EBU 3.5 provided adequate support. The second
obtuse marginal was wired with a Sion blue easily. With some
difficulty, we were able to deliver a 2.0 mm compliant balloon
with low pressure inflations in the mid circumflex and second
OM. Final angiography revealed TIMI 3 flow, no dissection, and
20% residual.
Conclusions:
Elevated left heart filling pressure.
Two vessel coronary artery disease.
Successful PCI balloon angioplasty of the circumflex coronary
artery ___ OM).
___ Head CT
There is no evidence of acute large territorial infarction,
intracranial hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of
age-related cerebral volume loss. Periventricular and
subcortical white matter hypodensities are nonspecific, though
likely sequelae of chronic small vessel ischemic disease.
Atherosclerotic vascular calcifications are noted.
No acute osseous abnormalities seen. Partially imaged
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits demonstrate bilateral postoperative
changes.
IMPRESSION: 1. No acute intracranial process within limitations
of this noncontrast study. No evidence of intracranial
hemorrhage. 2. Atrophy, probable small vessel ischemic changes,
and atherosclerotic vascular disease as described. Please note
MRI of the brain is more sensitive for the detection of acute
infarct.
DISCHARGE LABS
___ 08:40AM BLOOD WBC-4.4 RBC-2.99* Hgb-10.4* Hct-32.6*
MCV-109* MCH-34.8* MCHC-31.9* RDW-13.3 RDWSD-51.7* Plt ___
___ 08:40AM BLOOD Glucose-291* UreaN-28* Creat-6.2*# Na-137
K-4.2 Cl-93* HCO3-30 AnGap-14
___ 08:40AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ with H/O type 2 diabetes mellitus (HbA1c 7.8
in ___ complicated by nephropathy requiring hemodialysis on
___, CAD with prior silent IMI (basal to mid
inferior/inferolateral hypokinesis), HFpEF (LVEF >55% in ___,
paroxysmal atrial fibrillation not on anticoagluation (H/O
subarachnoid, subdural, intraventricular hemorrhage ___,
hypertension, hyperlipidemia, and PAD s/p bilateral tibial stent
and right femoral artery stent who presented with chest pain and
shortness of breath, troponin elevation, and EKG changes
consistent with NSTEMI (peak CK-MB 3, troponin-T 2.07) and
evidence of acute on chronic heart failure exacerbation. He was
initially managed with a nitroglycerin infusion. He underwent
cardiac catheterization via right radial access on ___ which
showed elevated LVEDP of 22, and two vessel coronary disease,
with the culprit lesion believed to be the ___ OM in addition to
a long chronic total occlusion of the RCA. He underwent balloon
angioplasty, but did not have a stent placed due to small vessel
size and difficult delivery of balloons. He was medically
optimized and experienced no complications from the procedure.
He was found to be volume up on admission with NT-pro-BNP of
>30,000. He was continued on his home hemodialysis schedule and
given torsemide 100mg PO on non-HD days. He was discharged with
home nursing services.
ACUTE ISSUES:
# NSTEMI, Chest pain, CAD: Although his troponin-T elevation may
have represented a combination of decreased renal clearance and
demand myocardial injury from his CHF exacerbation, his initial
symptom was retrosternal chest pressure that woke him up from
sleep and was relieved by nitroglycerin. This was concerning for
a type I NSTEMI with likely culprit lesion of the ___ OM seen on
angiogram. Heart failure also a possible contributor. He
appeared volume overloaded on exam with LVEDP 22 and markedly
elevated NT-Pro-BNP. He underwent HD on day of admission and
chest pain managed with nitroglycerin infusion discontinued a
few hours after initiation. Echocardiogram could not be
completed prior to discharge on a weekend. Non-contrast head CT
on therapeutic heparin/PTT revealed no abnormality. Per
neurosurgery team, the benefits of dual anti-platelet therapy
outweighed the risks of bleeding given history of TBI and
SAH/SDH. He was discharged on aspirin 81 mg, rosuvastatin 40 mg,
and metoprolol succinate 50 mg daily. In absence of evidence of
a large infarct or prior LV systolic heart failure, ACE-I was
deferred but may consider addition as outpatient for CAD
secondary prevention (as patient already on HD). The decision
about whether to increase aspirin back to 325 mg daily (his
prior outpatient regimen) or use clopidogrel monotherapy was
deferred to his outpatient cardiology team.
# HFpEF, with acute exacerbation and evidence of volume
overload: NT-Pro-BNP >30,000, volume overloaded on exam and CXR.
We were unable obtain echocardiogram over the weekend prior to
discharge. He received furosemide 200 mg in ED, and was
continued on home torsemide 100 mg PO daily on non-HD days.
LVEDP 22 at cardiac catheterization. He underwent hemodialysis
with renal on his usual schedule while an inpatient. Per
discussion with renal and the ___ outpatient cardiology
team, tamsulosin was stopped and metoprolol succinate was
changed to 50 mg on non-HD days and 25 mg on HD days to permit
more fluid removal at HD.
# Paroxysmal atrial fibrillation: NSR while inpatient, rates
well-controlled. He has not been on anticoagulation, had some
fast VRs 80-100 mg on metoprolol 25 mg so this was increased to
50 mg daily on non-HD days (and 25 mg on HD days, as above).
# CKD: Patient able to make urine despite HD on ___. He
underwent HD via Left UE AVF on normal outpatient schedule.
Continued on sevelemer 2400 mg TID with meals. Maintained on
strict I/Os.
CHRONIC ISSUES
# Type 2 diabetes mellitus: continued home insulin regimen
# BPH: continued on home tamsulosin initially, but this was
stopped around time of discharge (as above) to allow more blood
pressure for fluid removal at HD.
# Neuropathy: continued on gabapentin and nortriptyline.
# Vertigo: continued on Meclizine 12.5 mg PO Q12H:PRN
# Macular degeneration: continued on Brimonidine Tartrate 0.15%
Ophth. 1 DROP BOTH EYES BID
TRANSITIONAL ISSUES:
[ ] Patient discharged on aspirin 81 mg PO daily, lower than
home dose given lack of clear benefit and increased risk of
bleeding. Follow up with Dr. ___ to decide how to dose
aspirin vs. clopidogrel monotherapy following balloon
angioplasty (no stent) of CX/OM2
[ ] FYI: He has difficulty with fluid removal on outpatient
basis with 2 L generally his maximum goal. He will need to be
vigilant with both dietary sodium and fluid restriction as an
outpatient in order to prevent further episodes of volume
overload given this reasonably modest ultrafiltration maximum.
CHANGED MEDICATIONS: aspirin decreased from 325 mg to 81 mg,
rosuvastatin increased from 20 mg to 40 mg, metoprolol increased
from 25 mg to 50 mg on HD days and 25 mg on non-HD days
NEW MEDICATIONS: none
STOPPED MEDICATIONS: tamsulosin
- Discharge weight: 48.0 kg (105.82 lb)
- Discharge creatinine: 7.7
# CODE: DNR/DNI
# CONTACT: ___, HCP, daughter ___ ___ daughter
(___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Gabapentin 300 mg PO QHS
4. Gabapentin 400 mg PO 3X/WEEK (___) Additional dose at
night after dialysis
5. Nortriptyline 10 mg PO QHS
6. Rosuvastatin Calcium 20 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. Torsemide 100 mg PO 4X/WEEK (___)
9. Metoprolol Succinate XL 25 mg PO QPM
10. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
11. econazole 1 % topical DAILY
12. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID ear
itching
13. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
14. Calcitriol 1.25 mcg PO 3X/WEEK (___)
15. sevelamer CARBONATE 2400 mg PO TID W/MEALS
16. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
17. OxyCODONE (Immediate Release) 5 mg PO QHS:PRN Pain -
Moderate
18. Meclizine 12.5 mg PO Q12H:PRN vertigo
19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
20. capsaicin 0.1 % topical TID
21. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN irritation
22. Vitamin D 400 UNIT PO DAILY
23. Humalog ___ 27 Units Breakfast
Humalog ___ 27 Units Dinner
24. Humalog ___ 27 Units Dinner
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Humalog ___ 75 Units Breakfast
Humalog ___ 75 Units Dinner
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. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
6. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. Calcitriol 1.25 mcg PO 3X/WEEK (___)
9. capsaicin 0.1 % topical TID
10. econazole 1 % topical DAILY
11. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID ear
itching
12. Gabapentin 300 mg PO QHS
13. Gabapentin 400 mg PO 3X/WEEK (___) Additional dose at
night after dialysis
14. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN irritation
15. Meclizine 12.5 mg PO Q12H:PRN vertigo
16. Nephrocaps 1 CAP PO DAILY
17. Nortriptyline 10 mg PO QHS
18. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
19. OxyCODONE (Immediate Release) 5 mg PO QHS:PRN Pain -
Moderate
20. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY
21. sevelamer CARBONATE 2400 mg PO TID W/MEALS
22. Tamsulosin 0.4 mg PO QHS
23. Torsemide 100 mg PO 4X/WEEK (___)
24. Vitamin D 400 UNIT PO DAILY
===============
Per subsequent discussion with Dr. ___, Dr. ___, Dr.
___ Dr. ___ discharge medications to
discontinue tamsulosin, change metoprolol succinate to 50 mg on
non-HD days and 25 mg on HD days to permit more fluid removal at
HD. Dr. ___ the ___ daughter to instruct her to
revise the discharge medication instructions.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Non-ST segment elevation myocardial infarction
- Coronary artery disease with
- Chronic total occlusion of the right coronary artery
- Acute on chronic left ventricular diastolic heart failure with
preserved ejection fraction
- Paroxysmal atrial fibrillation
- Type II Diabetes Mellitus with
- End stage kidney disease on
- Hemodialysis
- Neuropathy
- Peripheral arterial disease
- Hypertension
- Benign prostatic hypertrophy
- Vertigo
- Macular Degeneration
- Prior intracranial bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain and shortness of breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have increased fluid in your body and were
given medications and hemodialysis to remove that fluid.
- You underwent a procedure to examine the vessels of your heart
for any blockages. One of the vessels was found to be blocked
and was re-opened with a balloon. No stent was placed.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor, ___,
at ___ if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop increased swelling in your legs, chest pain,
abdominal distention, or shortness of breath at night.
- Your discharge weight: 48.0 kg (105.82 lb). You should use
this as your baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10489424-DS-6 | 10,489,424 | 21,875,337 | DS | 6 | 2127-12-11 00:00:00 | 2128-01-01 05:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
Malaise, weakness in legs
Acute blood loss anemia
Major Surgical or Invasive Procedure:
LUE AV graft surgery ___
History of Present Illness:
___ yo male with history of Stage 4 CKD, HTN, HL DM2, and BPH who
was due to have an AV graft placed last ___ as he was
getting ready to start HD, but was instead referred to the ED
for exertional dyspnea. This was initially thought to be due to
uremia and hypercalcemia as troponins were stable and not
indicative of ACS. His hypercalcemia was thought to be a result
of exogenous medications - potentially hctz, calcitriol, or
calcium carbonate. These medications were held and his calcium
trended down. Of note, he has not had any fevers at home. He
has a chronic unchanged cough.
He was taken on ___ for placement of a left upper
extremity AV graft. His preop coags were noted to have a PTT
>150. Over the past two days his left arm has continuously
expanded and is now tense and painful. His hand has been cool
with some numbness. He had post-op serosanguinous leakage
around the site with a soft thrill and a quiet bruit. He has
had a 12 point hematocrit drop from 33 -> 21. Surgicel was
placed by the transplant surgery team. He was given 1 pRBC and
___ FFP on the floor. He received his last dose of Hep SQ at 1pm
on ___. His last dose of ddAVP was at 8pm today.
On arrival to the MICU, he reports some lightheadedness today,
but denies CP or SOB. He reports numbness/tingling in a cool
left hand with pain upon palpation. His last bowel movement was
yesterday.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-STAGE 4 CKD
-DIABETES TYPE II
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
-BENIGN PROSTATIC HYPERTROPHY
-CATARACTS
-DRY EYES
-OPEN ANGLE GLAUCOMA
-S/P CCY
Social History:
___
Family History:
Unknown
Physical Exam:
Vitals: afeb 98 113/54 16 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, distended
GU: no foley, using urinal
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left upper arm with swelling, fresh blood oozing out of
three portals of entry, large dependent hemaomta, ecchymoses,
palpable left radial pulse, dopplerable ulnar pulse, cool
fingers with slow capillary refill
Neuro: CNII-XII intact, ___ strength upper/lower extremities
Discharge exam:
GEN: pleasant, active, NAD
HEENT: NCAT, EOMI, MMM
NECK: supple
LUNGS: bibasilar crackles heard up to mid-level
CV: RRR, normal S1/S2, no m/r/g; no carotid bruits, no JVD
ABD: soft, protuberant, non-tender, non-distended, no HSM
RECTAL: stool guaiac negative, no prostatic tenderness
EXT: L arm mild soft swelling throughout, bandage over
newly-made fistula over L arm; warm with pulses, extensive
bruising in left armpit
MSK: strength grossly 5+ throughout
NEURO: CNII-XII grossly intact, finger squeeze even, awake,
alert, and oriented to time, place, self, and situation
Pertinent Results:
Admission labs
___ 05:50PM LACTATE-0.7
___ 05:40PM GLUCOSE-133* UREA N-102* CREAT-6.7*#
SODIUM-137 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 05:40PM CK(CPK)-366*
___ 05:40PM cTropnT-0.07*
___ 05:40PM CK-MB-5 proBNP-1037*
___ 05:40PM CALCIUM-13.3* PHOSPHATE-5.2* MAGNESIUM-2.2
___ 05:40PM WBC-6.6 RBC-3.58* HGB-11.6* HCT-34.2* MCV-96
MCH-32.5* MCHC-34.0 RDW-12.7
___ 05:40PM NEUTS-60.5 ___ MONOS-6.3 EOS-1.9
BASOS-0.7
___ 05:40PM PLT COUNT-218
___ 05:40PM ___ PTT-32.2 ___
Discharge labs
___ 07:48AM BLOOD WBC-6.0 RBC-3.64* Hgb-11.2* Hct-32.4*
MCV-89 MCH-30.6 MCHC-34.5 RDW-15.9* Plt ___
___ 05:13AM BLOOD Neuts-68.3 ___ Monos-8.8 Eos-1.5
Baso-0.6
___ 07:48AM BLOOD Plt ___
___ 07:48AM BLOOD ___ PTT-26.8 ___
___ 03:41AM BLOOD ___
___ 07:48AM BLOOD Glucose-105* UreaN-84* Creat-4.1* Na-142
K-3.8 Cl-105 HCO3-26 AnGap-15
___ 07:48AM BLOOD ALT-43* AST-60* CK(CPK)-683* AlkPhos-59
___ 07:48AM BLOOD CK-MB-3 cTropnT-0.47*
___ 05:13AM BLOOD CK-MB-3 cTropnT-0.39*
___ 03:41AM BLOOD CK-MB-7 cTropnT-0.36*
___ 08:28PM BLOOD CK-MB-8 cTropnT-0.27*
___ 05:43PM BLOOD CK-MB-8 cTropnT-0.25*
___ 10:50AM BLOOD CK-MB-7 cTropnT-0.19*
___ 04:50AM BLOOD CK-MB-5 cTropnT-0.13*
___ 01:37PM BLOOD CK-MB-3 cTropnT-0.08*
___ 07:45AM BLOOD CK-MB-5 cTropnT-0.07*
___ 11:30AM BLOOD CK-MB-5 cTropnT-0.06*
___ 05:40PM BLOOD cTropnT-0.07*
___ 05:40PM BLOOD CK-MB-5 proBNP-1037*
___ 07:48AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
___ 03:41AM BLOOD TSH-1.5
___ 12:25PM BLOOD PEP-TRACE ABNO IgG-913 IgA-166 IgM-36*
IFE-MONOCLONAL
___ 06:55AM BLOOD Hapto-31
___ 02:35AM BLOOD PTH-12*
___ 04:14AM BLOOD freeCa-1.26
___ 07:01PM BLOOD freeCa-1.06*
___ 01:49PM BLOOD freeCa-1.02*
___ 05:29AM BLOOD freeCa-0.98*
___ 08:33AM BLOOD freeCa-1.49*
___ 10:50AM BLOOD REPTILASE TIME-Test 15 (WNL <20)
Blood cultures, urine cultures negative.
___ ECHO EF 45%
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild global left ventricular hypokinesis (LVEF = 45 %). There is
no ventricular septal defect. Right ventricular chamber size is
normal. RV with borderline normal free wall function. 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 leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
___ ct chest without contraST
IMPRESSION:
1. Left upper extremity hematoma extending into the left
pectoral muscles and axilla. There is no intrapleural
involvement. Full extent is better
evaluated on the concurrent left upper extremity CT.
2. 4-mm lung nodules in the right upper lobe and within the
lingula.
Recommend followup CT in one year given the presence of
emphysema.
3. Atherosclerotic calcifications.
___ CT UE W/O CONTRAST
IMPRESSION:
1. Hematoma approximately 2 cm from the venous graft anastomosis
measuring 3.1 x 2.1 x 3.9 cm.
2. Second foci of hematoma at the distal end of the graft
measuring 1.2 x 1 cm.
3. Kinking of the venous portion of the AV graft concerning for
partial
occlusion.
4. Lytic lesion at the mid shaft of the ulna measuring 10 mm.
___ subclavian vein doppler
FINDINGS: There is normal compressibility and flow demonstrated
in the left subclavian vein. In addition, normal flow and
compressibility is demonstrated in the left internal jugular
vein.
___ RENAL US
IMPRESSION: Small kidneys with mild cortical thinning
consistent with
chronic kidney disease. No hydronephrosis.
___ CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
___ CXR
IMPRESSION: Patchy right lower lobe opacity concerning for
pneumonia.
___ EKG
Atrial fibrillation. Non-specific ST-T wave changes. Compared to
the previous tracing the patient is now in atrial fibrillation.
___ EKG
Sinus rhythm. Incomplete right bundle-branch block. T wave
inversions in
leads I, aVL and V4-V6. Compared to the previous tracing of
___ patient is now in sinus rhythm.
___ EKG
Atrial fibrillation with rapid ventricular response. Q waves as
well as
ST segment elevation in the inferior leads. Consider prior
inferior wall
myocardial infarction of indeterminate age. Anteroseptal ST-T
wave changes
also noted. Compared to the previous tracing of ___ the rate
is faster. Otherwise, no diagnostic change.
Brief Hospital Course:
___ yo male with a history of DM2, HTN, HL, CAD, and Stage 4 CKD
that presented with malaise, weakness, and fatigue in the
setting of progressive uremia and hypercalcemia. Hypercalcemia
likely due to medication effect (calcitriol and calcium
carbonate) and improved with hydration and gentle diuresis.
Hospital course complicated by AV graft placement in the setting
of greatly elevated PTT and left arm hematoma, patient was
transferred to the ICU for further management. There he had
multiple transfusions of pRBCs, cryoprecipitate, and FFPs. Once
his hematocrit improved, he was transferred to the floor.
# Left arm hematoma due to AV graft leak: s/p 5 units of PRBC,
4 units of cryoprecipitate and reversal of his PTT with
protamine and FFP. HCT stable, PTT stable, patient was
transferred to the floor from MICU. His exam was less
concerning for compartment syndrome, with palpable left radial
pulse, less arm swelling and no complaints of left arm pain. He
was followed by the transplant surgery team. The likely etiology
of the elevated PTT is secondary to SC heparin for DVT
prophylaxis. He is very sensitive to SC heparin which should be
noted in the future.
# Hypercalcemia: Thought secondary to starting calcitriol. This
medication was stopped and he had gentle hydration and was given
furosemide with good effect. His calcium level returned to
normal. Calcitriol was not continued on discharge. With
improvement in his calcium, his original symptoms of malaise and
fatigue resolved.
# Afib with RVR. He spontaneously converted. CHADS2 score of
2. He converted on his own prior to 48 hours. Likely in
setting of electrolyte imbalance vs volume depletion. Was in
sinus on day of discharge.
# Demand Ischemia in setting of RVR with ST depression in V4/V5
and Avl. Has no cardiac symptoms, including no chest pain,
dyspnea, nausea, diaphoresis, or vomiting. Troponin elevated
with negative CK-MB. Resolution of ST depression with sinus
rhythm and transfusion initially but repeat EKG on ___ AM
had slight depression in Avl which was persisting. The patient
will likely benefit from cardiac stress test as an outpatient.
# CKD Stage 5: No indication for urgent dialysis. Normal
electrolytes and volume balance. Continue to monitor. He was
followed by Nephrology team in house. His AVG had a bruit
without a thrill at discharge. Per transplant surgery, it seemed
to be functioning well.
# DM-2: humalog ___ mix and HISS
# Hyperlipidemia: continued rosuvastatin
# BPH: continued tamsulosin
Outpatient Follow up
- 4-mm lung nodules in the right upper lobe and within the
lingula.
Recommend followup CT in one year given the presence of
emphysema.
-Lytic lesion at the mid shaft of the ulna measuring 10 mm- f/u
SPEP/UPEP and consider PSA
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverPharmacy.
1. Calcitriol 0.5 mcg PO DAILY
2. Carvedilol 12.5 mg PO BID
hold for SBP<100, HR<60
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
5. econazole *NF* 1 % Topical BID
6. Humalog ___ 12 Units Breakfast
Humalog ___ 14 Units Dinner
7. Tamsulosin 0.4 mg PO HS
8. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
9. Lisinopril 5 mg PO DAILY
hold for SBP<100
10. Hydrochlorothiazide 25 mg PO DAILY
11. Calcium Carbonate 600 mg PO TID
12. Fish Oil (Omega 3) 1000 mg PO TID
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
hold for SBP<100, HR<60
2. Humalog ___ 12 Units Breakfast
Humalog ___ 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *Humalog 100 unit/mL Up to 10 Units per sliding scale four
times a day Disp #*200 Milliliter Refills:*1
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
6. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 capsule(s) by mouth one per day Disp #*30
Capsule Refills:*2
7. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *Renvela 800 mg 1 tablet(s) by mouth three times per day with
meals Disp #*90 Tablet Refills:*2
9. Fish Oil (Omega 3) 1000 mg PO TID
10. econazole *NF* 1 % Topical BID
11. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
12. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Hypercalcemia
Chronic kidney disease
AV graft placement
Left arm hematoma due to AV graft leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for
your health care. You were admitted to our hospital for a high
level of calcium in your blood, which caused you to feel weak.
This was most likely due to dietary supplements of calcium and
vitamin D. You were treated with medications (called diuretics)
which helped your kidneys excrete the calcium, as well as
excrete fluids. You were followed by the nephrology team and the
endocrinology team.
While you were in the hospital, you also had surgery to place an
AV graft. This graft will be used for hemodialysis in the
future. Initially you had some bleeding which required
monitoring in the medical intensive care unit but you
stabilized. You are being discharged home in good condition.
You should make sure to follow up with your nephrologist,
transplant team, and primary care provider after being
discharged from the hospital. Also, because of your irregular
heart rhythm and risk factors for heart disease you should see
Cardiology. Please see appointments below.
Note that while you were here, you had elevated blood sugars so
you are being discharged on your usual twice-a-day insulin but
also Humalog insulin correction scale. This was reviewed with
your daughter, who will help administer the insulin. If you
note values <80 or >300 please seek emergent help from your PCP
___ providers.
While you were here, some changes were made to your medications:
Please START:
-Furosemide, 40 mg per day.
-Nephrocaps, one capsule per day.
-Sevelamer Carbonate, 800 mg three times a day with meals.
-Aspirin 325mg daily.
Please STOP:
-Calcitriol until your outpatient providers restart it.
-___ until your outpatient providers restart it.
-___ carbonate (Tums) until your outpatient providers
restart it.
-___, until your outpatient providers restart it.
___ take your other medications as previously prescribed.
Followup Instructions:
___
|
10489424-DS-9 | 10,489,424 | 22,079,618 | DS | 9 | 2129-04-22 00:00:00 | 2129-04-22 22:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of CAD, dCHF, IDDM, ESRD presents for syncope. He was in
his USOH cooking in his kitchen as he does every day when he
passed out. Wife's back was turned at the time so she only saw
him on the ground. Family believes he hit his head and he was
unconscious for about 2 minutes. No post-ictal state, rhythmic
movements. He does not remember passing out and denies any CP,
SOB, nausea, diaphoresis, vision changes, dizziness prior to
episode. He took all his medications from pillbox in the morning
and his AM fingerstick was normal. Denies any recent illness,
diarrhea, polyuria, dysuria, fevers, chills, sweats. Of note, pt
was seen by his cardiologist in early ___ and his
amlodipine
was increased at that time form 5mg to 7.5mg daily. Never had
syncopal episode before this.
In the ED, intial vitals 98.0 60 166/70 18 98%.
ECG showed sinus rhythm, signs of old IMI, LVH, stable from
prior
Labs notable for trop 0.04 (bl), creat 7.1 (most recent in
___
6.1, bl ___, bicarb 17 (gap 18), Hct 35 (bl), lactate normal.
CT Head showed subarachnoid blood in the frontoparietal region
and left posterior fossa, subdural blood along right
anterior/posterior falx w/o mass effect, no fracture. CT neck
and
CXR were negative. UA with small blood, 30 protein, trace
glucose. Urine and blood cxs pending.
Patient received morphine x 1.
ROS:
(+) Per HPI gait instability, mild frontal headache, grandson
had cold recently
(-) Denies weight change, orthopnea, leg edema, PND, DOE, CP,
palpitations, neck stiffness, URI sxs shortness of breath.
Denied
chest pain or tightness, palpitations, vomiting, numbness,
weakness, constipation or abdominal pain. No recent change in
bowel or bladder habits. Denied arthralgias or myalgias.
Past Medical History:
1. Chronic diastolic heart failure.
2. AF: episode ___ after large AV graft bleed; on ASA 325.
3. Coronary artery disease c.w. prior silent IMI; EF 40-45%
4. HTN: (carvedilol, imdur, furosemide)
5. HLD: 8.13:TC141,TG138.H64.L49; rosuva 40).
6. PAD: b/l tibial arterial disease (ABI ___
7. Diabetes mellitus: A1c 6.9, 8.13, on insulin.
8. CKD, stage V (___)
Social History:
___
Family History:
No known premature CAD, arrhythmia, or SCD but family history is
largely unknown
Physical Exam:
Vitals: 98.1 76 142/62 16 98% RA
General: well-appearing, oriented, ___, NAD
HEENT: EOMI, pupils equal and small bilaterally
Neck: no JVD
CV: regular no murmurs
Lungs: CTAB, slight crackles at L base
Abdomen: S/NT/ND, normal BS
Ext: no edema
Neuro: CNs intact, ___ strength throughout, notes double vision
Skin: no ecchymoses
Language: ___ speaking
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Discharge exam:
98.5, 138/59 (117-130s/50-60s), 70, 18, 98RA
General: Elderly male in NAD, walking down the hall with cane in
NAD
HEENT: PEERLA, EOMI, no oropharyngeal lesions
Caridac: RRR, no MRG apprciated
Lungs: CTAB
Abd: soft, nontender, nondistended
Extremities: no peripherale edema
Neuro: CNII-XII intact, Strength ___ in UE and ___.
Sensation grossly intact.
Pertinent Results:
Admission labs:
___ 12:01PM GLUCOSE-151* UREA N-85* CREAT-7.1* SODIUM-143
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-17* ANION GAP-22*
___ 12:01PM WBC-5.3 RBC-3.52* HGB-11.5* HCT-35.0* MCV-99*
MCH-32.8* MCHC-33.0 RDW-13.5
___ 12:01PM PLT COUNT-280
___ 12:01PM cTropnT-0.04*
___ 03:37PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
DIscharge labs
___ 06:16AM BLOOD WBC-6.9 RBC-3.33* Hgb-11.0* Hct-33.1*
MCV-99* MCH-33.0* MCHC-33.2 RDW-12.9 Plt ___
___ 06:16AM BLOOD Glucose-86 UreaN-87* Creat-7.3* Na-141
K-3.5 Cl-108 HCO3-20* AnGap-17
___ 06:16AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2
IMAGING:
___: CT head: IMPRESSION:
1. Bifrontal subarachnoid hemorrhage and subarachnoid
hemorrhage along the
left quadridgeminal plate and cerebellopontine angle cisterns.
2. Subdural hemorrage along the falx and along the right
tentorium without
mass effect.
3. Intraventricular hemorrhage in the body of the right lateral
ventricle.
___: Repeat CT head: IMPRESSION: Stable appearance of
bifrontal and quadrigeminal plate cistern subarachnoid
hemorrhage, small subdural hemorrhage along the falx and right
tentorium and right intraventricular hemorrhage. No mass
effect.
___: CT cspine: IMPRESSION; No evidence of acute fracture or
malalignment.
___: CXR IMPRESSION: No acute cardiopulmonary process.
___: TTE: The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
basal to mid inferior and inferolateral hypokinesis. The
remaining segments contract normally (LVEF = 45 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Regional left ventricular systolic dysfunction c/w CAD.
Preserved right ventricular function. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
Mr. ___ is an ___ yo M w/ PMH of CAD, paroxysmal Afib, CKD
stage V, DM2, hypertension who presented with syncope leading to
SDH, SAH and IVH without neurologic deficit who had no further
events while inpatient.
#Syncope: Patient had unclear origin to his syncopal event. He
had no clear prodrome and was confused when he came to (but also
had sustained an intracranial hemorrhage). Workup involved EKG,
Telemetry, TTE, carotid dopplers, laboratory data, orthostatics
which were all negative for source of syncopal event.
Cardiology was consulted and Electrophysiology was also
consulted and felt that this was unlikely to be a VT event, but
did suggest getting an event monitor and a possible outpatient
EP study. He had no further episodes while here. As amlodipine
had recently been increased from 5 mg daily to 7.5 mg daily, we
decreased this back to 5 mg daily to be sure this hadn't
contributed to his fall.
#Intracranial hemorrhage- he had SDH, SAH and IVH while here
without mass effects. He had a repeat head CT without change.
He denied any headaches. He had some double vision
intermittently since the fall without any evidence of unstable
plaque on carotid dopplers. He will need a followup appointment
and CT scan in ___.
#CAD- no chest pain and EKG at baseline. He will hold his
aspirin x 7 days from his admssion day and then resume. All
other medications were kept the same.
#CKD Stage V- no indications for dialysis during this admission.
Labs were monitored and renal medications were continued.
Medications on Admission:
Aspirin 325mg daily
carvedilol 25 mg BID,
furosemide 100mg daily
rosuvastatin 20mg daily
imdur 60mg QD
fenofibrate 54mg daily
amlodipine 7.5 mg QD
sevelamer 1600mg TID
tamsulosin 0.4mg daily
humalog ___ 10 in AM, 7 in ___ and HISS
nephrocaps daily
econazole
calcitriol 0.5mg daily
vitamin D 2000u daily
timolol and brimonidine daily
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
3. Calcitriol 0.5 mcg PO DAILY
4. Carvedilol 25 mg PO BID
5. Furosemide 100 mg PO DAILY
6. Humalog ___ 10 Units Breakfast
Humalog ___ 7 Units Dinner
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Rosuvastatin Calcium 20 mg PO QPM
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Tamsulosin 0.4 mg PO HS
11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
12. Aspirin 325 mg PO DAILY
Hold for 7 days
13. fenofibrate 54 mg oral daily
14. folic acid-B complex & C ___ mcg/5 mL oral daily
15. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Subarachoid hemorrhage
Subdural hemorrhage
Interventricular hemorrhage
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 here at ___. You were
admitted to the hospital after you passsed out at home and
suffered bleeding within your brain. You were initially on the
neurosurgical service and had no problems with regards to moving
to talking. We did a full workup for why you had the loss of
consciousness and everything has come back negative. You will
be sent home with an event monitor should you feel anything odd
in your chest or if you have dizziness or loss of consciousness.
We recommend holding his aspirin for four more days.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10489449-DS-20 | 10,489,449 | 26,168,200 | DS | 20 | 2185-05-15 00:00:00 | 2185-05-16 12:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
referral for workup of pulmonary nodules
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ without significant PMH who was referred by PCP for
evaluation of numerous pulmonary nodules.
Pt reports L flank pain since ___, that peaked in severity on
___ (day before presentation) and subsided on day of
presentation. He reports pain is pleuritis. No cough, SOB. No
fevers, wt loss. Night sweats only last night. Recent travel to
___ in last ___ ___. Also road-tripped for work to
___ in ___. He also went camping this past
weekend in ___ where he was hiking but remembers no tick
exposures. He reports approx ___ weeks ago he had a red itchy
and scaly rash on his posterior wrists bilaterally and extensors
surfaces of elbows bilaterally. He applied aquaphor and the rash
resovled in approx 1wk. No prior history of this pain or rash.
He went to PCP for rash and had CXR which was followed by a CT
to workup pulm nodules found. Smokes marijuana but no IVDU. No
dysuria or hematuria. Pt married with 2 kids and other family
well. He believes his mother and sister also had a pulm nodule.
In the ED initial vitals were: 98.2 85 133/81 15 100%
- Labs were significant for WBC 11.5, CRP 66.7. UA was
unremarkable.
- Patient was given no medications
Vitals prior to transfer were: 98.5 78 128/74 17 99% RA
Past Medical History:
Left rotator cuff impingement
Anxiety
Social History:
___
Family History:
Paternal grandfather: emphysema
Father: kidney stone
Mother: lung nodule, thyroid procedure
Sister: benign lung nodule
Brother: healthy
Physical ___:
Admission PE:
Vitals - 98.5 78 128/74 17 99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: excoriation across mid back, no CVA tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, minor folliculitis on scalp
.
Discharge PE:
Vitals - 98, 122/63, 72, 18, 100% RA
GENERAL: nontoxic well-appearing male in NAD
HEENT: anicteric sclera
NECK: nontender supple neck, no LAD
CARDIAC: RRR, no murmurs
LUNG: CTAB, breathing comfortably
ABDOMEN: soft, NT, ND, no splenomegaly appreciated
BACK: no CVAT, no tenderness over posterior and lateral L ribs
EXTREMITIES: no ___ edema
LYMPH: no cervical, supraclav and axillary LAD
SKIN: minor folliculitis on scalp
Pertinent Results:
Admission Labs:
___ 07:45PM BLOOD WBC-11.5* RBC-4.81 Hgb-15.9 Hct-43.6
MCV-91 MCH-33.0* MCHC-36.5* RDW-13.1 Plt ___
___ 07:45PM BLOOD Neuts-81.1* Lymphs-9.7* Monos-8.3 Eos-0.3
Baso-0.6
___ 07:45PM BLOOD ___ PTT-44.7* ___
___ 07:45PM BLOOD Glucose-108* UreaN-18 Creat-1.1 Na-139
K-4.1 Cl-100 HCO3-29 AnGap-14
___ 07:45PM BLOOD ALT-22 AST-18 LD(LDH)-161 AlkPhos-45
TotBili-1.0
___ 08:56AM BLOOD Calcium-9.6 Phos-2.7 Mg-2.0
.
Pertinent Labs:
___ 11:39AM BLOOD ANCA-PND
___ 11:39AM BLOOD ___
___ 08:56AM BLOOD RheuFac-18*
___ 07:45PM BLOOD CRP-66.7*
___ 08:56AM BLOOD HIV Ab-NEGATIVE
___ 01:05PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
___ 11:52AM BLOOD VITAMIN D ___ DIHYDROXY-PND
___ 11:52AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-PND
___ 11:52AM BLOOD ANTI-GBM-PND
___ 11:52AM BLOOD B-GLUCAN-PND
___ 11:51AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 09:36PM BLOOD SED RATE-PND
.
MICRO:
- bl cx pending
- induced sputum
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Preliminary):
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
ACID FAST CULTURE (Preliminary):
.
IMAGING:
CT Chest: Symmetric mediastinal and hilar lymphadenopathy and
numerous spiculated peribronchovascular nodules some cavitating.
The differential diagnosis includes sarcoidosis, vasculitis,
metastases and septic emboli. Correlation with the clinical
history may narrow the differential, but wedge biopsy may
ultimately prove necessary.
Brief Hospital Course:
___ without significant PMH who was referred by PCP for
evaluation of numerous pulmonary nodules found in workup for 5d
of L pleuritic flank pain.
.
# Numerous pulm nodules with mediastinal and hilar LAD: Pt
asymptomatic from a pulm perspective and only with L flank pain
that seems unrelated.
Pulmonary consult described the following:
His CT scan does reveal multiple lung nodules of varying sizes
with ___ 'blush' and early cavitation in some. These
are
not subpleural in location but there is accompanying ___ in the
subcarinal and paratracheal region.
These nodules have the appearance of an infectious/inflammatory
syndrome. I am concerned about the recent inhalational exposure
with marijuana that may be temporally related. His RF is faintly
positive but other serology is pending.
Please review pulmonary consult note in OMR.
I reviewed CT chest with radiology who felt that without any
symptoms and given current exam, metastatic disease or septic
emboli is unlikely and the adenopathy could be consistent with
sarcoidosis but at the time of my review with radiology, I did
not know of his exposure to an old water pipe for marijuna.
DDx for nodules can be broad. Pt without any risk factors or
clinical signs of endocarditis (no murmur), so septic emboli
seem less likely (bl cx pending). Pt without exposure to put at
risk for TB. HIV neg. Given pt with travel throughout US, also
think about fungal nodules like histo, cocci, blasto. Pt is
clinically very well and asymptomatic so in large part this
should be an OP workup. Pulm consulted and guided sending off a
number of tests for broad DDx. Induced sputum collected, a
number of studies sent and pending including ___, ANCA,
anti-CCP, ACE, fungal markers and urine histo Ag. Pt to f/u with
pulm. If all studies return unreavealing, then ___ recommends
repeat CT in 6wks.
.
# Anxiety: Increased anxiety surrounding recent medical issues.
Continued lexapro and PRN Xanax
.
>> Transitional issues:
- PPD place at 17:10 on ___. Asked pt to call to see an RN or
MD to get PPD ___ on ___
- Pulm f/u (phone numbers provided for Dr. ___ at ___ and
Dr. ___ pt prefers to f/u at ___
- Pulm also thinks it is reasonable to do an outpt TTE given
septic emboli on the differential. Blood cultures are pending
and no murmur, but for completeness
- Pending studies: ANCA, ___, galactomannan, glucan, 1,25-vit D,
anti-CCP, anti-GBM, ACE, ESR, urine histo Ag, induced sputum
results, blood cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 15 mg PO DAILY
2. ALPRAZolam 0.25-0.5 mg PO QHS:PRN anxiety/insomnia
3. Ibuprofen 600 mg PO Q12H:PRN pain
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. ALPRAZolam 0.25-0.5 mg PO QHS:PRN anxiety/insomnia
2. Escitalopram Oxalate 15 mg PO DAILY
3. Ibuprofen 600 mg PO Q12H:PRN pain
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: numerous pulmonary nodules
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 in the hospital. You were
referred into the hospital because of nodules found in your
lungs on imaging. Your were evaluated by the lung doctors
(___) and a number of tests were sent off. You should
follow-up with the pulmonologists in the clinic to follow-up on
the pending tests.
For your flank pain, please continue to take ibuprofen (600mg)
up to 3 times daily with food as needed.
Please call to schedule an appointment with a pulmonologist.
Below is the information for Dr. ___ here at ___ or the
pulmonologist at ___, Dr. ___.
Please also arrange to have your PPD read at ___ on ___,
___.
Followup Instructions:
___
|
10490155-DS-22 | 10,490,155 | 27,580,009 | DS | 22 | 2184-05-04 00:00:00 | 2184-05-04 17:08:00 |
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
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
___ gentleman who is now six months status post liver transplant
(three months status post acute cellular rejection) and
pancytopenia thought to be medication induced, who presented
with fever.
He presents with a six-hour history of fevers. He denies any
other complaints at this time. He has had a mild frontal
headache intermittently over the past, which he describes as a
very mild nagging pain. Denies vision change, change in chronic
numbness to right leg. Denies weakness. Denies cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, dysuria. No change in chronic right lower extremity
swelling. He did have some rhinorrhea for several days which has
since resolved.
He had an episode of rejection 3 months ago. He was recently
seen in Liver Clinic on ___, at which his cellcept was stopped
and he was switched to prednisone given his worsening (thought
to be medication induced) pancytopenia.
In the ED, initial vitals were: 102.8 101 166/76 20 99% RA.
Labs were notable for WBC count of 0.6 (0.9 on ___ with ANC of
460, Hg stable at 8.3, and platelets 87 (previously in 120s).
Creatinine 1.4, at baseline. Lactate 1.2. LFTs were normal.
RUQ US with duplex revealed patent vasculature.
He received 2g IV cefepime, 1g IV vancomycin, 650mg Tylenol, and
1L NS.
On the floor, initial vitals were 98.9 117/61 85 22 99% RA. He
was feeling much improved after fluids and Tylenol.
Past Medical History:
- History of DVT many years ago, formerly on coumadin
- Bilateral knee replacements - with subsequent E. coli
infections requiring replacements over the span 10 to ___ ago
- EtOH cirrhosis s/p Liver transplant ___
- DVT ___
- E coli bacteremia ___
- Neutropenia ___
Social History:
___
Family History:
HTN
DM
No history of liver diasese
Physical Exam:
ADMISSION PHYSICAL
==================
Vital Signs: 98.9 117/61 85 22 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, b/l edema R > L (per patient chronic)
Neuro: CNII-XII grossly intact, moving all extremities
LABS: see below
DISCHARGE PHYSCAL
=================
Vitals: 98.5 ___ 65-69 18 100%RA
General: Alert, oriented, no acute distress
HEENT: NCAT
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, well healed scar from
liver transplant
GU: No foley
Ext: Warm, well perfused, b/l brawny edema(per patient chronic).
B/l scars on knees without tenderness or effusion. R > L leg
edema.
Neuro: A&Ox3 moving all extremities
Pertinent Results:
ADMISSION LABS
==============
___ 02:00AM BLOOD WBC-0.6* RBC-2.97* Hgb-8.3* Hct-26.2*
MCV-88 MCH-27.9 MCHC-31.7* RDW-13.4 RDWSD-42.9 Plt Ct-87*
___ 02:00AM BLOOD Neuts-73* Bands-4 ___ Monos-0 Eos-0
Baso-0 ___ Metas-2* Myelos-0 AbsNeut-0.46* AbsLymp-0.13*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 02:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 02:00AM BLOOD Glucose-174* UreaN-24* Creat-1.4* Na-138
K-4.6 Cl-102 HCO3-23 AnGap-18
___ 02:00AM BLOOD ALT-10 AST-10 AlkPhos-71 TotBili-0.4
___ 02:00AM BLOOD Albumin-3.8
___ 07:34AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.0*
___ 07:34AM BLOOD tacroFK-4.4*
___ 02:06AM BLOOD Lactate-2.1*
DISCHARGE AND PERTINENT LABS
============================
___ 04:47AM BLOOD WBC-1.9* RBC-3.32* Hgb-9.1* Hct-29.8*
MCV-90 MCH-27.4 MCHC-30.5* RDW-14.2 RDWSD-45.1 Plt ___
___ 04:47AM BLOOD Neuts-44 Bands-8* ___ Monos-9 Eos-2
Baso-0 ___ Metas-1* Myelos-0 AbsNeut-0.99* AbsLymp-0.68*
AbsMono-0.17* AbsEos-0.04 AbsBaso-0.00*
___ 06:03AM BLOOD Neuts-50 Bands-3 ___ Monos-5 Eos-5
Baso-1 Atyps-1* ___ Myelos-0 AbsNeut-0.74* AbsLymp-0.50*
AbsMono-0.07* AbsEos-0.07 AbsBaso-0.01
___ 05:19AM BLOOD Neuts-28* Bands-1 Lymphs-60* Monos-8
Eos-3 Baso-0 ___ Myelos-0 AbsNeut-0.29*
AbsLymp-0.60* AbsMono-0.08* AbsEos-0.03* AbsBaso-0.00*
___ 04:44AM BLOOD Neuts-28* Bands-0 Lymphs-57* Monos-12
Eos-2 Baso-1 ___ Myelos-0 AbsNeut-0.34*
AbsLymp-0.68* AbsMono-0.14* AbsEos-0.02* AbsBaso-0.01
___ 04:47AM BLOOD ___ PTT-42.8* ___
___ 04:47AM BLOOD Glucose-87 UreaN-10 Creat-0.9 Na-138
K-4.4 Cl-103 HCO3-23 AnGap-16
___ 06:03AM BLOOD ALT-17 AST-19 AlkPhos-62 TotBili-0.2
___ 04:47AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.5*
___ 05:40AM BLOOD VitB12-698 Folate-8.0
___ 04:47AM BLOOD tacroFK-6.3
MICROBIOLOGY
============
Log-In Date/Time: ___ 2:24 am
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
=======
STUDIES:
___ ___:
Note: The bone marrow aspirate smears revealed trilineage
hematopoiesis with maturation. However, the myeloid precursors
are left-shifted and show mild to moderate dysplasia. Erythroid
precursors do not show significant dysplasia and although
megakaryocytes are increased in number only rare abnormal forms
are seen. The core biopsy shows similar findings although it is
suboptimal for evaluation due to aspiration artifact. Evidence
of an infiltrative marrow process is not present. Corresponding
flow cytometry revealed no diagnostic evidence of
leukemia/lymphoma (see separate report ___ for full
results). Cytogenetics work-up revealed a normal male karyotype
and a MDS FISH panel was negative (see separate report CY16-803
for full details). In this patient with a history of infection,
antibiotic therapy, and treatment with immunosuppressive agents,
the cause of the bone marrow findings and pancytopenia is likely
multifactorial. If all secondary causes of myelodysplasia are
excluded and cytopenias persist, a repeat biopsy could be
considered if clinically indicated for further evaluation.
Correlation with clinical and laboratory findings is
recommended.
IMAGING:
___ CXR:
IMPRESSION:
Interval placement of right PICC, terminating in the lower
superior vena cava. Otherwise stable radiographic appearance of
the chest since the prior study of ___.
___ Knee US:
IMPRESSION:
Trace fluid in the right and left knee joints without evidence
of effusion.
These findings were discussed with ___ MD from ___
by ___ MD at the time of discovery on ___ at
3:50pm, and given the lack of effusion and discussion of risks
and benefits of the procedure, it was decided to not perform the
aspiration at this time.
___ CT Abd/pelvis:
IMPRESSION:
1. No evidence of infection in the abdomen or pelvis.
2. 6 mm calculus in the distal left ureter with mild
hydroureter. No hydronephrosis. 3. Deep vein thrombosis within
the left common femoral vein and IVC. 4. Low-density lymph nodes
are noted in the bilateral groin, right greater the left, as
well as retroperitoneum. Differential includes fungal
infections, Whipple's disease, celiac disease, among others.
Right groin nodes would be amendable to ultrasound-guided biopsy
as clinically indicated. 5. Splenomegaly up to 21 cm is noted,
similar to prior.
RECOMMENDATION(S): Ultrasound-guided biopsy of right groin lymph
nodes as clinically indicated
___ Bilateral knees:
IMPRESSION:
Status post bilateral knee prostheses in overall anatomic
alignment.
Note is made of that the right and left lateral views are
extremely similar (though the AP views are different). Both
views show lucency along the distal femur posteriorly, deep to
the posterior flange of the femoral component, concerning for
early osteolysis, and soft tissue swelling suggestive of
possible joint effusion.
No prior films are available for comparison. If there is
concern for which knees being depicted on lateral views, then
repeat lateral views of both knees can be obtained
___ RUQ with Dopplers:
IMPRESSION:
Patent transplant vasculature with appropriate waveforms.
___ CXR:
IMPRESSION:
Clear lungs.
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman who is now six months
status post liver transplant (three months status post acute
cellular rejection) with pancytopenia thought to be medication
induced, who presented with fever due to E coli bacteremia from
unclear source and found to have DVTs.
# Neutropenic fever, found to have E coli bacteremia: ANC 460 on
admission. Presented with high fever in ED. Patient has a
history of bilateral TKA with history of E. coli infections
requirement hardware replacement at ___ 10 to ___
yrs ago. Has had GBS septic knee in ___, b/l prosthetic
infection s/p washout and liner exchange in ___ treated with 8
weeks CTX then 3 mo cipro, and pansensitive e coli bacteremia,
tx with ertapenem then switched to cipro for pancytopenia. This
admission, blood culture showed E coli resistant to
ciprofloxacin. CT abd/pelvis without clear source of E coli but
did show DVT and low-density lymph nodes in groin and
retroperitoneum, differential for which includes malignancy,
fungal disease, whipple's, and celiac. Given prior infections of
knee, ___ joint aspiration was attempted, however there
was only trace effusion present on ___. He was initially started
on vancomycin/ cefepime, which was transitioned to CTX 2gm q24
hours per sensitivities, likely needing a 6 week course for
infected clot. PICC was placed ___. CMV was negative. Decreased
tacro to 5 BID given high level and active infection. He was
given neupogen ___ & ___ with improvement of neutropenia. He
will have OPAT follow-up and labs on discharge.
# DVT: Noted to have incidental L-sided common femoral DVT on CT
abd/pelvis as well as clot in IVC. Initally on heparin gtt,
switched to lovenox bridge to Coumadin. Warfarin to was
increased to 10 mg ___
# Pancytopenia: thought to be medication induced, cellcept
recently stopped. Now with ANC in 400s. No clinical evidence of
bleeding. S/p BM Bx ___ which showed nonspecific changes without
evidence of MDS or leukemia. He was transfused 1u PRBC ___ and
was given Neupogen ___
#HTN: pt had HTN to 190s on admission, improved to 150s-160s
after starting amlodipine.
#Lymphadenopathy: In groin and retroperitoneal. Concern for
lower GI etiology, but deferring evaluation given cytopenia.
# Alcoholic cirrhosis s/p transplant: Goal tacro ___. Decreased
tacro to 5mg BID on ___ and continued on prednisone 10mg daily.
S/p pentomadine for PCP ___ ___
#Acute kidney injury, RESOLVED: Cr 1.4 on admission. Improved
from prior Cr 1.8 couple weeks ago. Possibly pre-renal vs
medication induced from tacrolimus.
# Chronic pain: continued home oxycodone and gabapentin
# GERD: continued home pantoprazole
TRANSITIONAL ISSUES:
===================
- Patient was started on Ceftriaxone 2g q 24 on ___. Will need
6 week course for infected clot. Will have OPAT monitoring
outpatient.
- Labs to check weekly: CBC with differential, BUN, Cr, AST,
ALT, Total Bili, ALK PHOS
--- Send to ATTN: ___ CLINIC - FAX: ___
- Patient was given pentomadine IH ___ for PCP ___. Can
consider repeating ___ this due to concerns for marrow toxicity
of other agents
- Will need colonoscopy as outpatient for atypical lymph nodes
in groin/retroperitoneum.
- Patient was started on amlodipine for hyptertension to 190s
- Patient has been counseled on neutropenic diet
- Consider outpatient neupogen
- Patient's Lasix and metoprolol were held inpatient. Please
consider restarting in the outpatient setting.
- Patient was started on Coumadin and is on a lovenox bridge.
Goal INR ___. Will have INR checked ___.
- Discharged on magnesium for repletion
# CODE: Full
# CONTACT: fiancee ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Tacrolimus 6 mg PO BID
3. Furosemide 40 mg PO DAILY:PRN edema
4. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN pain
5. Pantoprazole 40 mg PO Q24H
6. Gabapentin 200 mg PO BID
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm UV q24H
Disp #*14 Intravenous Bag Refills:*0
2. Outpatient Lab Work
ICD10: ___
ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC -
FAX: ___
PLEASE DRAW THE FOLLOWING LABS WEEKLY: CBC with differential,
BUN, Cr, AST, ALT, Total Bili, ALK PHOS
3. Outpatient Lab Work
ICD10: D70.9
Please Check CBC with differential, INR on ___ and
send to:
TRANSPLANT CLINIC Re: Dr. ___
___s
Dr. ___: ___
4. Gabapentin 200 mg PO BID
5. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7. PredniSONE 10 mg PO DAILY
8. Tacrolimus 5 mg PO BID
RX *tacrolimus 1 mg 5 capsule(s) by mouth daily Disp #*150
Capsule Refills:*0
9. amLODIPine 10 mg PO DAILY
RX *amlodipine [Norvasc] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 100 mg/mL 100 mg/mL subcutaneous every twelve
(12) hours Disp #*10 Syringe Refills:*1
11. Warfarin 10 mg PO DAILY16
RX *warfarin 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Magnesium Oxide 400 mg PO DAILY Duration: 30 Days
Do not take if you are having diarrhea
RX *magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neutropenic fever
E coli bacteremia
S/p Liver transplant
DVT
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were seen at ___ for your fever. You were found to have E
coli in your blood. We were unable to figure out where the E
coli was coming from, but you will need 6 weeks of IV
antibiotics.
You were also noted to have low blood counts. We did a bone
marrow biopsy that showed no evidence of cancer or pre-cancer.
Most likely, your low counts are due to a mixture of your
previous predisposition, your acute illness, your
immunosuppressants, and the antibiotics (that you unfortunately
need for your E coli infection). You were given a medication to
increase your white blood cell count. Your white blood cell
count will need to be monitored as an outpatient.
Finally, we discovered blood clots in some of your veins. You
will need anticoagulation with Coumadin (a blood thinner) as
well as injections with another blood thinner, lovenox, until
your Coumadin (aka ___) level is high enough. You will need
to have your blood checked for a therapeutic INR as an
outpatient on ___. Please call Dr. ___ (___) on
___ to discuss changes to your Coumadin and lovenox, if
needed.
Please continue to take your medications as prescribed and
follow up at your outpatient appointments.
It was a pleasure taking care of you and we wish you the best in
your health,
Your ___ team
Followup Instructions:
___
|
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