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10490202-DS-17 | 10,490,202 | 27,057,949 | DS | 17 | 2130-05-31 00:00:00 | 2130-05-31 20:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Intubation
Mechanical ventilation
PICC placement and removal
History of Present Illness:
The patient is a ___ with known substance abuse who presented
initially to OSH with unresponsiveness, now transferred to ___
with acute respiratory failure; urine tox screen positive for
methadone, barbiturates, benzodiazepines, cocaine.
Per report, EMS was called by patient's girlfriend after patient
was unresponsive for more than an hour and a half. He was found
to have agonal breathing at the scene; he was treated with
Narcan with good response. On arrival to the outside hospital,
the patient was tachypneic to the ___, and he was intubated for
airway protection and respiratory distress and ssedated with
Propofol. Chest x-ray at OSH was concerning for a left-sided
infiltrate and the patient was started on vancomycin and Zosyn
for concern of aspiration pneumonia. His CK was markedly
elevated at 25,000. His urine tox screen was positive for
methadone, barbiturates, benzodiazepines, cocaine. His serum tox
screen was negative for salicylates, acetaminophen, tricyclics,
and alcohol. He was also given total 2L NS and 650mg
acetaminophen PR at OSH. Femoral CVL was placed. Patient was
given vecuronium en route to ___.
On arrival to the ED, VS: 100.6 111 148/91 24 97% on vent. Labs
were significant for WBC 14.1 (N 84.5%), plts 115, INR 1.5. ALT
was 131, AST 258. Cr 1.2, BUN 32. CK was ___, initial trop was
0.16. Urine tox was positive for benzos, barbs, cocaine,
methadone (negative for opiates and amphetamines). CXR showed
"perihilar opacities which could reflect pulmonary edema with
more confluent retrocardiac opacity which is concerning for
aspiration given the clinical setting. CT head showed no acute
intracranial process." Patient was given levofloxacin for ICU
PNA coverage; gentamycin was ordered for possible endocarditis,
but not given. EKG showed sinus tachycardia with rate 110. On
transfer, VS: 113 129/79 27 97% on vent. Settings on transfer
were: Tv 450 X RR 18, FiO2 100%, PEEP 12. ABG on those settings:
pH 7.29 pCO2 55 pO2 98. Patient received additional 2L NS at
___ (total 4L including OSH).
On arrival to the MICU, pt is intubated and sedated. He is not
arousable to voice or noxious stimuli. Some additional history
was provided by phone conversation with patient's parents.
Review of systems:
Unable to obtain
Past Medical History:
"Sinus problems"
History of polysubstance abuse, in a methadone program
Had an MVA where he crashed into a tree
Social History:
___
Family History:
Father just had AAA repair and is "partially blind." Paternal
grandfather and uncles had brain aneurysms.
Physical Exam:
ADMISSION EXAM:
VS: 99.7, 109, 126/69, 19, 97% on Tv 500, RR 14, PEEP 5, FiO2
40%
General: Well-appearing young male in no acute distress
HEENT: Pupils are 2mm and reactive, but left response is more
brisk. Mucous membs moist. Poor dentition, 2 uclers notes on
bottom of tongue.
Neck: Difficult to asses JVP
CV: S1/S2 Regular but tacycardic, no murmurs/gallops
appreciated
Lungs: Inspiratory crackles diffusely on anterior exam
Abdomen: Soft, nontender, normoactive bowel sounds
GU: foley
Ext: Warm, no peripheral edema peripheral pulses
Neuro: unable to asses, no apontaneous movement
DISCHARGE EXAM:
VS: 98.0 158/99 85 18 96%RA
GEN: Alert, mildly diaphoretic, otherwise NAD
HEENT: Pupils equal and reactive, sclerae non-icteric, OP clear,
MMM.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: CTAB.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema
PSYCH: Appropriate and calm.
Pertinent Results:
Admission Labs:
___ 05:44AM WBC-14.1* RBC-4.39* HGB-14.0 HCT-42.1 MCV-96
MCH-31.9 MCHC-33.2 RDW-12.9
___ 05:44AM NEUTS-84.5* LYMPHS-11.0* MONOS-3.9 EOS-0.1
BASOS-0.4
___ 05:44AM ___ PTT-35.3 ___
___ 05:44AM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-POS amphetmn-NEG mthdone-POS
___ 05:44AM ALBUMIN-4.0 CALCIUM-8.2* PHOSPHATE-3.8
MAGNESIUM-2.0
___ 05:44AM cTropnT-0.16*
___ 05:44AM CK-MB-52* MB INDX-0.4
___ 05:44AM ALT(SGPT)-131* AST(SGOT)-258* ALK PHOS-53 TOT
BILI-0.5
___ 05:44AM GLUCOSE-138* UREA N-32* CREAT-1.2 SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 06:06AM LACTATE-1.7
Other Pertinent Labs:
___ 06:53AM BLOOD WBC-6.3 RBC-4.00* Hgb-13.0* Hct-36.7*
MCV-92 MCH-32.4* MCHC-35.3* RDW-13.0 Plt ___
___ 06:53AM BLOOD Glucose-84 UreaN-22* Creat-0.6 Na-143
K-3.4 Cl-103 HCO3-28 AnGap-15
___ 06:53AM BLOOD ALT-98* AST-47* AlkPhos-64 TotBili-0.4
___ 05:44AM BLOOD ___
___ 06:17AM BLOOD ALT-126* AST-64* LD(LDH)-413*
CK(CPK)-1666* AlkPhos-60 TotBili-0.5
___ 11:44AM BLOOD CK-MB-50* MB Indx-0.3 cTropnT-0.18*
___ 03:50AM BLOOD CK-MB-18* MB Indx-0.2 cTropnT-0.10*
___ 11:44AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 11:44AM BLOOD HCV Ab-POSITIVE*
Pending Labs:
___ VIRAL LOAD-PENDINGINPATIENT
___ Viral Load-PENDINGINPATIENT
___ CULTUREBlood Culture,
___ CULTUREBlood Culture,
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY ___
CULTUREBlood Culture, Routine-PENDINGEMERGENCY
Studies:
___ CT head: No acute intracranial process.
___ TTE: Vigorous biventricular function. No clinically
significant valvular disease or pericardial effusion is seen.
Mild biatrial enlargement noted. No prior exams for comparison
___ RUQ U/S: 1. Hepatomegaly with diffusely increased
echogenicity of the liver likely represents diffuse hepatic
steatosis with focal fatty sparing adjacent to the gallbladder
fossa. Other forms of more advanced liver disease such as
cirrhosis/hepatic fibrosis cannot be excluded. No suspicious
hepatic lesions.
2. Borderline splenomegaly. No abdominal ascites.
3. Patent portal vein with normal hepatopetal flow.
4. Cholelithiasis without sonographic evidence of acute
cholecystitis.
___ CXR: Interval removal of endotracheal tube and
nasogastric tube. Heart size is normal, accompanied by mild
pulmonary vascular congestion and improving multifocal pulmonary
opacities which now predominantly involve the left lung.
Brief Hospital Course:
The patient is a ___ with known substance abuse who presented
initially to OSH with unresponsiveness, then transferred with
acute respiratory failure due to drug overdose.
# ACUTE RESPIRATORY FAILURE: He reportedly had tachypnea to ___
and respiratory distress prior to intubation at OSH. Elevated
A-A gradient based on ABG in ED was likely combination of
multifocal PNA and aspiration, with cocaine contributing. He was
initially treated with Zosyn only but sputum gram stain showed
GPC in pairs and chains and Vancomycin was started. Patient self
extubated on the evening of ___ and subsequently was saturating
well on on room air. Given sputum culture with mixed flora and
clinical improvement with under dosed vancomycin (trough was in
___ range), discontinued Vancomycin on ___. He was switched to
levaquin and continued on an 8 day course of antibiotics.
# RHABDOMYOLYSIS: CK on admission ___ in setting of
prolonged period of time down/immobilized. Trended down with
hydration, maintained UOP > 100cc/hr. Continued to downtrend
prior to discharge.
# Elevated troponins: Likely demand ischemia vs cocaine-induced
vasospasm. No ST/T wave changes consistent with ischemia on
initial EKG at ___. Troponin starting to downtrend after
peaking at 0.18. Echo without evidence of wall motion
abnormality.
# TRANSAMINITIS: Acute elevation likely secondary to alcohol vs
rhabdo. Though low Plt and elevated INR suggests more chronic
disease. Hep serologies positive for HCV and Hep B core ab. HCV
and hepatitis B viral loads pending at the time of discharge.
# POLYSUBSTANCE ABUSE: Tox screen positive for Alcohol,
Cocaine, Benzos and Barbiturates. Has known history of substance
abuse on methadone maintenance. Per girlfriend, on a monthly
basis, he commonly uses drugs heavily after he gets his paycheck
and usually "sleeps it off." ___ clinic was
contacted and confirmed he is on Methadone 90mg daily. He was
seen by social work and our addiction nurse during this
admission. He endorsed wanting to stop using drugs but
acknowledged that is difficult and did not want inpatient
treatment on discharge. He denied any intentional overdose or
suicidality.
# THROMBOCYTOPENIA: Unclear etiology. Could be related to EtOH
use or viral hepatitis. Could also be related to liver disease.
TRANSITIONAL ISSUES:
- Continued substance abuse counseling as an outpatient
- Blood cultures pending at the time of discharge
- Hepatitis C Ab positive during this admission, viral load
pending at the time of discharge. Liver clinic f/u scheduled.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methadone 90 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Sertraline 150 mg PO DAILY
4. ClonazePAM 1 mg PO BID
Discharge Medications:
1. Methadone 90 mg PO DAILY
2. ClonazePAM 1 mg PO BID
3. Gabapentin 600 mg PO TID
4. Sertraline 150 mg PO DAILY
5. Levofloxacin 500 mg PO DAILY Duration: 3 Days
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Drug overdose
2. Respiratory depression
3. Aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because of respiratory depression in the
setting of a drug overdose. You were intubated at an outside
hosiptal and transferred to the ICU at ___
___. There was concern that you had a pneumonia and
you were started on antibiotics. Your breathing improved and
you took out your endotracheal tube by yourself. You were then
transferred to the general medical floor.
It was noted that your liver function tests were elevated. You
have hepatitis C and have been exposed to hepatitis B. We have
made you appointments in the liver clinic to discuss treatment
of your hepatitis C.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Followup Instructions:
___
|
10490439-DS-19 | 10,490,439 | 29,037,588 | DS | 19 | 2169-02-12 00:00:00 | 2169-02-12 22:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o CAD s/p DES in ___, HTN, HLD presents with abdominal
pain. Woke up yesterday morning with diffuse lower abdominal
pain. Progressively worse throughout the day to the point where
he had to unbutton his pants. Episode of diarrhea at 2 pm,
another at 4 pm, emesis x1. No fevers/chills. No abdominal
surgeries. On plavix. No history of kidney stones. Long car ride
here, every bump had abdominal pain. Only recent change was
increase in fatty food/alcohol for past few weekends.
In the ED intial vitals were: 96.4 77 177/100 16 100%
- Exam: voluntary guarding, diffuse abdominal pain, LUQ/LLQ
tenderness.
- Labs were significant for: WBC 13 (79%N), Hct 50.9, BUN/Cr
___, lactate 1.8, lipase 949, AST/ALT 75/116
- CT abd with duodenitis and focal inflammatory changes of the R
colon likely from proximity, may also be gastritis (thickening
of the antrum)
- Patient was given: dilaudid x2, zofran x2, percocet, flagyl,
lisinopril
Vitals prior to transfer were: 98.8 74 193/97 16 97% RA
On the floor, pt reports persitent abdominal pain, nausea.
Abdominal pain is epigastric as well as radiating around abdomen
in band in lower quadrant. Worse w/movement. Nauseous (had
episode of bilious emesis during interview). Denies fevers,
chills, SOB or CP.
Past Medical History:
- CAD s/p DES ___
- HTN
- Dyslipidemia
- Skin cancer (basal cell/squamous cell) excision x 3
- Asymmetric prostate
Social History:
___
Family History:
Father died at age ___ from a stroke. Uncle also died from a
stroke.
Maternal grandfather died at age ___ of CAD. Mother is ___ and has
PVD.
Physical Exam:
ADMISSION EXAM:
================
Vitals- 97.7 182/97 82 18 97% RA
General- obese gentleman, uncomfortable
HEENT- PERRL, MMM
Lungs- largely clear to auscultation, with faint crackles at
bases
CV- RRR, nl S1/S2
Abdomen- +BS, diffusely tender, with tenderness to percussion as
well as rebound tenderness, most markedly in epigastrum and left
quadrants, soft, no masses
GU- no foley
Ext- no ___ edema, WWP
Neuro- AOx3, CN ___ grossly intact
.
DISCHARGE EXAM:
===========
itals- 98.2 143/77 68 16 91% on RA (back on NC)
UOP: 3.75 L
General- obese gentleman, resting comfortably
HEENT- PERRL, MMM
Lungs- crackles at bases (improved from prior exams)
CV- RRR, nl S1/S2, with patient at 30 degrees, JVD at mid neck
Abdomen- +BS, diffusely tender, improved from yesterday, most
markedly in epigastrum and left quadrants, but with no rebound,
soft, no masses
GU- no foley
Ext- no ___ edema, WWP
Neuro- AOx3, CN ___ grossly intact
Pertinent Results:
ADMISSION LABS:
================
___ 10:00AM GLUCOSE-117* UREA N-23* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
___ 10:00AM ALT(SGPT)-83* AST(SGOT)-49* ALK PHOS-61 TOT
BILI-1.1
___ 10:00AM LIPASE-490*
___ 10:00AM CALCIUM-8.1* PHOSPHATE-3.6 MAGNESIUM-1.7
___ 10:00AM WBC-12.7* RBC-5.19 HGB-15.6 HCT-47.8 MCV-92
MCH-30.1 MCHC-32.7 RDW-12.8
___ 10:00AM PLT COUNT-185
___ 03:02AM LACTATE-1.8
___ 02:46AM GLUCOSE-117* UREA N-30* CREAT-1.3* SODIUM-138
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17
___ 02:46AM ALT(SGPT)-116* AST(SGOT)-75* ALK PHOS-73 TOT
BILI-1.1
___ 02:46AM LIPASE-949*
___ 02:46AM ALBUMIN-4.8
___ 02:46AM WBC-13.0* RBC-5.65 HGB-16.8 HCT-50.9# MCV-90
MCH-29.8 MCHC-33.1 RDW-12.7
___ 02:46AM NEUTS-79.0* LYMPHS-13.3* MONOS-6.6 EOS-0.3
BASOS-0.7
___ 02:46AM PLT COUNT-256
.
IMAGING:
========
- CT abd/pelvis ___: Moderate amount of intra-abdominal free
fluid in the anterior pararenal space and surrounding Gerota's
fascia bilaterally with associated soft tissue stranding the
duodenum and right colon. Although pancreas appears normal,
findings are most compatible with early uncomplicated
pancreatitis.
.
RUQ US ___: 1. No gallstones and no biliary dilatation.
2. Echogenic liver consistent with fatty infiltration.
Other forms of liver disease and more advanced liver
disease including significant hepatic fibrosis/cirrhosis
cannot be excluded on this study.
.
EKG: 68 NSR, LAD, LBBB
.
CXR ___: The lung volumes are low. There is minimal blunting
of the right costophrenic sinus, potentially suggesting presence
of a small right pleural effusion. There also is minimal volume
loss in the middle lobe. At the left lung bases, a discoid
atelectasis is seen. Mild cardiomegaly at relatively lower lung
volumes. No pulmonary edema. No pneumonia.
.
CXR ___: Asymmetric interstitial edema, left worse than right.
Low lung volumes. New retrocardiac opacity with air bronchograms
may represent aterlectasis versus aspiration.
.
TTE ___: The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF = 45 %) secondary to a dyssynchronous mechanical
activation sequence (left bundle branch block pattern). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened (?#). There is mild aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
MICROBIO:
=========
___ 1:35 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ 12:44.
.
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-12.8* RBC-4.15* Hgb-12.4* Hct-37.3*
MCV-90 MCH-29.8 MCHC-33.2 RDW-12.2 Plt ___
___ 07:35AM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-136
K-3.7 Cl-97 HCO3-29 AnGap-14
___ 07:35AM BLOOD ALT-39 AST-31 AlkPhos-80 TotBili-0.9
Brief Hospital Course:
Mr ___ is a ___ year old gentlman with CAD, HTN, HLD
presents with diffuse lower abdominal pain found to have
pancreatitis.
.
ACUTE ISSUES:
=============
# Pancreatitis: presents with abdominal pain, diarrhea, mildly
elevated LFTs and a lipase in the 900s, found to have
inflammation of organs surrounding pancreas (duodenum, stomach,
general free fluid) on CT abd/pelvis. No gallbladder distention,
billiary distention or stones on CT or subsequent RUQ U/S.
Triglycerides, calcium with normal limits. Not on any meds known
to cause pancreatitis. Does have a higher than recommended
alcohol intake; 2 "good sized" glasses of wine daily, ___ on
weekend days. Started on IV pain meds and anti-emetics, IV
fluids, made NPO. Course complicated by development of E.coli
bacteremia and flash pulmonary edema (see issues below). On ___
able to advanced diet, transition to PO pain meds, and by ___
patient's pain was well controlled on progressively decreasing
doses of oxycodone, and he was eating full liquids. Most likely
culprit of pancreatitis is alcohol; limiting alcohol intake was
discussed with patient prior to discharge. Had planned on
keeping patient another day, advancing diet and weaning off
narcotics further, however on ___ patient's laptop, which had a
lot of business data on it was stolen by his roommate who
eloped, and patient wanted to go home to take care of some
security issues for his company. Patient was sent home with
instruction to decrease pain medication while advancing to a low
fat diet.
.
# E. coli Bacteremia: Patient febrile ___ and ___, GNRs grew
from blood on ___, started on IV zosyn. GNRs speciated to E.
coli sensitive to ciprofloxacin, transitioned to cirpo on ___.
Discharged on PO cirpo, to complete 2 week course on ___. E.
coli bacteremia most likely occured from transient translocation
of gut bacteria in setting of inflammation of duodenum and
stomach from pancreatitis.
.
# CHF/Hypoxia: Patient agressively fluid resuscitated in setting
of pancreatitis, recieving IVF at rate of 200cc/hr for first
48hrs of admission. Developed progressive hypoxia with IVFs,
eventually developing flash bilateral pulmonary infiltrates in
the setting of hypertension causing respiratory distress
requiring brief transfer to the ICU. Also had slight bump in
troponins (0.02), but without EKG changes. Hypoxia responded
well to nitrates and lasix in the unit, and he was transfered
back to the floor. Echo showed mild left ventricular hypertrophy
and LVEF of 45% in part due to dysnchronous activation (left
bundle branch block). Patient did not recieve any further IVFs
given CHF and the fact that at this point he had progressed to
taking PO fluids. Oxygenation improved with further diuresis and
mobilization of patient, to the point where he was weaned onto
room air at time of discharge. Already on b-blocker, ace-i,
statin and aspirin.
.
# Hypertension: Blood pressures difficult to control,
particularly while patient was recieving aggressive fluid
resuscitation. Continued on home coreg, lisinopril, as well as
addition of isosorbide and hydralazine for immediate control.
Eventually transitioned off isosorbide and hydralazine to
amlodipine, on which patient was discharged.
.
# ___: Cr 1.3 on admission from baseline of 0.9 in ___,
improved back to baseline with IVF.
.
CHRONIC ISSUES:
===============
# CAD: s/p DES in ___. Continued on aspirin, plavix, coreg and
lisinopril. Spoke to outpatient cardiologist about the continued
need for plavix (no clear indication), who said they would
follow up with patient as and outpatient. On statin as well.
.
# HLD: Lipids very well controlled; continued on home statin on
discharge.
.
TRANSITIONAL ISSUES:
====================
# Blood cultures from ___ and ___ pending at time of discharge
(NGTD)
# Noted to have fatty liver on imaging; LFTs nomralized at time
of discharge. To follow up as outpatient, would likely benefit
from weight loss, reduction in alcohol consumption.
# Found to have sCHF on echo; not previously symptomatic,
already on appropriate medications (ace-i, b-blocker), but would
benefit from follow up with outpatient cardiologist.
# Hypertension difficult to control in setting of aggressive
fluid repletion; improved on discharge with addition of 10mg
amlodipine, should follow up with PCP for further adjustments.
# To follow up with cardiologist to discuss continued necessity
of clopedigrel.
# Found to have 3 RBCs on UA; should have repeat UA as
outpatient to rule out further hematuria.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral daily
5. milk thistle 140 mg oral daily
6. Clopidogrel 75 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
q6hrs Disp #*28 Tablet Refills:*0
7. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth twice a day Disp
#*15 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hrs Disp #*24
Tablet Refills:*0
9. Multivitamins 1 TAB PO DAILY
10. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral daily
11. milk thistle 140 mg oral daily
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*14 Capsule Refills:*0
13. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*14 Tablet Refills:*0
14. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# PRIMARY: Acute Pancreatitis, E. coli Bacteremia
# SECONDARY: Congestive Heart Failure, Coronary Artery Disease,
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 at the ___
___. You were admitted for abdominal pain,
and found to have acute pancreatitis. This is an inflammation of
your pancreas, which we think may have been linked to the amount
of alcohol you drink. We strongly recommend you drink no more
than 1 alcoholic drinks a day, no more than 7 alcoholic drinks a
week.
You also had bacteria in your blood, likely due to the
pancreatitis. For this, you will complete a 2 week course of
oral ciprofloxacin, to be completed ___.
As we gave you lots of fluid to treat your pancreatitis, you
developed difficulty breathing as fluid accumulated on your
lungs. This was partially because you have congestive heart
failure, or your heart doesn't pump quite as well as it should.
For this you should follow up with your cardiologist.
We also noted on imaging that you have a "fatty liver", which
can either be associated with alcohol or your weight. This is
not permanent liver damage, but could lead to it. This will be
followed up by your PCP, but it could be improved with either
weight loss or decreased alcohol consumption.
I sincerely apologize that your laptop was stolen during your
stay with us. When you go home, continue to slowly increase your
oral intake while decreasing the amount of oxycodone you are
taking. Stick to a low fat diet and try to avoid all alcohol for
a while.
Followup Instructions:
___
|
10490455-DS-13 | 10,490,455 | 20,539,733 | DS | 13 | 2178-09-09 00:00:00 | 2178-09-10 23:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Abdominal pain, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ year old male with a history of HIV and
AIDS as well as anal squamous cancer treated with definitive
radiation in ___, Major Depressive Disorder requiring recent
hospitalization who presents with abdominal pain and
constipation.
Prior to presentation, patient had not had a bowel movement for
30 hours. Denies fever, chills, night sweats, back pain,
dysuria.
He has also had several episodes of vomiting, describes it is
dark-colored and nonbilious. No blood in the vomit. No cough. No
history of bowel obstructions in the past.
He has a reported history of anal squamous cell cancer treated
in
___ with radiation and re-evaluation in ___ with negative
biopsies at that time although condyloma present.
In the ED:
- POCUS: negative for bowel obstruction
- CT Abdomen obtained:
1. 3 mm stone in the proximal left ureter with minimal upstream
ureteral dilatation and minimal pelvic fullness.
2. 3 mm stone in the distal right ureter without associated
hydroureter or hydronephrosis.
3. No evidence of diverticulitis
- Patient given enema and passed stool
- Pain control attempted with Acetaminophen and Ketorolac and
given lack of pain control, patient admitted
Labs:
Chemistry: Na 135, Cl 103, BUN 11, K 5.3, BUN 21, Sr Cr 1.0
CBC: WBC 8.1 Hgb 12.3 Plt 169
Lactate 0.9
UA: Trace blood, 30 protein, 0 WBC, no bacteria
On arrival to the floor patient is hemodynamically stable, but
reports pain and asking for IV Tylenol. Patient reports that his
abdominal pain is primarily in the rectum. He endorses feeling
the need to pass a stool, but being unable to. He says he sits
at
the toilet, but has no bowel movement. He also endorses some
pain/discomfort of the lower abdominal area, primarily midline.
He does feel his abdomen is distended. He tried having coffee,
consuming vegetables that have helped him pass stool in the
past,
and using senna without results. He has also induced vomit 3
times, mostly vomiting coffee and food he had consumed. He has
also tried to digitally induce a bowel movement and has felt
hard
stools, but has been not been successful in inducing a bowel
movement. He denies any blood per rectum and denies feeling any
masses internally/externally. He denies fevers, nausea, loss of
appetite.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. Question of Anal Squamous Cell Cancer, diagnosed ___,
received radiation without chemotherapy, lost to follow up. CT
Torso ___
with no evidence of distant metastatic disease, MR ___ with
anal irritation, no obvious mass. Exam under Anesthesia
completed
with Dr. ___ in ___ with negative biopsies, condyloma
found at that time.
2. HIV/AIDS, CD4 count nadir of 32.
3. Anal condyloma.
4. Schizoaffective disorder.
5. Depression: Recently hospitalized until ___ in setting
of SI and plan. 3 past suicide attempts (___)
6. Anxiety.
7. PTSD
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Brother with bipolar disorder and multiple hospitalizations for
depression. Maternal grandfather completed suicide
___ use disorders: many family members; notably patient's
mother had a severe substance use disorder and effectively
abandoned him when he was ___
Physical Exam:
ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
Vitals: ___ 1006 Temp: 98.0 PO BP: 126/85 HR: 68 RR: 18 O2
sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
HEENT: Moist mucous membranes. No oropharyngeal lesions.
CARDIOVASCULAR: Regular rate, normal S1, S2. No S3, S4,
murmurs, rubs or gallops.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Bowel sounds present. Abdomen is soft, nontender,
nondistended. There are no masses or hepatosplenomegaly.
LIMBS: No tremors, clubbing, edema or asterixis.
SKIN: He has a follicular rash that appears treated and
hyperpigmented on his front and back across his chest, abdomen
and back without substantial rash on his arms, although somewhat
there. He also has some discoloration of the shins.
ANAL: no frank growths externally no bulging masses appreciated,
internal exam deferred
NEUROLOGIC: Grossly nonfocal.
DISCHARGE PHYSICAL EXAM
PHYSICAL EXAM:
Vitals:
24 HR Data (last updated ___ @ 1153)
Temp: 97.8 (Tm 98.6), BP: 120/80 (108-126/64-85), HR: 63
(61-68), RR: 18, O2 sat: 95% (94-95), O2 delivery: Ra
General: awake, answers questions appropriately
HEENT: PERRL, MMM
Lungs: No increased WOB, clear to auscultation bilaterally
CV: RRR, no murmurs, rubs, or gallops
GI: soft, non-tender, mildly distended, BS+
Ext: warm and well perfused, 2+ pedal pulses
Neuro: no gross neurologic abnormalities
Pertinent Results:
ADMISSION LABS
**************
___
WBC-8.1 RBC-4.31* Hgb-12.3* Hct-38.7* MCV-90 MCH-28.5 MCHC-31.8*
RDW-12.6 RDWSD-41.6 Plt ___
Glucose-99 UreaN-9 Creat-0.9 Na-144 K-4.2 Cl-109* HCO3-21*
AnGap-14
ALT-12 AST-23 AlkPhos-65 TotBili-0.9
Albumin-4.3
Lactate-0.9
CT ABD/PELVIS ___
IMPRESSION:
1. 3 mm stone in the proximal left ureter with minimal upstream
ureteral
dilatation and minimal pelvic fullness.
2. 3 mm stone in the distal right ureter without associated
hydroureter or
hydronephrosis.
3. No evidence of diverticulitis.
DISCHARGE LABS
**************
___
WBC-5.1 RBC-4.06* Hgb-11.5* Hct-36.0* MCV-89 MCH-28.3 MCHC-31.9*
RDW-12.4 RDWSD-40.5 Plt ___
Glucose-99 UreaN-9 Creat-0.9 Na-144 K-4.2 Cl-109* HCO3-21*
AnGap-14
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of HIV and
AIDS as well as anal condyloma, Major Depressive Disorder
requiring recent hospitalization who presents with abdominal
pain and constipation with concern for constipation and anal
inflammation as etiology.
# Abdominal Pain
#Constipation
Patient presented reporting significant constipation as trigger
for abdominal pain. Initial concern for anal pathology (history
of anal condyloma, hx radiation ___ ?anal cancer) as etiology
of pain, however CT (___) demonstrated rectal thickening (known
finding), no obvious mass, no SBO, and a significant amount of
stool in the rectosigmoid. Trigger for constipation is unclear
as no reported changes to diet, no increased opiods. He was put
on bowel regimen: standing Senna 17.2mg BID, Bisacodyl 10mg PR,
Miralax 17g daily, and enemas. Oxycodone was reduced to 15mg q6h
prn from home 30mg q4h prn, and received a dose of
methylnaltrexone. By time of discharge, patient's abdominal pain
had improved, abdomen was less distended, and he was having BMs
without help from enemas.
# Nephrolithiasis:
CT scan ___ also showed 3mm stone present in left ureter with
minimal
ureteral dilatation and pelvic fullness. Renal function was at
baseline. Initial concern that stones could correlate with acute
presentation. However, in the setting of small stones,
uncharacteristic pain for nephrolithiasis, and improvement of
abdominal pain after BMs, unlikely that these stones were
contributing. He received IV fluids, pain was controlled with
acetaminophen, and Lidocaine patch.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QID:PRN anxiety
2. ARIPiprazole 5 mg PO QHS
3. Dapsone 100 mg PO DAILY
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
6. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain -
Moderate
7. CloNIDine 0.1 mg PO BID:PRN ___ line anxiety
8. Escitalopram Oxalate 10 mg PO DAILY
9. Nicotine Patch 14 mg/day TD DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a
day Disp #*14 Packet Refills:*0
3. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
4. ALPRAZolam 0.5 mg PO QID:PRN anxiety
5. ARIPiprazole 5 mg PO QHS
6. CloNIDine 0.1 mg PO BID:PRN ___ line anxiety
7. Dapsone 100 mg PO DAILY
8. Dolutegravir 50 mg PO DAILY
9. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
10. Escitalopram Oxalate 10 mg PO DAILY
11. Nicotine Patch 14 mg/day TD DAILY
12. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
CONSTIPATION
NEPHROLITHIASIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital due to abdominal pain and
constipation.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you had a CT scan to look for
any causes of constipation. Your CT scan showed that you had a
large amount of stool and also showed that you had small kidney
stones. To help with constipation, you received a number of
enemas, suppositories, other medications to help you with bowel
movements. These treatments helped you have better bowel
movements and your pain improved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take Colace and senna for constipation.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10490455-DS-8 | 10,490,455 | 26,326,595 | DS | 8 | 2174-04-08 00:00:00 | 2174-04-11 23:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfa
Attending: ___
Chief Complaint:
HMED Admission Note
___
cc: gluteal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with HIV/AIDS (CD4 46) on HAART who presents with L
gluteal pain s/p recent injection. Pt recently moved from ___
to ___. Pt established care at ___ and saw a provider
last week. Pt was noted to have skin findings which were
concerning for syphilis so he was given two injections of
Bicillin. Pt reports severe pain in the L buttock in the days
following. Pt reports constant severe sharp pain on the L
buttock, worse with movement and tender to touch. He says he has
been sitting in a bathtub all weekend and took some of his home
oxycodone with no relief. He denies fevers. Has chills usually.
No drainage. Pt with known history of anal condylomas but no hx
of perirectal abscesses. No change in BM or blood in stools.
Of note, pt reports being treated for syphillis ___ years ago.
RPR was negative in ___ on chart pt has brought in with him. He
says that his skin findings have been present for a long time
and was told they were due to folliculitis.
Pt came to the ED where he was afebrile. No leukocytosis.
Tendenress but no erythema at site of injection. CT pelvis
showed some inflammatory changes but no abscess or fluid
collection. Pt given IV vanc and Unasyn and adnitted for further
care.
ROS: negative except as above
Past Medical History:
# HIV CD4 46, VL 116; on Truvada/Prezista/Norvir (restarted on
HAART in ___, CD4 of 6 at the time)
# Anal condylomas
# Hx of tx for syphillis
# Bipolar/PTSD - per pt, not on meds
Social History:
___
Family History:
No family history of autoimmune disease.
Physical Exam:
Vitals: 99.0 119/80 87 18 99%RA
Gen: NAD
HEENT: NCAT, no oral thrush
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, nt/nd, +bs
Ext: no edema
Buttock: exquisite tenderness to palpaiton in L buttock with no
induration or fluctulance; no erythema; mildly warm to touch
Neuro: alert and oriented x 3, no focal deficits
Skin: hyperpigmented maculopapular lesions throughout chest
likely consistent with folliculitis
Pertinent Results:
___ 04:57PM WBC-7.1 RBC-4.54* HGB-12.4* HCT-36.7* MCV-81*
MCH-27.2 MCHC-33.7 RDW-13.4
___ 04:57PM PLT SMR-LOW PLT COUNT-81*
___ 04:57PM ___ PTT-28.6 ___
___ 04:57PM GLUCOSE-97 UREA N-15 CREAT-0.7 SODIUM-135
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
___ 04:50PM LACTATE-1.0
___ 06:00PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
CT Pelvis:
Soft tissue stranding and induration surrounding the left
gluteal muscles
which may reflect inflammatory changes related to prior
intramuscular
injection. There is no evidence of abscess formation.
Brief Hospital Course:
___ year old M with HIV/AIDS here with L buttock pain and
tenderness following recent antibiotic Bicillin injection at
___ for concern of syphilis. Pt with inflammatory
changes on imaging but clinical findings are low suspicion for
cellultis.
1. L buttock pain: From recent Bicillin injection for suspicion
of syphilis at outpatient clinic through pt had negative VDRL
and no clinical signs or symptoms consistent with syphilis.
Pt's pain was treated with toradol which was transition to
naproxen and also IV dilaudid transitioned to oxycodone. Given
the pain and mild erythema over the area, pt will complete 5 day
course of keflex, though low suspicion for cellulitis.
2. HIV/AIDS: Most recent CD 4 count=21, Last viral load ___,
HIV resistance genotype pending from ___
Pt's med list from ___ demonstrated that he was recently
represcribed his prior HAART regimen with truvada, darunavir,
ritonavir. This was initially restarted in house but the
patient developed vomiting which he is sure is from his HAART
meds. He states that this had happened to him in the past as
well when he restarted his HAART meds. Further history
clarified that the pt had started taking his HIV meds (truvada,
prezista, norvir) in ___, stopped in ___, restarted
in ___. The meds made him sick and he lost his
insurance so he had been off them until seeing ___ and having
them represcribed, so has been off them for about 3 months.
Given this, his HIV meds were stopped until the genotype panel
returned from ___. He requested an ___ provider and will
follow with one of the HIV ___ providers. Please call ___ to contact ___ prior to his appt to have his HIV
resistance panel faxed. He was continued on weekly azithromycin
and daily dapsone for PPX.
3. Thrombocytopenia - likely HIV related
- monitor with heparin
4. Anxiety: Continued on xanax.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. RiTONAvir 100 mg PO BID
3. Darunavir Dose is Unknown PO Frequency is Unknown
4. OxycoDONE (Immediate Release) 20 mg PO Frequency is Unknown
5. ALPRAZolam 2 mg PO Frequency is Unknown
6. Dapsone Dose is Unknown PO DAILY
7. Azithromycin 250 mg PO Frequency is Unknown
Discharge Medications:
1. ALPRAZolam 2 mg PO DAILY:PRN anxiety
2. Azithromycin 1200 mg PO 1X/WEEK (___)
3. Dapsone 100 mg PO DAILY
4. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*6 Capsule Refills:*0
5. Acetaminophen 1000 mg PO Q8H
6. Naproxen 500 mg PO Q12H Duration: 5 Days
RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
7. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain
RX *oxycodone 10 mg ___ tablet(s) by mouth every six (6) hours
Disp #*32 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gluteal pain from? cellulitis
AIDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for gluteal pain after a pencillin injection.
There may be the start of a cellulitis there so you were given a
short course of antibiotics to complete. You will follow up
with your new physicians who will choose a new HIV regimen based
on your resistance panel
Followup Instructions:
___
|
10491101-DS-11 | 10,491,101 | 27,856,978 | DS | 11 | 2139-04-03 00:00:00 | 2139-05-05 21:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall over handle bars of bike
Major Surgical or Invasive Procedure:
Facial sutures
History of Present Illness:
___ s/p fall over handle bars of bike earlier this morning. +LOC
for 5 minutes and associated retrograde amnesia. He was taken by
ambulance to OSH, where imaging revealed C6/C7 fractures and
multiple facial fractures, after which he was transferred to
___
Past Medical History:
PSH: pyloric stenosis repair
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
O: T: 98.2 BP: 140/64 HR: 80 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD. Hard Cervical collar in place.
Multiple abrasions over face.
HEENT: Pupils: 2 -> 1 bilateally EOMs intact
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, place, and date.
Motor:
D B T Grip WE WF IO IP Q H AT ___
G
R
L 5 5 5 4 5 5
*Left wrist extension, flexion, and grip limited ___ abrasions
and pain on back of wrist
Reflexes: B T Br Pa Ac
Right ___ 1 1
Left * ___ 1
*not examined secondary to IV lines
Negative for clonus, Babinski, and ___ bilatarally.
Toes downgoing bilaterally
Pertinent Results:
___ 02:30PM GLUCOSE-108* UREA N-15 CREAT-1.0 SODIUM-141
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 02:30PM WBC-12.4* RBC-4.43* HGB-14.2 HCT-39.9* MCV-90
MCH-32.1* MCHC-35.7* RDW-12.4
___ 02:30PM NEUTS-90.5* LYMPHS-5.2* MONOS-3.9 EOS-0.2
BASOS-0.1
___ 02:30PM PLT COUNT-189
___ 02:30PM ___ PTT-25.5 ___
Imaging:
___ Chest CT Right ___ Post rib fracture, possible clav
fracture
___ C-Spine C6 vertebral body and C7 Trans Process
fractures
___ Facial CT Left orbital, Right maxillary sinus, nasal
bone, hard palate fractures
___ Right Shoulder xray neg
Brief Hospital Course:
He was admitted to the Acute Care Surgery team with multiple
injuries. Neurosurgery was consulted for the C6 vertebral body
and right C7 transverse process fractures. These injuries were
managed non operatively with a hard cervical collar to be worn
for at least ___ weeks. He will follow up in ___ clinic
in about 4 weeks for repeat imaging.
Plastic Surgery was consulted for the multiple facial fractures.
Antibiotics were initiated for a short course and a soft diet
was recommended. Operative intervention to be discussed when
patient returns for follow up appointment in Plastics clinic.
OMFS were consulted for the fractured and missing teeth - no
acute intervention was indicated. Peridex rinses were
recommended and outpatient follow up with his primary dentist
was also recommended.
Otolaryngology was also consulted for the left temporal bone
fracture - an outpatient audiogram and follow up in ___ clinic
were recommended.
An Occupational therapy evaluation was done due to loss of
consciousness and he was deemed to be cognitively intact.
He was discharged to home with appointments scheduled for the
above specialists and also with his PCP.
Medications on Admission:
Denies
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours
Disp #*40 Tablet Refills:*0
3. Senna 1 TAB PO BID:PRN constipation
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
RX *chlorhexidine gluconate 0.12 % 15 ML's 4 times a day Disp
#*500 Milliliter Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Bike crash
Injuries:
1. Right ___ incisor missing
2. Right lateral maxillary wall fracture
3. Right palatal fracture
4. Left zygomatic fracture Left medial maxillary wall fracture
5. Left pterygoid fracture
6. Bilateral minimally displaced nasal bone fracture
7. Left ___ metacarpal neck with anterior angulation of the
distal fracture fragment
8. C6 vertebral body fracture
9. Right C7 Transverse Process fracture
10.Right first posterior rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a bike crash sustaining
multiple injuries. You were seeen and evalauted by the
Neurosurgery team for your fractures of your spine bone in your
neck and being recommended to wear a hard collar for at least
the next month at which time you will follow up with
Neurosurgery in clinic.
The Plastic Surgery doctors ___ for your facial and
finger fractures and at this time surgery was not idicated
acutely. You will follow up in about 1 week to discuss further
tratments/surgery if indicated.
Please follow these discharge instructions:
Medications:
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
* Take prescription pain medications for pain not relieved by
tylenol.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
.
Call the office IMMEDIATELY if you have any of the following:
* Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness, or unusual drainage.
* Fever greater than 101.5 oF
* Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Activities:
* No strenuous activity
* Exercise should be limited to walking; no lifting, straining,
or excessive bending.
* Unless directed by your physician, do not take any medicines
such as Motrin, Aspirin, Advil or Ibuprofen etc
.
Comments:
* Please sleep on several pillows and try to keep your head
elevated to help with drainage.
* Please maintain SOFT diet until your follow up clinic visit
and you can ask your surgeon whether you can advance your diet
at that time.
* Please avoid blowing your nose.
* Sneeze with your mouth open
* Try to avoid sipping liquids through a straw
Followup Instructions:
___
|
10491376-DS-7 | 10,491,376 | 25,016,659 | DS | 7 | 2111-11-06 00:00:00 | 2111-11-09 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vomiting, RUQ pain
7mm stone R distal ureter
Major Surgical or Invasive Procedure:
___: CYSTOSCOPY, RIGHT RETROGRADE PYELOGRAM, RIGHT
URETERAL STENT PLACEMENT
History of Present Illness:
Patient is a ___ female who presented to the ER with two weeks of
vomiting. Last night she developed severe RUQ pain which did not
resolve and therefore presented to the ED. Was seen at an
outside ER on ___ after tripping and injuring her R foot but
at that time was having too much pain from her foot to mention
the vomiting. She has had some chills at home, no true fevers.
No
hematuria/dysuria. No history of nephrolithiasis.
Past Medical History:
PMHx:
DIARRHEA
HEMATOCHEZIA
LEUKOCYTOSIS
PSHx:
INGUINAL HERNIA
In childhood
Social History:
___
Family History:
No Family History currently on file.
Physical Exam:
Gen: No acute distress, alert & oriented
Chest: no tachypnea
BACK: Non-labored breathing, no CVA tenderness bilaterally
ABD: Soft, non-tender, non-distended, no guarding or rebound
EXT: Moves all extremities well
PSY: Appropriately interactive
Pertinent Results:
___ 09:25AM BLOOD WBC-13.7* RBC-4.24 Hgb-13.3 Hct-40.1
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.7 RDWSD-43.7 Plt ___
___ 08:47AM BLOOD WBC-17.7* RBC-4.08 Hgb-13.0 Hct-38.7
MCV-95 MCH-31.9 MCHC-33.6 RDW-12.6 RDWSD-43.8 Plt ___
___ 08:18PM BLOOD WBC-19.3* RBC-4.62 Hgb-14.7 Hct-43.6
MCV-94 MCH-31.8 MCHC-33.7 RDW-12.7 RDWSD-43.7 Plt ___
___ 08:18PM BLOOD Neuts-82.9* Lymphs-9.9* Monos-6.4
Eos-0.0* Baso-0.3 Im ___ AbsNeut-15.99* AbsLymp-1.91
AbsMono-1.24* AbsEos-0.00* AbsBaso-0.05
___ 08:47AM BLOOD Glucose-120* UreaN-8 Creat-0.9 Na-137
K-3.7 Cl-98 HCO3-21* AnGap-18
___ 08:18PM BLOOD Glucose-106* UreaN-8 Creat-0.9 Na-139
K-4.2 Cl-99 HCO3-23 AnGap-17
___ 08:18PM BLOOD ALT-13 AST-16 AlkPhos-66 TotBili-0.4
___ 08:18PM BLOOD Lipase-17
___ 08:18PM BLOOD Albumin-4.5
___ 08:24PM BLOOD Lactate-1.1
___ 10:25PM URINE Color-Straw Appear-Hazy* Sp ___
___ 10:25PM URINE Blood-SM* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG*
___ 10:25PM URINE RBC-11* WBC-39* Bacteri-FEW* Yeast-NONE
Epi-1
___ 10:25PM URINE UCG-NEGATIVE
___ 10:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ presenting with vomiting and RUQ pain found to have 7mm
distal right ureteral stone with moderate hydronephrosis. U/A
positive for WBC/bacteria/nitrite, WBC 20 concerning for acute
infection with obstructing stone. She was admitted from the ED
on ___ and prepped for urgent intervention; taken to the OR
emergently with Dr ___ cystoscopy, R retrograde
pyelogram, R JJ stent placement on ___. She tolerated the
procedure well and was recoved in the PACU before transfer to
the ___, general surgical floor. Intravenous fluids,
Toradol and Flomax were given to facilitate symptoms and she was
kept on Ceftriaxone IV. Late afternoon on POD0, she spiked fever
to 103 and Vancomycin was added. By ___ she was afebrile for
24hrs and feeling much better. Her foley was discontinued and
she was discharged home on oral antibiotics. At discharge, Ms.
___ pain was well controlled with oral pain medications, she
was tolerating regular diet, ambulating without assistance, and
voiding without difficulty. She was explicitly advised to
follow up as directed as the indwelling ureteral stent must be
removed and or exchanged, her stone must be managed, and her
infection treated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
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. Oxybutynin 5 mg PO TID:PRN bladder spasms
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*30 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #*15 Tablet
Refills:*0
6. Phenazopyridine 100 mg PO TID PRN dysuria Duration: 3 Days
RX *phenazopyridine [Pyridium] 100 mg ONE TAB by mouth Q8HRS
Disp #*9 Tablet Refills:*0
7. Senna 8.6 mg PO BID
8. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth DAILY
Disp #*30 Capsule Refills:*0
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12.WORK NOTE
Please excuse Ms. ___ from work effective ___ and through
___. Thank you.
Discharge Disposition:
Home
Discharge Diagnosis:
Nephrolithiasis
Obstructive nephrolithiasis
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-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)
Pyridium is a medication that can turn your urine to bright
orange. This medication helps with urethral discomfort/dysuria.
Flomax is a medication that helps the ureter to relax (the tube
which now houses the stent)
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
Followup Instructions:
___
|
10491477-DS-14 | 10,491,477 | 20,042,822 | DS | 14 | 2147-09-16 00:00:00 | 2147-09-17 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / mushrooms
Attending: ___
Chief Complaint:
- Subpleural lesion with pathology concerning for cryptococcus
- Headache, fever, night sweats, fatigue, and neck soreness
Major Surgical or Invasive Procedure:
LP ___
History of Present Illness:
Mr. ___ is a ___ gentleman with Hashimoto
thyroiditis, chronic back pain s/p MVA in ___ who presents per
his PCP's recommendations with pulmonary biopsy results
demonstrating cryptococcus and with ___ months of headache,
fever, night sweats, fatigue, and neck soreness with concern for
meningitis.
Mr. ___ reports the onset of headache, fever, night sweats,
fatigue, and neck soreness approximately ___ months prior to
presentation. He experiences a pounding headache in the
right/anterolateral forehead that is ___ at worst and that
occurs daily and comes on suddenly, after which it lasts for
"several hours;" it is self-limited without precipitants or
palliating factors (it does not respond to NSAIDs or oxycodone).
He has had no loss of consciousness, vision changes, or
neurological deficits. No aura or scotomas. He notes neck
soreness without restriction of range of motion. He did not
initially seek medical care for these symptoms.
He reports jogging approximately 3 weeks ago and "straining his
diaphragm," 5 days after which he visited his PCP and had ___ CXR
that demonstrated a R pulmonary nodule. Follow-up chest CT
demonstrated a R subpleural lung mass, which, when biopsied,
demonstrated necrotic tissue and cryptococcus. On receipt of
these findings on the day of admission ___, his PCP instructed
him to go to the ED. In the ED, initial vitals were 98.2 88
138/81 18 98% RA. He received an LP and HIV testing and tylenol
was given for residual headache. On transfer to the floor,
vitals were 98.1 71 135/80 12 97% RA.
On the floor, he describes a constant ___ pounding R
anterolateral forehead headache. He has no vision changes,
rhinorrhea, lightheadedness, or drowsiness. He describes
"minimal" soreness with complete neck extension. He has no
fever, chills, diaphoresis, or vomiting. He notes nausea "due to
the headache." He denies IVDU. He is married to a male partner;
he does not use condoms or barrier protection and the
relationship is monogamous. He denies a history of STIs. He
denies sick contacts. He notes that a bird defecated on his
backpack, which he cleaned off, approximately 6 weeks prior to
admission. He has cats at home. No recent travel. No hikes, cave
exploration, or swims in freshwater lakes. He notes losing 50-60
lbs over the past year, which he attributes to running up to 50
miles/wk. He denies history of malignancy. He denies cough, but
notes that "weeks ago" he had a cough productive of thin green
sputum.
ROS: per HPI above. Additionally, no chest pain or pressure,
shortness of breath, abdominal pain, or leg pain. Notably, he
says he has had diarrhea since ___.
Past Medical History:
- Hypothyroidism due to Hashimoto thyroiditis
- Chronic back pain s/p MVA in ___ (reports 3 courses of
dexamethasone 4 mg qid x 10 days, last course in ___ also
notes several medrol trigger point injections in shoulder and
knees)
- Trochanteric bursitis
- Tinea versicolor ___ treated with ketoconazole
topical)
Social History:
___
Family History:
Notes family members with diabetes and familial Mediterranean
fever.
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals- 97.8 125/78 70 20 100% RA
General- alert, oriented, no acute distress
HEENT- sclera anicteric, EOMI, PERRL, dry mucous membranes,
oropharynx clear
Neck- supple, no JVD, no submandibular/cervical/supraclavicular
LAD, mild tenderness to full neck flexion
Lungs- clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, nontender, nondistended, 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
Skin- no rash
DISCHARGE PHYSICAL EXAM:
Vitals- 98.4 131/70 74 16 98% RA
General- alert, oriented, no acute distress
HEENT- sclera anicteric, EOMI, PERRL, MMM, oropharynx clear
Neck- supple, no JVD, no LAD
Lungs- CTAB, no wheezes, rales, rhonchi
CV- RRR, nl S1/S2, no mrg
Abdomen- soft, NTND, nl BS, no HSM
GU- no foley
Ext- warm, well perfused, 2+ pulses
Neuro- CNs2-12 intact, motor function grossly normal
Skin- Randomly distributed 2-10 mm blanching reddish brown
macules on back without tenderness, induration, erythema,
warmth, or discharge.
Pertinent Results:
LABS:
___ 11:15PM BLOOD WBC-8.9 RBC-4.58* Hgb-13.8* Hct-38.9*
MCV-85 MCH-30.1 MCHC-35.5* RDW-13.7 Plt ___
___ 11:15PM BLOOD Neuts-63.0 ___ Monos-4.7 Eos-6.3*
Baso-0.7
___ 08:00AM BLOOD WBC-9.4 RBC-4.54* Hgb-13.7* Hct-39.5*
MCV-87 MCH-30.2 MCHC-34.7 RDW-13.7 Plt ___
___ 11:15PM BLOOD ___ PTT-31.1 ___
___ 11:15PM BLOOD Glucose-110* UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-104 HCO3-27 AnGap-13
___ 08:00AM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
___ 08:00AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.1
___ 11:38PM BLOOD Lactate-1.3
___ 12:20AM BLOOD HIV Ab-NEGATIVE
___ 12:20 am IMMUNOLOGY: HIV-1 Viral Load/Ultrasensitive:
HIV-1 RNA is not detected.
___ 6:00 am SEROLOGY/BLOOD: CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
___ 11:15 pm BLOOD CULTURE: pending on discharge
___ 6:00 am BLOOD/FUNGAL/AFB CULTURE: pending on discharge
___ RAPID PLASMA REAGIN TEST: pending on discharge
.
CSF:
___ 04:15AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-2
___ ___ 04:15AM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-68
___ 4:15 am CSF;SPINAL FLUID: CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary): pending on discharge
FUNGAL CULTURE (Preliminary): pending on discharge
.
PERTINENT STUDIES:
___ CT HEAD W/O CONTRAST
FINDINGS: There is no evidence of fracture, hemorrhage, edema,
mass effect, or infarction. Ventricles and sulci are normal in
size and configuration. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.
IMPRESSION: Normal study.
.
___ CT LUNG/MEDIASTINAL BX
FINDINGS: 4.0 cm x 2.1 cm ovoid subpleural lesion in the
posterior segment of right lower lobe.
IMPRESSION: CT-guided biopsy of right lower lobe posterior
subpleural lesion. Core biopsy samples were sent to pathology,
and a sample was sent for microbiology (Gram stain, culture and
sensitivity, TB and fungi).
.
PATHOLOGIC DIAGNOSIS:
___ Lung, right lower lobe, biopsy:
Necrotic tissue with abundant fungal organisms. See note.
Note: The specimen consists of entirely necrotic lung parenchyma
with
round, ___ micrometer budding yeast that are positive on
Fontana Masson stain, most consistent with Cryptococcus. GMS and
PAS stains highlight these organisms. A mucicarmine stain is
non-contributory.
Special stains for bacteria and acid fast organisms are
negative.
Brief Hospital Course:
PRINCIPAL REASON FOR ADMISSION:
___ with Hashimoto thyroiditis, chronic back pain s/p MVA in
___ who presents per his PCP's recommendations with pulmonary
biopsy results demonstrating cryptococcus and with ___ months of
headache, fever, night sweats, fatigue, and neck soreness which
was initially concerning for meningitis, but unlikely after
further diagnostic work-up in ED
.
ACTIVE ISSUES:
# Cryptococcal subpleural collection: Pt was seen by his PCP in
___ with complaint of right rib pain radiating to the back and
was found to have lung mass on CXR. Chest CT on ___ demonstrated
a 4.0 cm x 2.1 cm ovoid subpleural lesion in the posterior
segment of right lower lobe that was found to have budding yeast
that are suspicious for cryptococcus. He denies any pulmonary
symptoms but notes cough productive of greenish sputum "weeks
ago." Pt is HIV negative and has no identifiable source of
exposure. He has been afebrile throughout admission. A lumbar
puncture was performed on ___ which was negative for
meningitis. Both CSF and serum cryptococcal antigen were
negative. Pt has several reddish brown blanching macules on his
back which have been present since at least ___, seen by
dermatology who said lesions are not consistent with
disseminated cryptococcus. Pt was initially started on
flucystosine and ambisome and transitioned to PO fluconazole
400mg/day the day of discharge to be taken for ___ months with
OPAT f/u on ___. Mycotic blood cultures are pending.
.
# Headache, chronic w/ neck soreness: Patient's headaches,
although chronic, were initally concerning for cryptoccal
meningitis. CT head showed no acute intracranial process, no
masses. Pt had no meningeal signs on exam and remained afebrile
throughout admission. LP on ___ showed 1 WBC, 0 RBC, Prot 19,
and Glc 68, decreasing the likelihood of infection. Also, CSF
cryptococcal antigen was negative. Most likely chronic tension
headache. Pt reported post-LP headache on ___ with associated
nausea and lightheadedness on moving from supine to sitting or
standing, resolved with conservative medical management.
# ? immunesupression: in the context of cryptococcal infection
question of immune suppression was raised. HIV Ab and VL were
negative. Patient did report receiving multiple doses of
intrarticular and trigger point steroid injections over the past
year as well as a few courses of systemic steroids which may
have rendered him somewhat immune suppressed. We thus recommend
avoiding further steroid exposure whenever possible.
.
# CODE STATUS: Full- confirmed
# CONTACT: ___ ___
# CONSULTS: ID, pulmonology, dermatology
.
###TRANSITIONAL ISSUES:
1) f/u with PCP or pulmonary clinic for repeat chest imaging in
approximately 6 wks from ___
2) f/u in headache clinic w/ Neuro
3) f/u LFT's while on fluconazole as per ID recommendations
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Promethazine 12.5 mg PO Q6H
2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Diazepam 2 mg PO Q12H:PRN anxiety
5. carisoprodol 350 mg Oral Q12HR:PRN muscle pain
6. ketoprofen 200 mg Oral DAILY
7. Epinephrine 1:1000 0.3 mg IM ONCE MR1 anaphylaxis
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
Discharge Medications:
1. Diazepam 2 mg PO Q12H:PRN anxiety
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
3. Levothyroxine Sodium 25 mcg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
5. Promethazine 12.5 mg PO Q6H
6. carisoprodol 350 mg Oral Q12HR:PRN muscle pain
7. Epinephrine 1:1000 0.3 mg IM ONCE MR1 anaphylaxis
8. ketoprofen 200 mg Oral DAILY
9. Fluconazole 400 mg PO Q24H Duration: 2 Months
Discharge Disposition:
Home
Discharge Diagnosis:
- Subpleural lesion with pathology concerning for cryptococcus
- Chronic headache, fatigue, and night sweats
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for administration of intravenous antifungal
medications due to your pulmonary cryptococcus infection. We did
an LP and blood work which did not show any evidence of
cryptococcal meningitis or other disseminated infection. You
will need to take oral antifungal medications for the next
several months and follow up with the infectious disease and
pulmonology doctors. You may want to see a neurologist about
your chronic headaches. It has been a pleasure taking care of
you.
Followup Instructions:
___
|
10491539-DS-14 | 10,491,539 | 23,142,305 | DS | 14 | 2159-10-07 00:00:00 | 2159-10-08 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceclor / Tylenol / Erythromycin Base / Cephalosporins / Cinnamon
Attending: ___.
Chief Complaint:
Gait instability/fall, worsening dysphagia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pmhx of ___ Disease, lobular breast ca, COPD
and hypothyroidism who presents with increased instability,
falls and worsening dysphagia. For the past couple days, she has
had increasing feeling of dysequilibrium, has fallen several
times to her knees and side, but never on head. Pt states that
since she was dx with ___ about ___ years ago, she has had
intermittent gait instability. Occasionally she will have "good
days" where she is able to walk without assistance and other
days she will have "bad days" where she needs the help of a cane
or walker. Feels that her instability has worsened for past
several days. Denies any lightheadedness or dizziness. No LOC.
No CP or palpitations. Recently seen by PCP who tried holding
evening ropinirole dose in response to her symptoms. No
fever/chills, neck stiffness, chest pain or SOB, abd pain,
dysuria, diarrhea. Did note increased urinary frequency last
night. Does have incontinence at baseline as well. No suprapubic
discomfort or flank pain.
As recently as ___, she has had a neg MRI at ___
___, and a PET scan ordered by her neurologist Dr. ___ at
___ which shows abnormal signal in basal ganglion per pt.
Imaging done out of concern that ___ symptoms may not be ___ to
Parkinsons but may actually be MSA given ___ poor response to
Parkinsons medications. This is per patient report and we
unfortunately cannot get records in a timely manner here.
Pt also endorses worsening dysphagia. She has hx of esophageal
spasm, cricopharyngeal dysfunction, right vocal cord immobility
scar secondary to muscle tension dysphonia. She is s/p ENT
procedure with dilatation and botox injection in ___. Now feels
that her dysphagia has been worsening over past several days.
Feels her mouth is very dry and she will occasionally have
"surges of mucus" which get lodged in her throat. Is able to
swallow liquids and solids but has difficulty with thick
consistency foods such as peanut butter. She has had a 20 lb
weight loss in past several months in setting of decreased PO
intake.
In the ED, initial vs were: T 99.5 HR 81 111/61 18 97% Labs
were remarkable for UA with mod leuks, 11 wbc and few bacteria
Patient was given Nitrofurantoin. Vitals on Transfer: T 97.4 HR
91 172/80 18 99% RA
On the floor, vs were: T 99.5 HR 81 111/61 18 97%. Pt
Review of sytems:
(+) Per HPI plus constipation
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
INFORMATION FROM ___ ___ OUTPATIENT NEUROLOGIST:
-summary of ___ neurological course:
Early ___ first seen by Dr. ___ recent dx of
Parkinsons. was started on L dopa with dyskinesias which would
be unusual for Parkinsonian pts to develop so early in course of
dz. Tried starting amatidine
___ stopped ___ increasing weakness, BP issues.
Started mirapex and L dopa in effort to decrease L dopa dose.
DaTSCAN at that time abdnormal and findings c/w ___
disease, also showed microvascular changes in brain
___ been increasing miraxpex over several months although
pt had been reporting difficulty. B12 found to be borderline. Pt
also found to be hypothyroid. Also c/o back pain. Spine imaging
showed cervical disc disease w/o spinal canal narrowing.
Moderate stenosis at L3, L4. No tx given at that time. Pt now
developing bladder symptoms, increasing weakness
___ tremor worsening in spite of uptitrating meds.
___ now requiring can to walk, increased autonomic problems
such as orthostatic hypotension, bladder inc.
___ now with breathing difficulties. PFTs showed
obstructive lung d/o, could not r/o restrictive component.
Continued to show lack of response to ___ meds
___ started and mirapex stopped ___ lack of response to
mirapex. Initially pt better with improved stability but began
to develop increasing SOB and dysphagia. Pt had workup for
dysphagia at BI by ENT. Found to have R vocal cord paralysis.
___ and botox injection by ENT. Afterwards pt
continues to have dry mouth and thick mucus. Requip dose
decreased as pt had associated her symptoms with requip.
Decreased requip from 16 mg to 12 mg to 8 mg. With this decrease
in requip pt noted weakness, instability and falls. Also had
recent MRI at ___ which showed small vessel disease
but no evidence of neurodegenerative processes. PET scan to r/o
MSA: hypometabolic in frontal and anterior temporal lobes
bilaterally. NL FTG activity in basal ganglia.
Per Dr. ___ main concern for pt is that pt is breathing
well, she is evaluated by ___ and speech and swallow. ___ benefit
from rehab at ___.
Past Medical History:
Rapidly progressive parkinsons disease
peripheral neuropathy
COPD
depression
___ esophagous
lichen sclerosis
lobular breast cancer
osteopenia
osteoparosis
hypothyroidism.
Social History:
___
Family History:
Father--DM
Sister--epilepsy
Physical Exam:
ON ADMISSION:
Vitals: T 99.5 HR 81 111/61 18 97%
General: AOx3, pleasant, NAD
HEENT: dry MMM, anicteric sclera
Neck: shotty mobile NT L cervical LN, supple
Lungs: CTAB, no wheezes, rubs or crackles
CV: RRR, no MRG
Abdomen: +BS, NTND, soft, no rebound or guarding
Ext: warm, well perfused, no edema; R hand Dupuytren's
contracture Skin: no rashes
Neuro: involuntary lower extremity movements, CN II-VI grossly
intact with exception of decreased smile ___ masked facies, ___
strength in right upper and lower extremity, ___ strength in
left upper extremity, ___ strength in left lower extremity,
cerebellar -- slowed FNF on left side, heel-shin testing wnl,
festinating gait
ON DISCHARGE:
Vitals: T: 97.4, 85, 153/75, 20, 100% on RA
General: AOx3, NAD
HEENT: dry MMM, anicteric sclera, hematoma on occiput
Neck: shotty mobile NT L cervical LN, supple
Lungs: CTAB, no wheezes, rubs or crackles
CV: RRR, no MRG
Abdomen: +BS, NTND, soft, no rebound or guarding
Ext: warm, well perfused, no edema; R hand Dupuytren's
contracture Skin: no rashes
Back: hematoma on coccyx, NT to palpation
Neuro: few involuntary lower extremity movements, CN II-VI
grossly intact with exception of decreased smile ___ masked
facies, ___ strength in right upper and lower extremity, ___
strength in left upper extremity, ___ strength in left lower
extremity--unchanged from previous exams
Pertinent Results:
ON ADMISSION:
___ 02:11PM BLOOD WBC-6.4 RBC-4.11* Hgb-11.8* Hct-37.5
MCV-91 MCH-28.7 MCHC-31.5 RDW-13.3 Plt ___
___ 02:11PM BLOOD Neuts-63.5 ___ Monos-7.0 Eos-2.0
Baso-0.9
___ 02:11PM BLOOD Glucose-75 UreaN-14 Creat-1.0 Na-139
K-4.7 Cl-103 HCO3-27 AnGap-14
___ 02:11PM BLOOD TSH-2.1
___ 02:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 02:55PM URINE RBC-0 WBC-11* Bacteri-FEW Yeast-NONE
Epi-<1
MICRO:
URINE CULTURE (Final ___: <10,000 organisms/ml.
ON DISCHARGE:
___ 06:05AM BLOOD WBC-9.5# RBC-4.23 Hgb-12.1 Hct-38.5
MCV-91 MCH-28.6 MCHC-31.4 RDW-13.2 Plt ___
___ 06:05AM BLOOD Glucose-89 UreaN-12 Creat-1.1 Na-139
K-4.4 Cl-101 HCO3-29 AnGap-13
IMAGING:
CT Head: There is no evidence of an acute intracranial
hemorrhage, edema, large vessel territorial infarction, or shift
of the midline structures. The ventricles and sulci are
prominent in size and configuration, likely representing
age-related cortical atrophy. There are bilateral
periventricular white matter hypodensities, likely representing
sequela of chronic spots small-vessel ischemic changes. No
acute fracture is identified. The visualized mastoid air cells
and paranasal sinuses are clear.
IMPRESSION:
No acute intracranial injury.
CXR: IMPRESSION: Probable chronic obstructive pulmonary
disease. No pneumonia. No displaced fracture is seen, but if
clinical concern for rib fracture is high, rib series or CT is
more sensitive.
Brief Hospital Course:
___ year old female with history of ___ Disease, lobular
breast cancer, COPD and hypothyroidism who presents with
increased instability and falls as well as worsening dysphagia.
ACTIVE ISSUES:
# Increased instability and falls: Patient reports worsening
gait instability for several weeks although symptom has acutely
worsened in the past several days. No history of head trauma or
syncope was reported. Presentation was unconcerning for cardiac
etiology as no chest pain, palpitations or syncope. Cause was
felt to be less likely orthostatic as patient denied feeling
lightheaded when standing, and anti-hypertensive medications had
been held as an outpatient. Workup for infectious causes
revealed a positive urinalysis but with < 10K colonies (see
below). Increased instability was possibly exacerbated in
setting of urinary tract infection in setting of recent decrease
in ropinirole for control of ___ disease. Patient was
seen and evaluated by the Neurology consult service. Per
inpatient consult service and in discussion with Dr. ___
___ neurologist) the patient's Levodopa portion of
Sinemet dosing was decreased. Patient was also evaluated by
physical therapy who recommended an acute rehab stay.
# Dysphagia: patient has history of esophageal spasm,
cricopharyngeal dysfunction, and right vocal cord immobility
scar secondary to muscle tension dysphonia. She is s/p ENT
procedure with dilatation and botox injection on ___. She also
recently had video swallow on ___ with speech and swallow
therapy that showed she remained safe to continue with her diet
of regular solids and thin liquids, and taking pills whole with
thin liquids as tolerated. Chest X-ray on ___ was without
evidence of aspiration. She was evaluated by speech and swallow
on ___ and symptoms were felt to be unchanged since her most
recent video swallow on ___. Based on the results of the
current evaluation, it is suggested that she continue with
baseline regular diet, self selecting soft/moist solids for
comfort and ease of chewing.
# Fall: Patient had one mechanical fall while in the hospital.
CT head was negative for acute process.
# Urinary tract infection: only symptom patient noted was
increased urinary frequency x 1 day. She was started on
Macrobid in the ED, then switched to bactrim on ___ulture returned with < 10K colonies however
she was empirically treated given that an acute infection can
worsen ___ symptoms. She will continue DS bactrim BID
for 3 days for uncomplicated UTI.
CHRONIC ISSUES:
# ___ disease: patient was continued on Sinemet and
ropinirole, with decrease in Sinemet per neurology and Dr.
___. Pharmacy does not carry patient's home XL ropinirole
and therefore she was treated with short acting until her home
medication could be obtained.
# Depression: patient was continued on bupropion and citalopram
# COPD: chronic and stable. Patient was continued on her home
albuterol inhaler
# Anxiety: patient was continued on her home lorazapam. Per
patient, she has been taking this for ___ years and is unable to
sleep without it. We discussed that this could be worsening her
instability and would like to try other medications such as
trazadone but patient declined at this time.
# Hypothyroidism: patient was continued on her home
levothyroxine
# GERD: patient was continued on her home pantoprazole
TRANSITIONAL ISSUES:
[ ] will need to complete 3 day course of Bactrim for
uncomplicated UTI (day 1 = ___ which will end on ___
[ ] Pt will need f/u with Dr. ___ outpatient neurologist,
regarding her gait instability and ___ medications upon
discharge from rehab
[ ] per outpatient ENT, Dr. ___: can consider metoclopramide
and hydration to decrease mucous production, and consider
Mucinex or treating rhinitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Cream 1 Appl TP Frequency is
Unknown
2. Gabapentin 300 mg PO HS
3. BuPROPion (Sustained Release) 150 mg PO DAILY
4. Lorazepam 0.5 mg PO BID:PRN anxiety
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. bisoprolol fumarate 2.5 mg oral HS
7. saliva substitution combo no.3 mucous membrane daily
8. Carbidopa-Levodopa (___) 1 TAB PO ___ TABLET AT 9 AM, 1PM
AND 9PM; 1 TABLET AT 5 ___
9. Guaifenesin ER 600 mg PO Q12H
10. rOPINIRole 4 mg oral take 2 tablets at by mouth 9am and 1
tablet at 1pm
11. Pantoprazole 40 mg PO Q24H
12. albuterol sulfate 90 mcg/actuation inhalation ___ puffs q
___ h PRN cough/wheezing
13. Citalopram 20 mg PO DAILY
14. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Gabapentin 300 mg PO HS
5. Guaifenesin ER 600 mg PO Q12H
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Pantoprazole 40 mg PO Q24H
9. albuterol sulfate 90 mcg/actuation inhalation ___ puffs q ___
h PRN cough/wheezing
10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
11. saliva substitution combo ___ MUCOUS MEMBRANE DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO BID
Last day ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*3 Tablet Refills:*0
13. Carbidopa-Levodopa (___) 0.5 TAB PO 0.5 TAB 9AM, 1PM, AND
9PM
14. Carbidopa-Levodopa (___) 0.75 TAB PO ___ TAB AT 5PM
15. rOPINIRole 4 mg oral take 2 tablets at by mouth 9am and 1
tablet at 1pm
this is the long acting ropinirole
16. Docusate Sodium 100 mg PO BID
17. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
___ 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. ___, you were admitted to the hospital for
worsening gait instability. This is most likely because of an
infection in your urine which we treated with antibiotics. You
were also having difficulty swallowing. You were evaluated by
the speech and swallow therapists who cleared you to eat solid
foods and drink thin liquids. You were evaluated by the
physical therapists as well who thought you would benefit from
rehab. Please follow up with your primary care physician and
neurologist after you leave rehab.
Followup Instructions:
___
|
10491778-DS-10 | 10,491,778 | 21,410,553 | DS | 10 | 2156-11-20 00:00:00 | 2156-11-20 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
palpitations, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___
woman with a recent diagnosis of stage IV diffuse large B-cell
lymphoma (bony involvement) who is s/p C2 of DA-EPOCH-R
presenting with palpitations and chest discomfort, found to have
acute pulmonary embolism in the right upper lobe posterior basal
segmental artery.
Since discharge ___, patient reports feeling well. Mild
soreness of her gums, never developed ulcerations, now resolved.
She has been eating and drinking well. She denies fevers,
chills,
rigors, night sweats, headache, nausea, vomiting, abdominal pain
or abdominal cramping. Four days ago, she noticed palpitations
and mild chest discomfort.
Her palpitations with tachycardia was noted on her fitbit. At
home, her heart rate immediately increased to 120-150 with
minimal exertion (as in sitting up in bed). Her palpitations was
not associated with difficulty breathing, DOE, severe chest pain
or pedal edema. She did have some chest discomfort. Her chest
discomfort was very mild and did not seem to be exacerbated by
activity or deep breathing.
She was seen outpatient on ___ and ___. Her palpitations
were thought to be hypovolemia driven and as such, she was
advised to increase her oral intake; however, at home she
reported no improvement in her palpitations or associated
tachycardia/chest discomfort so she came to the ED for further
evaluation.
In the ED, she received 1L of NS and CTA Chest was obtained.
Initially the CTA was interpreted as below:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No pleural effusion or evidence of active intrathoracic
infection.
3. Similar appearance of a soft tissue lytic lesion in the right
scapular body.
4. 2 mm right upper lobe nodule is unchanged from prior
However, upon second review by the radiologist, her CTA report
was updated to read:
1. Likely acute segmental pulmonary embolism in the right upper
lobe posterior basal segmental artery. No evidence aortic
abnormality.
2. No pleural effusion or evidence of active intrathoracic
infection.
3. Similar appearance of a soft tissue lytic lesion in the right
scapular body.
4. 2 mm right upper lobe nodule is unchanged from prior.
REVIEW OF SYSTEMS: She denies recent fevers, chills, rigors,
night sweats, headache, dizziness, lightheadedness, nausea,
vomiting, diarrhea or constipation. She has been stooling daily.
She denies ___ edema, new rashes or lesions. She denies chest
pain, SOB, DOE, or URI/UTI symptoms. All other ROS negative.
Negative except as noted in HPI.
Past Medical History:
ONCOLOGIC HISTORY (PER OMR):
Presenting history: ___ woman presented in ___
with progressive abdominal pain. Imaging demonstrated large
abdominal mass. Peripheral blood with elevated LDH. EUS biopsy
was performed ___ demonstrated diffuse large B-cell
lymphoma. Staging imaging demonstrated lymphadenopathy above and
below the diaphragm and bony and pancreatic involvement.
Cytogenetics with a gain of BCL 6. Bone marrow biopsy was free
of evidence of involvement.
TREATMENT HISTORY (PER OMR):
-___ C1 DA-R-EPOCH with IT MTX
-___ C2 DA-R-EPOCH
PAST MEDICAL/SURGICAL HISTORY: None
SH: ___
Family History:
Several family members with hypertension and diabetes. No family
history of malignancy or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: TC 98.0 PO ___ 18 100 Ra
GEN: NAD, well appearing
HEENT: PERRL, EOMI, MMM, OP clear
LAD: No cervical, axillary or inguinal LAD
CV: RRR, no MRG
RESP: CTAB, no wheezes
ABD:+BS, NT, ND, no HSM
EXT: No PE, good pulses. No palpable cord or edema in the arm or
hand. Non-tenderness or warmth
Neuro: CN II-XII intact. Otherwise grossly normal.
Skin: No new rashes or lesions
Access: PIV
DISCHARGE PHYSICAL EXAMINATION:
___ ___ Temp: 99.1 PO BP: 104/67 L Sitting HR: 79 RR: 16
O2
sat: 100% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___
GEN: NAD, well appearing
HEENT: PERRL, EOMI, MMM, OP clear
LAD: No cervical, axillary or inguinal LAD
CV: RRR, no MRG
RESP: CTAB, no wheezes
ABD:+BS, NT, ND, no HSM
EXT: No PE, good pulses. No palpable cord or edema in the arm or
hand. Non-tenderness or warmth
Neuro: CN II-XII intact. Otherwise grossly normal.
Skin: No new rashes or lesions
Access: PIV
Pertinent Results:
ADMISSION LABS
-------------------
___ 12:39AM ___ PTT-24.4* ___
___ 12:39AM PLT SMR-NORMAL PLT COUNT-271
___ 12:39AM HYPOCHROM-NORMAL ANISOCYT-1+*
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+*
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
___ 12:39AM NEUTS-61 BANDS-3 LYMPHS-14* MONOS-15* EOS-1
BASOS-0 ___ METAS-5* MYELOS-1* NUC RBCS-2* AbsNeut-9.79*
AbsLymp-2.14 AbsMono-2.30* AbsEos-0.15 AbsBaso-0.00*
___ 12:39AM WBC-15.3* RBC-3.25* HGB-8.1* HCT-27.5* MCV-85
MCH-24.9* MCHC-29.5* RDW-15.0 RDWSD-45.4
___ 12:39AM CALCIUM-9.6 PHOSPHATE-5.6* MAGNESIUM-1.8
___ 12:39AM GLUCOSE-123* UREA N-5* CREAT-0.9 SODIUM-140
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 12:44AM LACTATE-2.6*
___ 12:44AM COMMENTS-GREEN TOP
___ 12:46AM cTropnT-<0.01
___ 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:50AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:50AM URINE UCG-NEGATIVE
___ 01:50AM URINE HOURS-RANDOM
DISCHARGE LABS:
___ 07:53AM BLOOD WBC-10.9* RBC-3.32* Hgb-8.4* Hct-27.9*
MCV-84 MCH-25.3* MCHC-30.1* RDW-15.6* RDWSD-46.7* Plt ___
___ 07:53AM BLOOD Neuts-57 Bands-12* Lymphs-15* Monos-6
Eos-1 Baso-2* Atyps-3* Metas-1* Myelos-1* Promyel-2* NRBC-3*
AbsNeut-7.52* AbsLymp-1.96 AbsMono-0.65 AbsEos-0.11
AbsBaso-0.22*
___ 07:53AM BLOOD Glucose-96 UreaN-3* Creat-0.8 Na-142
K-4.3 Cl-106 HCO3-26 AnGap-10
___ 07:53AM BLOOD ALT-25 AST-23 LD(LDH)-370* AlkPhos-111*
TotBili-0.2
___ 07:53AM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.7* Mg-2.0
Brief Hospital Course:
___ is a ___ woman with a
recent diagnosis of stage IV diffuse large B-cell lymphoma (bony
involvement) who is s/p C2 of DA-EPOCH-R presenting with
palpitations and chest discomfort, found to have acute pulmonary
embolism in the right upper lobe posterior basal segmental
artery.
ACUTE CONDITIONS:
#PULMONARY EMBOLISM:
#PLEURITIC CHEST PAIN:
#PALPITATION:
Hemodynamically stable. Provoking risk factor could be the
underlying malignancy. Most emboli are thought to arise from
lower extremity proximal veins and more than 50 percent from
proximal vein deep venous thrombosis but patient has no
clinically significant swelling on any extremities. Albeit the
most common presenting symptoms for pulmonary embolism is
dyspnea
followed by chest pain (classically pleuritic in nature), cough,
and symptoms of deep venous thrombosis, patient initially did
not
have any of these. Her primary symptom was palpitation w/
associated tachycardia and transient non-pleuritic chest pain.
Given that the mainstay of therapy is anticoagulation, she was
initiated on Lovenox as she had normal platelets counts and
normal renal function. Given new PE, she was approached for
clinical trial participation and she signed consent on ___
for participation in ___ trial ___, 6mon of dalteparin
vs.
apixaban (randomized) for treatment of VTE in patients with
cancer. She was randomized to dalteparin.
She developed increased intensity of pleuritic chest pain on mid
chest/epigastric region similar to her initial presentation but
worsened on ___. She
described this as sharp and stabbing in nature. This pain was
intense for 30 minutes. Palpitations have since resolved. She
denies headache, dizziness, or lightheadedness. Unclear etiology
but differential includes: possible reflux vs. esophageal spasm
vs. sternal pain from recent neupogen vs. pulmonary infarction
vs. pulmonary embolism extension vs. exacerbation of pleuritic
pain
associated with known PE. CTA Chest was repeated
to evaluate for pulmonary infarction, extension of PE or other
pulmonary etiologies and was negative.
-___ ___ units SC DAILY Duration: 28 Days
-Cardiac enzymes within normal limits
-telemetry with no acute abnormalities
-EKG NSR
#DLBCL: Relatively new diagnosis, s/p ___ EUS/bx of pancreas
showing DLBCL. FISH negative for ICH/BCL2, MYC, BCL6 from BMBx;
BCL6 gain seen on pancreatic biopsy. ___ PET showing lymphoma
at superior mediastinum, intracardiac within RV, abdominally,
and
at bilateral scapula. MRI brain and PET without overt CNS
involvement. At risk for CNS disease so she received IT MTX on
___ which showed no CNS involvement. She will receive
intrathecal methotrexate given her risk from pancreatic and bony
involvement next during cycle 3(alternating cycles). She
underwent DA-EPOCH-R and is status post two cycles. She received
filgrastim support and her counts have recovered. Her next
outpatient appointment is ___ ___ she most
likely will be admitted for cycle 3 of EPOCH then. She has a
scheduled POC placement on the same date.
#VITAMIN D DEFICIENCY: Initiated on vitamin d repletion.
#MILD NEUROPATHY: This is attributed to chemotherapy (VCR).
Continue to monitor prior to each cycle therapy.
#FERTILITY PRESERVATION: She continues on monthly leuprolide at
maintenance dosing, last received on ___. She is next due on
___.
CORE ISSUES:
----------------
#FEN: Regular, IVF/Encourage PO, Replete Electrolytes PRN
#PPX:
DVT: Lovenox as above
Bowel: Senna/Colace PRN
Pain: PRN
#ACCESS: PIV
#CODE: Full Code (presumed)
#COMMUNICATION: Patient
#EMERGENCY CONTACT HCP: ___ (mother) ___
DISPO: home f/u ___ or sooner if issues arise
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. Filgrastim-sndz 480 mcg SC Q24H
4. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting
5. Pantoprazole 40 mg PO Q24H
6. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. ___ ___ units SC DAILY Duration: 28 Days
2. Vitamin D 1000 UNIT PO DAILY
3. Acyclovir 400 mg PO Q12H
4. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting
5. Pantoprazole 40 mg PO Q24H
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. HELD- Filgrastim-sndz 480 mcg SC Q24H This medication was
held. Do not restart Filgrastim-sndz until Dr. ___ you
to do so
Discharge Disposition:
Home
Discharge Diagnosis:
lymphoma
pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___
You were admitted due to chest pain and found to have a blood
clot in your lungs (pulmonary embolism) we started you on a
clinical trial medication to treat this. You will continue this
at home. You will follow up with Dr. ___ as stated below. It
was a pleasure taking care of you.
Followup Instructions:
___
|
10491778-DS-12 | 10,491,778 | 21,058,781 | DS | 12 | 2156-12-11 00:00:00 | 2156-12-12 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Palpitations, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with DLBCL, known
intracardiac lesion, and PE who is admitted from the ED with
persistent episosodes of tachycardia and palpitations with
minimal exertion.
Patient developed episodes of tachycardia and palpitations
following her second episode of DA-EPOCH. She was subsequently
diagnosed with PE and started on dalteparin investigational
drug.
Since starting the dalteparin, she has not had any significant
improvement in her epsisodes of tachycardia and palpitations.
They occur mainly with any minimal exertion, and she sometimes
developed associated chest discomfort. The episodes typically
resolve quickly with rest. She denies any fevers or chills. No
cough. No diarrhea. No blood in stool. No emesis. She just
recently completed C3 of DA-EPOCH-R which she tolerated well.
Over the last few days she has noted some episodes even at rest,
and occasional atypical chest discomfort. On ___, she was
sitting on the couch, she developed palpitations at rest and
associated pain on the left side of her chest. The pain is
sharp,
stabbing, and is not worsened with palpation of the chest wall.
She presented to the ED.
In the ED, initial VS were pain 5, T 98.4, HR 98, BP 104/62, RR
16, O2 99%RA. Initial labs notable for normal chem 10, LFT"s,
and
WBC 7.4 (92%N), HCT 25.9, PLT 390. INR 1.1, UA negative.
Lacatate
1.9. CTA showed no PE. CXR showed no new process. TTE was
normal.
Patient was given acyclovir, neupogen, bactirm NS, and
dalteparin. She continued to develop symptomatic tachycardia up
to the 150's with ambulation, so she was admitted for further
management. VS prior to transfer were pain 0, T 98.8, HR 88, BP
111/75, RR 18, O2 98%RA.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ woman presented in ___ with progressive
abdominal pain. Imaging demonstrated large abdominal mass.
Peripheral blood with elevated LDH. EUS biopsy was performed
___ demonstrated diffuse large B-cell lymphoma. Staging
imaging demonstrated lymphadenopathy above and below the
diaphragm and bony and pancreatic involvement. Cytogenetics
with
a gain of BCL 6. Bone marrow biopsy was free of evidence of
involvement.
- ___ C1 DA-R-EPOCH with IT MTX
- ___ C2 DA-R-EPOCH, dose level 2 (vincristine capped at
2mg)
- ___ C3 DA-R-EPOCH, dose level 3 (vincristine capped at
2mg)
PAST MEDICAL HISTORY:
- DLBCL
- RV mass (presumed DLBCL)
- PE
Social History:
___
Family History:
Several family members with hypertension and diabetes. No family
history of malignancy or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.2 HR 93 BP 104/70 RR 18 SAT 100% O2 on RA
GENERAL: Pleasant and well appearing young woman lying in bed
comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM
PHYSICAL EXAM:
24 HR Data (last updated ___ @ 521)
Temp: 98.2 (Tm 98.4), BP: 102/65 (98-108/62-74), HR: 91
(79-97), RR: 18 (___), O2 sat: 100% (95-100), O2 delivery: RA,
Wt: 180.2 lb/81.74 kg
GENERAL: no acute distress
HEENT: sclerae anicteric, MMM
RESP: breath sounds clear bilaterally without wheezes, rales,
rhonchi
CV: normal rate, reg rhythm no MRG
GI: soft, NDNT
EXT: warm, no edema
SKIN: no rash
Pertinent Results:
ADMISSION LABS
==============
___ 09:45PM BLOOD WBC-7.4 RBC-3.09* Hgb-8.0* Hct-25.9*
MCV-84 MCH-25.9* MCHC-30.9* RDW-15.3 RDWSD-46.5* Plt ___
___ 09:45PM BLOOD Neuts-92* Bands-0 Lymphs-7* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-6.81*
AbsLymp-0.52* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00*
___ 09:45PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Tear Dr-OCCASIONAL
___ 09:45PM BLOOD ___ PTT-37.6* ___
___ 09:45PM BLOOD Glucose-157* UreaN-7 Creat-0.5 Na-138
K-3.8 Cl-100 HCO3-26 AnGap-12
___ 09:45PM BLOOD ALT-27 AST-12 AlkPhos-93 TotBili-0.2
___ 09:45PM BLOOD Lipase-15
___ 09:45PM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.8 Mg-2.0
___ 09:45PM BLOOD TSH-1.8
RELEVANT LABS
=============
___ 06:54AM BLOOD Cortsol-12.1
___ 06:33AM BLOOD 25VitD-23*
MICRO
=====
Blood culture, urine cultures NG final
IMAGING
=======
___ CTA Chest
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Stable inferior right scapular lytic lesion.
___ TTE
Overall left ventricular systolic function is low normal, 55%.
There is mild regional left ventricular systolic dysfunction
with apparent hypokinesis of the basal inferoseptum (see
schematic) and preserved/normal contractility of the remaining
segments. This finding may be related to imaging the left
ventricular outflow tract in the basal septum given the similar
appearance in the prior echo.
___ Cardiac MR
___ left ventricular wall thickness, biventricular cavity
sizes, and regional/global biventricular systolic function. No
intracardiac mass seen. Mild to moderate mitral regurgitation.
Mild tricuspid regurgitation.
Review of the prior study suggests the prior "mass" was a
prominent moderator band/normal variant.
DISCHARGE LABS
==============
___ 06:35AM BLOOD WBC-13.3* RBC-3.56* Hgb-9.1* Hct-30.2*
MCV-85 MCH-25.6* MCHC-30.1* RDW-16.0* RDWSD-48.9* Plt ___
___ 06:35AM BLOOD Neuts-64 Bands-5 Lymphs-12* Monos-5 Eos-0
Baso-0 ___ Metas-7* Myelos-6* Blasts-1* NRBC-2*
AbsNeut-9.18* AbsLymp-1.60 AbsMono-0.67 AbsEos-0.00*
AbsBaso-0.00*
___ 06:35AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-1+* Ovalocy-1+*
Schisto-1+* Tear Dr-1+*
___ 06:35AM BLOOD Plt Smr-LOW* Plt ___
___ 06:35AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-143
K-4.4 Cl-105 HCO3-26 AnGap-12
___ 06:35AM BLOOD ALT-16 AST-14 LD(LDH)-308* AlkPhos-100
TotBili-0.2
___ 06:35AM BLOOD Albumin-4.3 Calcium-9.8 Phos-5.4* Mg-2.2
Brief Hospital Course:
SUMMARY
=======
___ is a ___ year old woman with diffuse large B-cell
lymphoma and history of pulmonary embolism who was admitted from
the ED with persistent episodes of tachycardia and palpitations
with minimal exertion. She had tachycardia around 100-110s at
rest with worsening up to 160s with ambulation; there is no
change in blood pressure. Patient described occasional dyspnea
on exertion at home with this, and darkening of vision though
never syncope.
CTA for PE was negative. Electrocardiogram pre and post walking
showed sinus tachycardia, no arrythmia. Her orthostasis was
mildly responsive to fluids, but not considerably and she
appeared euvolemic throughout. She was given 1 unit of packed
red blood cells, which decreased the sensation of palpitations
and pounding in her ears, though did not resolve them, and did
not change heart rates. Repeat TTE ___ showed inferobasal
hypokinesis unchanged from prior. TSH normal. AM cortisol was
normal. She had had a 1.3cm right ventricular mass noted on
prior cardiac MRI, though repeat cardiac MR this admission
showed no mass and review of the original scan is suggested
there may not have been a mass, but instead, a prominent
moderator band.
Patient was seen by cardiology, who diagnosed orthostasis with
sinus tachycardia, and suggested fluid repletion, compression
stockings, and outpatient follow-up with Dr. ___. She was
also evaluated by neurology, in particular, Dr. ___ who is
an expert in autonomic dysfunction. She went for autonomic
testing and results are pending at time of discharge though the
team suggested that they had no concerns about her discharge.
On discharge, the patient continued to have tachycardia to the
160s with activity, though her resting heart rate sitting
upright significantly decreased from the time of admission, to
the ___. Furthermore, she reported less palpitations, no
dyspnea or decreased vision. It was felt that symptoms in part
related to anemia, and that her orthostasis was multifactorial,
including fluctuating fluid status, deconditioning, effect of
recent chemotherapy, and possible small fiber neuropathy and
autonomic dysfunction. Autonomic testing will be following up by
outpatient oncologist, as will further symptoms. No new
medications were started.
ACUTE MEDICAL ISSUES
====================
# Sinus tachycardia
# Orthostasis
# Palpitations
Presentation as above. Afebrile, not neutropenic, no signs or
symptoms of infection and negative cultures and chest xray. TSH,
AM coristol were normal. She was given 2L in the ED without
improvement in symptoms or orthostatic signs. She received 1U
PRBC with mild improvement in symptoms. Patient reported that
she had frequent urination as well as nocturia, so workup was
pursued for diabetes insipidus and was negative for such. This
is most likely due to polydipsia. Cardiology and neurology were
consulted as above. Etiology of symptoms likely caused by both
anemia and orthostasis. And orthostasis was multifactorial,
including fluctuating fluid status, deconditioning, effect of
recent chemotherapy, and possible small fiber neuropathy and
autonomic dysfunction.
#History of right ventricular mass
Right ventricular mass was noted during previous admission. She
is now completed additional chemotherapy and no further mass was
noted on repeat cardiac MRI this admission. Cardiologist we read
the prior cardiac MRI, and called the initial finding into
question. They suggested there may be more prominent moderator
band rather than an intracardiac mass.
#Diffuse large B-cell lymphoma
Patient recently completed cycle 3 DA-EPOCH-R, which she
tolerated well. Prophylaxis with Bactrim and acyclovir were
continued.
CHRONIC MEDICAL ISSUES
======================
# History of pulmonary embolus
Diagnosed ___. None on CTA this admission. She was continued
on study dalteparin ___ units daily.
# Fertility Preservation: She continues on monthly leuprolide at
maintenance dosing, last received on ___.
# Vitamin D Deficiency: As she was mildly hyperphosphatemic,
vitamin D level was checked and was low normal. Continued
vitamin d repletion.
TRANSITIONAL ISSUES
===================
[] F/u final read on autonomic testing by neurology
[] Patient symptoms improve when she was transfused from a
hemoglobin of 7.9 to 9.2. Would consider a higher transfusion
threshold for her if she remains symptomatic.
[] Fertility preservation: ___ leuprolide due
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. dalteparin (porcine) 18,000 anti-Xa unit/0.72 mL subcutaneous
DAILY
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Filgrastim-sndz 480 mcg SC Q24H
5. Ondansetron ___ mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. dalteparin (porcine) 18,000 anti-Xa unit/0.72 mL
subcutaneous DAILY
3. Ondansetron ___ mg PO Q8H:PRN Nausea/Vomiting - First Line
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Diffuse large B-cell lymphoma with
intracardiac mass, orthostatic sinus tachycardia
Secondary diagnosis: History of pulmonary embolus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a privilege caring of ___ at ___.
WHY WAS I IN THE HOSPITAL?
-___ are having shortness of breath, very fast heart rate and
palpitations.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Scans were performed, and it was shown that ___ do not have a
new pulmonary embolism.
- Your blood counts were checked, and ___ were found to have
mildly low hemoglobin.
- ___ received a transfusion in an attempt to improve your fast
heart rate by giving her body more red blood cells to deliver
oxygen
- The cardiologist saw ___ and did not recommend any new
medications, and recommended follow-up with a cardiac oncologist
Dr. ___
- ___ underwent cardiac MRI, which showed no mass
- Neurology saw ___ and recommended autonomic testing, which ___
got today. Results will come back in the next ___ weeks.
- Your outpatient oncologist will follow this up with ___.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Stay hydrated, but no need to drink large amounts of water in
last couple hours before bed.
- Continue to take all your medicines and keep your
appointments.
We wish ___ the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10491778-DS-16 | 10,491,778 | 23,541,935 | DS | 16 | 2157-05-27 00:00:00 | 2157-05-27 17:42:00 |
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
Major Surgical or Invasive Procedure:
___
Right VATS, anterio mediastinal mass biopsy
History of Present Illness:
___ is a ___ year old woman with DLBCL s/p 6 cycles of
R-EPOCH ___ with remission, provoked PE s/p dalteparin, who
presents with 2 weeks of worsening chest pain and abdominal
pain.
___ completed therapy for DLBCL in ___. PET scan
___ showed ___. She was last seen in follow up with Dr
___ ___ and reported feeling well apart from some mild
therapy-related neuropathy and improvement in postural
tachycardia/palpitations that have been followed by Dr ___
___
are thought to be from a combination of autonomic dysfunction
and
steroid withdrawal.
She was in her USOH until 2 weeks ago, when she began to notice
some mild chest pains. She has had chest pain, which she
describes as a feeling of "something in her chest", so she did
not think much of this. However, over the last few days, her
pain
got worse and was notably different from baseline in that it was
"sharp" and radiating up her neck and to her left shoulder. She
sometimes noticed worsening with movement. The day prior to
presentation, she developed "excruciating" abdominal pain after
eating a tuna sandwich, which prompted presentation to the ED.
On ROS: She has had some generalized fatigue over the last week.
No dyspnea on exertion, SOB. Her postural palpitations are
improving. No N/V, diarrhea/constipation. She denies fevers. She
has had intermittent hot flushes/chills, night dampness, which
is
unchanged from baseline. No changes in appetite or weight. No
dysuria, decreased urine output, dark urine. No
bruising/bleeding. No new lumps, rashes noted.
In the ED: afebrile, HR 70, BP 119/77, 100% RA. A CTA Chest and
CT A/P were obtained, which demonstrated a 7.8 x 3.4 cm
mediastinal mass abutting the pericardium c/f relapse. EKG
demonstrated NSR at 65 w/ PACs and J point elevation; no acute
changes.
All other review of systems are negative unless stated otherwise
Past Medical History:
Presenting history: ___ woman presented in ___
with progressive abdominal pain. Imaging demonstrated large
abdominal mass. Peripheral blood with elevated LDH. EUS biopsy
was performed ___ demonstrated diffuse large B-cell
lymphoma. Staging imaging demonstrated lymphadenopathy above
and
below the diaphragm and bony and pancreatic involvement.
Cytogenetics with a gain of BCL 6. Bone marrow biopsy was free
of evidence of involvement.
- ___ C1 DA-R-EPOCH with IT MTX
- ___ C2 DA-R-EPOCH, dose level 2 (vincristine capped at
2mg)
- ___ C3 DA-R-EPOCH, dose level 3 (vincristine capped at
2mg)
- ___ C4 DA-R-EPOCH dose level 4 (vincristine held)
- ___ C5 DA-R-EPOCH dose level 4 (vincristine decreased)
- ___ C6 DA-R-EPOCH dose level 4 (vincristine decreased)
-___- IT MTX for CNS ppx
--___- IT MTX for CNS ppx
Social History:
___
Family History:
Several family members with hypertension and diabetes. No family
history of malignancy or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 98.4 PO BP: 95/70 HR: 76 RR: 20 O2
sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
General: Well appearing pleasant young ___ woman,
sitting up in bed
Neuro: PERRL, palate elevates symmetrically
Alert, oriented, answers questions appropriately. Provides crisp
history
HEENT: Oropharynx clear, MMM, no lesions. No scleral icterus. No
palpable cervical/supraclavicular adenopathy.
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended. Bowel sounds are present
Extr/MSK: WWP, no peripheral edema, no calf tenderness
Skin: No obvious rashes noted on exam
Access: PIV
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 626)
Temp: 99.4 (Tm 99.6), BP: 123/80 (113-125/67-80), HR: 85
(82-97), RR: 18, O2 sat: 100% (98-100), O2 delivery: RA
General: Lying in bed in NAD
Neuro: PERRL, palate elevates symmetrically
HEENT: Oropharynx clear, MMM, no lesions. No scleral icterus. No
palpable cervical/supraclavicular adenopathy.
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally; right sided
biopsy site with bandage without surrounding erythema
Abdomen: +BS, soft, NDNT
Extr/MSK: WWP, no peripheral edema, no calf tenderness
Skin: No rashes or lesions
Pertinent Results:
ADMISSION LABS:
================
___ 12:00PM BLOOD WBC-4.0 RBC-4.09 Hgb-11.2 Hct-36.2 MCV-89
MCH-27.4 MCHC-30.9* RDW-11.9 RDWSD-37.9 Plt ___
___ 12:00PM BLOOD Neuts-55.9 ___ Monos-7.5 Eos-2.0
Baso-0.3 Im ___ AbsNeut-2.24 AbsLymp-1.35 AbsMono-0.30
AbsEos-0.08 AbsBaso-0.01
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-24 AnGap-13
___ 12:00PM BLOOD ALT-11 AST-12 LD(LDH)-169 AlkPhos-121*
TotBili-0.5
___ 12:00PM BLOOD Lipase-16
___ 12:00PM BLOOD Albumin-4.8 UricAcd-5.2
MICROBIOLOGY:
===============
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
URINE CULTURE (Final ___: < 10,000 CFU/mL.
KEY IMAGING:
===============
___ CTA Chest/Abdomen:
1. No definite evidence of PE, no acute aortic injury. No signs
of pulmonary infarction, main pulmonary arterial dilatation or
right ventricular strain.
2. New mediastinal mass abutting the superior pericardium
measuring up to
7.8 x 3.4 cm is concerning for lymphoma recurrence, differential
diagnosis
includes thymic hyperplasia although this seems less likely.
3. Stable pulmonary nodules measuring up to 4 mm.
4. No acute findings within the abdomen or pelvis to correlate
with the
patient's pain.
___ ___ Biopsy Mediastinal Mass:
Unsuccessful attempt at anterior mediastinal soft tissue lesion
biopsy due to soft nature of the lesion and proximity to the
ascending aorta. No immediate complication.
___ CXR: Tiny right apical pneumothorax with right chest
tube in place.
___ CXR: The right chest tube has been removed and the tiny
right apical pneumothorax has resolved. There is subsegmental
atelectasis in the lung bases. No focal consolidation or
pleural effusion is identified. The cardiomediastinal
silhouette is stable in appearance. There are no acute osseous
abnormalities.
___ TTE:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection fraction is >=60%. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient.
Tissue Doppler suggests a normal left ventricular filling
pressure (PCWP less than 12mmHg). Normal right ventricular
cavity size with normal free wall motion. Tricuspid annular
plane systolic excursion (TAPSE) is
normal. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter.
There is no evidence for an aortic
arch coarctation. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. 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: 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. No intracardiac or
extracardiac mass identified. Compared with the prior TTE
(images reviewed) of ___, the findings are similar.
CLINICAL IMPLICATIONS: Based on the echocardiographic findings
and ___ ACC/AHA recommendations, antibiotic prophylaxis is NOT
recommended.
DISCHARGE LABS:
=================
___ 06:15AM BLOOD WBC-6.0 RBC-3.50* Hgb-9.5* Hct-30.6*
MCV-87 MCH-27.1 MCHC-31.0* RDW-11.9 RDWSD-37.9 Plt ___
___ 06:15AM BLOOD Neuts-68.4 ___ Monos-10.5
Eos-0.7* Baso-0.3 Im ___ AbsNeut-4.12 AbsLymp-1.19*
AbsMono-0.63 AbsEos-0.04 AbsBaso-0.02
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-26.7 ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-106* UreaN-5* Creat-0.8 Na-143
K-4.4 Cl-104 HCO3-26 AnGap-13
___ 06:15AM BLOOD ALT-8 AST-11 LD(LDH)-149 AlkPhos-91
TotBili-0.6
___ 06:15AM BLOOD Albumin-3.9 Calcium-9.8 Phos-4.5 Mg-1.7
UricAcd-2.4
___ 06:15AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:15AM BLOOD HIV Ab-NEG
Brief Hospital Course:
___ with DLBCL s/p 6 cycles of R-EPOCH ___ with remission,
provoked PE s/p dalteparin, who presents with 2 weeks of
worsening chest pain and abdominal pain with CT torso
demonstrating new large mediastinal mass concerning for relapse,
though found to be hyperplastic thymus mass.
TRANSITIONAL ISSUES:
====================
[ ] PET scan ___ at 730 AM to evaluate for recurrence of change
in thymus mass
[ ] Can discuss birth control/fertility options with patient.
Previously on Lupron while receiving treatment.
[ ] Consider surgical referral if thymus mass does not resolve
[ ] Started back on Acyclovir prophylaxis. Can determine length
of treatment going forward.
[ ] f/u final cytogenetics, pathology report on mediastinal mass
# Thymus Mass
# DLBCL s/p 6 cycles of R-EPOCH and 3 cycles IT-MTX for CNS ppx
completed ___ Diagnosed ___ when she presented with
abdominal pain and large abdominal mass. CT torso with LAD above
and below diaphragm, bony involvement, pancreatic involvement.
Cytogenetics with gain of BCL6. Last PET ___ showed ___. Now
presents with new mediastinal mass c/f relapse. Labs and
clinical exam not suggestive of spontaneous TLS. Failed ___
CT-guided biopsy ___, though able to have surgical biopsy ___.
Pathology from mediastinal mass consistent with hyperplastic
thymus without any evidence of lymphoma cells. TTE performed
normal without any pericardial effusion. She does not require
further inpatient work-up, though will have PET scan performed
to evaluate for recurrence or change in thymus mass. She was
maintained on Allopurinol and Acyclovir, both stopped prior to
discharge.
# Postural tachycardia- followed by Dr ___. Thought to be
combination of autonomic dysfunction from chemo and steroid
withdrawal. Symptoms gradually improving over last few months.
Patient monitored on telemetry with tachycardia to 130s while
ambulating. Otherwise hemodynamically stable.
# History of Provoked Pulmonary Embolism
No definitive clot seen on CTA. Previously enrolled in protocol
# ___ for dalteparin, which she completed ___. ?perfusion
defect on CT reviewed with radiology and likely just artifact.
On Lovenox prophylaxis while inpatient.
#Concern for UTI
UA demonstrating trace ___, 6WBC, negative nitrites. Urine
culture demonstrating ___ Group B beta streptococcus.
Repeat UA bland with urine culture pending at discharge. As
patient remained asymptomatic, was not treated for UTI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % Apply to painful area
QPM Disp #*5 Patch Refills:*0
3. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
anterior mediastinal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___
It was a privilege caring of you at ___.
WHY WAS I IN THE HOSPITAL?
-You were having chest pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You had a mediastinal mass noted on your CT scan. We performed
a biopsy and determined that the mass was your thymus gland and
not lymphoma.
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:
___
|
10492044-DS-13 | 10,492,044 | 22,675,677 | DS | 13 | 2110-08-28 00:00:00 | 2110-09-09 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o man with
history of hypertension who presented after a fall with
headstrike.
He reports that he was in his usual state of health. He was at
his church in ___ on the day of presentation, and he was
going to the basement to look for a shovel to clear the snowy
sidewalk. It was dark, and as he felt for the light switch he
lost his footing and tumbling down a flight of stairs. He does
not recall losing consciousness. He does remember the falling
down the stairs. The next thing that he recalls is being
upstairs
in the church with his wife. His wife corroborates this, and
adds
that she found her husband in the church with significant
bleeding from the back of his head. She also reports finding
blood at the bottom of the stairs and along the walls of the
stairwell.
Mr. ___ reports that he felt well up until the fall. He had a
mild cold characterized by nasal congestion, but otherwise felt
well. He had no fevers, chills, chest pain, palpitations,
nausea,
diaphoresis, dizziness, lightheadedness, shortness of breath,
cough or any other symptoms. He had no symptoms immediately
antecedent to the fall. He has never had a fall or lost
consciousness before. He reports that he is able to climb a
flight of stairs without chest discomfort or shortness of
breath.
He was brought by ambulance to the ___ ED.
In the ED, initial vitals were: 98.5 92 152/63 17 99% RA
Exam notable for: 2 cm complex laceration left occiput, with
boggy hematoma, no palpable skull fracture
Labs notable for: WBC 12.7 H/H ___, plt 144, lactate 2.4, BMP
wnl
EKG: NSR at 70 bpm, mild first-degree AV block (PR 234), NA,
otherwise normal intervals, no acute ST-Twave changes
Past Medical History:
hypertension
BPH
GERD
Social History:
___
Family History:
Mother with multiple myeloma. No known family
history of CAD, MI, CHF
Physical Exam:
Vitals:
___ 1520 Temp: 98.3 PO BP: 154/78 HR: 72 RR: 18 O2 sat: 96%
O2 delivery: Ra
Telemetry: Reviewed, normal sinus rhythm, no events
General: AOx3, in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear; sutured
occipital laceration
Neck: Supple, JVP not elevated
CV: RRR, S1/S2, no m/r/g; no carotid bruits
Lungs: CTAB, no wheezes, rales, or rhonchi
GI: Soft, NT/ND, BS+
MSK: Warm, well perfused, 2+ pulses, no edema; mild tenderness
to
palpation over left dorsal forearm
Neuro: CN2-12 tested and intact
Skin: No rash or lesion
Pertinent Results:
___ 02:01PM GLUCOSE-134* UREA N-25* CREAT-1.2 SODIUM-140
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-27 ANION GAP-12
___ 02:01PM estGFR-Using this
___ 02:01PM WBC-12.7*# RBC-4.62 HGB-15.3 HCT-44.9 MCV-97
MCH-33.1* MCHC-34.1 RDW-12.4 RDWSD-44.2
___ 02:01PM NEUTS-86.8* LYMPHS-6.9* MONOS-5.4 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-11.05* AbsLymp-0.87* AbsMono-0.68
AbsEos-0.01* AbsBaso-0.02
___ 02:01PM PLT COUNT-144*
___ 10:19AM PH-7.44 COMMENTS-GREEN TOP
___ 10:19AM GLUCOSE-113* LACTATE-2.4* NA+-139 K+-5.7*
CL--103 TCO2-25
___ 10:19AM HGB-15.8 calcHCT-47 O2 SAT-86 CARBOXYHB-3 MET
HGB-0
___ 10:19AM freeCa-0.99*
___ 10:09AM VoidSpec-SAMPLE REJ
___ 10:09AM WBC-7.5 RBC-4.65 HGB-15.7 HCT-45.6 MCV-98
MCH-33.8* MCHC-34.4 RDW-12.5 RDWSD-45.1
___ 10:09AM PLT COUNT-142*
___ 10:09AM ___ PTT-28.2 ___
___ 10:09AM ___
Brief Hospital Course:
He was brought by ambulance to the ___ ED.
In the ED, initial vitals were: 98.5 92 152/63 17 99% RA
Exam notable for: 2 cm complex laceration left occiput, with
boggy hematoma, no palpable skull fracture
Labs notable for: WBC 12.7 H/H ___, plt 144, lactate 2.4, BMP
wnl
EKG: NSR at 70 bpm, mild first-degree AV block (PR 234), NA,
otherwise normal intervals, no acute ST-Twave changes
Imaging:
- NCHCT:
1. No acute intracranial process.
2. No fractures. Left occipital scalp laceration and underlying
subcutaneous swelling and air.
3. Paranasal sinus disease as described above.
- CT C-spine:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the cervical supine as
described above.
- CXR: No comparison. The lung volumes are normal. Normal size
of
the cardiac silhouette. Mild elongation of the descending aorta.
No evidence of rib fractures. No pneumothorax, no pulmonary
edema, no pleural effusions. No pneumonia.
Consults: None
The patient was admitted to the general surgery service. His
laceration was repaired. He presented on ___, stayed
overnight for monitoring, and was appropriate for discharge on
___. During his stay, his vital signs were stable and is
pain was adequately controlled. He was discharged with the
appropriate medications and instructions for follow up and
monitoring his status after discharge.
Medications on Admission:
- Atenolol 75 mg ___
- Trandalopril 1 mg ___
- Tamsulosin 0.4 mg QHS
- Omeprazole 20 mg ___
Discharge Medications:
Home medications and:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
fall from standing
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 you sustained
your fall.
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.
Please make sure to take your time changing positions and/or
getting up from a laying or sitting position.
Followup Instructions:
___
|
10492386-DS-7 | 10,492,386 | 23,942,757 | DS | 7 | 2140-04-02 00:00:00 | 2140-04-03 10:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
tPA
History of Present Illness:
The pt is a ___ year-old right-handed woman from ___ with
history of HTN, DMII, HPL and DVT presented to ED after
developing right sided weakness and difficulty in speech.
She was last seen normal on her usual state of health on
___ at 2200 when she and her husband were done with their
dinner and went to bed, in the middle of the night she woke up
with right arm heaviness, difficulty in making words, expressing
what she wanted to say and heavy tongue.
She said it was difficult for her to talk or move the right arm,
her husband called ___ and she was transferred to ___ by
ambulance and a code stroke was called at 00:52am. Her NIHSS at
the time was 6, with notable R facial and arm weakness, profound
dysarthria and expressive difficulty.
Her BP was in the 160s/80s with a BS of 198.
No hx of anticoagulants recently, no recent surgery.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. has difficulties in producing and
comprehending speech with dysarthria,. has focal weakness and
heaviness in right arm and face. No numbness, parasthesiae. No
bowel or bladder incontinence or retention. Denies new
difficulty
with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN, DM, HPL for many years, could not obtain more details.
left knee surgery, DVT in ___, on Coumadin for an unknown
period.
Social History:
___
Family History:
There is no KNOWN history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
Vitals: T:98.3 P:104 R:14 BP:164/84 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.
Full range of motion OR decreased neck rotation and
flexion/extension.
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. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
- Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language: initially when she was evaluated she had mumbled and
severely dysarthric speech with difficulty in naming in low
frequency objects but after 20 min she improved, became more
fluent. No right- left confusion with intact repetition and
comprehension.
Normal prosody. Initially she had paraphasic errors which
improved.
Speech is still dysarthric.
NAMING Pt. was able to name high frequency objects, with initial
problem in naming low frequency objects.
READING - she could not read sentences or words, but can read
letters
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Blinks to
threat bilaterally. Funduscopic exam reveals no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: Right facial weakness, facial musculature asymmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. right pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Del bic Tris WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 5 ___ 5 5 5 5 5 ___
R 4+ 5 4+ ___ 5 5 5 5 5 ___
- DTRs:
BJ SJ TJ KJ AJ
L ___ 1 1
R ___ 2+ 1
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense and proprioception is impaired at the level of
great toe bilaterally. No extinction to DSS.
There was no evidence of clonus.
___ negative. Pectoral reflexes absent.
Plantar response was flexor on the left side and extensor on the
right side.
- Coordination: No intention tremor, slow finger tapping on the
right. No dysmetria on FNF in the left hand, dysmetria in the
right hand because of weakness.
- Gait: deferred
Pertinent Results:
___ 12:46PM GLUCOSE-100 UREA N-11 CREAT-0.7 SODIUM-140
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-29 ANION GAP-10
___ 12:46PM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.8
___ 01:32AM URINE HOURS-RANDOM
___ 01:32AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:32AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:32AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:32AM URINE RBC-4* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:32AM URINE MUCOUS-RARE
___ 01:05AM UREA N-13 CREAT-1.1
___ 01:05AM LIPASE-46
___ 01:05AM WBC-9.5 RBC-3.92* HGB-11.4* HCT-35.6* MCV-91
MCH-29.1 MCHC-32.0 RDW-14.4
___ 01:05AM ___ PTT-33.3 ___
___ 12:55AM CREAT-1.1
___ 12:55AM estGFR-Using this
CTA head and Neck:
1. No acute intracranial abnormalities.
2. Major intracranial and cervical vessels are patent, with
scattered mild
atherosclerotic disease. No intracranial aneurysm or
arteriovenous
malformation.
MRI brain
Subcentimeter acute-to-subacute left lateral thalamic/posterior
limb of the internal capsule infarct, without acute hemorrhage.
No
significant parenchymal edema. No midline shift. Superimposed
mild-to-moderate chronic microvascular ischemic changes.
ECHO:
Mild symmetric LVH with small LV cavity size and
near-hyperdynamic systolic function. Consequently there is a
mild LVOT gradient during systole. Early appearance of agitated
saline bubbles in the left atrium/ventricle at rest This finding
suggests a stretched PFO/small ASD.
Brief Hospital Course:
This is a ___ year-old right-handed woman with history of HTN,
DMII, and prior DVT presenting with sudden onset of right sided
weakness and speech difficulty (anomia and dysarthria). CTA
shows calcification in vessels but no cutoff. She got tPA for
presumed left sided infarct and had improved symptoms within
hours of administration.
NEURO: The patient was admitted to the NeuroICU for post-tPA
monitoring. She showed continued imrovement in both her language
and right arm strength. She had an echocardiogram which revealed
LVH as well as a PFO/ASD. There were no DVTs on lower extremity
ultrasounds. She had an MRI about 24 hours post-tPA which showed
a Left thalamic infarct with no hemorrhagic conversion. Stroke
risk factors were checked including A1c (6.4) and LDL (74).
CARDS: The patient had negative cardiac enzymes. She was
monitored on telementry. BLood pressure medications were held to
allow for autoregulation. Her blood pressure remained 130-150
regardless so on discharge she was instructed to restart home
antihypertensives slowly under the care of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 100 mg PO QHS
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Simvastatin 10 mg PO DAILY
4. Oxybutynin 15 mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Atenolol 100 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Oxybutynin 15 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. TraMADOL (Ultram) 100 mg PO QHS
8. Hydrochlorothiazide 25 mg PO DAILY
9. Amlodipine 10 mg PO DAILY
restart ___. Losartan Potassium 50 mg PO DAILY
restart ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left thalamic ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Naming intact (though limited due to language). Follows
commands. No facial droop. EOMI, PEERL. Full strength except
Right DELT 5-, Bic 5, TRi 5-, Fex 4+.
Discharge Instructions:
You came to the hospital because of sudden right sided weakness.
You got tPA, a powerful blood thinner, for a presumed stroke.
You had an MRI which confirmed a stroke on the left side of your
brain. You had an echocardiogram which showed a small hole in
your heart. Many people have this and it is unlikely that it
caused your stroke. It is more likely the cause of the stroke
was small vesssel disease from diabetes and high blood pressure.
Followup Instructions:
___
|
10493397-DS-9 | 10,493,397 | 28,290,546 | DS | 9 | 2184-10-07 00:00:00 | 2184-10-07 16:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
large L renal capsular hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o F w/ h/o hyperlipidemia and recurrent
pancreatitis, NIDDM, referred from ___ for large L
renal capsular hematoma s/p extracorporeal shock wave
lithotripsy for obstructive stone.
Of note, patient has never had nephrolithiasis before. Pt had
left flank pain started ___, seen at ___, where 7.5 mm
obstructing kidney stone was found, which was lithtripsied
yesterday, discharged home around 4pm. Pt represented to the ED
w/ severe left flank pain, non contrast CT showed large left
renal capsular hematoma. HCT has dropped from 44 to 35 (at
2300). Pt given ancef 1g. No fevers. Pt had nausea and vomiting
last night, but denies any other symptoms thereaafter.
Patient's 5am Hct was 33.6.
In the ED, initial vital signs were:
- Exam was notable for: 97.4 64 111/68 18 99% RA
- Labs were notable for: H/H 11.1/33.6
- Imaging: OSH CT abdomen/pelvis in life image
- The patient was given: 1L NS, 4 mg IV morphine
- Consults: Urology
Urology consulted and recommended serial Hct and bedrest, with
plan to proceed with ___ guided angio and embolization if hct
continues to drop.
Upon arrival to the floor, patient still reports left flank pain
but much improved.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, nausea,
vomiting, diarrhea, constipation, hematochezia, dysuria, rash,
paresthesias, and weakness.
Past Medical History:
- HLD
- Recurrent Pancreatitis
- NIDDM
- Prior opiate use on suboxone
Social History:
___
Family History:
No history of renal stones
Physical Exam:
============================
ADMISSION PHYSICAL EXAM:
============================
VITALS: T98.4 BP 116/68 HR 66 RR 16 Sats 98 RA FSBG 148
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
LEFT FLANK: Some pain on palpation. No hematoma or bruising
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
============================
DISCHARGE PHYSICAL EXAM:
============================
VITALS: 98.3, 63, 108/72, 18, 96%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
LEFT FLANK: Some pain on palpation. No hematoma or bruising
Pertinent Results:
===========================
LABS ON ADMISSION
===========================
___ 02:45AM BLOOD WBC-11.3* RBC-3.81* Hgb-11.1* Hct-33.6*
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.5 RDWSD-43.6 Plt ___
___ 02:45AM BLOOD Neuts-67.0 ___ Monos-10.6
Eos-0.8* Baso-0.4 Im ___ AbsNeut-7.59* AbsLymp-2.36
AbsMono-1.20* AbsEos-0.09 AbsBaso-0.05
___ 02:45AM BLOOD ___ PTT-33.3 ___
___ 02:45AM BLOOD Glucose-129* UreaN-15 Creat-0.9 Na-137
K-3.7 Cl-102 HCO3-23 AnGap-16
===========================
PERTINENT INTERVAL LABS
===========================
___ 04:10PM BLOOD Hct-30.0*
___ 10:00PM BLOOD Hgb-9.8* Hct-29.8*
___ 01:02AM BLOOD Hct-30.2*
___ 06:10AM BLOOD WBC-8.0 RBC-3.39* Hgb-9.7* Hct-30.8*
MCV-91 MCH-28.6 MCHC-31.5* RDW-13.9 RDWSD-46.3 Plt ___
___ 01:30PM BLOOD Hgb-10.1* Hct-32.2*
===========================
LABS ON DISCHARGE
===========================
___ 04:50AM BLOOD WBC-9.2 RBC-3.31* Hgb-9.6* Hct-30.2*
MCV-91 MCH-29.0 MCHC-31.8* RDW-13.5 RDWSD-45.3 Plt ___
===========================
MICROBIOLOGY
===========================
___ Urine culture - no growth
===========================
IMAGING/STUDIES
===========================
___ CT w/o contrast:
1. Again seen is hyperdense blood in the left renal fascia
surrounding the left kidney, and along the septa of ___, not
significantly changed compared to prior. There is some layering
hyperdensity in the posterior para renal fascia. Multiple renal
stones are seen in the bilateral kidneys, most notable for 7 mm
midpole stone on the left kidney (02:38) and 7 mm lower pole
renal stone on the right kidney (02:40). There is no
hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
2. Hepatic steatosis.
Brief Hospital Course:
This is a ___ y/o F w/ h/o hyperlipidemia and recurrent
pancreatitis, NIDDM, referred from ___ for large L
renal capsular hematoma s/p lithotripsy for obstructive stone.
#LEFT CAPSULAR HEMATOMA: The patient presented to ___
with severe left flank pain after having undergone
extracorporeal shock wave lithotripsy. She was seen on imaging
there to have a large left capsular hematoma, and was
transferred to ___. She was admitted to the medicine service.
Urology saw the patient and felt that the hematoma would likely
self-tamponade as is bleeding into contained capsular space.
They recommended bedrest and serial hct checks. The patient
remained stable, with her hgb stabilizing at 9.6. A repeat CT on
___ showed her perinephric hematoma was stable in size, and she
was able to be discharged with urology followup.
CHRONIC ISSUES:
===============
#PRIOR OPIATE USE: Denies IVDU but now on suboxone 6mg daily,
which was continued as an inpatient.
#DM: Patient is on metformin as an outpatient. Was kept on
insulin sliding scale in house.
#HYPOTHYROIDISM: Continued home levothyroxine.
#HLD: Continued home statin.
============================
TRANSITIONAL ISSUES
============================
- The patient's h/h should be checked at her next appointment to
be sure they are stable. Discharge h/h 9.6/30.2.
- Please do not take your suboxone until you meet with you PCP.
- The patient will have followup with outpatient urology for
ongoing evaluation of nephrolithiasis.
- The patient should have close blood pressure monitoring given
risk of Page kidney and hypertension.
- The patient's CT scan showed hepatic steatosis, which could be
further evaluated as an outpatient.
# CONTACT: ___ (___) ___
# CODE STATUS:Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
2. Fenofibrate 145 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Fenofibrate 145 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Left kidney capsular hematoma
Secondary Diagnoses
- opiate addiction
- diabetes mellitus
- hypothyroidism
- 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 to be a part of your care team at ___
___. You were admitted because you were
bleeding around your kidney after you had a procedure to break
up your kidney stone. We watched your blood counts, which
stabilized. We did another image of your kidneys, which showed
the blood around your kidney was not growing too large, and you
were able to go home.
Again, it was very nice to meet you, and we wish you all the
best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10493948-DS-17 | 10,493,948 | 21,212,354 | DS | 17 | 2131-05-15 00:00:00 | 2131-05-15 11:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Metformin / Lisinopril / Nsaids
Attending: ___.
Chief Complaint:
Nausea, Dizziness, Subdural Hematoma
Major Surgical or Invasive Procedure:
___ Left craniotomy for ___ evacuation
History of Present Illness:
___ is a ___ female who with hx of DM, CKD, CVA, HTN,
HLD, and complex partial seizures who presents to ___
on ___ with c/o of sudden dizziness, nausea and vomiting
while getting her hair done at the hair___. EMS was
activated and she was brought to ___ where she was
found to have left acute on chronic SDH, no MLS and very mild
mass effect. She was then transferred here to ___ for
further work up and evaluation. Per the patient she does not
recall if she is still on Aggrenox, however per OMR the last
time
this medication was ordered last ___. At this time the
patient denies any n/v, headache, dizziness, blurred vision,
SOB,
CP, fevers or chills.
Past Medical History:
DMII, HTN, 2 CVAs (last ___, chronic
renal insufficiency, seizure disorder (pt reports last seizure
was ~1 month ago, unsure what happened), benign neck tumors,
deaf
in left ear (unclear reason)
PSYCHIATRIC HISTORY:
Diagnoses: Late-onset delusional disorder (tactile, olfactory,
gustatory, and auditory)
Family History:
Pt reports extensive family history
of depression. States one sister (___) had depression and
may
have committed suicide. Another sister (___) reportedly has
bipolar disorder and schizophrenia. Mother died of ___
disease.
Mother with DM, ___, died in her ___. Dad with prostate
cancer died in his ___. Sister with bipolar disorder. Family
history of stroke, blood clots.
Physical Exam:
============
ON ADMISSION
============
Physical Exam:
T: 95.6 BP: 144/65 HR: 66 RR: 16 O2 Sat: 99% RA
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck:
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension, slightly
slurred ___ previous stroke.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally, sluggish. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact with a baseline
left
sided droop.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
============
ON DISCHARGE
============
Awakes to voice, oriented x3, R facial droop, tongue midline,
MAE full motor except for RUE- R delt ___, R bicep ___, R tricep
___.
Pertinent Results:
============
IMAGING
============
___ CT HEAD W/O CONTRAST Study Date of ___ 12:10 AM
1. Stable acute on chronic left subdural hematoma measuring up
to 11 mm in
maximal thickness. No evidence of new hemorrhage.
2. No evidence of midline shift. Basal cisterns are patent.
3. Partial opacification of left mastoid air cells.
___ CT HEAD W/O CONTRAST Study Date of ___ 4:51 ___
IMPRESSION:
1. No significant interval change in acute on chronic left
hemispheric
subdural hematoma.
2. No new hemorrhage.
___ pre-op Chest Xray:
Compared to chest radiographs since ___, most recently ___.
Borderline cardiomegaly is long-standing. Lungs grossly clear.
No pleural abnormality.
___ CT HEAD W/O CONTRAST
1. Since ___, there has been interval left
craniotomy with
evacuation of previous subdural hematoma and expected
postsurgical changes.
2. No shift of normally midline structures. Basal cisterns are
patent.
Brief Hospital Course:
#___
Patient was transferred to ___ from OSH with finding of acute
on chronic SDH with 6mm MLS. On exam she was intact. She was
admitted to the floor for observation and her repeat Head CT was
stable. She had an episode of right lower extremity weakness
and aphasia on ___ concerning for seizure; lamictal was
increased and she did not have any further episodes. She was
monitored and taken to the OR on ___ with Dr. ___ a
drain was left in place. She tolerated the procedure well and
recovered in the PACU. POD 1 the drain had high output and
remained in place. On ___ the drainage slowed down,
subsequently removed. Her incision remained intact with some
drainage at the most distal portion from a pin site- given its
proximity to her ear, no additional staple could be added. She
remained stable and was cleared for discharge to rehab on ___.
#DM:
Metformin, Januvia, Glipizide held and she was put on insulin
sliding scale.
___
She had a creatinine bump to 1.8 (1.3-1.5 baseline). She was
continued on fluid and given 500cc NS bolus. Cre trended down to
baseline. On ___ her creatinine was back to baseline at 1.3
#UTI
The patients urine culture grew group B strep. She was treated
with ampicillin and transitioned to Keflex when taking POs x 3
days.
___
The patient was evaluated by ___ and recommended rehab. On ___
she was screened for rehab and accepted at ___. On ___
she was discharged to rehab in stable conditions.
Medications on Admission:
AMLODIPINE - amlodipine 10 mg tablet. 1 Tablet(s) by mouth once
a
day
ASPIRIN-DIPYRIDAMOLE [AGGRENOX] - Aggrenox 25 mg-200 mg capsule,
extended release. 1 Cap(s) by mouth twice a day
ATORVASTATIN - atorvastatin 10 mg tablet. 1 tablet(s) by mouth
at
bedtime
GLIPIZIDE - glipizide 10 mg tablet. 1 tablet(s) by mouth twice a
day
HYDROCORTISONE - hydrocortisone 2.5 % topical cream. apply to
skin folds on arms twice a day
LABETALOL - labetalol 300 mg tablet. 2 tablet(s) by mouth three
times per day to combine with 100 mg tablet TID for total of 700
mg TID
LABETALOL - labetalol 100 mg tablet. 1 tablet(s) by mouth three
times a day to be combined with labetalol 300 mg x 2 tablets
tid;
total daily dose 700 mg tid
LAMOTRIGINE [LAMICTAL] - Lamictal 100 mg tablet. 1 tablet(s) by
mouth twice a day
METFORMIN - metformin 500 mg tablet. 1 tablet(s) by mouth at
dinnertime
RISPERIDONE - risperidone 2 mg tablet. 1 tablet(s) by mouth at
bedtime
SITAGLIPTIN [JANUVIA] - Januvia 50 mg tablet. 1 tablet(s) by
mouth once a day
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical
ointment. apply affected areas twice a day
ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 Tablet(s) by
mouth
twice a day
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit tablet. one tablet(s) by mouth daily
MULTIVITAMIN - multivitamin capsule. 1 Capsule(s)(s) by mouth
once a day
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Cephalexin 500 mg PO Q8H
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Heparin 5000 UNIT SC BID
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
7. Senna 8.6 mg PO QHS
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
9. LamoTRIgine 150 mg PO DAILY
10. amLODIPine 10 mg PO DAILY
11. Atorvastatin 10 mg PO QPM
12. Labetalol 700 mg PO TID
13. LamoTRIgine 100 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. RisperiDONE 2 mg PO QHS
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mixed density subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage with Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Incision:
- Your incision can be open to air. You have some leakage from a
pin site, a small dressing can be applied if needed.
- Suture/staples should remain in place for ___ days post-op.
Removal can be done at rehab.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Your home lamictal dosing was increased to provide seizure
coverage. Please continue the discharged dose until you are seen
in the office by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10493948-DS-18 | 10,493,948 | 22,916,735 | DS | 18 | 2134-01-26 00:00:00 | 2134-01-26 19:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Metformin / Lisinopril / Nsaids / aspirin
Attending: ___
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS:
==================================
The patient is a ___ woman with prior left frontal
stroke
in ___ and subsequent memory difficulties, acute on chronic
left
SDH, facial spasms, and complex partial seizures as well as HTN,
poorly controlled DM (A1c 11% in ___, and HLD who presents
with dysarthria.
It is currently not clear exactly when her dysarthria first
started. The patient states that it started 2 days ago. She is
unable to provide further details, noting that it started when
"doing normal things." Family, meanwhile, states that they
noticed it while speaking to her on the phone 2 hours prior to
presentation.
I spoke to the patient's daughter, ___ (___), who
states that she noticed it when she was on the phone with her
mother at 5 ___ this evening. She states that it sounded as if
her
mother "did not have her teeth in." She later describes it as if
"her mouth was full of something." The patient spoke with her
sister and nephew, both of whom corroborated ___ concern
that the ___ "didn't sound right." Accordingly, EMS was
called and the patient was brought to ___ as a code stroke.
Per EMS, the patient's sister - with whom she speaks on a daily
basis, multiple times per day - said that she did not have
slurred speech yesterday.
On neurological ROS, the patient's daughter states that "her
mind
has been going a bit" especially lately. The patient denies
headache, loss of vision, blurred vision, diplopia, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the patient endorses right leg
pain. She denies recent fever or chills. No night sweats or
recent weight loss or gain. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
DIABETES MELLITUS
HEARING LOSS AFTER XRT AS A CHILD
PERIPHERAL NEUROPATHY
RIGHT FEMORAL EMBOLUS
HYPERTENSION
COMPLEX PARTIAL SEIZURES
HYPERLIPIDEMIA
CHRONIC KIDNEY DISEASE
ANEMIA OF CHRONIC DISEASE
S/P PAROTID TUMOR REMOVAL
MILD COGNITIVE IMPAIRMENT FOLLOWED BY ___. ___
___ MOOD DISORDER ___ CVA, DELUSIONAL, PARANOIA
DIABETIC NEPHROPATHY
PULMONARY NODULE
SUBDURAL HEMATOMA
H/O CERVICAL ARTHRITIS
H/O KNEE PAIN
Social History:
___
Family History:
Pt reports extensive family history
of depression. States one sister (___) had depression and
may
have committed suicide. Another sister (___) reportedly has
bipolar disorder and schizophrenia. Mother died of ___
disease.
Mother with DM, ___, died in her ___. Dad with prostate
cancer died in his ___. Sister with bipolar disorder. Family
history of stroke, blood clots.
Physical Exam:
Admission Physical Exam:
Neurologic Exam:
-Mental Status: Alert, oriented to ___,
and
___. Unable to name the president. Unable to provide much
history. Unable to name ___. On the stroke card, she calls a
glove a "hand." Language is fluent with intact repetition and
comprehension. Normal prosody. There were a few paraphasic
errors
such as calling eye glasses "eyes" and the watch band a
"handle."
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2.5 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: She endorses decreased sensation on the left face V1-3
compared to the right, approximately 80-90%
VII: There is marked facial asymmetry with widening of the left
palpebral fissure though with ptosis of the right lid and
drooping of the lower lip towards the right.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. She has mild dysarthria
with lingual, guttural, buccal, and diaphragmatic sounds
including "ha ha."
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted. IOs on the left hand are ___ compared to ___ on
the right.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 5- ___ ___ 5 5 5
R 5 ___ 5 4* 5 5 5 5 5
* Pain limited
-Sensory: Trigeminal nerve deficits as noted above. She endorses
reduced light touch sensation, roughly 80 - 90%, on the right
hemibody compared to the left. Pin prick intact, with no
asymmetry, though there are hyperesthesias to pin prick in the
feet. Initially she said that the right felt "stronger" than the
left to pin prick. Subsequently said the exact opposite. Intact
proprioception throughout. Vibratory sense is reduced in the big
toes bilaterally, ~ 5 seconds each. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was extensor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait/Station: Did not assess.
Discharge Neurological Exam:
-Mental Status:
Alert, comfortable and pleasant. Oriented to ___. She is able to identify her daughter and follows all
commands. Naming intact. She does have dysarthria particularly
with labial sounds.
-Cranial Nerves:
II, III, IV, VI: PERRL 2.5 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch
VII: There is marked facial asymmetry with widening of the left
palpebral fissure though with ptosis of the right lid and
drooping of the lower lip towards the right.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. She has mild dysarthria
with lingual, guttural, buccal sounds.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted. IOs on the left hand are ___ compared to ___ on
the right.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 ___ 5 ___ 5 5 5
* Pain limited
-Sensory: left facial sensation decreased to light touch, which
is chronic. Light touch and pinprick equal throughout.
Temperature and vibration sense not examined.
-DTRs: deferred
-___: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait/Station: Able to walk independently with a slow and narrow
based gait.
Pertinent Results:
___ 07:20AM BLOOD WBC-4.3 RBC-3.61* Hgb-10.4* Hct-33.2*
MCV-92 MCH-28.8 MCHC-31.3* RDW-14.6 RDWSD-49.1* Plt ___
___ 07:50PM BLOOD ___ PTT-48.3* ___
___ 07:50PM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-90 UreaN-28* Creat-1.5* Na-145
K-4.3 Cl-108 HCO3-27 AnGap-10
___ 07:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
___ 05:55AM BLOOD %HbA1c-6.8* eAG-148*
___ 05:55AM BLOOD Triglyc-102 HDL-66 CHOL/HD-3.0
LDLcalc-115
___ 05:55AM BLOOD TSH-5.2*
___ 05:55AM BLOOD Free T4-1.0
MRI Brain
FINDINGS:
There is a small focal region of slow diffusion within the right
paramedian
pons with trace corresponding FLAIR hyperintensity compatible
with acute
infarct. There is no evidence of hemorrhage, edema, masses,
mass effect or
midline shift. The basilar cisterns remain patent.
As before, patient is status post left frontoparietal craniotomy
with
underlying left frontal, temporal and parietal lobe volume loss
and stable
T2/FLAIR white matter hyperintensity. There is been progressive
volume loss
of the left frontal and temporoparietal parenchyma since head CT
from ___.
In the setting of known chronic occlusion of the left internal
carotid artery,
this finding is suggestive of insufficient collateral supply to
this region.
Foci of increased signal loss on the gradient echo images
underlying the
craniotomy site may reflect calcifications, as noted on the
recent head CT,
+/- hemosiderin deposition related to old hemorrhage. There is
mild ex vacuo
dilatation of the left lateral ventricle occipital and temporal
horns.
There is mild ethmoid mucosal thickening. A left maxillary
sinus mucosal
retention cyst is seen. A left mastoid effusion is noted. The
patient is
status post bilateral lens replacement.
IMPRESSION:
1. Small right paramedian pontine acute infarction.
2. No evidence of mass or hemorrhage.
3. Progressive left hemisphere volume loss since ___ suggests
ongoing
ischemia in the setting of known chronic occlusion of the left
internal
carotid artery.
CTA head and neck
IMPRESSION:
1. CT HEAD: Status post left frontoparietal craniotomy with
underlying volume
loss and postoperative changes. Subcentimeter hypodensity
within the right
paramedian pons, not seen on the previous head CT dated ___, may
reflect acute infarct. This findings is confirmed on subsequent
MRI performed
___ at 01:25 hours. Progressive volume loss of the
left parietal,
frontal and temporal lobes since ___ suggests insufficient
collateral
vessels.
2. CTA HEAD: Redemonstrated chronic occlusion of the
intracranial left
internal carotid artery. There is normal filling of the left
anterior and
middle cerebral arteries.
3. There is a 4 mm saccular aneurysm at the right middle
cerebral artery
bifurcation. Otherwise, the vessels of the circle of ___
appear within
normal limits.
4. CTA NECK: Chronic occlusion of the left common carotid artery
from the
level just above its origin. Mild atherosclerotic
calcifications involving
the right carotid bifurcation without stenosis by NASCET
criteria. No
evidence of acute dissection or aneurysm formation.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with prior left frontal stroke
in ___ and
subsequent memory difficulties, acute on chronic left SDH,
facial
spasms, and complex partial seizures as well as HTN, poorly
controlled DM (A1c 6.8%), and HLD who was admitted to the
Neurology stroke service with dysarthria secondary to an acute
ischemic stroke in the right paramedian pons. Her stroke was
most likely secondary to a small artery event event given
involvement of the perforator arteries off of the basilar
artery. She was not on any antiplatelet therapy prior to this
hospitalization. She was started on antiplatelet therapy of
Plavix 75 mg given ASA allergy. She continued to have dysarthria
compared to her baseline speech, but her speech was intelligible
and she did not experience any dysphagia. Discussed with her
daughter/HCP plan for discharge home.
ACUTE ISSUES:
============
#Right paramedian pontine acute infarction ___ small artery
disease.
Patient has reported allergy to aspirin, and was started on
Plavix 75 mg and Atorvastatin 40 mg. She was seen by ___, who
found no new motor deficits and felt she was mobilizing at her
baseline and was safe for discharge home. We provided a 1 week
prescription of medication at her local pharmacy, and sent the
rest to her mail order pharmacy where her medications are bubble
packed for her.
#Hypertension
Home torsemide 10mg daily was continued, along with labetalol
700mg TID. Her blood pressures were well controlled during
hospitalization, and she should continue to follow up with her
PCP to maintain goal normotension.
#Diabetes
Hemoglobin a1c 6.8. She was seen by ___, who made some minor
changes to regimen while inpatient and recommended continuation
of home regimen on discharge.
#Seizures
Her home Lamotrigine 150mg QAM and 100mg QPM was continued.
#Mood
Continued on home risperidone 2mg PO QHS.
___
Creatinine 2.2 on admission, she was given a small amount of IVF
and this downtrended to baseline 1.9.
#Transitional issues
- Follow up with PCP ___: 1) continued blood sugar control, 2)
blood pressure control and risk factor optimization, 3)
incidental finding of multiple hypoattenuating lesions of the
left thyroid lobe which measure up to 5 mm, 4) elevated TSH at
5.6
- Follow up with stroke neurology; you will be called with an
appointment.
Her stroke risk factors include the following:
1) DM: A1c 6.8%
2) Hyperlipidemia: Started on atorvastatin 40 mg on with LDL
115
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - () Not confirmed ââ¬â () 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 = 115) - () 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 if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Clotrimazole Cream 1 Appl TP BID
3. Labetalol 700 mg PO TID
4. LamoTRIgine 150 mg PO QAM
5. LamoTRIgine 100 mg PO QHS
6. RisperiDONE 2 mg PO QHS
7. SITagliptin 25 mg oral DAILY
8. Torsemide 10 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. GlipiZIDE 5 mg PO BID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP BID
5. GlipiZIDE 5 mg PO BID
6. Labetalol 700 mg PO TID
7. LamoTRIgine 100 mg PO QHS
8. LamoTRIgine 150 mg PO QAM
9. RisperiDONE 2 mg PO QHS
10. SITagliptin 25 mg oral DAILY
11. Torsemide 10 mg PO DAILY
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were hospitalized due to symptoms of difficulty speaking
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, high blood pressure, diabetes
We are changing your medications as follows:
- START Plavix 75 mg daily to prevent future stroke events
- START Atorvastatin 40 mg daily to decrease your blood
cholesterol
We have sent a 2 week supply of these medications to ___ in
___. We have sent 6 months of refills to your mail order
pharmacy so that they can be put in blister packs for you.
Please take your other medications as prescribed without
changes. You should continue to check your blood sugars after
meals as you did before and follow up with your PCP.
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:
___
|
10494062-DS-14 | 10,494,062 | 23,889,601 | DS | 14 | 2121-09-30 00:00:00 | 2121-10-01 21:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ year old male with history of polysubstance abuse who
presented to OSH after being found unresponsive yesterday
afternoon after his mother's funeral. He was transferred from
OSH to ___ for multiorgan dysfunction of unclear etiology; he
is admitted to the MICU for rhabdomyolysis, ___, transaminitis,
troponinemia.
Per pt's wife, his last known normal was ___ evening. She
spoke to the pt by phone (they no longer live together) and
thought he sounded intoxicated with alcohol. She notes he has a
history of ETOH abuse and opiate abuse. The patient subsequently
did not arrive at his mother's funeral, and friends/family
became worried. They went to his residence and found him
"incoherent" and lying in bed, with beer cans strewn about. Of
note, a cut straw with white powder was also found. His
acquaintances were concerned about a fall, because pt apparently
had a lump on his head. At that time, he apparently was unable
to hear normally. He refused to go to the hospital at that time;
however, his wife eventually convinced him to go, and on the
evening of ___, they drove to ___. Pt reportedly
vomited several times en route.
He was seen at ___, where Labs were notable for
transaminitis and ___. Carboxyhemoglobin level and aspirin
levels were slightly elevated as well. NCHCT was reportedly
negative. He was transferred to ___ for multiorgan dysfunction
of unclear etiology.
In the ED, vitals were: 97.7 100 124/72 18 96% NC. Eval notable
for:
- Exam: Patient was A+Ox3 with rotational nystagmus, which is
reportedly at baseline. Patient unable to hear.
- Labs were notable for WBC 12.9, Na 130, Cr 3.3 (unclear
baseline), ALT 3163, AST 6938, Alk phos 54, Tbili 0.6, CK
38,330, and troponin 0.93. Serum tox was negative. UTox was
positive for opiates and amphetamine.
- Studies: EKG showed sinus tachycardia, interventricular delay,
and ST depressions in V3-V6.
- Consults: Cardiology for troponinemia, Neurology for ___
findings, Tox for ? ingestion, Hepatology for liver injury.
Their recommendations are summarized below.
- Interventions: 2L crystalloid at OSH, 2L crystalloid at BI;
acetylcysteine.
Decision was made to admit to MICU for further diagnosis and
treatment.
Vitals prior to transfer: 98.1 102 139/76 18 93 4L NC.
Consults in the ED:
- Cardiology: Picture c/w rhabdo and toxic cardiomyopathy. Low
susp for ACS. Follow biomarkers and get TTE. They will follow.
- Hepatology: acknowledged consult, hasn't yet seen pt.
- Neuro: CT hypodensities possibly c/w transient hypoxemia in
stg of being found down, but doesn't explain bilat hearing loss.
Get MRI head with contrast with thin cuts through CN VIII and
basal ganglia, get ENT consult for further hearing loss
evaluation.
- Tox: acknowledged consult, hasn't yet seen patient.
On arrival to the MICU, patient endorses the history above. He
remembers the night before his mother's funeral, and then
vaguely remembers being awakened by his friends but doesn't
recall the details. His next memory is of waking in ___. He
currently reports diffuse pain -- chronic back pain associated
with a prior MVA and surgery, and acute pain worst on R side
(particularly R shoulder). He notes taking ___ mg oxycodone
twice a day for pain; used to get them from PCP but can't say
where he's getting them now.
He denies any cardiac, respiratory, neurologic, or GI symptoms.
Past Medical History:
PAST MEDICAL HISTORY:
- Polysubstance abuse (ETOH, prescription opiates)
- Chronic MSK back pain s/p MVA
- Decreased visual acuity ___ a hereditary syndrome (brother
also has ___ Syndrome)
- HTN
PAST SURGICAL HISTORY
- back surgeries s/p MVA
Social History:
___
Family History:
Noncontributory to this admission
Physical Exam:
ADMISSION EXAM:
===========
Vitals: 130/111 99 94%
GENERAL: Alert, oriented, new onset hearing loss/deaf
bilaterally.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
===========
Vitals: T:98.4 BP:133/72 (133-183/72-87) ___ R:20 O2:99% RA
Last 24hr: -1400/+540
Last 8hr: -600/+540
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, +Rotary/lateral nystagmus. Large
circular erythematous bruise on Rt occiput.
Lungs: Clear to auscultation bilaterally, no w/c/r
CV: RRR, normal S1 + S2, no m/g/r
Abdomen: soft, +BS, NDNT, no rebound tenderness/guarding, no HSM
Ext: WWP, 2+ pulses, no c/c/e
Skin: No jaundice, rashes, echymosses. Surgical scar mildline
spine.
Neuro: hearing Rt>Lt
Pertinent Results:
ADMISSION LABS:
===========
___ 06:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 06:50AM URINE RBC-2 WBC-5 BACTERIA-MOD YEAST-NONE
EPI-0
___ 06:50AM WBC-12.9* RBC-4.08* HGB-13.6* HCT-39.7*
MCV-97 MCH-33.3* MCHC-34.3 RDW-11.9 RDWSD-42.8
___ 06:50AM NEUTS-85.0* LYMPHS-10.1* MONOS-3.7* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-11.00* AbsLymp-1.30 AbsMono-0.48
AbsEos-0.01* AbsBaso-0.04
___ 06:50AM PLT COUNT-164
___ 06:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 06:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:50AM CK-MB-336* MB INDX-0.9 cTropnT-0.93*
___ 06:50AM LIPASE-290*
___ 06:50AM ALT(SGPT)-3163* AST(SGOT)-6938*
___ ALK PHOS-54 TOT BILI-0.6
___ 06:50AM GLUCOSE-119* UREA N-30* CREAT-3.3*
SODIUM-130* POTASSIUM-5.4* CHLORIDE-98 TOTAL CO2-17* ANION
GAP-20
___ 06:56AM ___ PO2-49* PCO2-45 PH-7.25* TOTAL
CO2-21 BASE XS--7
___ 07:08AM ___ PTT-24.1* ___
___ 09:28AM LACTATE-0.9
___ 03:54PM CK-MB-262* MB INDX-0.9 cTropnT-0.56*
___ 03:54PM ALT(SGPT)-2474* AST(SGOT)-4169*
___ ALK PHOS-44 TOT BILI-0.6 DIR BILI-0.1 INDIR
BIL-0.5
___ 03:54PM GLUCOSE-105* UREA N-34* CREAT-4.1*
SODIUM-132* POTASSIUM-6.4* CHLORIDE-99 TOTAL CO2-16* ANION
GAP-23*
___ 06:15PM CALCIUM-7.2* PHOSPHATE-5.7* MAGNESIUM-1.9
URIC ACID-13.1*
___ 06:15PM GLUCOSE-104* UREA N-34* CREAT-4.2* SODIUM-133
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-17* ANION GAP-22*
___ 03:54PM WBC-11.4* RBC-3.77* HGB-12.3* HCT-35.9*
MCV-95 MCH-32.6* MCHC-34.3 RDW-11.9 RDWSD-41.6
___ 03:54PM NEUTS-84.9* LYMPHS-8.4* MONOS-5.5 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-9.65* AbsLymp-0.95* AbsMono-0.63
AbsEos-0.01* AbsBaso-0.02
IMAGING
======
___ CXR
AP portable upright view of the chest. Low lung volumes limits
assessment. Overlying EKG leads are present. There is
bronchovascular crowding at the lung bases. No convincing
evidence for pneumonia or edema. No large effusion or
pneumothorax. Cardiomediastinal silhouette is stable. Imaged
osseous structures are intact. No free air below the right
hemidiaphragm is seen.
___ ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
___ RENAL US
No hydronephrosis. Sonographic appearance of the kidneys is
within normal limits.
___ MRI HEAD w/o CONTRAST
1. Bilateral areas of slow diffusion are identified in the
basal ganglia withadditional punctate areas of slow diffusion
involving the frontal lobes, left side of the corpus callosum,
right temporal lobe and bilateral cerebellar hemispheres, given
the clinical history, the possibility of carbon monoxide
poisoning is a consideration.
2. There is no evidence of mass effect shifting of the normally
midline structures or intracranial hemorrhage.
MICRO:
=====
MRSA Screen ___: Neg
HBV/HCV Ab: Neg
DISCHARGE LABS:
===========
___ 05:41AM BLOOD WBC-16.1* RBC-3.98* Hgb-12.7* Hct-39.0*
MCV-98 MCH-31.9 MCHC-32.6 RDW-11.9 RDWSD-42.8 Plt ___
___ 05:40AM BLOOD ___ PTT-27.6 ___
___ 05:41AM BLOOD Glucose-95 UreaN-96* Creat-7.8*# Na-138
K-5.0 Cl-96 HCO3-27 AnGap-20
___ 05:41AM BLOOD ALT-126* AST-16 CK(CPK)-52 AlkPhos-58
TotBili-0.4
___ 05:41AM BLOOD Calcium-9.8 Phos-6.3* Mg-1.9
___ 02:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 02:44PM BLOOD HCV Ab-NEGATIVE
___ 04:40PM BLOOD O2 Sat-88 COHgb-1
___ 12:09PM URINE Hours-RANDOM UreaN-305 Creat-53 Na-72
K-12 Cl-45
Brief Hospital Course:
Mr. ___ is a ___ with history of polysubstance abuse who
presented to OSH after being found unresponsive from likely
toxic ingestion with acute onset bilateral hearing loss, found
to have Rhabdomyolysis, ___, transaminitis on admission to
___. Pt was found to have positive opiate UTox, transferred to
the ICU with extremely elevated CK to ___, given IVF w/short
pressor requirement, had positive troponins thought to be ___ to
ingestion. LFTs, CK, and trops normalized, though pt awoke with
acute b/l hearing loss which has improved with steroids. Pt was
initially anuric, now w/increased UOP but still w/elevated Cr
that is downtrending.
ACTIVE ISSUES:
=========
# Rhabdo / ___:
Rhabdomyolysis is most likely due to being unresponsive with
ischemic muscle injury. CK ___ on presentation, likely the
cause of patient's renal injury, causing ATN. Renal U/S on ___
was negative for hydronephrosis. Metabolic acidosis with AG 15
likely ___ uremia. Hyponatremia likely in the setting of IVF
resuscitation and renal failure, mild in 130s. He was given
aggressive fluid hydration and UOP was decreased initially, but
increased to 35-40 cc/hr on day of MICU to floor transfer,
eventually increased to ___ per day by the time of DC. Renal
was following, but patient did not necessitate emergent HD
during MICU or inpatient admission. Pt was placed on various
phos binders for hyperphosphatemia ___ ___ and his Sodium bicarb
was DC'd after AG normalized. Pt's Cr began to rise on transfer
from the MICU, though pt was making lots of urine, and by time
of DC Cr was downtrending, though still elevated. Pt had
intermittent hyperkalemia throughout his admission that appeared
resolved on DC.
# Transaminitis: Pt's elevated ALT/AST c/w acute hepatitis
without evidence of obstruction, T Bili and INR were relatively
wnl. Acetaminophen and EtOH levels upon arrival to ___ were
negative, though OSH labs were unknown. Most likely was due to
ischemic hepatopathy in the setting of polysubstance ingestion
and being found down vs pigment induced hepatic injury from
rhabdo. HBV/HCV was negative. Pt finished NAC protocol for acute
hepatitis. LFTs eventually downtrended towards normalization by
time of DC.
# CT hypodensities: Most likely represented a hypoxemic insult
in the setting of being incapacitated from polysubstance
ingestion. MRI showed multiple areas of insults, one in
particular concerning for carbon monoxide, but still of
questionable significance. Neurology was consulted. Of note,
carboxyhemoglobin levels were elevated at OSH but within range
of a smoker (which he is). MRI showed basal ganglia damage that
may be secondary to CO poisoning and Rt temporal lobe damage as
well. Patient had no recollection of incident, though appeared
w/o significant neuro deficits apart from his sensorineural
hearing loss which was improving on discharge.
# Pancreatitis?: Pt had a Lipase of 293 on admission, though the
patient was without abdominal pain over his whole admission and
tolerated PO without difficulty, most likely was related to
ischemic injury.
# Bilat hearing loss: Most likely toxigenic in nature versus
carbon monoxide poisoning, as case reports had shown both
opioids and CO causing b/l hearing loss. Both tox and ENT were
consulted and were in agreement to start high dose steroids
(prednisone 60 mg x 2 weeks with quick taper) to recover
sensorineural hearing loss. Pt's hearing began to improve on the
floor and he was DC'd with ENT f/u.
# Substance abuse: Pt had a hx of heroin and ETOH abuse. tested
positive for opiates at ___ ETOH negative at OSH and ___.
Amphetamines were falsely positive. He was evaluated by psych
who inquired whether he wanted counseling for depression and/or
substance abuse, but declined. He denied any SI or that this was
a suicidal attempt, despite it being on the day of his mother's
funeral. He does not remember the episode at all. He was given
thiamine, MVI, and folate.
# HTN: Pt developed HTN over his admission, though was not very
aggressive in keeping BPs down ___ to previous hypoxic event and
ATN. Pt was started on hydralazine and amlodipine, amlodipine
was titrated up as tolerated and Labetalol was started instead
of hydralazine soon before DC.
RESOLVED ISSUES:
===========
# Troponinemia: Pt with elevated trops and possible EKG changes
in the ED, it was initially unclear if it was ACS vs
rhabdomyolysis vs hypoxia. Pt's TTE was unremarkable and
troponins trended down, pt was seen by Cards who had no concern
for ACS and recommended conservative management.
# Hypoxemia: Pt initially with mild hypoxia of unclear etiology,
required NC in ED. No known pulmonary history, CXR clear. DDx
included aspiration in the setting of being found down. Did not
require O2 in the MICU or on the floor.
***TRANSITIONAL ISSUES***
-Pt will need Chem-10 checked in ___ days and faxed to ___
___ (please fax to the attention of Dr. ___ at
___
-Pt will need f/u with ENT for outpatient appointment and
audiogram on the same day
-Pt denied need for assistance with substance abuse on this
admission, should continue to be suggested
-Pt started on high dose Prednisone for 2 weeks for acute
hearing loss from ___, to then be tapered 10mg daily:
50mg ___, 40mg ___, 30mg ___, 20mg ___, 10mg ___
(final dose)
-Pt started on Amlodipine 10mg and Labetalol 100mg BID for HTN,
should be monitored in the outpatient setting. If Cr and Lytes
normalize and pt w/o CKD, can consider starting on ACE-I if
still with BP med requirement
-Pt started on sevelamer 1600mg TID w/meals for hyperPhos,
please discontinue when phos stable
-Pt can check his home CO monitor to see that the carbon
monoxide level was at home
# CODE: Full (confirmed)
# CONTACT: ___ (HCP)
Relationship: Ex-wife
Phone number: ___
--___ secondary contact, not HCP but can know
info ___
Medications on Admission:
None
Discharge Medications:
1. Amlodipine 10 mg PO HS
RX *amlodipine 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
4. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
RX *prednisone 50 mg 1 tablet(s) by mouth once Disp #*1 Tablet
Refills:*0
RX *prednisone 20 mg 2 tablet(s) by mouth once Disp #*2 Tablet
Refills:*0
RX *prednisone 20 mg 1.5 tablet(s) by mouth once Disp #*1.5
Tablet Refills:*0
RX *prednisone 20 mg 1 tablet(s) by mouth once Disp #*1 Tablet
Refills:*0
RX *prednisone 10 mg 1 tablet(s) by mouth once Disp #*1 Tablet
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply to shoulder once a day
Disp #*30 Patch Refills:*0
9. Outpatient Lab Work
Acute tubular necrosis ICD9 584.5
Chem-10: BMP, Mg, Ca, Phosphorous
Fax to:Dr. ___ ___
10. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate [___] 800 mg 2 tablet(s) by mouth
TID w/meals Disp #*42 Tablet Refills:*0
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*7 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute Tubular Necrosis
Acute Hypoxic Hepatitis
Rhabdomyolysis
Acute Sensoneural Hearing Loss
HTN
Hypoxic Brain Injury
SECONDARY:
History of Polysubstance Abuse
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 ___ from an outside hospital after you
were found at home to be confused and intoxicated from an
unknown substance. You were transferred to the ICU due to your
poor clinical condition, which included kidney and liver damage
along with muscle breakdown. You also developed hearing loss
that has slowly improved. An MRI of your brain showed signs of
possible brain damage as well. All of these were attributed to
the toxic substance you ingested, which we think may have been
an opiate product. While here your labs improved and your liver
appears to have recovered. You were given steroids for your
deafness, which has slowly improved too. Your kidneys are still
damaged but are showing signs of recovery. You were transferred
to the general medicine service as you recovered.
We hope you are able to seek help to prevent yourself from using
opiates and other drugs soon.
You will need to continue to take several medications to
compensate for the decreased kidney function. You will take
steroids for another ___ weeks to help your hearing improve.
It was a pleasure taking care of you!
Your ___ Team
***Please take your prednisone daily in the following amounts:
60mg daily last day ___ (final dose)
Followup Instructions:
___
|
10494089-DS-42 | 10,494,089 | 29,396,953 | DS | 42 | 2146-01-06 00:00:00 | 2146-01-08 14:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Episode of aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with a PMZH of DMII c/b
ESRD
on HD MWF via tunnelled line, retinopathy, PVD and neuropathy,
hypothyroidism, a-fib on coumadin, CHF w LVEF 30% and severe
aortic stenosis who presents today for an episode of garbled
speech.
She was at her dialysis session today, which went well.
Following
dialysis, she was talking with the nurse who was unhooking her
from the machine and about to take her over to get a standing
weight when the nurse noted that Ms. ___ was having "garbled
speech." Ms. ___ said that she thought she was speaking just
fine and did not know why everyone was making a fuss. She did
not
lose consciousness. Her blood sugar was in the 120s and her SBP
was in the ___ which is good for her. Per report, the episode
lasted ___ minutes. Ms. ___ denies any symptoms, like
headache, lightheadedness, numbness/tingling or focal weakness.
She has a history of hypotension which is treated with midodrine
prior to dialysis sessions. She took this today. Of note,
instead
of her usual ___ dialysis sessions this week, she had
___ due to the holiday. She has never had an
episode like this before. She has no history of strokes or
seizures. She has no muscle twitching.
She is on coumadin and gets her INR checked once weekly. She has
had her dose adjusted often.
Of note, she was seen by neurology consult in ___, when she was
admitted with pyelonephritis, and was diagnosed with a metabolic
encephalopathy. MRI at this time showed chronic small vessel
disease and EEG showed moderate encephalopathy.
On neuro ROS, she 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. +chronic gait difficulty due to
PVD/neuropathy, uses a walker, gait unchanged.
On general review of systems, she denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
1. End-stage renal disease (from diabetic nephropathy) s/p
failed transplant (transplanted ___, back on HD in ___ on HD
MWF
2. Hypothyroidism, last TSH 2.7 in ___ (wnl)
3. Global cardiomyopathy with LVEF of 32% (followed by Dr. ___
___
4. Hypotension on midodrine (started about ___ years ago)
5. Type II diabetes followed at ___ - Stopped insulin in ___, diagnosed at age ___
6. Paroxysmal atrial fibrillation on Coumadin
7. Spinal stenosis
8. Lymphedema
9. Pancreatic cysts
10. Transplanted kidney pelvic lesion, also with native kidney
lesions c/w complex cysts, followed by urology and with imaging
11. Right breast abscess in ___
12. Venous stasis ulcers
13. Gout
14. Post-menopausal bleeding, imaging and endometrial bx benign,
GYN saw her and no need for further screening
15. Enlarged ovary, followed in past by MRI, per GYN no need for
further surveillance
16. Severe aortic stenosis - valve area of 0.9 cm2, peak
gradient of 64 and a mean gradient of 36, stable on last ECHO in
___.
17. Valvular heart disease (severe AS, 2+ MR, 2+ TR, ___ AR)
18. Severe pulmonary hypertension
19. Peripheral vascular disease
20. LLE Cellulitis admitted to ___ ___
21. Diabetic retinopathy s/p surgery ___, seen at ___
___
22. Chronic anemia
PAST SURGICAL HISTORY:
1. Transmetatarsal right foot ampuations secondary to gangrene,
___.
2. Left ___ toe amputation secondary to gangrene/osteomyelitis,
___.
3. Renal transplant - failed.
4. Cholecystectomy.
Social History:
___
Family History:
___ sisters with HTN/CAD (denies other family members with
diabetes). Has 2 half brothers, healthy as far as she knows.
Parents did not go to the doctor, does not know of any health
issues, deceased of unknown causes. One sister with bladder
cancer, no other history of cancers that the patient is aware
of. Children all with HTN, grandchildren in good health as far
as patient knows. All of her siblings have passed, most recent
sister in ___.
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
Vitals: 97.8 64 103/40 19 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, bilateral exophthalmos, 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: irregular rhythm, +SEM
Abdomen: soft, obese, nontender
Extremities: Bilateral venous stasis ulcers. Right foot
amputation, several toe amputations.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. 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. 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. Full strength throughout.
-Sensory: Decreased sensation to light touch, pinprick in
stocking distribution in bilateral lower extremties, decreased
sensation to vibration in lower extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
-Coordination: Past-pointing bilaterally, and slow, innaccurate
RAM bilaterally.
-Gait: Not tested.
==========================
DISCHARGE PHYSICAL EXAM
==========================
Unchanged from admission exam, apart from:
-Coordination: Intact finger-nose-finger. RAM intact.
-Gait: Stable with cane.
Pertinent Results:
======
LABS
======
___ 06:45AM BLOOD ___ PTT-40.5* ___
___ 06:24AM BLOOD ___ PTT-63.4* ___
___ 09:00AM BLOOD ___ PTT-78.2* ___
___ 07:20AM BLOOD ___ PTT-33.6 ___
___ 11:30AM BLOOD ___ PTT-38.9* ___
___ 07:20AM BLOOD CK-MB-2 cTropnT-0.06*
___ 11:23PM BLOOD CK-MB-2 cTropnT-0.06*
___ 11:30AM BLOOD cTropnT-0.06*
___ 11:23PM BLOOD %HbA1c-5.5 eAG-111
___ 11:23PM BLOOD Triglyc-90 HDL-88 CHOL/HD-2.0 LDLcalc-70
___ 11:23PM BLOOD TSH-1.9
Blood Culture, Routine (Final ___: NO GROWTH.
==============
IMAGING
==============
NCHCT (___):
No evidence of acute intracranial process. White matter changes
likely
sequela of chronic small vessel disease. Old bilateral
cerebellar infarcts. If there is clinical suspicion for stroke,
consider obtaining MRI which is more sensitive.
MRA HEAD AND NECK, MRI BRAIN (___):
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Tiny punctate focus of increased signal on diffusion-weighted
imaging
within the left frontal lobe, without definite ADC correlate,
which may be artifactual although a tiny focus of subacute
ischemia is not excluded.
3. A tiny focus of negative susceptibility in the right frontal
lobe adjacent to the sulci series 19, image 15 and 16, can
relate to mineralization or prior blood products and partly
similar to the prior study. However, limited assessment for
acute hemorrhage on MRI.
4. Brain parenchymal volume loss and presumed sequelae of
chronic small vessel ischemic disease and prior infarcts.
5. Decreased flow related enhancement within the V4 segments of
the vertebral arteries which likely represents slow
flow/tortuous course.
6. No evidence of aneurysm more than 3mm, hemodynamically
significant
stenosis, or pathologic large vessel occlusion within the
vasculature of the head and neck.
7. Extensive paranasal sinus disease including complete filling
of the left maxillary sinus, as described.
8. Possible Right pleural effusion- correlate with CXR.
CXR (___):
In comparison with the earlier study of this date, allowing for
the erect PA view, there is probably little change in the degree
of cardiomegaly. No definite vascular congestion or acute
pneumonia. Opacification of the left bases consistent with
pleural fluid and atelectatic. Changes central catheter is
unchanged.
EEG (___):
IMPRESSION: Abnormal EEG, due to independent multi-focal
slowing, involving left mid-temporal, right frontotemporal and
right mid to posterior temporal regions, most consistent with a
multi-focal vascular insufficiency of acute or chronic nature.
Brief Hospital Course:
Mrs. ___ is a ___ year old woman with a past medical history
significant for DMII complicated by ESRD on hemodialysis MWF via
tunnelled line, retinopathy, and neuropathy, atrial fibrillation
on coumadin, CHF (LVEF 30%) and severe aortic stenosis who
presented to ___ from ___ on ___ following an episode of
garbled speech. NCHCT was unremarkable. Pt was admitted to the
stroke neurology service for further management.
Episode was attributed to hypoperfusion due to know hypotension
during hemodialysis and severe aortic stenosis. TIA or seizure
was also possible; however, MRI did not show an acute stroke or
evidence of aneurysm more than 3mm, hemodynamically significant
stenosis, or pathologic large vessel occlusion. Routine EEG also
did not show any epileptiform discharges nor seizures.
As INR was below the therapeutic range at presentation (INR =
1.4), pt was placed on a heparin drip bridge while restarting
warfarin. On day of discharge, INR was 2.0.
Otherwise, pt was continued on her home medications while in the
hospital. SBP ran from the ___ which was baseline for the
patient. Pt underwent HD on MWF. CXR did show a pleural effusion
that can be monitored as an outpatient. Blood cultures were
negative.
Pt did not experience any recurrent episodes while in the
hospital. On day of discharge, pt was feeling well. Physical
therapy cleared pt for discharge home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Levothyroxine Sodium 62.5 mcg PO DAILY
3. Midodrine 10 mg PO ASDIR
4. Nephrocaps 1 CAP PO DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Cinacalcet 90 mg PO EVERY OTHER DAY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
8. LOPERamide 2 mg PO QID:PRN loose stool
9. Warfarin 5.5 mg PO DAILY16
Discharge Medications:
1. Levothyroxine Sodium 62.5 mcg PO DAILY
2. Cinacalcet 90 mg PO EVERY OTHER DAY
3. Allopurinol ___ mg PO DAILY
4. LOPERamide 2 mg PO QID:PRN loose stool
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Nephrocaps 1 CAP PO DAILY
7. Midodrine 10 mg PO MWF dialysis
8. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
9. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Language difficulty concerning for stroke.
2. TIA evaluation
3. Seizure evaluation
4. End stage renal disease
5. Hyponatremia
6. Atrial fibrillation
7. CHF
8. Severe aortic stenosis
9. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital because of a brief episode of language
difficulty while at dialysis. You had an MRI which did not show
an acute stroke. This may, however represent a "mini stroke" or
transient ischemic attack.
You are at risk for stroke because of your atrial fibrillation
as well as your heart failure. You are on coumadin to decrease
your risk of stroke from these medical conditions. Your INR was
too low when you presented to the hospital. We restarted your
coumadin and on day of discharge your INR was at a therapeutic
level.
We wish you all the best!
Followup Instructions:
___
|
10494497-DS-12 | 10,494,497 | 24,195,083 | DS | 12 | 2164-01-07 00:00:00 | 2164-01-08 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flexeril
Attending: ___.
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
Radiation
History of Present Illness:
___ w/ pT3N1bMx stage IIIB colon adenocarcinoma, with Lynch
syndrome, s/p laparoscopic right colectomy ___ later found
to have recurrence at surgical anastomosis site with liver mets,
adenocarcinoma proven on liver biopsy ___. Admitted to
colorectal surgery on ___ with increased abdominal pain,
fever for few weeks, nausea, vomiting and diarrhea. CT showed
significant increase in size of mass now involving right kidney,
right psoas muscle and abutting liver. No surgical intervention
was recommended and he was transferred to oncology for further
treatment on ___. He was found to have microperforations and
started on antibiotics with improvement in his symptoms and
discharged on ___.
He states he has been doing well since his discharge up until 5
days ago when he developed increased stools (moving them about 5
times a day) and described them as green in color. 3 days ago,
on ___, he had a Frap and he developed N/V and presented to
___ (he was visiting his father there). He
received IVF and felt better. Since then he had been unable to
tolerate much PO. He presented on ___ to ___ where he
received fluids and was transferred here.
He denies fevers, sick contacts, chest pain, SOB.
Past Medical History:
ONCOLOGIC HISTORY:
___ initially presented with fatigue and dark-colored
stools which prompted evaluation by his PCP. He was found to be
anemic with a hemoglobin of 5.4 g/dL, and colonoscopy identified
a circumferential mass in the ascending colon. On ___,
he underwent right laparoscopic colectomy. Pathology showed
pT3N1bMx adenocarcinoma invading the muscularis propria with 3
of 14 lymph nodes involved. Tumor was KRAS wild type. An MSH6
mutation was identified consistent with Lynch syndrome. No
lymphovascular invasion was seen. Perineural invasion was
present. He received 11 of 12 planned infusions of adjuvant
FOLFOX chemotherapy under the care of Dr. ___ at
___. In ___ he presented with an increase in
liver function studies, right upper quadrant discomfort and a
___ pound weight gain associated with recurrent fevers. CT
___ identified a 1.2 x 1.9 cm hypodensity in the right
liver as well as a 4.4 x 4.8 x 3.8 cm mass at his surgical
anastomosis. This grew rapidly, prompting hospitalization
___ for abdominal pain, diarrhea, and fevers. He
underwent duodenal stent placement and was treated with
radiation and concurrent infusional fluorouracil.
PAST MEDICAL HISTORY:
1. History of attention deficit disorder.
2. Prehypertension.
3. GERD.
4. History of iron deficiency anemia.
5. Colon cancer as above.
Social History:
___
Family History:
Maternal aunt with breast cancer at age ___. His father's brother
had colon cancer in his ___ and survived. He has three maternal
great aunts with colon
cancer: one diagnosed in her ___, one in her ___, and one in her
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================
Vitals: T:99 BP:139/55 P:92 RR: O2:96%RA
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, ND, much less tender to deep palpation of RLQ
than previous hospitalization
LIMBS: No edema
SKIN: No rashes or skin breakdown
NEURO: Grossly wnl though much less interactive than previous
admissions
DISCHARGE PHYSICAL EXAM:
==================
Vitals: T:98.0 BP:120/76 P:93 RR:18 O2:95% on RA
General: NAD other than post-prandial abdominal pain
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy
CV: Tachycardic, normal S1/S2, no S3S4, no M/R/G
PULM: CTAB
ABD: BS+, soft, ND, much less tender to deep palpation of RLQ
than previous hospitalization, however is now tender to
palpation in subepigastrium b/l
LIMBS: No edema
SKIN: No rashes or skin breakdown
NEURO: Grossly within normal limits, although much less
interactive than previous admissions per nocturnist
Pertinent Results:
ADMISSION LABS:
==========
___ 04:10PM BLOOD WBC-5.7 RBC-3.28* Hgb-9.4* Hct-30.9*
MCV-94 MCH-28.7 MCHC-30.5* RDW-19.2* Plt ___
___ 04:10PM BLOOD Neuts-86.2* Lymphs-5.9* Monos-6.7 Eos-1.0
Baso-0.1
___ 04:10PM BLOOD ___ PTT-36.5 ___
___ 04:10PM BLOOD Glucose-103* UreaN-5* Creat-0.4* Na-141
K-3.5 Cl-107 HCO3-24 AnGap-14
___ 04:10PM BLOOD ALT-8 AST-28 AlkPhos-108 TotBili-0.6
___ 04:10PM BLOOD Lipase-18
___ 04:10PM BLOOD Albumin-3.0*
___ 04:10PM BLOOD CEA-7.4*
DISCHARGE LABS:
==========
___ 06:50AM BLOOD WBC-6.0 RBC-3.25* Hgb-9.6* Hct-30.7*
MCV-95 MCH-29.5 MCHC-31.2 RDW-19.9* Plt ___
___ 06:50AM BLOOD ___ PTT-37.6* ___
___ 06:50AM BLOOD Glucose-79 UreaN-3* Creat-0.4* Na-141
K-3.4 Cl-104 HCO3-30 AnGap-10
___ 09:27AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:50AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
___ 09:27AM BLOOD D-Dimer-1164*
RELEVANT STUDIES:
============
- OFFICIAL READ OF CT ABDOMEN/PELVIS W/ CONTRAST (___):
1. Ileitis with a small amount of adjacent fluid within the
right abdomen, likely related to radiation therapy due to its
location adjacent to the mass in the region of the colonic
anastomosis. No evidence of obstruction.
2. Large mass in the region of the colonic anastomosis
continues to invade the right kidney, duodenum and psoas muscle,
but is slightly decreased in size from ___.
3. Prior hepatic segment VI lesion concerning for metastatic
disease is not seen on this exam.
4. Splenomegaly.
Brief Hospital Course:
HOSPITAL COURSE: Mr. ___ is a ___ year old man with pT3N1bMx
stage IIIB colon adenocarcinoma, with Lynch syndrome, who had a
laparoscopic right colectomy ___, then found to have
recurrence at surgical anastomosis site with possible liver mets
although unconfirmed. He was admitted for persistent
nausea/vomiting/diarrhea, likely a reaction to his
chemoradiation. He has a history of C. diff, which was ruled out
by PCR. Nausea and vomiting resolved during course and pt was
able to tolerate regular diet. Diarrhea improved but was still
present at time of discharge, and was occasionally associated
with abdominal pain. Pt continued to receive final chemo and
radiation treatments while in house. He was discharged home in
stable condition after final radiation session on ___. Of note
pt's mental status was deemed changed from prior, as he had a
delayed response to questions and flat affect.
# NAUSEA/VOMITING/DIARRHEA: This has been an ongoing issue for
him. Also has undocumented history of C. diff at an outside
hospital in ___ many years ago. In the past when he
first presented with these symptoms, they were found to be due
to duodenal stricture and abdominal mass, so pt underwent
placement of a duodenal stent on ___. On this
hospitalization, pt presented with loose green stools and
nausea/vomiting concerning for infectious etiology vs reaction
to chemoradiation therapy. C. diff cultures/PCR was negative,
making chemoradiation side effect most likely explanation. Over
the course of hospitalization, nausea/vomiting resolved,
diarrhea improved, and pt was able to tolerate a regular diet at
time of discharge although he was experiencing intermittent
post-prandial abdominal pain, relieved by home narcotic
medication. Was also sent home on his home zofran, dronabinol,
and compazine for symptomatic management.
# ADENOCARCINOMA OF COLON WITH METASTATIC RECURRECENCE:
Receiving neoadjuvant chemotherapy/radiation following stent
placement ___ ___. CEA was checked, and was 7.4 on
___, down from 62 on ___. ___ pump was set up in-house so
pt could receive the final 48 hours of his treatment. While
admitted, he also went to his two remaining radiation
treatments. Pt was discharged ___ after ___ and final
radiation treatment.
# CHEST PAIN: Triggered ___ AM for feeling of chest pain and
"tightness" like someone was "sitting on my chest." Improved
when sitting up and leaning forward, sharp pain across chest
then migrating to left side, worse with inspiration. Concerning
for pulmonary embolism give pleuritic chest pain associated with
tachycardia to 100s. EKG unremarkable other than sinus
tachycardia. Cardiac enzymes negative. D-dimer positive, but
likely secondary to malignancy rather than clot. Not hypoxic by
pulse ox. Resolved spontaneously.
# PAIN: Secondary to tumor burden. Pt was continued on home
oxycontin 60mg twice a day, and ___ mg oxycodone every three
hours. Pt's oxycontin dose was recently increased from 45 to
60mg twice a day, which was believed to be the cause of his
change in affect and unusual mental status on exam.
# COAGULOPATHY: Likely nutritional, labs not suggestive liver
dysfunction. Antibiotics may have contributed as well. Was given
oral vitamin K for two days, after which INR dropped to 1.1 on
___, so vitamin K was discontinued and subcutaneous heparin
injections for clot prophylaxis were initiated.
# NORMOCYTIC ANEMIA: Stable. Pt was continued on home iron
supplementation.
TRANSITIONAL ISSUES:
====================
- F/u with heme/onc
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID pain
2. Dronabinol 5 mg PO BID
3. Gabapentin 100 mg PO Q8H
4. Multivitamins 1 TAB PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Augmentin XR (amoxicillin-pot clavulanate) 1,000-62.5 mg oral
BID Microperforation
9. OxycoDONE Liquid ___ mg PO Q3H:PRN pain
10. Phytonadione 5 mg PO DAILY
11. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
14. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO BID pain
2. Dronabinol 5 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 100 mg PO Q8H
5. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
9. OxycoDONE Liquid ___ mg PO Q3H:PRN pain
10. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal side effects from chemotherapy and radiation
Metastatic adenomcarcinoma of colon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to us because ___ were having persistent nausea,
vomiting, and diarrhea, likely due to your cancer treatments.
___ have a history of C. difficile colitis, so we were concerned
about your diarrhea, however, we were able to rule this out with
a culture. Your nausea and vomiting resolved and ___ were able
to tolerate a diet. Your diarrhea improved, but is still
occurring occasionally. ___ continued to receive your remaining
chemotherapy and radiation treatments while ___ were here.
Please note the medication changes and follow-up appointments
scheduled for ___ as detailed below.
Followup Instructions:
___
|
10494497-DS-13 | 10,494,497 | 27,146,755 | DS | 13 | 2164-01-13 00:00:00 | 2164-01-15 14:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flexeril
Attending: ___.
Chief Complaint:
Nausea, vomiting, diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ pT3N1bMx stage IIIB colon adenocarcinoma, with Lynch
syndrome, s/p laparoscopic right colectomy ___ later found
to have recurrence at surgical anastomosis site with mass
invading the right kidney and psoas muscle, most recently
discharged ___ after admission for nausea/vomiting/diarrhea
presents with recurrence of those symptoms.
Regarding his onc history, he underwent right laparoscopic
colectomy on ___ followed by 11 cycles adjuvant FOLVOX. ___ had liver mets and mass at the surgical anastomosis which
grew very rapidly. He was hospitalized ___ for abdominal
pain, diarrhea, and fevers felt to be ___ microperf and was
treated with antibiotics. (In fact, the last ID note states he
should still be on those antibiotics while getting chemo but it
appears he was not on them during his last admission). Surgery
did not want to operate at that time and he was transferred to
onc service ___. He underwent duodenal stent placement and
subsequently got XRT and concurrent ___. He was readmitted
___ for diarrhea, nausea, vomiting and abdominal pain.
C.diff negative. He underwent his final XRT session ___ and
continued to receive ___ while in house (last ___ was ___ per his report today).
Patient reports since his discharge 4 days ago, his nausea,
vomiting, diarrhea, and abdominal pain has progressively
worsened. Initially he was able to keep food down. Had 4
episodes
of vomiting today, nonbloody nonbilious. His presentation feels
consistent with how he felt when he came in for his recent
admission. He reports baseline dull abdominal pain and
intermittent sharp superimposed pains which seem to be at their
worst when he goes from lying down for a while to a seated or
standing position. He is not able to keep much down PO including
medications. He has had several episodes of diarrhea today and
yesterday and has to wear diapers because he is not making it to
the toilet fast enough. Nonbloody. No urinary symptoms. No
fevers. He states he has coughed up some phlegm intermittently
but really no significant cough or trouble breathing. He had a
minor cough during his last admission but states this improved
dramatically. No headaches.
ED COURSE:
- Triage 19:57 3 97.7 106 127/75 15 100%
- labs showed: 136/4.3; 96/29; ___ <94.
ALT: 8 AP: 157 Tbili: 0.6 Alb: 3.3 AST: 47 (slightly hemolyzed)
CBC: 5.2 > 11.6/37.4 < 211. 71% PMNs.
- imaging: CXR c/f RML PNA but no free air
- KUB (to my eye) no obstruction or air fluid levels
- interventions: 1L NS. He was given 10mg prochlorperazine IV
x1,
zofran 4mg IV x1, dilaudid 1mg IV.
v/s prior to transfer: Today 22:15 98.2 101 133/56 18 98% RA
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, sinus
tenderness, rhinorrhea, or congestion. (some phlegm as above)
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No shortness of breath, hemoptysis, or wheezing.
GI: No hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
Past Medical History:
ONCOLOGIC HISTORY:
___ initially presented with fatigue and dark-colored
stools which prompted evaluation by his PCP. He was found to be
anemic with a hemoglobin of 5.4 g/dL, and colonoscopy identified
a circumferential mass in the ascending colon. On ___,
he underwent right laparoscopic colectomy. Pathology showed
pT3N1bMx adenocarcinoma invading the muscularis propria with 3
of 14 lymph nodes involved. Tumor was KRAS wild type. An MSH6
mutation was identified consistent with Lynch syndrome. No
lymphovascular invasion was seen. Perineural invasion was
present. He received 11 of 12 planned infusions of adjuvant
FOLFOX chemotherapy under the care of Dr. ___ at
___. In ___ he presented with an increase in
liver function studies, right upper quadrant discomfort and a
___ pound weight gain associated with recurrent fevers. CT
___ identified a 1.2 x 1.9 cm hypodensity in the right
liver as well as a 4.4 x 4.8 x 3.8 cm mass at his surgical
anastomosis. This grew rapidly, prompting hospitalization
___ for abdominal pain, diarrhea, and fevers. He
underwent duodenal stent placement and was treated with
radiation and concurrent infusional fluorouracil.
PAST MEDICAL HISTORY:
1. History of attention deficit disorder.
2. Prehypertension.
3. GERD.
4. History of iron deficiency anemia.
5. Colon cancer as above.
Social History:
___
Family History:
Maternal aunt with breast cancer at age ___. His father's brother
had colon cancer in his ___ and survived. He has three maternal
great aunts with colon
cancer: one diagnosed in her ___, one in her ___, and one in her
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
General: NAD, weak appearing, lying in bed resting calmly
VITAL SIGNS: T 97.4 RR 20 HR 98 BP 148/60 99% RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, tender in RLQ and epigastrium
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
reflexes are 2+ upper and lower extremities
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T:97.6 BP:168/74 P:89 RR:20 O2:100% on RA
General: NAD other than abdominal pain
HEENT: MMM, no OP lesions
CV: RRR, normal S1/S2, no S3S4, no M/R/G
PULM: CTAB
ABD: Soft, BS+, tender in RLQ and epigastrium
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
reflexes are 2+ upper and lower extremities
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM BLOOD WBC-5.2 RBC-3.97* Hgb-11.6* Hct-37.4*
MCV-94 MCH-29.2 MCHC-31.1 RDW-20.2* Plt ___
___ 09:00PM BLOOD Neuts-71.2* Lymphs-9.5* Monos-15.5*
Eos-3.3 Baso-0.5
___ 09:00PM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-136 K-4.3
Cl-96 HCO3-29 AnGap-15
___ 09:00PM BLOOD ALT-8 AST-47* AlkPhos-157* TotBili-0.6
___ 09:00PM BLOOD Albumin-3.3*
DISCHARGE LABS:
===============
___ 05:39AM BLOOD WBC-3.8* RBC-3.16* Hgb-9.7* Hct-29.8*
MCV-94 MCH-30.6 MCHC-32.5 RDW-19.9* Plt ___
___ 05:39AM BLOOD ___ PTT-45.0* ___
___ 05:39AM BLOOD Glucose-101* UreaN-4* Creat-0.5 Na-139
K-3.5 Cl-103 HCO3-29 AnGap-11
___ 05:39AM BLOOD ALT-5 AST-25 AlkPhos-129 TotBili-0.4
___ 05:39AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.9
RELEVANT STUDIES:
=================
- KUB (___): No evidence of pneumoperitoneum.
- CXR (___): Right middle lobe consolidation worrisome for
pneumonia. Given patient's history of metastatic disease,
neoplastic process is not excluded although given development
since the prior chest radiograph from 7 days prior, felt to more
likely represent pneumonia.
Brief Hospital Course:
HOSPITAL COURSE: Mr. ___ is a ___ year old man with Lynch
syndrome and stage IIIB colon adenocarcinoma s/p right colectomy
___ and recurrence at anastomotic site (large mass invading
kidney and psoas and possible liver mets) now readmitted for
recurrent nausea/vomiting/diarrhea causing dehydration.
Discharged ___ after admission for the same. At that time it
was attributed to chemo/radiation and his CT showed some mild
ileitis. No signs clinically or on imaging to suggest
obstruction, perforation, or infection; most likely acute
worsening of pt's baseline sx due to chemo/radiation and
malignancy. Pt had symptomatic improvement with IVF and narcotic
pain medication. Able to tolerate a regular diet, with no other
active symptoms, so is being discharged home ___ with plans for
IVF at home from an infusion company, in order to prevent
further hospital admissions for the same issue. Got 3mg IV
dilaudid total during stay for additional pain control.
Discharged with scripts for extra zofran, compazine, and
oxycodone, and will follow-up on ___, day after discharge, in
clinic.
# NAUSEA/VOMITING/DIARRHEA: Discharged ___ after admission or
the same. At that time it was attributed to chemo/radiation and
his CT showed some mild ileitis. On this admission there was
nothing to suggest obstruction or perforation (abdominal x-ray
without free air or air-fluid levels). No fevers to suggest
infectious etiology and he did not have neutropenia or
leukocytosis. Most likely this was again chemo/radiation effect.
Held off on CT given pt was relatively symptom free on arrival
to the floor and had recent CT from ___. Was treated with IVF
hydration, bowel rest followed by slow advancement of diet to
regular, home dronabinol, home zofran/compazine, and home PPI.
Was discharged home with plan for home infusion company to give
IVF at home to prevent symptom recurrence and/or dehydration,
and hopefully keep pt from requiring another admission.
# ADENOCARCINOMA OF COLON WITH METASTATIC RECURRECENCE:
Receiving neoadjuvant chemotherapy/radiation following stent
placement ___ ___. CEA was checked, and was 7.4 on
___, down from 62 on ___. Per pt last ___ was in house
___. Last radiation was on ___ (final treatment).
Outpatient providers were notified, and pt was discharged on
___ with a follow-up appointment scheduled for the next day in
the ___ clinic.
# PAIN: Secondary to tumor burden. Pt had symptoms while
admitted, which were treated by continuing his home long acting
oxycontin 60mg twice a day, along with Dilaudid IV prn, which
was successfully transitioned back to his home oral oxycodone on
the day of discharge.
# NORMOCYTIC ANEMIA: Stable. Held home iron supplement during
admission given abdominal symptoms.
TRANSITIONAL ISSUES:
====================
- Needs to go to ___ clinic on ___ for follow-up
- Home infusion services set up to get 1L NS on ___ and
___ via port at home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Dronabinol 5 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 100 mg PO Q8H
5. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
9. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Dronabinol 5 mg PO BID
3. Gabapentin 100 mg PO Q8H
4. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
5. Ferrous Sulfate 325 mg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth every 3 hours Disp
#*10 Tablet Refills:*0
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours Disp #*30 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
12. Intravenous fluids
Normal Saline 0.9%; volume 1000ml at 100ml/hr via port-a cath
for dehydration and poor oral intake.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal pain
Diarrhea
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
You came to us because you were having another episode of
abdominal pain, diarrha, nausea, and vomiting, causing
dehydration. We hydrated you and treated your pain and you felt
better. We have arranged for you to get IV hydration in clinic
as an outpatient, in order to prevent you from having severe
episodes like this in the future.
Please note the medications and follow-up appointments scheduled
for you, as detailed below.
Followup Instructions:
___
|
10494497-DS-14 | 10,494,497 | 27,128,417 | DS | 14 | 2164-02-13 00:00:00 | 2164-02-15 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flexeril
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male h/o pT3N1Mx stage IIIB colon
adenocarcinoma, KRAS wild type, MSH6 mutated consistent with
Lynch syndrome, recurrence at anastomotic site (large mass
invading kidney and psoas and possible liver mets). He is
admitted from ED with severe vomiting after last cycle of chemo
(C1 D22 irinotecan/cetuximab on ___. He is here with brother.
Developed nausea and one episode of emesis immediatly after
receiving chemo. then went to sleep early. Woke up this am,
tried some cereal but vomited, couldnt keep down meds, did not
eat or drink anything else. Had at least 4 emesis through the
day. Brother brought him in because soem of emesis had quarter
sized dark brown-black material, no bright red blood. Did not
have painful emesis but some dry heaving. Reported to ED > 10
episodes bilious emesis and also some worsening R sided ab pain.
On arrival to floor states that ab pain is ok, in typical place
on R. Has been using oxycodone less than daily. He denies
fevers, chills, cough, chest pain, shortness of breath or
dysuria. He has hemorrhoids but denies black or bloody stool.
Stools now loose again but only few per day. Had guiac + light
brown stool and hemorrhoids on exam in ED
ED vitals: 98.4 78 159/69 16 100% 0
He was given dilaudid x 3, zofran x 2 and 2L NS in ED, still no
UOP thus given ___ L prior to transfer. Ab U/S obtained given
RUQ tenderness which showed known RLQ mass and liver lesions. He
is feeling better now, no emesis since about 4:30 pm.
Past Medical History:
ONCOLOGIC HISTORY:
___ initially presented with fatigue and dark-colored
stools which prompted evaluation by his PCP. He was found to be
anemic with a hemoglobin of 5.4 g/dL, and colonoscopy identified
a circumferential mass in the ascending colon. On ___,
he underwent right laparoscopic colectomy. Pathology showed
pT3N1bMx adenocarcinoma invading the muscularis propria with 3
of 14 lymph nodes involved. Tumor was KRAS wild type. An MSH6
mutation was identified consistent with Lynch syndrome. No
lymphovascular invasion was seen. Perineural invasion was
present. He received 11 of 12 planned infusions of adjuvant
FOLFOX chemotherapy under the care of Dr. ___ at
___. In ___ he presented with an increase in
liver function studies, right upper quadrant discomfort and a
___ pound weight gain associated with recurrent fevers. CT
___ identified a 1.2 x 1.9 cm hypodensity in the right
liver as well as a 4.4 x 4.8 x 3.8 cm mass at his surgical
anastomosis. This grew rapidly, prompting hospitalization
___ for abdominal pain, diarrhea, and fevers. He
underwent duodenal stent placement and was treated with
radiation and concurrent infusional fluorouracil.
PAST MEDICAL HISTORY:
1. History of attention deficit disorder.
2. Prehypertension.
3. GERD.
4. History of iron deficiency anemia.
5. Colon cancer as above.
Social History:
___
Family History:
Maternal aunt with breast cancer at age ___. His father's brother
had colon cancer in his ___ and survived. He has three maternal
great aunts with colon
cancer: one diagnosed in her ___, one in her ___, and one in her
___.
Physical Exam:
General: NAD, pale
VITAL SIGNS: 98.4 102/64 85 18 95%RA
HEENT: MM slight tachy, no OP lesions
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, mild ttp RLQ no rebound or guarding, palpable
RLQ mass
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, moves all ext, sensation intact to light touch, no
clonus
Pertinent Results:
___ 02:59PM BLOOD WBC-3.0* RBC-2.98* Hgb-9.0* Hct-26.7*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.7* Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-8 Creat-0.6 Na-141 K-3.3
Cl-106 HCO3-24 AnGap-14
___ 08:20PM BLOOD ALT-31 AST-40 AlkPhos-178* TotBili-0.6
___ 07:00AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
Brief Hospital Course:
Mr ___ is a ___ yr old male with hx of Lynch syndrome and
colorectal adenoCa metastatic to liver currently treated with
cetuximab and irinotecan who is admitted with severe vomiting
and dehydration following chemotherapy.
#Chemotherapy related N/V with dehydration:
Pt has had multiple admissions for similar symptoms following
chemotherapy. Pt had reportedly coughed up some quarter sized
blood clots after dry heaving at home. He was not observed to be
actively bleeding in the hospital. He was resuscitated with IV
fluids for dehydration and his nausea was treated with IV
antiemetics with good response. His CBC was trended and
monitored overnight. H/H remained relatively stable overnight
and he denied any symptoms concerning for ongoing bleeding. He
was discharged in stable condition.
#ABDOMINAL PAIN:
Pt reported right-sided abdominal pain that was consistent with
his chronic pain in location but moderately worse than baseline.
A RUQ U/S showed no evidence of cholecystitis or other acute
patholoy. His known masses in the abdomen were stable compared
to prior imaging. Pain was treated with IV dilaudid with good
relief and pain did not recur overnight after admission.
Transitional issue:
-It would be recommended to re-evaluate pt's antinausea
medication/regimen given he has had multiple admissions for
chemotherapy related nausea/emesis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Dronabinol 5 mg PO BID
3. Gabapentin 100 mg PO Q8H
4. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
5. Ferrous Sulfate 325 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Clindamycin 1 Appl TP BID
12. Lorazepam 1 mg PO Q4H:PRN nausea, vomiting
13. Omeprazole 20 mg PO BID
14. LOPERamide 4 mg PO QID:PRN diarrhea
Discharge Medications:
1. Clindamycin 1 Appl TP BID
2. Dronabinol 5 mg PO BID
3. Gabapentin 100 mg PO Q8H
4. LOPERamide 4 mg PO QID:PRN diarrhea
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
7. Senna 8.6 mg PO BID:PRN constipation
8. Acetaminophen 1000 mg PO BID:PRN pain
9. Ferrous Sulfate 325 mg PO DAILY
10. Lorazepam 1 mg PO Q4H:PRN nausea, vomiting
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Chemotherapy-related nausea and vomiting
Secondary: Colon cancer, attention deficit disorder,
gastroesophageal reflux disease, iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
hospitalized for nausea, vomiting, and dehydration from side
effects due to chemotherapy. You were treated with IV fluids and
pain and nausea medications. An ultrasound of your abdomen
showed no new abnormalities. You did not experience any bleeding
in the hospital and laboratory values were checked to ensure you
were not actively bleeding.
You are discharged in stable condition to follow up with the
appointments listed below.
Thank you,
___, MD
___
Followup Instructions:
___
|
10494497-DS-15 | 10,494,497 | 29,653,551 | DS | 15 | 2164-03-31 00:00:00 | 2164-03-31 17:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flexeril
Attending: ___.
Chief Complaint:
intractable nausea/vomiting/diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with h/o Lynch syndrome, recurrent colon cancer
currently being treated with cetuximab/irinotecan who presents
with intractable n/v/d. He was last treated with
cetuximab/irinotecan on ___. About 2 days later he started
developing symptoms. He usually feels unwell around this time
but then improves over the next few days. This time he continued
to have n/v/d 5 days post chemo. He was unable to keep down much
food or drink. He was having diarrhea several times per day, now
about ___ times per day. His mom called the on call oncology
fellow ___ and initially plan was to try to manage at home,
since ___ gets IV hydration at home on ___. However,
later ___ felt he needed to come in and presented to ___
ED.
In the ED he received 5L of IVF, dilaudid for abd pain,
reglan/zofran for n/v. A preliminary read of a CXR suggested RLL
pneumonia and he was given IV levaquin 500mg. He is admitted for
IV hydration and symptom management.
On arrival to the floor, he feels slightly better, but still
unwell. Has not vomited since coming to ED but still nauseous.
Abd pain is ___, about the same as usual. He has been taking
oxycontin and oxycodone at home. had diarrhea once this morning.
no fevers or chills. no cough or SOB. He is slow to answer
questions and does acknowledge feeling foggy.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, or weakness. Denies
dysuria, arthralgias or myalgias. Denies rashes or skin changes.
All other ROS negative
Past Medical History:
ONCOLOGIC HISTORY:
___: presented with fatigue and dark-colored stools which
prompted evaluation by his primary care physician. He was found
to be anemic with a hemoglobin of 5.4 g/dL, and colonoscopy
identified a circumferential mass in the ascending colon.
___: right laparoscopic colectomy. Pathology showed
pT3N1bMx adenocarcinoma invading the muscularis propria with 3
of
14 lymph nodes involved. Tumor was KRAS wild type. An MSH6
mutation was identified consistent with Lynch syndrome. No
lymphovascular invasion was seen. Perineural invasion was
present. He received 11 of 12 planned infusions of adjuvant
FOLFOX chemotherapy under the care of Dr. ___ at
___.
___: increase in liver function studies, right upper
quadrant discomfort and a ___ pound weight gain associated
with
recurrent fevers. CT ___ identified a 1.2 x 1.9 cm
hypodensity in the right liver as well as a 4.4 x 4.8 x 3.8 cm
mass at his surgical anastomosis.
___: Admitted for abdominal pain, diarrhea, and fevers.
He underwent duodenal stent placement and was started on
radiation and concurrent infusional fluorouracil that he
completed ___: hospitalization for dehydration
___: hospitalization for dehydration, pain control
___: Cetuximab/Irinotecan C1D1
___: Admitted for 1 night for vomiting, dark red blood
___: CT shows some decrease in tumor size
___: Cetuximab/Irinotecan C2D1
___: C2D8 cetuximab
PAST MEDICAL HISTORY:
1. History of attention deficit disorder.
2. Prehypertension.
3. GERD.
4. History of iron deficiency anemia.
5. Colon cancer as above.
Social History:
___
Family History:
Maternal aunt with breast cancer at age ___. His father's brother
had colon cancer in his ___ and survived. He has three maternal
great aunts with colon
cancer: one diagnosed in her ___, one in her ___, and one in her
___.
Physical Exam:
Admission Physical Examination:
GEN: Alert, oriented to name, place and situation. pale and
chronically ill
appearing, resting in bed
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
CV: RRR no m/r/g
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, tender RLQ > LLQ at site of palpable mass without
guarding or rebound,
non-distended
EXTR: No lower leg edema, muscle wasting. L sided portacath
without erythema
Neuro: muscle strength grossly full and symmetric in all major
muscle groups ___ strength in upper and lower extremities, no
asterixis, oriented x3
PSYCH: Appropriate and calm.
Discharge Physical Exam;
VS: T 98.1 BP 118-126/58 HR 100 RR 16 97%RA
GEN: sitting in bed working on computer. pale and weak
appearing
but with more energy than prior and engaged in activity
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: RRR no m/r/g
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, mild-mod tender in all quadrants though improved from
prior, without guarding or
rebound, non-distended
EXTR: No lower leg edema. L sided portacath without erythema
Neuro: muscle strength grossly full and symmetric in all major
muscle groups ___ strength in upper and lower extremities, no
asterixis, oriented x3. Pt seen ambulating with normal gait
(later this morning)
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
Admission labs:
___ 12:20AM BLOOD WBC-1.8*# RBC-3.29* Hgb-9.6* Hct-29.6*
MCV-90 MCH-29.2 MCHC-32.5 RDW-17.6* Plt ___
___ 12:20AM BLOOD Neuts-75* Bands-0 ___ Monos-6 Eos-0
Baso-0 ___ Myelos-0
___ 12:20AM BLOOD Glucose-141* UreaN-9 Creat-0.5 Na-135
K-3.0* Cl-99 HCO3-21* AnGap-18
___ 12:20AM BLOOD ALT-23 AST-20 AlkPhos-127 TotBili-0.8
___ 12:20AM BLOOD Lipase-16
___ 12:20AM BLOOD Albumin-3.5
___ 03:08AM BLOOD Lactate-1.3
Discharge Labs:
___ 06:53AM BLOOD WBC-3.4* RBC-2.99* Hgb-8.5* Hct-26.6*
MCV-89 MCH-28.5 MCHC-32.2 RDW-19.4* Plt ___
___ 06:53AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-137 K-3.4
Cl-102 HCO3-28 AnGap-10
___ 06:30AM BLOOD ALT-76* AST-75* AlkPhos-189* TotBili-0.4
___ 06:53AM BLOOD ALT-43* AST-30 AlkPhos-152* TotBili-0.3
==================================
Radiology
==================================
CHEST (PA & LAT)Study Date of ___ 2:42 AM
preliminary report
FINDINGS:
AP upright and lateral chest radiographs were obtained.
Comparison is made to prior study dated ___. Lungs
appear symmetrically inflated.
Cardiomediastinal and hilar contours are stable in appearance.
Increased
periobronchial right lower lung zone density may reflect early
pneumonia or
alternatively aspiration. Again identified is a left
Port-A-Cath, its tip
within the mid superior vena cava in unchanged position.
CXR ___ - Compared to ___ chest radiograph, right
lower lobe opacities have resolved. There are no new areas of
consolidation to suggest the presence of pneumonia
CXR ___ - FINDINGS:
A nonobstructive bowel gas pattern is visualized with scattered
air-fluid
levels within nondistended loops of bowel. Gas is seen distally
within the
rectosigmoid region. There is no free intraperitoneal air.
Surgical clips are present in the right upper quadrant of the
abdomen, and note is made of a duodenal stent in the mid
abdomen.
Brief Hospital Course:
Assessment and Plan: ___ yo with recurrent colon cancer being
treated with cetuximab/irinotecan presents with n/v/d, inability
to tolerate PO and maintain hydration.
# Refractory N/V/D with dehydration: Pt with failure to thrive,
recurrent admissions for nausea/vomiting decreased PO intake in
setting of chemotherapy and given symptoms persisted longer than
C1D36 (he was admitted for symptom management but was still here
when chemo was due) his next chemo was given while he was in the
hospital - he received irinotecan/cetuximab on ___. He had a
protracted course of nausea/vomiting afterwards and struggle
with pain control, see below. Supportive measures were
undertaken with standing anti-emetics and IVF. By ___ he was
starting to take some PO but extremely minimal due to very
reduced appetite, and was finally eating a bit more by the time
of discharge. On the day of discharge (___) he received
cetuximab and he will get the last dose of cetuximab for the
cycle on ___ at ___. This had been pre-arranged as ___
is much closer to his home and his mother confirmed this was in
place.
# Malnutrition - major issue at this point is his ongoing weight
loss with difficult PO in between cycles. He also has very poor
appetite at baseline. Continued ensure TID per nutrition recs.
Started dex 2mg daily in order to stimulate appetite which did
have some effect but this was discontinued prior to discharge in
order to avoid the adverse effects of long term steroids. Also
started mirtazapine 7.5mg qhs for appetite stimulation, along
with ritalin 5mg BID.
# Flat affect - this is his more recent baseline (since cancer
diagnosis) per family and other medical providers, however may
be contributing to his lack of desire to motivate himself to try
to eat which is contributing to weight loss. Would suggest
psychiatry consultation in the future as outpatient.
Alternatively could consider an antidepressant with some
activating tendencies such as cymbalta or effexor. However
during this hospitalization he was started on mirtazapine for
its antidepressant and also appetite stimulating properties.
# Diarrhea: cdiff negative, likely ___ chemo (irinotecan),
resolved at the time of discharge.
# Abd pain: chronic RLQ, ___ to tumor burden. Pain was poorly
controlled with home regimen 40mg oxycontin BID so this was
increased to 60mg BID with good effect. He continues using
___ oxycodone q4prn for breakthrough. Also, his neurontin
was increased from 100 TID to ___ BID with the third dose
increased to 300mg qhs.
# Colon cancer: on cetuximab/irinotecan. due for C3D1 on ___
but held given ongoing symptoms as above, subsequently when
symptoms resolved a bit he was given 250 irinotecan, 500mg
cetuximab on ___ inpatient and premed with IV zofran, dex ___,
benadryl. Received cetuximab again ___. Side effects of
nausea/dehydration as noted above. Plans to follow at ___ to
get cetuximab on ___. Has plan for repeat staging scan ___
and f/u with oncology ___.
# Elevated LFTs - very mild, and coincided with improvement in
abdominal pain so less likely represented a concerning process.
None of his meds seemed likely to be responsible. AST/ALT <100
and Tbili remained normal, he will have this followed as an
outpatient. No known disease in the liver on ___ scans, so
that will be re-evaluated on upcoming CT scan with medical
oncology. Hepatits serologies were sent however very low
suspicion for such but these should be followed as outpatient.
#Iron deficiency/Chemo-associated anemia - likely ___
microscopic GI bleed from tumor and marrow suppression from
chemo, also has intermittent hemorrhoids but no frank
hematochezia, retics low, iron low but improved w/ ferrous
sulfate, transfused 2U PRBCs ___ as Hgb steadily below 8 and
anticipate worsening after last
chemo, Hct did not quite bump fully but has remained stable.
#Ext hemorrhoids - stable and very minimal bleeding, used
hydrocort cream prn and discharged pt with this.
TRANSITIONAL ISSUES:
Please follow up hepatitis serologies pending at the time of
discharge
Pt should see psychiatry as outpatient evaluation
Consider uptitration of ritalin for appetite stimulation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clindamycin 1 Appl TP BID
2. Dronabinol 5 mg PO BID
3. Gabapentin 100 mg PO Q8H
4. LOPERamide 4 mg PO QID:PRN diarrhea
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
7. Senna 8.6 mg PO BID:PRN constipation
8. Acetaminophen 1000 mg PO BID:PRN pain
9. Ferrous Sulfate 325 mg PO DAILY
10. Lorazepam 1 mg PO Q4H:PRN nausea, vomiting
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Colon cancer
Dehydration
Severe nausea, vomiting and diarrhea
Abdominal pain
Discharge Condition:
Condition - stable
Mental status - alert, coherent
Ambulatory status - independent
Discharge Instructions:
Mr ___ it was a pleasure caring for you during your stay at
___. You developed severe nausea, vomiting, abdominal pain
and dehydration following chemotherapy on ___ and the next
week's cycle had to be delayed due to these side effects. No
infection, bowel obstruction or other cause was found. You were
able to receive the next cycle of irinotecan and cetuximab on
___ and your side effects were less as we continued IVF,
anti-nausea medications and steroids afterwards here in the
hospital.
Followup Instructions:
___
|
10494894-DS-23 | 10,494,894 | 22,103,276 | DS | 23 | 2194-09-21 00:00:00 | 2194-09-22 21:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegretol / Tegretol XR / Almond Sweet Oil / Chantix Starting
Month Pak / Diltiazem / Amlodipine / Bisoprolol / Diovan /
Lisinopril / Hytrin / Provigil / Compazine
Attending: ___.
Chief Complaint:
Brain masses w/ edema, most ___
Major Surgical or Invasive Procedure:
Bronchoscopy.
History of Present Illness:
___ with a PMH significant for bladder cancer in remission since
___, 50 pack year smoking history, and Crohn's disease who p/w
a ___ week history of new expressive aphasia, ataxia, and
shortness of breath. Symptoms started with word finding
difficulty 5 weeks ago. This was shortly followed by difficulty
with gait. Pt motions that he was walking in a "zigzag" fashion,
and had difficulty assessing locations and distances. Has had at
least 3 falls during this time period that did not result in any
bodily injury. Was seen by PCP ___ ___ with recommendation
for MRI w/contrast. FOund to have multiple ring enhancing
lesions throughout cortex and cerebellum. Instructed by PCP to
come to BID for prompt management and treatment.
In the ED was given 10mg IV dexamethasone and dilaudid for pain.
Cr slightly elevated at 1.3 which returned to baseline with 1L
NS bolus. Initial Na 130 which returned to ___ IVF.
This AM pt is very anxious and emotionally labile. He became
quite tearful at various times during the interview. Is aware of
the likely diagnosis of metastatic brain tumor, and had many
questions regarding prognosis, treatment, etc.
Past Medical History:
Bladder cancer
- Papillary urothelial cell carcinoma, high grade
- Resection via transurethral approach ___
- Treated with BCG finished ___.
BPH
-Treated with Avodart.
Congenital right eye blindness and strabismus.
Trigeminal neuralgia
Crohn's disease
SBO/pSBO
Social History:
___
Family History:
Autoimmune thyroiditis. His mother survives, and father
deceased
Physical ___:
Admission Exam:
VITAL SIGNS: temp 98.3, ___ 96% RA
HEENT: He has got an old right extropia with slight ptosis and
slight right facial droop (reportedly chronic). external ocular
muscles intact, PERRLA. CN testing normal with exception of
chronic findings
LUNGS: decreased breath sounds in R mid and lower lung fields.
CARDIOVASCULAR: RRR no mrg
ABDOMEN: NTND, no organomegaly
LYMPH: no cervical, supraclavicular, axillary or inguinal
adenopathy
NEUROLOGIC: AOx3. Speech fluent, has some word finding
difficulties. 2+ dtrs in ___ and ___ b/l. toes down going.
Finger-to-nose has got some endpoint dysmetria in the upper
extremities. gait not assessed. L pronator drift. Normal
sensation in ___ and ___ b/l. Normal strength in ___ extremities
.
Discharge Exam:
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear. Mild tongue
deviation to R
NECK supple, no JVD, no LAD. Facial and neck erythema compared
to BLE
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact but mild R facial droop and R eye down and
out (chronic issue per pt), motor function and sensation grossly
normal, strength ___ in all muscle groups, significant ataxia on
finger-nose test and unsteady gait, unable to perform heel to
toe walking, positive Romberg
Pertinent Results:
Admission Labs:
___ 04:40PM BLOOD WBC-9.9 RBC-6.38*# Hgb-17.3 Hct-53.4*
MCV-84# MCH-27.2# MCHC-32.5 RDW-16.7* Plt ___
___ 07:10AM BLOOD ___ PTT-38.5* ___
___ 04:40PM BLOOD Glucose-92 UreaN-17 Creat-1.3* Na-130*
K->10 Cl-99 HCO3-23
___ 07:10AM BLOOD Calcium-9.3 Phos-2.2* Mg-1.8
.
Discharge Labs:
___ 11:00AM BLOOD WBC-12.8* RBC-6.35* Hgb-17.1 Hct-53.3*
MCV-84 MCH-26.9* MCHC-32.1 RDW-16.6* Plt ___
___ 11:00AM BLOOD ___ PTT-30.8 ___
___ 11:00AM BLOOD Glucose-107* UreaN-23* Creat-1.4* Na-137
K-4.6 Cl-101 HCO3-27 AnGap-14
___ 11:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8
.
Micro:
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
.
Studies:
___ MRI at OSH: There are innumerable contrast-enhancing
masses of varying sizes, seen more abundantly within the
posterior aspects of the cerebral hemispheres. Some of the
lesions are extra-axial in location. The largest lesion, ovoid
in shape, measuring up to 22 mm in diameter is seen indenting
the right side of the splenium, in a parafalcine location.
There is an extensive amount of edema within the right
parietal/occipital lobe white matter, and to a lesser extent in
a similar location on the left side. There is also a small
amount of right posterior temporal lobe edema. One of the
lesions, within the right frontal lobe also has small amount of
associated edema. Finally, a tiny left frontal vertex lesion
also has edema surrounding it. Despite the multiplicity of
these lesions, there is no hydrocephalus or shift of normally
midline structures.
Within the posterior fossa, there is an irregular,
ring-enhancing mass
within the pons, measuring up to 10 mm in diameter. There
also
appears to be an irregularly rim-enhancing mass, measuring
up to 9 mm
in diameter within the superior aspect of the right
cerebellopontine
angle cistern. It would be of interest to known whether
this was the
side of the previously diagnosed trigeminal neuralgia.
There is
marked pontine edema, extending into the middle cerebellar
peduncles.
The principal vascular flow patterns are identified.
There is no overt extracranial abnormality.
.
___ CXR: Consolidative opacity within the right upper lobe.
Given the history of brain metastases, findings are concerning
for a neoplastic process with postobstructive pneumonia or
adjacent atelectasis. Further evaluation with CT is
recommended.
.
___ CT Torso: Large right upper lobe mass with necrotic
center, with invasion into the mediastinum and adjacent necrotic
mediastinal lymph node. There is partial compression of the SVC.
Pulmonary satellite metastases in the right lung. No other
distant metastases identified.
.
___ CT Neck: No significant lymphadenopathy or masses. Small
hypodensity in the midline posterior to the hyoid bone; may
secondary to an incidental thyroglossal duct cyst. There is a
mass in the visualized portion of the right upper lung. Please
refer to dedicated chest CT for further evaluation. Partially
visualized portion of the brain demonstrates metastatic lesions
to the right occipital lobe and right splenium; however, please
refer to dedicated brain MRI for further evaluation and
characterization.
.
Pathology:
___ EBUS-TBNA for 4R, 11R and supraglotic lesion are all
positive for non small cell carcinoma
Brief Hospital Course:
___ with h/o bladder ca, long smoking history, presented to PCP
with subacute (5 week hx) of multiple neurological deficits.
Outpt MRI concerning for widely disseminated metastatic disease.
Subsequently found to have large mass in RUL positive for NSCLC
via IP biopsy. Seen by neuro-onc, rad-onc, heme-onc, and IP.
Will need whole brain irradiation and chest radiation, in
addition to chemo. Close follow-up with IP,heme/onc, and rad/onc
is necessary. Pt discharged from hospital to have further
work-up and treatment done as outpt.
.
Active Issues:
# Ring enhancing brain lesions - As per radiology report,
multiple masses most concerning for metastatic disease. CT scan
in-house demonstrated large obstructing lesion in RUL. IP
biopsied on day of discharge and positive for NSCLC. Based on
the subacute nature of neurological deficits, and lack of
hydrocephalus or mass effect on MRI and CT, pt did not need
emergent neurosurgical intervention. Given presence of edema,
did treat with IV dexamethasone. Converted to PO 6mg BID per rad
onc prior to discharge. Will need whole brain radiation per recs
from neuro-onc, heme onc, IP, and rad onc. Wished to have this
performed at ___, while maintaining access to all of
his physicians at ___. Will need to see rad/onc and heme/onc
as soon as possible for radiation mapping, and to establish
sessions at ___. Spoke with radiation-oncology prior to
discharge, and was reassured that everything could be set up as
outpatient, and no need to maintain as inpatient.
.
# R lobar consolidation - Pt denies having any recent cough,
nightsweats or fever, but does endorse some SOB. CT scan
positive for RUL mass w/necrotic center. S/p lung biopsy via IP
w/recommendation to treat for 7 days with augmentin for post
obstructive pneumonia. Biopsy of supraglottic lesion and lung
tissue positive for NSCLC. See above
.
#Secondary polycythemia: Hct of 53.1 on day of discharge and ___
yesterday. Thought to be secondary polycythemia by heme/onc.
Patient was asymptomatic. No intervention necessary per
heme/onc.
.
Chronic Issues:
# Crohn's - stable
.
# h/o bladder ca - reportedly treated and in remission since
___. o evidence of recurrence via CT
.
# HTN - continued atenolol in-house
.
# Anxiety - continued home diazepam dose.
.
#Trigeminal Neuralgia: On fentanyl patch 400mcg q72h for pain.
Continued in-house.
.
Trasitional Issues:
#Pt believes he may have metastatic lung cancer, however not
made aware of tissue diagnosis at the time of this DC summary.
Will need to be made aware.
#Will need very close rad/onc and heme/onc follow-up.
Unfortunately not able to schedule appts prior to discharge.
#Will need close social work involvement as this is a new
diagnosis of metastatic disease
#Follow-up blood cultures
Medications on Admission:
ATENOLOL - atenolol 100 mg tablet
1 Tablet(s) by mouth daily
CIPROFLOXACIN [CIPRO] - Cipro 500 mg tablet
1 (One) Tablet(s) by mouth twice a day as needed for as needed
for nausea and abdominal pain episodes
CLONAZEPAM - clonazepam 1 mg tablet
1 tablet(s) by mouth at bedtime as needed for insomnia
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vitamin B-12)
1,000 mcg/mL Injection
1 cc Im every 6 days
DIAZEPAM [VALIUM] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - Valium 5 mg tablet
1 (One) Tablet(s) by mouth four times a day as needed
FENTANYL [DURAGESIC] - (Prescribed by Other Provider) -
Duragesic 100 mcg/hr Transderm Patch
300mcg patches changed every 60 hours
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp
1 spray per nostril daily
FLUTICASONE [FLOVENT HFA] - Flovent HFA 220 mcg/actuation
Aerosol
Inhaler
1 inhalation(s) by mouth twice a day Rinse mouth after use
HYCODAN -
HYDROCODONE-HOMATROPINE -
Entered by MA/Other Staff - hydrocodone-homatropine 5 mg-1.5
mg/5
mL Syrup
1 tsp(s) by mouth every 6 hours as needed for for cough
LEFT FOOT ORTHOTIC -
METOCLOPRAMIDE HCL - metoclopramide 10 mg tablet
1 Tablet(s) by mouth every 6 hours as needed for nausea
OXYCODONE-ASPIRIN [PERCODAN] - (Prescribed by Other Provider)
(Not Taking as Prescribed: primary pain medication) - Percodan
4.8355 mg-325 mg tablet
1 (One) Tablet(s) by mouth every four (4) hours as needed
ZOSTER VACCINE LIVE (PF) [ZOSTAVAX (PF)] - ZOSTAVAX (PF) 19,400
unit Sub-Q Soln
1 dose sc once
Medications - OTC
ALOE ___ - (OTC) - aloe ___ 5,000 mg capsule
3 Capsule(s) by mouth twice a day
CALCIUM-MAGNESIUM - (Prescribed by Other Provider) - Dosage
uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other
Provider; OTC) - Vitamin D3 1,000 unit tablet
5 Tablet(s) by mouth once a day Taking as a 5000unit tablet
IBS ADVANTAGE - (OTC) -
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Centrum
Silver tablet
1 Tablet(s) by mouth once a day
OMEPRAZOLE - omeprazole 20 mg tablet,delayed release
1 Tablet(s) by mouth daily as needed for heartburn as needed
with
the nausea episodes
POLYETHYLENE GLYCOL 3350 [GLYCOLAX] - (OTC; Dose adjustment - no
new Rx) - GlycoLax 17 gram/dose Oral Powder
___ capful(s) by mouth once a day Use as needed and hold with
the diarrhea
SYRINGE WITH NEEDLE (DISP) [SYRINGE 3CC/25GX1"] - Syringe
3cc/25Gx1" 3 mL 25 x 1"
use for B12 IM every 2 weeks
Discharge Medications:
1. Atenolol 100 mg PO DAILY
hold for HR<60 and sbp<100
2. Dexamethasone 6 mg PO BID
Give at 8am and 4pm
RX *dexamethasone 6 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Diazepam 5 mg PO Q6H:PRN anxiety or insomnia
hold for sedation
4. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Tizanidine 4 mg PO BID:PRN neck pain
8. Fentanyl Patch 300 mcg/h TP Q72H
patches due to be changed ___ AM
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
hold for rr<12 and sedation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Metoclopramide 10 mg PO Q6HR:PRN nausea
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: numerous brain lesions (likely metastases),
right upper lobe lung mass
Secondary Diagnoses: Crohn's disease, hypertension, trigeminal
neuralgia, hypogonadism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You came to us at the request
of your Primary Care Physician, who wanted you to get an
expedited workup after you had brain imaging at another ___
that showed masses concerning for metastatic disease. You came
to our Emergency Department, where you were started on steroids
to control the brain swelling seen on the imaging from the other
hospital, and you had a chest x-ray that showed a concerning
finding in your right lung. You were then admitted to our
inpatient medicine unit for further workup. The next day, you
received a CT-scan of your neck, chest, abdomen, and pelvis to
look at the right lung in more detail, as well as to look for
any other masses that might be concerning for a primary cancer.
The CT scan showed a right lung mass and no other significant
findings, so you then underwent a bronchoscopy to obtain a
biopsy of the mass. At the time of your discharge, no other
masses were seen on the CT, and the pathology report on the
biopsy sample from the lung mass was still pending.
We found that your red blood cell count is elevated. Your
hematocrit was 53.3, which is slightly higher than the normal
range for men. The hematologists think that this may be due to
the testerone you are taking and recommend stopping testerone,
but you should discuss your concerns about this with your
Primary Care Physician and your ___ before stopping it.
Please make the following changes to your medications:
1. START Augmentin 875 mg every twice a day for one week.
2. START Dexamethasone 6 mg twice a day until you start whole
brain radiation.
3. START famotidine 20 mg twice a day. This medication is to
prevent ulcers in your stomach while you are taking steroids
4. Consider stopping testerone - Discuss this with your
oncologist and your PCP.
The Radiation Oncology office and the Hematology Oncology office
will call you with follow-up appointments. If you do not hear
from the office by ___, you should call the numbers we have
provided below.
Followup Instructions:
___
|
10495076-DS-9 | 10,495,076 | 27,232,413 | DS | 9 | 2170-12-29 00:00:00 | 2170-12-29 21:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
___ year old man with history of cholangiocarcinoma (dx ___ s/p
right trisegmentectomy (___), incidentally diagnosed PE ___
on lovenox, choledocholithiasis s/p
sphincterotomy/sphincteroplasty/stone extraction (___), HCV
in SVR, history of PUD, who presents with 2 days of dark tarry
stools.
Pt was initially diagnosed in ___ after initially presenting
with abdominal pain, and CT revealed RUQ mass that on biopsy was
adenocarcinoma consistent with cholangiocarcinoma-type
pathology. He underwent radiation therapy with Y90. In ___ he
was incidentally diagnosed with PE on an OSH CT, which he
reports was "very small", and was asymptomatic at that time. He
was placed on lovenox. He then underwent surgery in ___. On
a surveillance MRI in ___, he was noted to have
choledocholithiasis, with a stone within the distal CBD, which
is mildly dilated measuring up to 1.0 cm.
On ___, he underwent ERCP with
sphincterotomy/sphincteroplasty/stone extraction. He reports he
had been doing well since discharge but since ___, has
noticed several episodes of dark stools with no hematochezia
daily. He called Dr ___ today who directed him to
nearest ED. Otherwise, he reports he has been asymptomatic, with
no abdominal pain, nausea, vomiting, lightheadedness,
hematemesis, chest pain, shortness of breath. He did take his
lovenox on ___ AM. He does not take NSAIDs, or iron pills. He
initially presented to ___ and was found to have
Hct 28.9, PTT 28. He was given 1U FFP, 40mg IV protonix and
transferred here. He has had no further BMs or bleeding today.
Of note, he has undergone colonoscopy in ___ and ___, with
removal of aadenomatous polyp in ___. He also underwent an EGD
in ___ for follow up of previous ulcer disease and gastritis
(diagnosed ___. No pathology seen in stomach and esophagus on
limited views during recent ERCP.
In the ED, initial VS were: 98.3 70 168/79 16 99% RA
ED physical exam was recorded as trace guiac+
ED labs were notable for H/H 8.7/27.1
EKG showed sinus arrhythmia
Patient was given NS
Transfer VS were 98.1 75 159/83 11 99% RA
When seen on the floor, he denies any sxs or any further BMs
today.
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
1. Cholangiocarcinoma of the posterior segment of the right
lobe
of the liver, status post Y90 therapy on ___.
2. Post-Y90 therapy pulmonary embolus documented at an outside
facility with CT and treatment for one month with Lovenox.
3. History of recent prostate biopsy at ___, with
indeterminate result.
4. Choledocholithiasis and portacaval lymphadenopathy.
5. Past history of hepatitis C, now in sustained viral response
with negative viral load and no evidence of cirrhosis.
6. Degenerative disk disease of back and neck.
7. History of gastric ulcers.
8. History of anxiety and depression.
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION EXAM
Gen: NAD, appears younger than stated age, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, well healed surgical scar with no drainage on midline
of abdomen, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: actinic keratosis lesions on upper chest, no visible
rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
DISCHARGE EXAM
AVSS
General: NAD, walking around room
Cardiovascular: regular rate
Resp: lungs clear
GI: abdomen soft
MSK: extremities warm
NEURO: A&Ox3, CN II-XII intact, ___ BUE/BLE, SILT BUE/BLE
GU: no foley
Psych: pleasant, NAD
SKIN: no rash, no jaundice
Pertinent Results:
___ 10:58PM URINE HOURS-RANDOM
___ 10:58PM URINE UHOLD-HOLD
___ 10:58PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:58PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:25PM LIPASE-28
___ 10:25PM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-2.8
MAGNESIUM-1.7
___ 10:25PM PLT COUNT-130*
=
=
=
=
=
=
=
================================================================
EGD REPORT ___:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. The patient was placed in the prone position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization was performed. The procedure was
not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Findings:
Esophagus: Limited exam of the esophagus was normal
Stomach: Bilious fluid was seen in the stomach.
Duodenum: Limited exam of the duodenum was normal: bilious
contents, no blood
Major Papilla: Evidence of a previous sphincterotomy was noted
in the major papilla. A single non-bleeding periampullary
diverticulum was found at the major papilla: there was bilious
output. No evidence of bleeding
Impression: Evidence of a previous sphincterotomy was noted in
the major papilla. A single non-bleeding periampullary
diverticulum was found at the major papilla: there was bilious
output.
No evidence of bleeding noted on this examination
Recommendations: Clear fluids when awake then advance diet as
tolerated.
No further endoscopic measures at this time
Follow-up with Dr. ___ as previously schedule
There was no evidence of GI bleeding on this examination
If any abdominal pain, fever, jaundice, gastrointestinal
bleeding please call ERCP fellow on call ___
Additional notes: The procedure was performed by Dr. ___
___ the GI fellow. The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss = zero. No specimens were taken for
pathology.
=
=
=
=
=
=
================================================================
PERTINENT INTERVAL AND DISCHARGE LABS:
___ 07:00AM BLOOD WBC-3.3* RBC-3.00* Hgb-8.2* Hct-25.3*
MCV-84 MCH-27.3 MCHC-32.4 RDW-18.0* RDWSD-54.7* Plt ___
___ 05:15AM BLOOD WBC-3.0* RBC-2.80* Hgb-7.8* Hct-24.1*
MCV-86 MCH-27.9 MCHC-32.4 RDW-18.1* RDWSD-56.9* Plt ___
___ 07:00AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-134
K-3.4 Cl-99 HCO3-25 AnGap-13
___ 05:15AM BLOOD ALT-18 AST-27 LD(LDH)-134 AlkPhos-202*
TotBili-0.3
___ 07:00AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of
cholangiocarcinoma s/p right trisegmentectomy (___), s/p
sphincterotomy/sphincteroplasty/stone extraction (___), PE
(diagnosed ___ on lovenox), who presents with 2 days of dark
tarry stools, likely consistent with upper GI bleed.
He underwent EGD/ERCP on ___ which showed no bleeding. His diet
was resumed. We restarted his therapeutic lovenox and he was
monitored overnight for bleeding.
Rest of hospital course/plan are outlined below by issue:
# Acute on chronic anemia
# Melena, likely from upper GI bleed:
presented with melenic stools and small drop in Hb from 10 to
8.7 over a week with no associated sxs of anemia. Of note, he
had undergone colonoscopy in ___ and ___, with removal of
aadenomatous polyp in ___. He also underwent an EGD in ___ for
follow up of previous ulcer disease and gastritis (diagnosed
___. No pathology seen in stomach and esophagus on limited
views during recent ERCP and no GI source identified on repeat
upper endoscopy ___. Was initially treated with IV PPI, but
resumed home PO PPI prior to discharge. Initially held home LMWH
but resumed day prior to discharge and patient tolerated well.
Though still some dark stools, these were guaiac negative. He
did not require any transfusions.
# Cholangiocarcinoma: s/p Y90 radiation therapy which reduced
the tumor enough by for resection with right trisegmentectomy
with clean margin. Complicated by incidentally found PE, now
being treated with lovenox. Since therapy completion, he has had
significant improvement in his nutritional goals and his
strength and conditioning. A follow up MRI in ___ showed no
concerning hepatic lesion and unchanged retroperitoneal
lymphadenopathy.
# PE: He was incidentally diagnosed with a PE in ___ on an
OSH abdominal CT. He denied any sxs of chest pain, dyspnea,
tachypnea at that time. Reportedly the PE was "very small".
Given active malignancy, he was started on lovenox and has
continued to be on it. As above, it was held briefly and then
resumed on day prior to discharge. ___ was done for risk
stratification and negative. Given his weight, his enoxaparin
was increased to 70mg sc BID from home 60mg BID.
# Anxiety/depression: continued home aripiprazole, buproprion,
citalopram, propranolol.
# BPH: continued home tamsulosin 0.4 mg PO QHS.
# Hx of pedal edema: None seen on exam. He initially had his
home furosemide held, but was resumed on discharge.
# Transitional Issues:
-Follow up scheduled with Dr ___ on ___ and Dr ___ on
___
-please continue to monitor CBC and assess for signs of
bleeding. If persistent, can consider colonoscopy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 5 mg PO DAILY
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. Citalopram 30 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Propranolol 40 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Thiamine 100 mg PO DAILY
8. TraZODone 100 mg PO QHS
9. Vitamin B Complex w/C 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Cyclobenzaprine 10 mg PO PRN MUSCLE SPASM muscle spasm
13. Furosemide 40 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. triamcinolone acetonide 0.5 % topical DAILY
16. Enoxaparin Sodium 60 mg SC Q12H
Discharge Medications:
1. Citalopram 30 mg PO DAILY
2. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: First Routine
Administration Time
The dose was increased to match your weight.
RX *enoxaparin 80 mg/0.8 mL 70 mg sc twice a day Disp #*60
Syringe Refills:*0
3. Propranolol 40 mg PO BID
4. ARIPiprazole 5 mg PO DAILY
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Cyclobenzaprine 10 mg PO PRN MUSCLE SPASM muscle spasm
7. Furosemide 40 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Thiamine 100 mg PO DAILY
12. TraZODone 100 mg PO QHS
13. triamcinolone acetonide 0.5 % topical DAILY
14. Vitamin B Complex w/C 1 TAB PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for blood in your stool in the form of dark
back sticky stool called melena. Due to your recent ERCP
procedure, the ERCP team was consulted and you underwent an
upper endoscopy to look for a source of bleeding, however none
was found. Your bleeding will likely be self limited and should
resolve on its own. We temporarily held your lovenox due to the
bleeding but then you were able to tolerate it again.
Be sure to follow up with your outpatient providers as below.
Followup Instructions:
___
|
10495588-DS-11 | 10,495,588 | 23,047,100 | DS | 11 | 2144-09-14 00:00:00 | 2144-09-16 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / morphine / Erythromycin Base /
aspirin / IV Dye, Iodine Containing Contrast Media / Reglan /
Amitriptyline / Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
Colonoscopy (___)
History of Present Illness:
___ with hx of DM1 on insulin since pancreatectomy in ___,
legal blindness, severe gastroparesis with chronic abdominal
pain, seizure disorder, undergoing evaluation for possible
pancreatic transplant presenting with hyperglycemia in setting
of colonoscopy prep. Pt reports that she was under the
impression that she should hold all of her insulin while NPO for
colonoscopy. She last administered lantus 10u on ___ am
(although ED notes say last dose was ___ pm, and none ___ am),
and none since that time. She presented for her colonoscopy and
was found to have FSBG >450, and was sent to ED for further
evaluation.
In the ED:
VS 98.7, 83, 98/64, 16, 97% RA
UA negative for infection, +ketones
Na 132, glucose 398 on panel, anion gap 11
WBC 7.0
She received 1L NS, insulin 11u, and was admitted for monitoring
of FBSG and continued colonoscopy prep
On arrival to the floor, pt endorses her chronic abdominal pain,
which is ___, at the site of "nerve endings fromwhere my
pancreas used to be," sharp, present most of the time at
baseline. She notes that she is able to administer the correct
amount of insulin at home by listening for clicks on dispenser.
She has no services at home at this time. She denies chest pain,
F/C, cough, shortness of breath, dysuria, URI symptoms, N/V. She
notes that, approx 2 weeks prior to presentation, she was
walking with her guide dog, and she instructed him to turn L,
but pt got confused and went R, and walked into a cement pillar.
She was caught by someone prior to falling. The day before
presentation she walked into her bathroom door, but did not
fall.
Past Medical History:
Per OMR, confirmed with pt:
___ Syndrome with associated blindness - rare
autosomal recessive disorder which causes oculocutaneous
albinism and bleeding ___ platelet defect - per pt, has
previously required dDAVP for postprocedure bleeding
IDDM uncontrolled s/p pancreatectomy
Asthma
Gastroparesis
Bezoars
Numerous abdominal surgeries
Depression
Anxiety
Seasonal allergies
Constipation
Eczema
Lactase insufficiency
Irritable bowel syndrome
PSH:
Appendectomy
Cholecystectomy
___ fundoplication
Islet cell transplant
Hernia repairs
Hysterectomy
Oopherectomy
Jaw surgery for DMJ
Splenectomy
Pancreatectomy (for pancreatic divisum)
Celiac plexus neurolysis
Social History:
___
Family History:
Sister with ___ syndrome. Multiple family members
with T2DM and thyroid disorders.
Physical Exam:
At admission:
VS 99.0, 81, 88/56->98/62, 18, 95% RA
Gen: Lying in bed, albinism, pleasant, NAD
HEENT: PERRL, pink pupils, clear oropharynx, no cervical or
supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: TTP at epigastrium and RUQ (per pt, at baseline), soft,
nondistended, +BS, no rebound or guarding
Ext: WWP, no clubbing, cyanosis or edema
Neuro: Legally blind, otherwise grossly intact
At discharge:
VS: 98.4 80-100s/40-60s 60-70s 18 98%RA
GENERAL: Alert, oriented, no acute distress, EEG leads on,
ocularcutaneous albinism
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, ND, tender to palpation in RUQ, 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, mild
rotational nystagmus (chronic), patellar reflexes 2+ bilaterally
SKIN: No excoriations or rash.
Pertinent Results:
Labs at admission:
___ 05:11PM URINE HOURS-RANDOM
___ 05:11PM URINE UHOLD-HOLD
___ 05:11PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:00PM GLUCOSE-398* UREA N-17 CREAT-0.8 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-27 ANION GAP-16
___ 04:00PM estGFR-Using this
___ 04:00PM WBC-7.0 RBC-4.06* HGB-11.5* HCT-33.9* MCV-83
MCH-28.2 MCHC-33.8 RDW-16.1*
___ 04:00PM NEUTS-36.3* LYMPHS-54.7* MONOS-6.4 EOS-1.6
BASOS-0.9
___ 04:00PM PLT COUNT-439
Labs at discharge:
___ 04:27AM BLOOD WBC-7.6 RBC-2.97* Hgb-8.2* Hct-26.2*
MCV-88 MCH-27.6 MCHC-31.3* RDW-18.1* RDWSD-58.1* Plt ___
___ 04:27AM BLOOD Glucose-160* UreaN-10 Creat-0.5 Na-135
K-4.1 Cl-104 HCO3-25 AnGap-10
___ 04:27AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.6
Microbiology:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Culture, Routine (Final ___: NO GROWTH.
MRSA SCREEN (Final ___: No MRSA isolated.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging:
___
CHEST (PORTABLE AP)
No relevant change as compared to the previous image. Normal
lung volumes normal size of the cardiac silhouette. Normal
hilar and mediastinal contours. No pleural effusions. No
pneumonia, no pulmonary edema.
CT HEAD W/O CONTRAST: No acute intracranial process.
___
LIVER OR GALLBLADDER US:
1. Coarsened hepatic parenchyma with no focal liver lesions.
2. No evidence of biliary obstruction.
___
Colonoscopy: Normal mucosa in the colon. Otherwise normal
colonoscopy to cecum
Neurophysiology:
___
EEG: No focal or epileptiform features were identified during
this recording period. The presence of beta frequency activity
likely represented the intercurrent use of benzodiazepines or
barbiturates. Interim findings were relayed to the treating team
intermittently during this recording period to assist in medical
decision making.
___
EEG: The single prolonged pushbutton activation had no
epileptiform activity seen in conjunction with side-to-side head
shaking that involved more of the body at times, suggesting that
this event was nonepileptic in nature. Separately, the automated
algorithms also failed to identify epileptiform changes. The
presence of beta frequency activity superimposed upon the alpha
frequency background may represent the intercurrent presence of
benzodiazepines and/or barbiturates, or may be a physiological
variant. Interim findings were conveyed to the treating team
intermittently during this recording period.
___
EEG: This is a normal continuous EEG recording with no focal or
epileptiform features seen. The presence of beta activity most
often is related to the intercurrent presence of benzodiazepines
or barbiturates, but may be a physiologic variant. Interim
findings were conveyed to the treating team intermittently
during this recording period to assist in medical
decision-making.
___:
This continuous recording captured an extended period of
behavioral disturbance visually characterized by side to side
head shaking evolving into left hemibody movements; this event
was not associated with epileptiform changes on EEG. The
automated detection algorithms did not identify any epileptiform
abnormalities. The presence of beta frequency
activity can be seen with the intercurrent use of
benzodiazepines or barbiturates, or may be a physiologic
variant. Interim findings were conveyed to the treating team
intermittently during this recording period to assist in real-
time medical decision-making.
___:
This continuous EEG recording did not capture any epileptiform
activity. The presence of beta frequency activity likely
represents intercurrent use of benzodiazepines or barbiturates,
or may be a physiologic variant.
Brief Hospital Course:
___ with hx of DM1 on insulin since pancreatectomy in ___,
legal blindness, severe gastroparesis with chronic abdominal
pain, seizure disorder, undergoing evaluation for possible
pancreatic transplant presenting with hyperglycemia in setting
of colonoscopy prep.
ACUTE ISSUES:
#Episode of Unresponsiveness: On ___, 2 days into admission for
colonoscopy prep, "code blue" called approx 6:15 ___ for reported
PEA arrest, unresponsive. Patient received 2 minutes of chest
compressions. No VT/Vfib. No epi given. A pulse was detected
after 2 minutes but patient remained unresponsive. Shortly
afterwards, code team arrived. BG 69. Started on D10 drip.
Patient briefly rigid on the right, then developed right chin
twitching followed by deviation of her head to the left,
followed by generalized shaking. Lasted 8 minutes. Given 4 mg
total ativan and then activity ceased and patient remained
unresponsive. On further review with people that had responded
to code it was unlikely that patient lost a pulse and this
episode was thought to be related to her seizure disorder.
On arrival to the FICU, patient was unresponsive. She was
started on keprra 2g IV x 1. Non con head CT was performed given
recent head strike and hx of plt dysfunction and was negative.
Infectious work up was also started. On review of medications it
appeared that the patient had been given lower doses of keppra
compared to her usually keppra home dose. Patient woke up and
was responsive with no futher seizure activity. EEG was deferred
per neuro recs as she had a known seizure disorder. Patient was
restarted on home dose of keppra 1500mg BID. Patient was
informed of this error. Risk management was called. While in the
ICU her lantus was decreased from 8 units to 4 units and later
stopped for her hypoglycemia. GI recommended colonscopy once
patient stabilized. Another seizure occurred ___ in the
afternoon prompting increase in keppra to ___ mg BID per
neurology and further continuous EEG monitoring. Patient was
stabilized and transferred to the medicine floor.
#Seizure-like episodes: On transfer back to medicine, patient
was alert and oriented with no confusion and reassuring neuro
examination. Overnight ___, patient had a 30 min episode
of status epilepticus, received 8mg IV ativan, and transferred
to MICU. In the MICU, she was loaded with fosphenytoin and
continued on phenytoin. Continuous EEG data demonstrated no
epileptic activty and this episode was thought to be a
non-epileptic seizure (pseudoseizure). Upon transfer back to
medicine, phenytoin was discontinued. She had another
seizure-like episode on ___ and continuous EEG monitoring again
demonstrated no epileptic activity. At this point it is unclear
whether she has true underlying organic seizure disorder with
subsequent development of non-epileptic seizures or whether all
her prior seizure episodes were non-epileptic in nature. It is
not uncommon for patients with organic seizures to later develop
non-epileptic seizures. We continued her home keppra and there
were no organic, epileptic seizure activity recorded during this
hospitalization.
# Brittle diabetes with episodes of hyperglycemia and
hypoglycemia: Patient is s/p pancreatectomy and failed islet
transplants resulting in brittle diabetes. She is currently in
house for colonoscopy as part of work up in order to be listed
for pancreas transplant. Per ___ diabetes consult, we
restarted lantus 4u BID along with a more gentle SS.
# Colonoscopy: After tolerating moviprep and golytely without
complications, patient was clear and colonoscopy was performed.
Findings from colonoscopy were normal.
CHRONIC ISSUES:
# Transaminitis: Liver studies notable for ALT 168 AST 229 AP
108 Tbili 0.2 Alb 2.9. She has had elevation of her LFTs in the
past. Per GI notes (most recent ___, most likely etiology
is fatty liver as patient also had elevated hemoglobin A1C.
Normal Tbili reassuring of no obstructive pathology. Given
negative anti-mitochondrial and anti-smooth muscle antibody with
___ of 1:40, unlikely to be autoimmune. Due to chronic nature
with no clinical suspicion of acute liver pathology, we did not
trend her LFTs.
# Chronic abdominal pain: Patient complained of intermittment
RUQ pain that migrates in a dermatomal distribution around her
right side and to her back. Patient reports this pain since her
pancreatectomy. RUQ U/S negative for biliary obstruction. She is
s/p cholecystectomy. Patient reports she takes oxycodone 30 mg
at home approx once daily for her chronic pain. Oxycodone did
not appear on outpatient medication list. Held narcotics in
house. Continued home gabapentin.
# Seizure disorder: management per above, discharged on original
home dose of keppra (1500 mg BID).
# Depression/anxiety: Continued home regimen of doxepin,
escitalopram, and lorazepam
#Chest Pain: Secondary to chest compressions. Was sent home with
short supply of oxycodone PRN.
TRANSITIONAL ISSUES:
====================
-Recommend outpatient neurology follow-up to determine if
patient truly has organic seizures and needs to remain on
Keppra. No epileptiform activty was observed during her
seizure-like episodes during this hospitalization.
-Given patient's brittle diabetes s/p pancreatectomy with
episodes of hyper and hypoglycemia, would recommend close
outpatient monitoring of blood sugars and optimization of
insulin regimen.
-Per transplant attending, patient will need to complete
extensive list of testing (mammogram, nuclear stress test,
echocardiogram, chest x-ray, colonoscopy, records from history
of breast cancer) as well as social work and nutrition
evaluation prior to qualifying for deceased donor pancreas
transplant list.
-Next colonscopy due in ___ years.
-Patient with persistent rib pain from chest compressions she
received. This should be monitored
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxepin HCl 100 mg PO HS
2. Escitalopram Oxalate 30 mg PO DAILY
3. Gabapentin 600 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. LeVETiracetam 500 mg PO BID
7. Glargine 10 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Doxepin HCl 100 mg PO HS
2. Escitalopram Oxalate 30 mg PO DAILY
3. Gabapentin 600 mg PO TID:PRN pain
4. Glargine 4 Units Breakfast
Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. LeVETiracetam 1500 mg PO BID
6. Lorazepam 0.5 mg PO BID:PRN anxiety
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
8. Acetaminophen 325 mg PO Q6H:PRN headache
9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Seizures
DM s/p pancreatectomy
Right upper quadrant pain
Transaminitis
SECONDARY DIAGNOSES:
Depression/Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for a colonoscopy prep and
procedure. However, your hospital course was complicated by
seizure activity and an episode of unresponsiveness and you
underwent chest compressions. You had two episodes of
seizure-like movements while on the monitor that looks at your
brain activity. During those episodes, there was no brain
activity concerning for seizures. We continued your home
anti-seizure medication (Keppra). After your seizure-like
episodes had resolved, we performed a colonscopy which was
completely normal. The diabetes specialists also saw you and
helped to manage your blood sugars. After your colonoscopy and
when you were feeling better, we discharged you home. It will be
important to see your primary care doctor after leaving the
hospital in order to properly manage your diabetes and to ensure
you have completed all the testing required to be qualified for
a pancreas transplant. We also recommend seeing your neurologist
to better characterize and treat your seizure-like activity.
Thank you for letting us take part in your care.
Followup Instructions:
___
|
10495588-DS-9 | 10,495,588 | 27,358,492 | DS | 9 | 2141-09-11 00:00:00 | 2141-09-12 15:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / morphine / Erythromycin Base /
aspirin / IV Dye, Iodine Containing Contrast Media / Reglan
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with h/o pancreatic divisum defect s/p
pancreatectomy and failed islet cell transplant in ___, and
severe gastroparesis for which she was admitted in ___ who
was sent here from ___ for hyperglycemia. She recently
transferred her diabetes care to ___ given uncontrolled BG in
the 300-500s for the past ___ yrs, which the patient has been
told is potentially due to an insulin antibody. She denies any
recent infectious symptoms and states that she has been taking
her insulin as prescribed but states that she fell asleep on
___ and slept through ___ and did not take her insulin
during this time. She presented to ___ on the day of
admission with BG of 471 so she was referred to ED for control
of hyperglycemia. She reports significant fatigue, polyuria,
dizziness, polydipsia and intermittent epigastric abdominal
pain. Of note, she has recently had a 60 lb weight loss over the
past ___ year. She denies any vomiting, F/C, dysuria or recent
illness. ROS otherwise unremarkable.
In the ED, initial vitals are as follows: T98.3 HR73 BP106/71
RR16 satting 100% on RA. Exam notable for + ___ non-pitting
edema, RLQ Mass w/ + BS (present for 5 mos), fruity odor on
breath. PE otherwise not significant. Labs notable for BG of 365
and an AG of 17, otherwise with normal electrolytes. WBC of 9.3
with 67% lymphocytes, UA with glucosuria and ketones as well as
pyruia. VBG showed pH of 7.36, with normal venous pCO2, pO2 of
33, and lactate of 0.8. HCO3 of 28. Pt provided with 400 mg of
IV ciprofloxacin as well as 6 ___ insulin and approximately
2 L of NS. Vitals prior to transfer were 98.0, 73, 97/64, 16,
99% RA.
Past Medical History:
PMH:
___ Syndrome
IDDM uncontrolled s/p pancreatectomy
Asthma
Gastroparesis
Bezoars
Numerous abdominal surgeries
Depression/Anxiety
Seasonal allergies
Constipation
Eczema
Lactase insufficiency
Irritable bowel syndrome
Legally blind (from ___ pudlak syndrome)
PSH:
appendectomy
cholecystectomy
esophagogastric fundoplasty (GERD)?
hernia repairs
hysterectomy/oopherectomy
jaw surgery for DMJ
splenectomy
pancreatectomy
Social History:
___
Family History:
Multiple family members with T2DM and thyroid disorders.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.6, 112/60, 80, 18, 95% RA, FSG 403
GENERAL: comfortable, NAD
HEENT: MMM, no JVD
CARDIAC: RRR, normal S1 and S2, no m/r/g
LUNG: unlabored, CTAB
ABDOMEN: BS+, S/NT/ND, no HSM, ? RLQ mass
EXT: bilateral ___ edema, WWP
NEURO: CN VII-XII intact, sensation intact to light touch
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
___ 08:05PM BLOOD WBC-9.3 RBC-3.65* Hgb-11.9* Hct-36.1
MCV-99* MCH-32.7* MCHC-33.0 RDW-16.5* Plt ___
___ 08:05PM BLOOD Neuts-30* Bands-0 Lymphs-67* Monos-2
Eos-1 Baso-0 ___ Myelos-0
___ 08:05PM BLOOD Glucose-365* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-92* HCO3-26 AnGap-21*
___ 08:05AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.5*
___ 06:45AM BLOOD TSH-2.9
___ 06:45AM BLOOD T3-68* Free T4-0.92*
COSYNTROPIN STIM TEST:
___ 09:20AM BLOOD Cortsol-15.0
___ 09:50AM BLOOD Cortsol-23.7*
___ 10:22AM BLOOD Cortsol-28.8*
FOLATE/B12:
___ 05:55AM BLOOD VitB12-843 Folate-11.6
MICROBIOLOGY:
BCx ___: negative
UCx ___: negative
BCx ___: negative
MRSA screen ___: negative
UCx ___: mixed flora
IMAGING:
KUB ___ 0100: FINDINGS: Two views of the abdomen are
provided. There is a distended colon with stool as well as what
may be possibly distended stomach with food particles concerning
for gastric outlet obstruction. There is no evidence of small
bowel obstruction or large amount of free air. There are
degenerative changes at the lower lumbar spine.
IMPRESSION: Distended and stool-filled colon with possible
gastric outlet obstruction.
KUB ___ 0900: Single supine portable abdominal radiograph
was provided. Since the prior study, there has been improved
appearance of distended stomach versus colon in the mid abdomen.
Dilated and air filled loops of mostly large bowel persist. The
osseous structures are grossly unremarkable.
IMPRESSION: Improved appearance since prior radiograph with
mostly distended loops of large bowel.
CT A/P with PO contrast ___:
1. Marked colonic fecal loading without evidence of the
obstruction.
2. 5-mm left lower lobe pulmonary nodule. If this patient is
concerned high risk for malignancy recommend followup CT chest
in ___ months followed by ___ months. If this patient is low
risk, followup can be obtained in 12 months from the day of the
study.
KUB ___: There has been interval worsening dilatation of
large bowel loop projecting in the right lower quadrant.
Increased fecal material throughout the colon is again noted.
There is no evidence of a large pneumoperitoneum. Dilated
stomach has minimally improved.
IMPRESSION: Increased dilatation of large bowel loop in the
right lower quadrant.
KUB ___:
FINDINGS: There is nonspecific bowel gas pattern with air
within the colon. Previously seen dilated colon has improved now
with one dilated loop in the mid pelvis section. There is no
evidence of obstruction or free air. There are clips seen in
the right upper quadrant and right lower quadrant. The bony
structures are intact.
Brief Hospital Course:
TRANSITIONAL ISSUES:
[ ] f/u CT chest in ___ for pulmonary nodule that was
incidentally found on her CT abd/pelvis
[ ] patient will need L breast lump work up, follow up appt with
___ made for the patient
[ ] consider referral to ___ for SmartPill study
================================================
Hospital Course:
Ms. ___ is a ___ with a h/o chronic pancreatitis s/p
pancreatectomy, failed islet cell transplant, DM1, severe
gastroporesis and chronic abdominal pain who presented for
hyperglycemia. Her hospital course was complicated by persistent
hypoglycemia and hypotension requiring a transfer to MICU. She
also had acute on chronic abdominal pain and found to have
severe fecal loading and her bowel regimen were uptitrated. Her
insulin regimen was decreased given episodes of hypoglycemia.
# Uncontrolled diabetes mellitus: She initially admitted with
hyperglycemia and started on her reported home insulin regimen
of Lantus 60u BID and Humalog 17u-21u with meals. However, as it
caused hypoglycemia, it was decreased to 45 units Lantus BID and
less Humalog. As patient was persistently hypoglycemic despite
D50 amps and D5 gtt, patient was transferred to MICU for
frequent fingersticks and also for D10 gtt. Ultimately, her
lantus was changed to 7 units qHS with smaller humalog sliding
scale. Patient's blood glucose was very difficult to control
during this hospitalization. Prior to discharge, her glucose
readings ranged in 100-200s, with one episode of hypoglycemia to
55 due to extra dose of humalog, and one episode of
hyperglycemia in 400s. Patient was instructed to follow up with
___ closely and also to contact ___ clinic on call
physician as needed if she experienced persistent hypo- or
hyper-glycemia at home. She will likely need further adjustment
of her insulin and nutritional counseling as outpatient.
# Hypotension: Patient developed hypotension to ___ while she
was hypoglycemic, not very responsive to fluids. UCx and BCx
were checked and were negative. No known pump/cardiac issues.
Given this hypotension, AM cortisol was checked and was 3.0,
raising concern for adrenal crisis. However, her cortisol
responded appropriately to cosyntropin stim test. Hypotension
was thought to be related to decreased PO intake in setting of
fecal load/ileus. Patient had significant urine output on the
floor even in the setting of poor PO intake requiring IVF to
keep net even balance, for unclear reason. Possibility of ATN
diuresis was raised, but her creatinine never really bumped,
even after the hypotensive episodes prior to MICU transfer, so
less likely. Hypotension resolved on its own as patient began
taking better PO intake.
# Severe gastroparesis and constipation: Patient complaining of
acute worsening of abdominal pain on night of ___, and KUB was
done which showed distended and stool-filled colon with possible
gastric outlet obstruction. Aggressive bowel regimen was
started, and her CT abdomen/pelvis showed severe fecal loading
without evidence of obstruction. GI was consulted and
recommended aggressive bowel regimen. With mineral oil enema and
dulcolax suppositories, patient began having more regular bowel
movement with improvement in symptoms. Her gabapentin was also
uptitrated to 200 mg TID. Given her allergies to Reglan and
Erythromycin, treatment of her gastroparesis has been very
difficult. GI recommended evaluation of whole gut motility with
SmartPill study at ___, as normal small and large bowel motility
would make J-tube placement more reasonable. However, results
from the study would be most useful if done after bowel prep,
which could be difficult on this patient. This information was
discussed with the patient and passed onto her outpatient GI
physician, ___. She will need further treatment and work
up for this chronic issue.
# Left breast lump: patient began complaining of left breast
lump which had been present for couple months. On exam, the
breast lump was very mobile and soft. As it was not an acute
process, follow up appointment at ___ was made
for the patient for work up of this issue. Patient was
instructed to go to the follow up appointment.
# Weight loss: Patient complaining of chronic weight loss, ~60
lbs in ___ year. Thought to be due to gastroparesis. Pt reports
nausea when eating and poor appetite for ___ year.
# Pulmonary nodule: incidentally seen on CT of abd/pelvis during
this hospitalization. As patient is at low risk for malignancy
as a never smoker, follow up with chest CT in 12 months is
recommended. Patient was instructed to follow up with her PCP
for ___ repeat chest CT in 12 months.
CHRONIC ISSUES
# Pancreatic Divisum s/p Pancreatectomy: She was continued on
creon with meals.
# Asthma: She was continued on home advair/albuterol
# Depression/Anxiety: She was continued on escitalopram, ativan
prn and doxepin
# HLD: continued on Fish Oil
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient provided document.
1. Lantus *NF* (insulin glargine) 60 units SC BID
2. NovoLOG *NF* (insulin aspart) ASDIR Subcutaneous TID with
Meals
17 units SQ QBreakfast, 21 units SC QLunch, 17 units SC QDinner
3. Creon 12 3 CAP PO TID W/MEALS
4. Omeprazole 20 mg PO DAILY
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Lorazepam 0.5 mg PO QAM
Hold for RR < 10 or sedation
7. Lorazepam 1.5 mg PO HS
Hold for RR < 10 or oversedation
8. Escitalopram Oxalate 30 mg PO DAILY
9. Doxepin HCl 100 mg PO HS
10. Vitamin D 400 UNIT PO BID
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
13. Fish Oil *NF* (docosahexanoic acid-epa;<br>omega
3-dha-epa-fish oil;<br>omega-3 fatty acids;<br>omega-3 fatty
acids-fish oil;<br>omega-3 fatty acids-vitamin E;<br>salmon
oil-omega-3 fatty acids) 720 mg-2400 mg Oral BID
14. Gabapentin 100 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheezing
2. Creon 12 3 CAP PO TID W/MEALS
3. Doxepin HCl 100 mg PO HS
4. Escitalopram Oxalate 30 mg PO DAILY
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Gabapentin 200 mg PO TID
8. Lorazepam 0.5 mg PO QAM
Hold for RR < 10 or sedation
9. Lorazepam 1.5 mg PO HS
Hold for RR < 10 or oversedation
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 400 UNIT PO BID
12. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
13. Fish Oil *NF* (docosahexanoic acid-epa;<br>omega
3-dha-epa-fish oil;<br>omega-3 fatty acids;<br>omega-3 fatty
acids-fish oil;<br>omega-3 fatty acids-vitamin E;<br>salmon
oil-omega-3 fatty acids) 720 mg-2400 mg Oral BID
14. Polyethylene Glycol 17 g PO BID
RX *Miralax 17 gram 1 packet by mouth twice a day Disp #*60
Packet Refills:*0
15. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 Suppository(s) rectally once a day Disp
#*30 Suppository Refills:*0
16. Mineral Oil *NF* 1 enema RECTAL BID Reason for Ordering:
recommended by GI
RX *Fleet Mineral Oil 1 enema rectally twice a day Disp #*60
Not Specified Refills:*0
17. BD Ultra-Fine Nano Pen Needles *NF* (insulin needles
(disposable)) 32 x ___ Miscellaneous as needed
RX *BD Ultra-Fine Nano Pen Needles 32 gauge X ___ use one
needle for injection as needed Disp #*2 Box Refills:*3
18. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: patient's outpatient list
RX *Humalog KwikPen 100 unit/mL Up to 8 Units per sliding scale
four times a day Disp #*3 Not Specified Refills:*3
19. Glucerna *NF*
(nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose
intolerance,soy) 1 can Oral BID
RX *nut.tx.glucose intolerance,soy 1 can by mouth twice a day
Disp #*60 Container Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Insulin dependent diabetes mellitus,
gastroparesis, severe constipation
Secondary Diagnosis: Hermansky-Pudlak syndrome, legal blindness,
left breast lump
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 take care of you at ___
___. You were initially admitted for high blood
sugars but you had persistently low blood sugars on home dose of
insulin. So your insulin dose was decreased.
You also had worsening of your chronic abdominal pain, and it
was thought to be due to your severe constipation. Your bowel
medications were increased and enemas were added at
recommendation of gastroentrologists. You had some success with
bowel movements on this regimen. Please continue this at home.
CAT scan was done due to your abdominal pain, and showed a
nodule in your lung. Please have Dr. ___ a repeat CAT
scan of your chest in ___ year (___) so this nodule can be
monitored.
It is very important that you eat small frequent meals given
your gastroparesis. Please follow up with ___ doctors and
their ___ for further management of your diabetes.
Followup Instructions:
___
|
10495817-DS-22 | 10,495,817 | 21,908,036 | DS | 22 | 2124-04-19 00:00:00 | 2124-04-19 21:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / pravastatin
Attending: ___.
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ man with history of atrial
fibrillation on Eliquis, SSS s/p dual chamber pacemaker who
presents after an unwitnessed fall at home.
Mr. ___ was brought in by his ___, hours
after a fall that occurred overnight/early morning ___. Mr.
___ lives alone but ___ lives across the street and helps
care for him daily. ___ stayed over ___ at Mr. ___
house because he had several falls over the previous few days,
as well as decreased appetite, decreased PO intake, and
subjective weakness. The falls were reportedly mechanical,
related to tripping, and not associated with dizziness or loss
of consciousness. ___ reports that Mr. ___ has been shuffling
lately when walking. Mr. ___ describes that he feels his legs
are not listening to what his brain is telling them to do. He
also notes that he often coughs when he eats. He denies fevers,
chills, productive cough,
dysuria, abdominal pain, nausea, diarrhea, dizziness, headache,
neck pain, shortness of breath.
Of note, the patient was visiting his brother in ___
for the last 2 weeks and he was able to walk around with the
assistance of his walker and his brother's support behind him.
However, he had multiple falls while getting in and out of bed
there. He has had several falls over the past year. He has had
home health aides and at home physical therapy.
___ says that the patient is normally oriented to person,
place, and time, and very sharp. Per chart review, memory issues
have been becoming a problem over the last year.
In the ED:
- Initial vital signs were notable for:
T 99.1 P 68 BP 117/50 RR 16 O2 94% RA
He had an episode of hypoxia to 91% that improved on 2 L of
oxygen. He was also briefly confused in the ED.
- Exam notable for:
Bilateral peripheral edema to the ankle.
- Labs were notable for:
WBC 13.7 > 9.6 > 10.1
CK 4489 > 3008 > 2499 > 1631
ALT/AST 68/117
Trop .03 > .02 > <.01
CKMB 12
- Studies performed include:
CT head w/o contrast:
Small vessel disease. No hemorrhage. No fracture.
CT C-spine w/o contrast:
1. No acute fracture or dislocation.
2. Bilateral thyroid nodules appear decreased in size compared
to prior. Correlate with prior workup.
3. Multilevel facet and disc disease as described above.
CXR ___
Subtle opacity in the left lung base may represent atelectasis
or sequelae ofaspiration.
EKG: sinus rhythm, prolonged PR, left axis deviation, old
infarcts
- Patient was given:
___ 15:18IVFNSStarted 100 mL/hr
___ 15:30POAspirin 324 mg
___ 17:00IVFNS 250 mL
___ 20:15PO/NGApixaban 5 mg
___ 07:30PO/NGamLODIPine 10 mg
___ 07:30POMetoprolol Succinate XL 25 mg
___ 07:30PO/NGApixaban 5 mg
Vitals on transfer: T 97.9 BP 157/71 HR 62 RR 20 O2sat 93% RA
Upon arrival to the floor, the patient is feeling well. The
patient knows why he is in the hospital. ___ endorses the above
history.
Past Medical History:
atrial fibrillation on apixaban
sick sinus syndrome s/p pace maker ___
TIAs in setting of subtherapeutic INRs on warfarin in ___
hypertension
hyperlipidemia
GERD
chronic subdural hematomas
throat cancer s/p radiation
Falls
Lumbar compression fractures
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T: 97.9 PO BP: 157 / 71 HR:62RR: 20O2: 93 RA
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. EOMI. Sclera anicteric. Conjunctiva are
erythematous.
ENT: MMM. No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Basilar crackles on the left. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Gait was not observed. AOx3. Profound cogwheel
rigidity. Subtle resting tremor observed.
PSYCH: appropriate mood and affect. Oriented to city, place,
thought year was ___.
DISCHARGE PHYSCIAL EXAM:
Temp: 98.4, PO BP: 98 / 58 HR:62 RR18 93 Ra
GENERAL: Alert and interactive. In no acute distress. Mooned
facies, voice deep, slowed and soft
EYES: NCAT. EOMI. Sclera anicteric. Conjunctiva are
erythematous.
ENT: MMM. No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Basilar crackles on the left. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Gait was not observed. strength decreased on right
___ in comparison to left, cogwheel rigidity bilaterally, slowed
speech, mooned facies. No tremor.
PSYCH: appropriate mood and affect. Oriented to person, city,
place, year ___
Pertinent Results:
___ LABS:
___ 11:53AM BLOOD WBC-13.7* RBC-3.89* Hgb-12.1* Hct-37.4*
MCV-96 MCH-31.1 MCHC-32.4 RDW-14.4 RDWSD-50.3* Plt ___
___ 11:53AM BLOOD Glucose-103* UreaN-29* Creat-1.0 Na-136
K-4.5 Cl-102 HCO3-24 AnGap-10
___ 12:45PM BLOOD CK(CPK)-4489*
___ 12:45PM BLOOD CK-MB-12* MB Indx-0.3
___ 12:45PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.3
DISCHARGE LABS:
___ 07:25AM BLOOD WBC-7.3 RBC-3.52* Hgb-10.9* Hct-33.7*
MCV-96 MCH-31.0 MCHC-32.3 RDW-13.9 RDWSD-48.7* Plt ___
___ 03:49PM BLOOD Neuts-83.1* Lymphs-7.8* Monos-8.0
Eos-0.6* Baso-0.2 Im ___ AbsNeut-8.36* AbsLymp-0.78*
AbsMono-0.80 AbsEos-0.06 AbsBaso-0.02
___ 07:25AM BLOOD Glucose-94 UreaN-18 Creat-0.8 Na-140
K-4.0 Cl-102 HCO3-25 AnGap-13
___ 07:25AM BLOOD CK(CPK)-319
___ 03:49PM BLOOD cTropnT-<0.01
___ 07:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
___ man with history of atrial fibrillation on Eliquis,
s/p dual chamber pacemaker, HTN, HLD, who presents after a fall,
no acute bleed found on head CT, now with new diagnosis of
___ and started on Sinemet with improvement.
====================
TRANSITIONAL ISSUES:
====================
[ ] New diagnosis of ___. Please ensure follow up with
Neurology as outpatient. Appointment made in ___, though pt
endorsed wanting to move to ___ (see below).
[ ] Please uptitrate Sinemet as needed after recovery in rehab.
___ Neurology recommended follow up in ___.
[ ] Please obtain MRI brain as outpatient. Cardiology cleared
MRI brain as patient has a pacemaker.
[ ] Of note, patient visits ___ in the summer, but is
planning to live in ___ with daughter for duration of year.
[ ] Consider dose reducing Apixaban even though does not
formally meet 2 criteria (63kg) given repeated falls
[ ] Changed Metoprolol from 25 XL to 12.5 daily as heart rate
in 50-60s.
[ ] Discontinued amlodipine given SBPs in 130s and goal SBP
<150 (in light of falls)
====================
ACUTE ISSUES:
====================
# Parkinsonism
# Cognitive changes
# Falls
Patient has history of many falls over the last year that seem
mechanical by history but also likely have an orthostatic
component. On physical exam, the patient has clear Parkisonian
signs with masked facies, cogwheel rigidity, and subtle resting
tremor. Neuro consulted and agrees that patient has Parkinsons
and recommended starting sinemet inpatient with uptitration as
needed as outpatient. Recommend also obtaining head MRI to
further characterize etiology of ___. PLAN: Continue 0.5
(___) tab Sinemet TID with meals, uptitrate in ___, please
obtain brain MRI as outpatient
# Aspiration Risk: Video swallow showing patient is aspirating
to all liquids. Discussed with family and patient regarding
goals of care and risks for aspiration. They are in
understanding that patient could aspirate at any time and it may
be unlikely that his swallow improves, especially given history
of thyroid radiation. Recommend diet of soft solids and thin
liquids at rehab.
# Hypertension: Discontinued home amlodipine given recurrent
falls and SBPs predominantly were <150.
# Atrial Fibrillation: CHAD2VaSC 4. Has history of paroxysmal
atrial fibrillation. At a high risk for bleed in setting of
frequent falls. Continued 5 mg apixaban mg BID, changed
Metoprolol to 12.5 daily given heart rates in ___. Can
consider dose reduction of Apixaban as outpatient given
recurrent falls.
===============
CHRONIC ISSUES:
===============
#BPH: continue Flomax. did not discontinue despite falls given
pt has long history of severe BPH.
#HLD: continue pravastatin
===============
CORE MEASURES:
===============
#CODE: full code presumed
#CONTACT:
Name of health care ___
Relationship:son in law
Phone ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Tamsulosin 0.4 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) 0.5 TAB PO TID parkinsons
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
-___
-Aspiration risk
-Atrial fibrillation
SECONDARY DIAGNOSES
-Hypertension
-A-fib
-Hyperlipidemia
-Benign Prostatic Hyperplasia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having recurrent falls
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were diagnosed with ___ and started on a new
medication
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to follow up with neurology and primary care in
___. You will need to make these appointments when your
reach ___.
- In the interim, neurology will make a follow up appointment
for you. Please attend if you are in the ___ area.
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10496294-DS-8 | 10,496,294 | 26,881,671 | DS | 8 | 2189-04-27 00:00:00 | 2189-04-28 22:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with history of blindness and prostate
cancer presenting with shortness of breath.
He reports ___ days of shortness of breath, worse with exertion
unable to even walk a few steps without shortness of breath),
dizziness, and productive cough. His chest and nose feel
congested and he is unable to breathe out of the left nostril.
Unable to see color of sputum because he is blind. No chest pain
except when coughing. No fever/chills, nausea/vomiting, or
diarrhea. Reports LLQ pain with coughing. He smoked 1 ppd up
until four days ago, when he stopped due to shortness of breath.
He was evaluated at an OSH two days ago and was sent ___ with
pills (unclear if these were an antibiotic) and an inhaler,
which did not seem to help. Sister reports failure to thrive at
___ with progressive weight loss for years. Patient's twin
brother died of pancreatic cancer last year.
In the ED, initial vital signs were:
98.4 120 ___ 90% RA
- ED exam was notable for: Congested cough, lungs relatively
clear (?coarse BS at bases), scattered wheeze, abdomen tender in
LLQ but nondistended/soft, no edema. Smelled of smoke.
- Labs were notable for:
FluAPCR positive.
Lactate 1.2.
Electrolyte panel and CBC unremarkable.
CXR showed no cardiopulmonary acute process.
- The patient was given:
___ 16:06 IH Albuterol 0.083% Neb Soln 1 NEB
___ 16:06 IH Ipratropium Bromide Neb 1 NEB
___ 16:06 IVF 1000 mL NS 1000 mL
___ 19:06 PO Azithromycin 500 mg
___ 19:06 PO PredniSONE 40 mg
___ 22:04 IH Albuterol 0.083% Neb Soln 1 NEB
___ 22:04 IH Ipratropium Bromide Neb 1 NEB
He improved substantially after nebulizers. He was observed in
the ED, and was noted to have persistent hypoxia on room air. He
was admitted to medicine for further management.
Upon arrival to the floor, patient endorses improved dyspnea.
Endorses abdominal discomfort, but no recent diarrhea, no n/v.
REVIEW OF SYSTEMS:
[+] per HPI
Past Medical History:
BLINDNESS
ELEVATED BLOOD PRESSURE
H/O PROSTATE CANCER S/P ___ RADICAL PROSTATECTOMY
H/O GASTROESOPHAGEAL REFLUX
Social History:
___
Family History:
Significant for hypertension in his mother's side. Twin brother
died last year of pancreatic cancer.
Physical Exam:
====================
EXAM ON ADMISSION
====================
Vital Signs: 97.4 111/51 94 18 100% RA
General: Alert & oriented x 3; 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, II/VI systolic
murmur, rubs
Lungs: Bibasilar crackles, no wheezing, rhonchi
Abdomen: +bowel sounds, ecchymoses throughout, soft, tenderness
to palpation diffusely, more so on left lower quadrant.
+voluntary guarding. Tenderness over left flank, indurated,
erythematous, drain with 200cc of sanguinous pus.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis. 1+ edema
bilaterally Left > Right
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, gait deferred, +Asterixis.
====================
EXAM ON DISCHARGE
====================
Vital Signs: 99.3, 107, 110/63, 16, 99%RA
General: Thin gentleman, Alert, oriented, no acute distress,
more interactive than previous
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: thin, soft, nontender
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
========================
LABS ON ADMISSION
========================
___ 03:40PM BLOOD WBC-4.5 RBC-4.62 Hgb-14.3 Hct-44.8 MCV-97
MCH-31.0 MCHC-31.9* RDW-13.3 RDWSD-48.0* Plt ___
___ 03:40PM BLOOD Neuts-64.8 Lymphs-18.2* Monos-16.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-2.89 AbsLymp-0.81*
AbsMono-0.74 AbsEos-0.00* AbsBaso-0.01
___ 03:40PM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-138
K-4.9 Cl-97 HCO3-28 AnGap-18
___ 03:40PM BLOOD Calcium-10.2 Phos-4.1 Mg-2.2
___ 03:45PM BLOOD Lactate-1.2
========================
LABS ON DISCHARGE
========================
___ 09:00AM BLOOD WBC-7.2 RBC-4.34* Hgb-13.6* Hct-41.8
MCV-96 MCH-31.3 MCHC-32.5 RDW-14.3 RDWSD-50.5* Plt ___
___ 09:00AM BLOOD Glucose-130* UreaN-20 Creat-0.6 Na-139
K-3.7 Cl-98 HCO3-33* AnGap-12
___ 09:00AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1
========================
MICROBIOLOGY
========================
___ Blood culture - no growth to date
___ Urine culture - no growth
========================
IMAGING/STUDIES
========================
___ CXR - Lungs are hyperinflated without focal consolidation.
Cardiac, mediastinal and
hilar contours are normal. Pulmonary vasculature is not
engorged. No acute
osseous abnormalities seen.
Brief Hospital Course:
Mr. ___ is a ___ with history of blindness and prostate
cancer presenting with shortness of breath and positive flu PCR.
# Acute Influenza, COPD:
The patient presented with dyspnea and cough, and was found to
have a positive influenza PCR. A CXR showed no focal
consolidation, but was hyperinflated. Given the patient's 50
pack year smoking history and productive cough with wheeze on
exam, there was concern that the patient had additionally
triggered a COPD exacerbation, though he had no known diagnosis
of COPD. He was treated with oseltamivir for a 5 day course for
influenza. In addition, he was treated with a prednisone burst
and nebulizers. He was weaned to room air. However, as he
continued to desat and become acutely short of breath with
exertion, he was discharged to acute rehab to further recover.
He will likely benefit for further evaluation of COPD in the
outpatient setting.
# Failure to thrive/weight loss:
A review of the patient's chart and a discussion with his sister
showed that he has had significant weight loss. In ___ he
weighed around 150lb, in ___ 132lb, and during this
hospitalization 110lb (BMI 16.7). He has a history of prostate
cancer, s/p radical resection, but was noted to have PSA of 1.3
in ___. A colonoscopy in ___ was normal. There is
concern for lung malignancy given long smoking history. Could
also be related to living situation, as patient lives alone and
is reportedly not consistently able to eat full meals. While
working with ___ he was found to be very deconditioned, and was
discharged to rehab. Further workup was deferred to the
outpatient setting.
TRANSITIONAL ISSUES:
[]patient was discharged with prescriptions for inhalers for
symptom relief
[]please consider checking PFTs to evaluate for COPD
[]please encourage patient to continue to not smoke
[]please consider outpatient work up for weight loss and
consider low dose CT scan given smoking history
[]patient had some microscopic hematuria on admission UA. Please
repeat UA at PCP ___
[]patient currently is full code, but would like to discuss this
further.
[]patient and sister have been given number to elder services to
discuss additional resources.
# CONTACT: ___
Phone number: ___
# CODE STATUS: Full (patient feels unsure)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Nicotine Patch 21 mg TD DAILY
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
Primary: Flu, COPD exacerbation
Secondary: weight loss, failure to thrive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure having you here at the ___
___. You were admitted here after you were
experiencing shortness of breath. You were found to test
positive for the flu which we think caused your symptoms.
You were treated with Tamiflu (medication for flu) and a short
course of prednisone (to be completed on ___.
We wish you the very best,
Your ___ medical team
Followup Instructions:
___
|
10496294-DS-9 | 10,496,294 | 29,020,861 | DS | 9 | 2192-10-16 00:00:00 | 2192-10-16 20:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain, weight loss
Major Surgical or Invasive Procedure:
R Psoas Mass Biopsy: ___
History of Present Illness:
___ male with pmhx prostate ca s/p prostatectomy ___,
COPD and blindness here for months of chest pain and abdominal
pain.
He reports pain over the anterior ribs, stomach and back. He
says
that he is very picky about his food and thus will not eat
often,
he uses Meals on Wheels but says that he does not like with a
bring him.
He was seen in his PCPs today where he was normotensive and
tachycardic with normal O2 sat but had spine and posterior rib
tenderness diffusely. PCP reports that he has had a 50 pound
weight loss over the past 6 months.
Sister is concerned about failure to thrive and the fact that he
lives alone does not feel that he is safe continuing on this
way.
Patient denies any increasing any shortness of breath at this
time. No headache, dizziness, nausea, vomiting. He reports that
he is often constipated, does not know what his stools look like
and is not able to endorse that he has had any bloody stools.
In the ED:
- Initial vital signs were notable for:
97.4, 105, 116/85, 20, 100% 2L NC
- Exam notable for:
Cachectic, Poor aeration, tenderness of L anterior lower ribs,
TTP lower thoracic & upper lumbar spine
- Labs were notable for:
Fairly unremarkable
- Studies performed include:
CTA Chest, Abdomen, Pelvis
1. Heterogeneous right paraspinal soft tissue mass at the level
of the right psoas measuring up to 7.1 cm, associated with
cortical destruction of the adjacent vertebral bodies,
concerning
for neoplasm.
2. Heterogeneous appearance of bone matrix in the axial
skeleton,
concerning for metastatic involvement.
3. Probable acute/subacute compression fracture of L5.
4. Extensive emphysema without focal consolidation or pleural
effusion.
5. No pulmonary embolism.
- Patient was given:
None
Upon arrival to the floor, he gives the above history.
He specifically complains of back pain but denies urinary or
stool incontinence. Says he has long standing constipation.
He says he is here to "get this thing taken out of me."
Past Medical History:
BLINDNESS
ELEVATED BLOOD PRESSURE
H/O PROSTATE CANCER S/P ___ RADICAL PROSTATECTOMY
H/O GASTROESOPHAGEAL REFLUX
Social History:
___
Family History:
Significant for hypertension in his mother's side. Twin brother
died last year of pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS:
___ 0051 Temp: 97.6 PO BP: 127/80 R Sitting HR: 107 RR: 20
O2 sat: 97% O2 delivery: 4l
GEN: cachectic
HEENT: Blind
CV: RRR nl s1s2 no mrg
PULM: diminished breath sounds throughout, mild end expiratory
wheezing
GI: S/ND/NT
EXT: WWP, non-edematous
NEURO: Equal strength b/l ___
LYMPH: No definite LAD
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: 97.9, 104 / 56, 103, 18, 99% on 2L
GEN: Cachectic elderly man in NAD
HEENT: Blind
CV: RRR nl s1s2 no mrg
PULM: CTAB - no wheezes, rhonchi, or crackles
GI: S/ND/NT
EXT: WWP, non-edematous
MSK: +TTP lower back
Pertinent Results:
ADMISSION LABS
===============
___ 04:20PM BLOOD WBC-6.7 RBC-4.29* Hgb-12.5* Hct-41.6
MCV-97 MCH-29.1 MCHC-30.0* RDW-14.9 RDWSD-53.4* Plt ___
___ 04:20PM BLOOD ___ PTT-28.9 ___
___ 04:20PM BLOOD Glucose-115* UreaN-15 Creat-0.5 Na-139
K-4.9 Cl-96 HCO3-32 AnGap-11
___ 04:20PM BLOOD ALT-11 AST-28 LD(LDH)-283* AlkPhos-206*
TotBili-0.3
___ 07:14AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9 Iron-54
___ 07:14AM BLOOD calTIBC-203* Ferritn-640* TRF-156*
___ 07:14AM BLOOD PSA-3436*
___ 07:12AM BLOOD CEA-43.0*
___ 04:20PM BLOOD PEP-NO SPECIFI
___ 07:12AM BLOOD HIV Ab-NEG
PERTINENT OTHER LABS:
======================
___ 07:14AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9 Iron-54
___ 07:14AM BLOOD calTIBC-203* Ferritn-640* TRF-156*
___ 07:14AM BLOOD 25VitD-30
___ 12:07AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:07AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:07AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 06:44AM URINE Hours-RANDOM TotProt-17
___ 06:44AM URINE U-PEP-NO PROTEIN
PATHOLOGY:
==========
___ R Perispinal Biopsy:
- Metastatic carcinoma consistent with prostatic origin (see
note).
Note: By immunohistochemistry the tumor cells are positive for
NKX3.1, CDX-2 (patchy) and CK20 (focal) and are negative for
CK7.
IMAGING
=========
___ CTA C/A/P IMPRESSION:
1. Heterogeneous right paraspinal soft tissue mass at the level
of the right psoas measuring up to 7.1 cm, associated with
cortical destruction of the adjacent vertebral bodies,
concerning for neoplasm.
2. Heterogeneous appearance of bone matrix in the axial
skeleton, concerning for metastatic involvement.
3. Probable acute/subacute compression fracture of L5 with mild
loss of
vertebral body height.
4. Extensive emphysema without focal consolidation or pleural
effusion.
5. No pulmonary embolism.
___ CXR IMPRESSION:
Lung fields are hyperexpanded suggestive of COPD. Symmetric
small round
densities along the lower lobes are consistent the patient's
nipples. There is coarsening of the bronchovascular markings
and bullous changes bilaterally. No focal consolidation or
pneumothoraces are identified.
DISCHARGE LABS:
=================
___ 07:50AM BLOOD WBC-4.0 RBC-3.42* Hgb-10.1* Hct-33.6*
MCV-98 MCH-29.5 MCHC-30.1* RDW-16.9* RDWSD-60.8* Plt ___
___ 07:50AM BLOOD Glucose-135* UreaN-10 Creat-0.4* Na-140
K-4.5 Cl-96 HCO3-33* AnGap-11
___ 07:50AM BLOOD Calcium-9.8 Phos-2.8 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ man with history of prostate
cancer s/p prostatectomy (___), COPD, and blindness who
presented with months of chest pain and abdominal
pain, weight loss, and findings of R Psoas mass, now s/p biopsy
with demonstration of metastatic prostate cancer.
TRANSITIONAL ISSUES:
=====================
TRANSITIONAL ISSUES:
=====================
[] Follow up with Oncology after initiation of Bicalutamide
[] Follow up pain, titrate Oxycodone PRN
[] Ensure adequate BMs while on opioids; consider
methylnaltrexone if having difficulty
[] Consider Head CT for additional staging
ACUTE ISSUES:
=============
# Metastatic Prostate Cancer with bony metastases
Patient was found to have a 7 cm mass involving the R psoas,
with lumbar bony involvement. Of note, had a L3 compression
fracture last year s/p augmentation at ___, with
an additional acute/subacute compression fx of L5 on CT at
admission. S/p ___ biopsy of right psoas mass, PSA 3436, with
final pathology demonstrating prostatic adenocarcinoma. HIV,
SPEP, UPEP negative, CEA 43. Spine was consulted, and determined
that no further interventions or brace was needed. Oncology
consulted, who recommend Bicalutamide treatment. Discussed case
with ___ Oncology, who recommended trialing chemotherapy
first as this can often result in decreased pain prior to
pursing ___. As such, the patient will start Bicalutamide as an
outpatient. He is to follow up with his Oncologist within the
next several weeks.
# Chronic Pain
The patient's pain was treated with standing APAP 1g TID,
Oxycodone 5mg q6h standing and Oxycodone 10mg q4h PRN
breakthrough pain, as well as a Lidocaine patch. Discussed ___
treatments with Radiation Oncology, who recommended deferring
___ for
now given initiation of chemotherapy may be quite helpful in
pain treatment. If he continues to have pain despite oral
chemotherapy, they recommended consideration of outpatient
radiation oncology referral.
# COPD
He denied cough, sputum or any acute downturn in respiratory
status during his stay. Provided Duonebs + Albuterol nebs PRN.
# Constipation
The patient reports chronic constipation and was placed on a
bowel regimen. Recommend continued uptitration as needed for
goal BM ~1/day; particularly in the setting of opioid use.
# Dispo
Patient's sister, health care proxy, very concerned about his
ability to care for himself. Reports he has missed many
appointments and follow-ups including oncology appointments. ___
and OT teams recommended rehab.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Multivitamins 1 TAB PO DAILY
4. nicotine (polacrilex) 4 mg buccal ASDIR
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. bicalutamide 50 mg oral DAILY
RX *bicalutamide 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Bisacodyl 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN GI discomfort
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Multivitamins W/minerals 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q6H
Hold for RR<12 or sedation
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 hours Disp #*10
Tablet Refills:*0
8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
Hold for RR<12 or sedation
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 8.6 mg PO BID
11. Simethicone 40-80 mg PO QID:PRN bloating, gas
12. Thiamine 100 mg PO DAILY
13. TraZODone 12.5 mg PO QHS:PRN insomnia
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
15. nicotine (polacrilex) 4 mg buccal ASDIR
16. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Metastatic prostate cancer
Secondary:
Chronic pain
COPD
Constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital for weight loss and back
pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have a 7cm mass in back. A biopsy was
performed revealing prostate cancer. Oncology started you on
bicalutamide treatment for this prostate cancer.
- Your pain was treated with Oxycodone, Tylenol, and Lidocaine
patches
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:
___
|
10496352-DS-21 | 10,496,352 | 20,886,029 | DS | 21 | 2117-01-23 00:00:00 | 2117-01-23 14:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ethinyl estradiol / norelgestromin / morphine / Zofran (as
hydrochloride) / hydrocodone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy
Tracheal stent removal
History of Present Illness:
Ms ___ is a ___ with a severe asthma, possible vocal cord
dysfunction, TBM (diagnosed ___ s/p Y stent placement on ___
presenting with dyspnea which started suddenly at 7pm this
evening. She was lying ___ bed when she began feeling that she
was "drowning". She tried 2 nebs yesterday with no improvement.
She states she initially tolerated placement of a 14 (T 3cm) 10
(R 1.5cm) 10 (L 2cm) silicone stent well yesterday. She was able
to climb up and down stairs without difficulty. She does report,
however, that she had a large dry coughing fit but her shortness
of breath didn't start until the evening. She reports chest
tightness with radiation bilaterally but not into the back with
associated wheezing. Denies neck pain. She was seen at ___
___, where she received nebs, rac epi, 125mg
methylprednisolone and magnesium. At ___, she
describes a severe sensation of inability to breathe which
improved after being "slammed" ___ front and back of her chest,
?chest ___. She had improvement ___ her respiratory status with
Ativan ___ the ED and then with Versed from EMS during transport
to BI ED.
Review of systems was positive for nonproductive cough with
fever ___ yesterday and just before placement of Y stent. She
also notes associated nausea without vomiting or abdominal pain.
She denies dysuria.
Of note, patient has had 3 prior ICU stays for asthma
exacerbations. Per prior OMR notes, and to briefly summarize her
past history, Ms. ___ was diagnosed with asthma at the age of
___. She has had a long standing history of complicated and
difficult to manage asthma. Since ___ she has been on and off
prednisone non-stop. As she weans off, she will exacerbate
again and requirement repeat administration of prednisone. She
reports 2 hospitalizations and 3 ER visits ___
the last year for asthma exacerbations (although primarily ___
___. She has also had one intubation as a child and
prolonged hospitalization for an anaphylactic reaction. She
often requires bipap and heliox for exacerbations. She notes
that bipap and racemic epi often help her feel better. She had
been evaluated for xolair (omaluzimab) treatment but did not
have elevated IgE.
Of note, patient was seen ___ ___ by ENT her exam was found to
be consistent with incidental left vocal fold hypomobility,
laryngopharyngeal reflux, no paradoxical vocal fold motion.
___ the ED, initial vitals:
22:07 0 96.7 112 121/85 20 98% Nasal Cannula
She was noted to have upper airway expiratory wheezing which
decreases when her respiratory rate slows. There was concern
that tracheal stent may have dislodged.
Patient was given 1mg IV lorazepam and 0.5mL Racepinephrine X 2.
VBG showed pH 7.55 pCO2 20 with lactate 5.4.
Patient was unable to tolerate lying down for CT chest and was
admitted to ICU for further treatment and management.
CXR was without abnormalities.
On transfer, vitals were:
Today 22:55 124 149/87 18 100% RA
On arrival to the MICU, patient complains of ongoing dyspnea and
right sided chest pain with cough.
Review of systems:
(+) Per HPI
Past Medical History:
asthma (multiple hospitalizations)
esophageal manometry study is suggestive of ineffective
esophageal
motility
endometriosis
anxiety
ulcerative proctitis
migraines
Social History:
___
Family History:
No family h/o early onset lung disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T97.8 HR117 BP128/97 RR19 99% humidifier
GENERAL: Alert, oriented x 3, speaking full sentences between
coughing fits; tremulous; audible upper airway wheezing
HEENT: Sclera anicteric, dry MM, pale-appearing
NECK: supple, JVP not elevated, no LAD
LUNGS: good air movement b/l; no rhonchi; transmitted upper
airway sounds/wheezing
CV: tachycardic, no m/r/g; chest pain reproducible with
palpation over right chest
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
DISCHARGE PHYSICAL EXAM:
VS: 98.6PO 107/65 87 18 98 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, occasional wheeze.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
___ 11:30PM BLOOD WBC-10.5* RBC-5.20 Hgb-14.7 Hct-42.3
MCV-81* MCH-28.3 MCHC-34.8 RDW-13.2 RDWSD-38.9 Plt ___
___ 11:30PM BLOOD Neuts-86.1* Lymphs-11.5* Monos-1.4*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-9.03* AbsLymp-1.21
AbsMono-0.15* AbsEos-0.02* AbsBaso-0.04
___ 11:30PM BLOOD Plt ___
___ 11:30PM BLOOD Glucose-117* UreaN-12 Creat-0.8 Na-139
K-4.8 Cl-104 HCO3-15* AnGap-25*
___ 04:09AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0
___ 11:44PM BLOOD ___ pO2-44* pCO2-16* pH-7.56*
calTCO2-15* Base XS--4 Intubat-NOT INTUBA
___ 11:44PM BLOOD Lactate-5.4*
___ 04:39AM BLOOD freeCa-1.17
PERTINENT IMAGING:
CT chest without contrast ___:
New tracheobronchial Y stent positioned at the carina centered
___ the trachea and main bronchi, right upper lobe bronchial
orifice is clear. Trachea and main bronchi Normal caliber at
end inspiration.
CXR ___:
___ comparison with study ___, there has been placement of
a left
subclavian PICC line. The tip of the catheter extends to the
lower SVC.
The patient has taken a much better inspiration and there is no
evidence of acute cardiopulmonary disease.
TTE ___:
The left atrium is normal ___ size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF = 55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
MICROBIOLOGY:
___ 8:25 am BRONCHIAL WASHINGS
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CHAINS.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
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.
STENOTROPHOMONAS MALTOPHILIA. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STENOTROPHOMONAS
MALTOPHILIA
| |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
___ 2:22 pm BRONCHIAL WASHINGS Site: TRACHEA
TRACHEAL BRONCHIAL WASH.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # ___
(___).
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Blood culture ___: NGTD
DISCHARGE LABS:
___ 04:21AM BLOOD WBC-7.9 RBC-4.24 Hgb-11.7 Hct-35.7 MCV-84
MCH-27.6 MCHC-32.8 RDW-13.3 RDWSD-41.2 Plt ___
___ 04:21AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-139
K-4.4 Cl-105 HCO3-24 AnGap-14
___ 04:21AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ with a severe asthma, possible vocal cord
dysfunction, tracheobronchomalacia s/p Y stent placement on ___
presenting with acute dyspnea.
ACTIVE ISSUES
==============
# Dyspnea: Undifferentiated etiologies but may include asthma
exacerbation, paradoxical vocal cord dysfunction, or tracheal
stent migration. Patient s/p nebulizer, racemic epi,
methylprednisolone and magnesium ___ ED with some improvement.
Upper airway obstruction less likely given rapid improvement
with slowed breathing. CXR was negative for any consolidation
suggestive of pneumonia but she was started on azithromycin (day
1: ___ for possible atypical pneumonia. There was also a
component of her symptoms from her anxiety. The patient was also
serially seen by ENT for evaluation of possible paroxysmal vocal
cord fold movement which was a consideration. On ___, the
patient continued to have tachypnea with increased work of
breathing aslong with tachycardia to the 140's, so she was given
Heliox, nebs, and Ativan. Given development of rhonchi and
wheezing on ___, the patient initially received 60mg prednisone
X 1 ___ anticipation of further prednisone burst but IP wanted to
hold off. She then went to the ___ on ___ for a bronchoscopy,
which showed stent with some minimal mucous. She continued to
have symptoms, so she was considered to have failed stent trial,
and therefore went to the OR on ___ for Y-stent removal.
Subsequently, ___ wanted to perform PFTs with bronchodilator
trial so she was called out to the ___. Additionally,
thoracics was consulted for consideration of
trachobronchoplasty. She was maintained on multiple inhalers and
high dose PPI. She will continue use of Flovent and Advair, as
well as montelukast treatment. She will follow up with
Interventional Pulmonary and Thoracic Surgery following
discharge, with plan to under bronchothermoplasty. She is not
being discharge home with BiPAP. She will also follow up with
her PCP following discharge.
# Tracheitis: Patient with bronchial washings revealing MSSA and
Stenotrophomonas. She was initiated on vancomycin and
ceftriaxone on ___, eventually transitioned to PO
amoxicillin/clavulanate and DS TMP/SMX, plan for total 7 day
course. She was afebrile on discharge.
# Ventricular tachycardia: 30 beat run on ___, with associated
dizziness, and no recurrence. Potassium was mildly low at the
time. She was seen by Electrophysiology who recommended
outpatient Cardiology follow-up with event monitoring. Her PCP
___ help to arrange Cardiology follow-up closer to where she
lives.
CHRONIC ISSUES
===============
# Anxiety: Patient was placed initially on prn lorazepam and
then standing lorazepam 1 mg q6h while ___ the ICU, as well as
quetiapine. These medications were discontinued on discharge,
as anxiety was thought to be related to her hospitalization and
acute state.
# Migraines: Continued on prn Tylenol.
TRANSITIONAL ISSUES
=====================
# Follow-up: She will continue use of Flovent and Advair, as
well as montelukast treatment. She will follow up with
Interventional Pulmonary and Thoracic Surgery following
discharge, with plan to under bronchothermoplasty. She is not
being discharge home with BiPAP. She will also follow up with
her PCP following discharge.
Her PCP ___ help to arrange Cardiology follow-up closer to
where she lives.
# Communication: HCP: ___, husband ___
# Code: Full CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Omeprazole 20 mg PO DAILY
4. Montelukast 10 mg PO DAILY
5. Levalbuterol Neb 0.63 mg NEB Q8H:PRN wheezing
6. levalbuterol tartrate 45 mcg/actuation inhalation Q6H:PRN
wheezing
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. NuvaRing (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr
vaginal ONCE
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Montelukast 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. NuvaRing (etonogestrel-ethinyl estradiol) 0.12-0.015 mg/24 hr
vaginal ONCE
8. levalbuterol tartrate 45 mcg/actuation inhalation Q6H:PRN
wheezing
9. Levalbuterol Neb 0.63 mg NEB Q8H:PRN wheezing
10. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*7 Tablet Refills:*0
11. Sulfameth/Trimethoprim DS 2 TAB PO Q8H
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth every eight (8) hours Disp #*42 Tablet
Refills:*0
12. Acetaminophen 1000 mg PO Q8H pain
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Tracheobronchomalacia
Acute respiratory failure
Tracheitis
Ventricular tachycadia, non-sustained
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
came for further evaluation of shortness of breath following
tracheal stent placement. You were treated with numerous
medications and bronchoscopy, as well as BIPAP, and improved.
You were also found to have an infection called tracheitis,
which was treated with antibiotics.
It is important that you continue to take all medications
prescribed and follow up with the appointments listed below.
These appointments may be changed, and you will be contacted at
home with further information. You should have your primary
care doctor schedule ___ Cardiology appointment for you closer to
home. Eventually, you will need to wear an event monitor that
will be arranged through your PCP or cardiologist, to help make
sure your heart rhythm is not abnormal.
Good luck!
Followup Instructions:
___
|
10496352-DS-28 | 10,496,352 | 20,803,431 | DS | 28 | 2120-07-03 00:00:00 | 2120-07-03 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ethinyl estradiol / norelgestromin / morphine / hydrocodone /
adhesive tape / Zofran (as hydrochloride) / almonds
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
WBC 13.5--> 9.5
hgb, plt WNL
coags WNL
BMP w/ elevated glc to 143, otherwise WNL
TSH 3.6--> 0.75
ft4 1.9
vitamin D25OH 39
utox + for benzodiazepines and amphetamines
U/A w/ large leuks, neg nitrite, many bacteria & 64 WNC; 100
protein
___ Flu A/B neg
___ UCx mixed bacterial flor
___ legionella serogroup 1 neg
___ MR head w/ & w/o contrast:
Normal enhanced brain MRI.
___ MR cervical spine:
1. Minimal disc bulging at C5-C6 level, with no evidence of
neural foraminal
narrowing or spinal canal stenosis.
2. No focal or diffuse lesions are visualized throughout the
cervical spinal cord.
Brief Hospital Course:
___ female past medical history of TBM s/p stenting in
___, asthma, anxiety, who is presenting with cough and
shortness of breath, as well as spells of left-sided weakness.
#SOB: likely ___ protracted asthma exacerbation triggered by a
cold 1 month ago; Interventional pulmonology does not think that
her TBM is playing a significant role based on bronchoscopy done
in ___. They would like to repeat a CT in 6 weeks after her
symptoms are improved (below)
She was given a pulse of solumedrol and then prednisone 40mg
bid, and given nebs. With this intervention she felt improved.
# Left sided weakness, sensory deficits, tremor
She had MRI/MRA brain that did not show any structural deficits.
She was seen by neurology, they thought this could possibly be
complex migraine exacerbated by hypoxia. ceruloplasmin was sent
and considering starting topiramate of no contraindication.
For her severe essential tremor they recommended primidone 25mg
which could be increased to 50 in a week.
#UTI
She had dysuria on admission; she was treated w CTX for 2 days,
but culture was negative and d/c on ___.
#amphetamine use for exam studying
She was counseled to stop using for exam studying.
################
Transitional issues
- Please follow-up on pertussis swab (please call ___
for ___ laboratory)
- Please follow-up on ceruloplasmin
- If her tremor is still an issue, her primidone can be
increased to 50 qHS. Outpatient neurology at ___ was
scheduled, but she can follow-up locally if she prefers.
- We recommended she wean her steroids under direction of Dr.
___ Dr. ___. appt with Dr. ___ on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 12.5 mg PO QHS
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Tiotropium Bromide 1 CAP IH DAILY
4. PredniSONE 20 mg PO BID
5. Montelukast 10 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
8. Gabapentin 300 mg PO QHS
9. ALPRAZolam 1 mg PO BID:PRN anxiety
10. Diltiazem Extended-Release 120 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Prochlorperazine 5 mg PO Q8H:PRN Nausea/Vomiting - First
Line
Discharge Medications:
1. PrimiDONE 25 mg PO QHS tremor
Please increase to 50mg (two pills) on ___.
RX *primidone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*3
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. ALPRAZolam 1 mg PO BID:PRN anxiety
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 300 mg PO QHS
8. Montelukast 10 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. PredniSONE 20 mg PO BID
11. Prochlorperazine 5 mg PO Q8H:PRN Nausea/Vomiting - First
Line
12. Tiotropium Bromide 1 CAP IH DAILY
13. Zolpidem Tartrate 12.5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
asthma exacerbation
UTI
Tracheobronchomalacia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for difficulty breathing. You
were seen by the interventional pulmonary team, and they did not
think that your tracheobronchomalacia had a big impact. With
some increase in your steroids you felt better.
You also had brain imaging done because of your left-sided
numbness, and there were no abnormalities.
The neurology team started you on a medication to help with your
tremors.
It was a pleasure taking care of you!
Your ___ Care team
Followup Instructions:
___
|
10496439-DS-17 | 10,496,439 | 22,446,537 | DS | 17 | 2155-04-10 00:00:00 | 2155-04-10 12:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / contrast dye / Nitrofurantoin /
chlorthalidone
Attending: ___.
Chief Complaint:
Clotted fistula
Major Surgical or Invasive Procedure:
Fistulogram and thrombectomy ___
History of Present Illness:
Mr ___ has been in usoh until it was noted at his
___ dialysis appointment. He had gone to his ___ and
___ appointments without issue. Access tech noted no flow
today with attempted cannulation and referred to hospital.
Patient requested ___ admission over ___. Denies any
pain, swelling, numbness or tingling in left arm. He did not
realize anything had happened prior to HD - felt completely at
baseline. Otherwise no focal complaints or questions.
ED COURSE
- Initial Vitals: 0 98.1 56 152/74 18 100% RA
- Exam notable for: No palpable thrill
- Labs notable for: pending
- No imaging performed
- Transplant surgery consulted, recommended ___ consult
- Patient was given: Nothing
- Vitals prior to transfer: 0 98.2 58 152/75 16 100% RA
Past Medical History:
- Hypertension
- Type II Diabetes
- CAD/MI
- Hx CVA
- Prostate Cancer
- ESRD/HD
PAST SURGICAL HISTORY
- Scrotal cyst excision
- Left foot surgery
- Left AV fistula
- Right brachiocephalic AV fistula (___)
- Left forearm loop AV graft
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
===============
VS: 97.2 171 / 82 61 18 96 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: RRR. Normal S1+S2, no murmurs, rubs, gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left arm with palpable graft, but no thrills or bruit
along entire course. Left arms is fully mobile, without edema,
and non-tender to palpation. Normal cap refill.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
===============
98.8
PO 136 / 68 R Lying 71 18 97 RA
General: Alert, oriented, no acute distress
CV: RRR. Normal S1+S2, no murmurs, rubs, gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left arm with palpable graft, but no thrills or bruit
along entire course. Left arms is fully mobile, without edema,
and non-tender to palpation. Normal cap refill.
Pertinent Results:
ADMISSION LABS:
___ 10:10PM GLUCOSE-96 UREA N-59* CREAT-9.1*# SODIUM-137
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-26 ANION GAP-19
___ 10:10PM estGFR-Using this
___ 10:10PM ___ PTT-28.1 ___
___ 07:00PM VoidSpec-GROSSLY HE
___ 07:00PM WBC-6.8 RBC-3.16*# HGB-10.2* HCT-30.3*
MCV-96# MCH-32.3*# MCHC-33.7 RDW-15.4 RDWSD-51.2*
___ 07:00PM NEUTS-54.5 ___ MONOS-11.7 EOS-8.0*
BASOS-0.3 IM ___ AbsNeut-3.69 AbsLymp-1.72 AbsMono-0.79
AbsEos-0.54 AbsBaso-0.02
___ 07:00PM PLT COUNT-194
IMAGING:
FISTULOGRAM/THROMBECTOMY ___
FINDINGS:
1. Complete thrombosis of the left upper extremity AV graft to
the level of
the venous anastomosis of the graft.
2. Post thrombectomy, return of flow within the graft, but
persistent stenosis
at the level of the venous anastomosis of the graft
3. Post stenting with 8 mm Viabhan, substantial improvement in
the appearance
of the venous outflow of the graft and restoration of palpable
thrill
throughout the graft
4. Satisfactory appearance of the arterial anastomosis.
IMPRESSION:
Satisfactory restoration of flow following chemical and
mechanical
thrombolysis and venous outflow stenting with a good
angiographic and clinical
result utilizing CO2 contrast medium.
DISCHARGE LABS:
___ 05:05PM BLOOD WBC-5.8 RBC-3.13* Hgb-9.9* Hct-29.4*
MCV-94 MCH-31.6 MCHC-33.7 RDW-13.4 RDWSD-46.2 Plt ___
___ 05:05PM BLOOD Plt ___
___ 05:05PM BLOOD Glucose-74 UreaN-69* Creat-10.6*# Na-137
K-5.4* Cl-99 HCO3-21* AnGap-22*
Brief Hospital Course:
___ man with a PMH of ESRD on HD (___ at ___,
DMII, HTN who was admitted for a clotted AV fistula. He was
dialyzed on ___, but missed his scheduled dialysis session on
___. The patient was evaluated by transplant surgery and
underwent successful fistulogram and thrombectomy by
interventional radiology. The patient then underwent
hemodialysis on ___. The patient was continued on his home
medications, although it should be noted that the patient is
unsure if he is taking bumetanide although he filled a 6-month
prescription in ___.
TRANSITIONAL ISSUES
===================
- Review medication list and confirm that patient is still
taking Bumex
- Underwent dialysis on ___
CODE: Full (presumed)
CONTACT: ___ (spouse) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Bumetanide 2 mg PO BID
3. Calcium Acetate 1334 mg PO BID
4. HydrALAZINE 50 mg PO Q8H
5. Isosorbide Dinitrate 20 mg PO QID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bumetanide 2 mg PO BID
5. Calcium Acetate 1334 mg PO BID
6. HydrALAZINE 50 mg PO Q8H
7. Isosorbide Dinitrate 20 mg PO QID
8. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Clotted arteriovenous fistula
- End-stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ because your fistula clotted. You had
a procedure with interventional radiology to fix the fistula.
Your fistula was working again and you had hemodialysis. It is
now safe for you to go home. Please resume your usual dialysis
schedule.
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10496572-DS-13 | 10,496,572 | 29,908,222 | DS | 13 | 2148-02-11 00:00:00 | 2148-02-11 19:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___
Chief Complaint:
Lethargy, abdominal pain
Major Surgical or Invasive Procedure:
PTBD/biliary stent placement
History of Present Illness:
Mr. ___ is a ___ man with HTN, HLD, DMII, metastatic
pancreatic cancer, SMV thrombus on apixaban who is presenting
with abdominal pain and fatigue. He initially presented at ___ and found to be hypotensive requiring pressors. He
received
cefepime and vancomycin immediately. A CT scan was done but
there
were no acute findings. Tbili at OSH reported at 6. He was
transferred to ___ given his recent duodenal stent placement
here.
Of note, he was recently discharged for hospital admission stay
___ for abdominal pain, vomiting, and early satiety,
found
to have duodenal stricture on outpatient EGD ___ and admitted
for repeat EGD. He had successful EGD with duodenal stent
placed
(Wallflex ___ x 90mm uncovered duodenal metal stent) on ___
and was monitored for complications overnight, he was discharged
the next day with no issues.
In the ED, he was initially hypotensive to systolic ___ and
tachycardic to 110s, for which he was given IVFs and started NE.
He was initially enrolled in the Clover trial, during which NE
was discontinued and he received 5L of IVFs. However he
continued
to be hypotensive and was thus dis-enrolled from the trial, at
which point NE was started again.
- Initial Vitals:
98.5 ___ 16 97% RA
97.9 97 ___ 96% RA
- Exam:
General: In no acute distress
HEENT: Normal oropharynx, no exudates/erythema
Cardiac: RRR , no chest tenderness
Pulmonary: Clear to auscultation bilaterally with good aeration,
no crackles/wheezes
Abdominal/GI: Mild epigastric abdominal tenderness, chronic per
patient
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted
Neuro: Sensation intact upper and lower extremities, strength
___
upper and lower, moving all extremities
- Guaiac positive
- Labs:
Lactate 5.4 --> 3.6
INR 1.7
Hgb 7.0, plts 64
UA small blood, 8 WBC
Na 134, K 3.4, Cr 1.6, BUN 39
Ca 7.1
Bili 6.1, Albumin 2.4
ALT 125, AST 201
- Imaging:
CXR - kink in catheter tubing
Abdominal ultrasound - patent portal vein, mild intrahepatic
biliary duct dilatation, liver mets, trace ascites
CT A/P - no acute process, pancreatic mass and hepatic mets
unchanged from prior imaging (but limited by no iv contrast)
- Consults: ___, transplant surgery
- Interventions:
___ 13:32 IV DRIP NORepinephrine ___ mcg/kg/min ordered)
___ 15:30 IV MetroNIDAZOLE 500 mg
___ 15:30 IVF LR 1000 mL
___ 15:42 IV Pantoprazole 40 mg
___ 16:15 IVF LR 1000 mL
___ 16:25 IV Kcentra 3234 Units
___ 16:37 IV Potassium Chloride (40 mEq ordered)
___ 16:38 IV Magnesium Sulfate
___ 17:00 IVF LR 1000 mL
___ 17:40 IV DRIP NORepinephrine ___ mcg/kg/min ordered)
___ 17:59 IV Calcium Gluconate 2 g
___ 18:00 IV Magnesium Sulfate 2 gm
___ 18:43 IV Magnesium Sulfate 2 gm
___ 18:49 SC Insulin 2 Units
___ 19:48 IV Acetaminophen IV 1000 mg
On the floor, history is obtained from patient, wife, and
son/daughter. The patient notes that since undergoing duodenal
stent placement he has felt well. However, on ___ night he
took a nap and when he woke up had soaked the sheets in sweat.
On
___ evening he had 1 episode of vomiting after eating. On
___ morning he woke up and noted that he was a little dizzy
and tired. The son reports being called by his uncle, went to
see
the patient who was too weak to get out of bed and extremely
tired, though did not appear confused. They took his temperature
which was elevated to 102, at which time they called the
ambulance. Otherwise the patient denies any other significant
symptoms. He notes chronic abdominal and back pain which is
maybe
slightly worse but hard to tell compared to his baseline. He
denies headaches, chest pain, SOB, leg swelling, or confusion.
Past Medical History:
- Metastatic pancreatic cancer: diagnosed ___ when imaging
showed 2.3x2x2.5cm multilobulated lesion involving pancreatic
head. FNA c/w adenocarcinoma. Found to have involvement of SMA,
SMV, ___ portion of duodenum, and mesentery. Diagnosed as stage
III, unresectable due to vascular involvement. Underwent
palliative treatment with 3 cycles of FOLFIRINOX ___ -
___.
Developed pancreatitis. Subsequently received 3 cycles FOLFOX
(holding irinotecan) ___ re-staging
revealed
liver mets. CT ___ showed progression of disease, underwent
treatment with gemcitabine/abraxane ___. Subsequent
CT ___ showed progression of disease in pancreas and liver as
well as new lung nodule. ___ EGD showed new duodenal
stricture
and he underwent duodenal stent placement ___.
- SMV thrombus on Eliquis started ___
- HTN
- HLD
- DMII (last A1c 6.2%)
- COPD (PFTs in ___ with mild obstruction - FEV1/FVC ratio
69)
- Hypothyroidism
- GERD
- Nephrolithiasis s/p ESWL
- BPH
- Gout
- S/p right TKR
- S/p cataract surgery
- Anemia
Social History:
___
Family History:
- Mother with breast CA (age ___
- Father with gastric CA (age ___
- MGF with prostate CA
- Brother with in-situ bladder carcinoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 88 96/60 96% on RA
GENERAL: in no acute distress, lying in bed
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic
ejection murmur noted throughout precordium with radiation to
carotids bilaterally, no gallops or rubs
LUNGS: Clear to auscultation bilaterally. Mild expiratory
wheezing, no crackles. Mild increased work of breathing.
ABDOMEN: hypoactive bowel sounds, mildly distended, mildly
tender
in epigastrium, no rebound or guarding, liver percussed 2-3cm
below ribs
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength bilateral ___, ___
strength bilateral upper extremities with flexion/extension.
Normal sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM:
***************
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 01:51PM BLOOD WBC-11.4* RBC-2.81* Hgb-7.8* Hct-25.3*
MCV-90 MCH-27.8 MCHC-30.8* RDW-17.9* RDWSD-58.7* Plt Ct-73*
___ 01:51PM BLOOD Neuts-81* Bands-8* Lymphs-3* Monos-4*
Eos-1 ___ Metas-3* AbsNeut-10.15* AbsLymp-0.34* AbsMono-0.46
AbsEos-0.11 AbsBaso-0.00*
___ 01:51PM BLOOD ___ PTT-32.1 ___
___ 01:51PM BLOOD ___
___ 11:46PM BLOOD Ret Aut-1.1 Abs Ret-0.03
___ 01:51PM BLOOD Glucose-134* UreaN-39* Creat-1.6* Na-134*
K-3.4* Cl-99 HCO3-17* AnGap-18
___ 01:51PM BLOOD ALT-125* AST-201* AlkPhos-394*
TotBili-6.1*
___ 01:51PM BLOOD Albumin-2.4* Calcium-7.1* Phos-1.9*
Mg-1.4*
___ 11:46PM BLOOD Hapto-220*
___ 01:58PM BLOOD Lactate-5.4*
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ BLOOD CULTURE - no growth FINAL
___ URINE CULTURE - no growth FINAL
___ C DIFF PCR NEGATIVE
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ CHEST (PORTABLE AP)
Apparent kink in the catheter tubing, correlate with catheter
function.
___ LIVER OR GALLBLADDER US
1. Patent portal vein, with reversal of flow in the left portal
vein.
2. Mild intrahepatic biliary duct dilatation in the left hepatic
lobe is
similar to recent CT in ___.
3. Diffuse heterogeneity of the liver compatible with previously
seen
metastatic disease.
4. Trace ascites.
___ CT ABD & PELVIS W/O CONTRAST
1. Exam is limited by lack of IV contrast.
2. Interval placement of a duodenal stent which is present in
the third
portion of the duodenum.
3. No retroperitoneal hematoma or other acute process in the
abdomen or
pelvis.
4. Evaluation of patient's known pancreatic mass and hepatic
metastatic
disease is limited without IV contrast, however does not appear
significantly changed.
5. Evaluation of biliary duct dilatation is limited without IV
contrast,
however mild intrahepatic biliary duct dilatation in the left
hepatic lobe
does not appear significantly changed.
6. Small amount of ascites and splenomegaly are slightly
increased from prior.
Biliary Cath Check/Reposition ___:
1. Right anterior anchor drain was malpositioned outside the
liver in the perihepatic space.
2. Patency of the right posterior and left biliary stents.
3. Large volume sanguinous output from the right anterior
anchor drain which was located in the perihepatic space.
4. Final fluoroscopic image demonstrating removal of the left
and right posterior anchor drains with conversion of the right
the anterior anchor drain to a pigtail drain in the perihepatic
space.
CTA ABDOMEN/PELVIS ___
1. A linear hyperdense focus in segment 6 of the liver seen on
noncontrast images does not change in appearance on postcontrast
sequences compatible with previously administered contrast
during the interventional radiology procedure. No evidence of
active arterial extravasation. No free fluid in the abdomen.
2. Known hypoattenuating pancreatic mass and innumerable
metastatic liver lesions. The dominant liver lesion continues to
obliterate the left portal vein and left hepatic vein.
3. Persistent SMV thrombosis.
4. Splenomegaly.
HIDA SCAN ___
1. No abnormal focal collection of tracer. No evidence of bile
leak.
2. Gastric reflux of tracer raising the possibility of bile
gastritis.
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 06:09AM BLOOD WBC-9.4 RBC-2.90* Hgb-8.0* Hct-26.2*
MCV-90 MCH-27.6 MCHC-30.5* RDW-21.6* RDWSD-70.7* Plt ___
___ 06:09AM BLOOD ___ PTT-57.7* ___
___ 06:09AM BLOOD ALT-31 AST-47* AlkPhos-320* TotBili-7.5*
___ 06:09AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.9
Brief Hospital Course:
Mr ___ is a ___ year old man with a history of
metastatic pancreatic cancer (mets to liver, not currently
receiving chemotherapy but plan to restart when able with local
oncologist) c/b duodenal stricture s/p stenting and SMV thrombus
(apixaban), NIDDM, HTN, p/w obstructive jaundice c/b GNR
bacteremia and septic shock requiring ICU stay, now transferred
to the floor and s/p ___ PTBD and stent placement who was
discharged to hospice.
# Obstructive Jaundice
# GNR Bacteremia
# Septic Shock (resolved): Transferred from OSH to FICU with
septic shock with biliary source. He briefly required levophed
to maintain blood pressures, but was quickly weaned off after
receiving IVF and antibiotics. Blood cultures from OSH grew ___
bottles pan sensitive E coli. ___ BCx (after antibiotics) were
negative. He was treated with cefepime flagyl and then narrowed
to ceftriaxone/flagyl after sensitivities returned, and
completed course through ___. MRCP showed progression of his
metastatic pancreatic cancer. He could not undergo ERCP due to
duodenal stent, and so instead ___ was consulted and placed
biliary stent and anchoring drains. LFTs improved, AST/ALT
normalized and bilirubin started to decrease. Two out of three
drains were removed on ___. Unfortunately, the final drain had
been noted to be dislodged from liver and now in a pool of blood
in the perihepatic space. Third drain kept in abdomen after the
procedure. Patient had mild bilirubin elevation in this fluid
concerning for biliary leak, however HIDA scan negative for
contrast extravasation into abdominal cavity. Drain removed by
___ on ___.
# Pancreatic cancer with mets to liver: ___ oncologist: Dr.
___. Primary Oncologist: Dr. ___ oncologist, Dr.
___, met with the patient and family on ___ and explained
that he is not currently a candidate for chemotherapy, patient
remains hopeful that he will be able to improve nutritional and
functional status and that biliary intervention will improve his
liver function to the point that he will be able to receive
chemotherapy again. Palliatve care was consulted and discussed
goals of care and pain management with the patient. He remains
full code, but plan to discharge with palliative care ___. For
pain control he was started on oxycontin 10mg PO BID, continued
on home oxycodone PRN pain and provided with dilaudid IV PRN
breakthrough pain. His home bowel regimen was increased due to
constipation. On ___ patient's oncologist and palliative care
team met with patient and family, discussed that there are no
further chemotherapy options at this point, and decision was
made to have patient transition to DNR/DNI and go home with
hospice. MOLST form signed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Docusate Sodium 100 mg PO QHS:PRN Constipation - First Line
6. Losartan Potassium 50 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
9. Senna 17.2 mg PO QHS:PRN Constipation - First Line
10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
12. GlipiZIDE XL 2.5 mg PO DAILY
13. alfuzosin 10 mg oral DAILY
14. Apixaban 2.5 mg PO BID
15. Hydrochlorothiazide 25 mg PO DAILY
16. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*4 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 20 mg 1 tablet(s) by mouth once a day Disp #*20
Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. Docusate Sodium 100 mg PO QHS:PRN Constipation - First Line
7. GlipiZIDE XL 2.5 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
10. Montelukast 10 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
13. Senna 17.2 mg PO QHS:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangitis
Metastatic Pancreatic Cancer
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 jaundice, abdominal pain,
and low blood pressures due to infection in your biliary system
due to a blockage caused by your cancer. You were treated with
antibiotics and IV fluids and underwent a procedure open the
blockage in your biliary system. You were also treated for an
infection in your bile ducts, and completed a course of
antibiotics while you were here for that. Unfortunately we were
not able to completely unobstruct your bile ducts and your bile
pigments (bilirubin) remained elevated, therefore you are not a
candidate for any further chemotherapy for your pancreatic
cancer. After a discussion with your oncologist and family on
___, we decided that it was time for you to transition to home
with hospice care.
You will continue to follow up with your oncologist Dr.
___.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
10497097-DS-10 | 10,497,097 | 21,769,520 | DS | 10 | 2161-04-06 00:00:00 | 2161-04-06 21:00:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Chantix / tramadol / Iodinated Contrast Media - IV
Dye / levofloxacin
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
lumbar puncture by ___ ___
History of Present Illness:
Mr. ___ is a ___ yo Man w/ h/o type 1 DM (diagnose in his
___, COPD, Bipolar d/o, and recent diagnosis (___)
dementia, possibly ___ body dementia; who presented with fever
(to 104), d/t difficulty ambulating d/t dizziness, and altered
MS.
___ his wife, pt's baseline is fully coherent w/o good balance,
and persistently seeks to keep his blood sugars low (below 100).
Notably, pt was
started on 5 mg olanzapine about 5 days prior to admission. Two
days
prior to admission, pt had a FSBG of 40 in the morning, which is
lower than his usual (50 - 100) although his wife who I spoke
with denies any recent hypoglycemia or changes to his home
regimen. he has been eating well.
Patient endorsed a new bifrontal headache starting around
yesterday evening that was corroborated by his wife. The pain is
less intense now but denies trouble with vision or focal
weakness. . Wife endorsed a new
cough and the patient stated his breathing felt a little heavy
but denied chest pain or overt dyspnea.
In the ED, a CT of the head was unremarkable. An LP as attempted
but failed. he was started on empiric meningitis coverage with
ceftriaxone, vanco, acyclovir and admitted for further
management.
when asked about urinary issues, he did endorse dysuria but not
frequency. He felt feverish last night. no cough or sputum
production. Denies hallucinations. Denies focal weakness but
does generally feel "tired."
Remainder of comprehensive 10 point ROS it otherwise negative.
Past Medical History:
Diabetes mellitus type 1 c/b diabetic retinopathy and neuropathy
Chronic small vessel ischemic CNS disease per MRI ___
cognitive impairment, possible ___ Body dementia
COPD
Gastritis
Anemia
Bipolar disorder
Past episode of lithium toxicity
Major depression
Tension headaches
?Seizures - attributed to hypoglycemic episodes
Hypothyroidism
Pneumonia (presented with confusion)
s/p Lower jaw tooth extractions ___
s/p both cervical spine surgery and lumbar (Laminectomy ___
spine surgery around ___ per the patient for back pain
Hernia repair
Appendectomy
Carpal tunnel surgery
Social History:
per prior notes:
-born ___, large ___ family, lives with wife in
___
-retired ___, worked two nights per week as
___, wife works 6 days/week as ___, has
SSDI. He stays at home all day while she goes to work.
for back injury
-grown daughter (___) and son (___), close to family
-pt does ___
-per family, no history of violence, legal troubles
SUBSTANCE ABUSE:
-EtOH: ___, never detox, never sz or DTs, no admitted
problem with EtOH. Stopped ETOH when diagnosed with Bipolar
disorder, denies drinking currently.
-cocaine:Distant
-opiates: prescribed, history of buying from the street but
denies recently
-former smoker, 40 pk years
Family History:
Mother Living ___ DIABETES TYPE I
Father ___ ___ DIABETES TYPE II, PROSTATE CANCER
Brother Living ___ HEALTHY
Brother ___ 41 ALCOHOLIC CIRRHOSIS
Sister Living ___ HYPOTHYROIDISM
Physical Exam:
Vitals: ___ P 24 93% on RA
Consitutional: NAD, lying in bed comfortably, alert and
conversant.
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: scant wheezes and rales bilaterally
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: he can touch his chin to his chest without a problem.
he is a somewhat poor historian but able to tell me the correct
year, hospital, name, and knows that it is ___ but guessed
wrong when he said it was ___. he repeats questions
occasionally and when asked why he is in the hospital he says
"well to be honest I don't really know." He seems to confabulate
somewhat when answering questions. CNs are ___ intact. His
upper extremities are ___ bilaterally and he feels unsteady on
his feet but is able to stand.
Psych: Full range of affect
DISCHARGE:
Vitals: 98.3 146/70 65 18 94%RA
Gen: NAD, AxO to hospital "BI", ___, pleasant,
appropriate
Eyes: EOMI, sclerae anicteric, NCAT
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AxOx3, speech fluent without dysarthria, strength ___
throughout, ___ intact
Psych: Full range of affect
GU: no foley, otherwise deferred
Pertinent Results:
___ 02:40AM OTHER BODY FLUID ___
___
___ 03:29PM URINE ___
___
___ 02:40PM ___
___ 02:22PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 02:22PM ___ this
___ 02:22PM ALT(SGPT)-19 AST(SGOT)-35 ALK ___ TOT
___
___ 02:22PM ___
___ 02:22PM ___
___
___ 02:22PM ___
___ 02:22PM ___
___
___ 02:22PM ___
___ IM ___
___
___ 02:22PM PLT ___
CT Ab ___: IMPRESSION:
No acute findings to explain patient's symptoms.
CT Head ___:
FINDINGS:
Exam is limited by motion despite repeat acquisitions. There is
no
___ or ___ hemorrhage, mass, midline shift, or
acute major
vascular territorial infarct. ___ matter differentiation
is preserved.
Ventricles and sulci are grossly unremarkable. Basilar cisterns
are patent.
Included paranasal sinuses and mastoids are essentially clear.
Skull and
extracranial soft tissues are unremarkable.
IMPRESSION:
Significantly motion degraded exam without visualized acute
intracranial
process.
CXR ___: Relatively low lung volumes are noted. The lungs are
grossly clear. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
CXR ___:
ilateral predominantly perihilar and basilar opacities likely
reflect new
mild pulmonary edema since ___, likely due to acute CHF.
Small amount of perifissural fluid is seen in the right lung.
The heart size is unchanged. No pneumothorax.
IMPRESSION:
1. New mild pulmonary edema due to acute CHF since ___.
CSF RESULTS:
ANALYSIS WBC RBC Polys Lymphs Monos Eos
___ 12:45 51 1200* 74 17 9
TUBE4
___ 12:45 52 9350* ___ 1
1.STRAW AND SLIGHTLY HAZY
2.PINK AND HAZY
Chemistry
CHEMISTRY TotProt Glucose
___ 12:45 67* 162
MICRO:
___ CSF;SPINAL FLUID Enterovirus
___ INPATIENT
___ CSF;SPINAL FLUID GRAM ___ FLUID
___ INPATIENT
___ BLOOD CULTURE Blood Culture,
___ EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
___ EMERGENCY WARD
DISCHARGE LABS:
___ 07:25AM BLOOD ___
___ Plt ___
___ 07:25AM BLOOD ___
___
___ 07:25AM BLOOD ___
___ 10:00AM BLOOD ___
___ 02:22PM BLOOD ___
Brief Hospital Course:
Mr. ___ is a ___ yo man w/ h/o type 1 DM (diagnosed in
___, COPD, Bipolar d/o, and recent diagnosis dementia, possibly
___ body (___) (with episodes of confusion, hallucinations
at baseline); who presented with fever (to 104), with
difficulty ambulating due to dizziness, and altered MS; admitted
over concern for possible meningitis (started on empiric
meningitis coverage with vanco/ceftriaxone/acyclo) s/p
unsuccessful attempt at LP in the ED so obtained by ___ on ___
(CSF: 5WBCs 1200 RBCs (75% PMNs), gram stain neg, mildly
elevated protein 67, glucose normal (Given hyperglycemia)
consistent with aseptic meningitis.
Ceftriaxone, vanc, acyclovir discontinued (HSV negative) and no
other source of infection. Afebrile, WBC downtrended however
continued to be quite confused. Per his wife, this is typical
when he has gotten infections in the past (UTI, pneumonia in the
past year). He continued to improve, and with negative cultures,
improved gait, was discharged home with home services.
Rest of hospital course/plan are outlined below by issue:
# Fever/HA concerning for aseptic meningitis: Started on
ceftriaxone/acyclovir/vanco in the ED (___), ctx/vanc were
discontinued on ___ after results of LP came back). HSV PCR was
negative so acyclovir was discontinued as well and he was
monitored off of antibiotics with ongoing improvement, no clear
source of infection found, attributed to viral/aseptic
meningitis.
#Toxic metabolic encephalopathy/ acute on chronic confusion:
Multiple predisposing factors including dementia and evidence of
chronic small vessel disease on MRI ___. Polypharmacy may
account in part for his confusion alone (holding hydroxyzine,
gabapentin) versus hypoglycemia (to which he is prone) or
perhaps progression of his ___ body dementia. Lithium level
elevated, held during admission and upon discharge. Holding home
gabapentin as well upon discharge, worsened Cr clearance on
admission may have led to elevated levels of both Lithium and
gabapentin. Home olanzapine added back to regimen due to
agitation with improvement, as well as hydrozyzine given
positive response in the past.
- Per wife, mentally clearer and more steady than past discharge
day exams
#Mild ___: In setting of infection, likely prerenal. Holding ___
as level was elevated. Held Lithium upon discharge, will need to
follow up with psychiatrist prior to ___.
#DM: Discrepancy between reports of hyperglycemia and
hypoglycemia, ___ consulted, adjusted insulin while
inpatient. Advised wife and patient that wife should manage
insulin primarily at home. ___ recommended reducing his
lantus dosing to ___ ___, with evening lantus the evening
lantus dose was migrated to dinner instead of at bedtime to
avoid nighttime hypoglycemia episodes that were reported prior
to admission with HISS.
- restarted duloxetine upon discharge to avoid withdrawal
- per ___, considering ___ or ___ as outpatient
#Bipolar disorder/depression: continued home olanzapine
#COPD/shortness of breath: No hx of CHF per notes but CXR showed
e/o mild pulm edema following 3L normal saline administered in
the ED, no diuresis required during admission. No evidence of
COPD exacerbation throughout admission. Flu negative.
Continued home meds.
#Hypothyroidism: Continued levothyroxine at current dose of 175
mcg daily recent TSH 0.74 on ___ and within normal limits.
#Hypertension: Continued home propranolol
#Transitional:
- continued follow up with the neurocognitive/psych providers as
outpatient
- restart home medications in a stepwise fashion with the
assistance of outpatient psych/neurocognitive providers/PCP
- ___ code
- follow up with PCP
> 30 minutes spent on discharge day services, counseling,
coordination of care
Medically stable for discharge home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain
2. Albuterol Inhaler 1 PUFF IH ___ Shortness of breath
3. Docusate Sodium 100 mg PO BID:PRN cONSTIPATION
4. Duloxetine 60 mg PO BID
5. Gabapentin 800 mg PO TID
6. Gabapentin 800 mg PO QHS
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Lithium Carbonate 300 mg PO BID
9. Pravastatin 10 mg PO QPM
10. Propranolol 40 mg PO TID
11. Ranitidine 150 mg PO BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
13. LidoPatch ___ % topical BID:PRN Shoulder
pain
14. OLANZapine 5 mg PO BID
15. Glargine 12 Units Breakfast
Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. ___ Diskus (100/50) 1 INH IH BID
17. HydrOXYzine 25 mg PO QAM, QLUNCH AND 50 MG QHS
18. Loratadine 10 mg PO DAILY
19. ___ 1 Appl TP APPLY TO AFFECTED
AREA OF SKIN ON BACK DAILY AS NEEDED
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain
2. Albuterol Inhaler 1 PUFF IH ___ Shortness of breath
3. Docusate Sodium 100 mg PO BID:PRN cONSTIPATION
4. ___ Diskus (100/50) 1 INH IH BID
5. HydrOXYzine 25 mg PO TID:PRN agitation
6. Glargine 10 Units Breakfast
Glargine 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Levothyroxine Sodium 175 mcg PO DAILY
8. OLANZapine 5 mg PO BID
9. Propranolol 40 mg PO TID
10. Ranitidine 150 mg PO BID
11. Duloxetine 60 mg PO BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
13. Loratadine 10 mg PO DAILY
14. Pravastatin 10 mg PO QPM
15. LidoPatch ___ % topical BID:PRN Shoulder
pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aseptic Meningitis,
___ Body Dementia
Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for headache, fever, and you had a lumbar
puncture done which showed that you had aseptic meningitis,
which was likely due to a viral illness.
Your hospital course was complicated by confusion relating to
your underlying ___ body dementia, which was improving prior to
going home.
Please make sure to follow up with your primary care doctor and
your psychiatrist to slowly restart all of your home
medications, as many of them were stopped when you were
admitted.
We wish you the best.
Followup Instructions:
___
|
10497097-DS-13 | 10,497,097 | 28,483,352 | DS | 13 | 2162-02-12 00:00:00 | 2162-02-12 20:42:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Chantix / tramadol / Iodinated Contrast Media - IV
Dye / levofloxacin / lisinopril / Benadryl / Geodon / Geodon
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male, past medical history of Type 1 diabetes
mellitus, hypothyroidism, hypothyroidism, ___ of aspiration
pneumonia, and bipolar disorder on lithium, Depression,
presenting with tachycardia and fever to ___ F. Associated with
a cough earlier in the week. Began earlier today while shopping.
Main complaints was feeling very cold. Developed a headache and
wife gave him ___. Denies any sick contacts, abdominal pain,
nausea, or vomiting. In the emergency department he received 2
liters of normal saline, 1 gram of Ceftriaxone, 30 mg of
Toradol, and Azithromycin 500 mg. Patient being admitted to the
MICU for tachycardia.
In ED initial VS: Temp: 101.9 HR: 147 BP: 154/91 RR: 18 SO2: 94%
RA
Exam: Decreased breath sounds in left lower lobe
Patient was given: as above
Imaging notable for: possible bl lower lobe pna, mild
congestion
Consults: respiratory for flu swab
VS prior to transfer: Temp: 99.7 HR: 134 BP: 110/51 RR: 20 SO2:
96% RA
On arrival to the MICU, Patient was stable. Saturating 94% on
Room air. Has pleuritic chest pain on the left side. No
shortness of breath. Had recent hospitalization in ___ at
___ requiring intubation for 1 week for pneumonia.
Has been told he has aspiration risk from speech therapist.
Recent addition of lorazepam to medication list. Otherwise feels
well except for being tired. Currently being worked up for ___
Body Dementia
Past Medical History:
-ENDOCRINE
Diabetes mellitus type 1 c/b diabetic retinopathy and neuropathy
Hypothyroidism
-PULM
COPD
-GI
Gastritis
-HEME
Anemia
-PSYCH
Bipolar disorder
Past episode of lithium toxicity
Major depression
-NEURO
Cognitive impairment, possible ___ Body dementia
Tension headaches
?Seizures - attributed to hypoglycemic episodes
Chronic small vessel ischemic CNS disease per MRI ___
-INFECTIOUS
Pneumonia (presented with confusion) ___ aspiration
SURGERY:
s/p Lower jaw tooth extractions ___
s/p both cervical spine surgery and lumbar (Laminectomy L4-L5)
spine surgery around ___ per the patient for back pain
Hernia repair
Appendectomy
Carpal tunnel surgery
Social History:
per prior notes/discussion with patient and family:
-born ___, large ___ family, lives with wife in
___
-retired ___, worked two nights per week as
___, wife works 6 days/week as ___, has
SSDI. He stays at home all day while she goes to work.
-grown daughter (___) and son (___), close to family
-pt does ___
-per family, no history of violence, legal troubles
SUBSTANCE ABUSE:
-EtOH: Life-long, never detox, never sz or DTs, no admitted
problem with EtOH. Stopped ETOH when diagnosed with Bipolar
disorder, denies drinking currently.
-cocaine:Distant
-opiates: prescribed, history of buying from the street but
denies recently
-former smoker, ___ pk years
Family History:
Per ___ DC summary:
Mother Living ___ DIABETES TYPE I
Father ___ ___ DIABETES TYPE II, PROSTATE CANCER
Brother Living ___ HEALTHY
Brother ___ ___ ALCOHOLIC CIRRHOSIS
Sister Living ___ HYPOTHYROIDISM
Physical Exam:
Admission Physical Exam:
VITALS: HR: 119 BP: 96/50 RR: 16 SO2: 95% on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilateral lower lobe crackles
CV: Tachycardia, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no ___ edema
SKIN: No rashes, flushed face
NEURO: Moves all extremity, Sensation intact, no tremor
ACCESS: PIV
Discharge:
==========
VS: 98.1 PO 153 / 83 R Lying 87 18 96 RA
Gen: Well nourished, well developed, no acute distress
HEENT: Multiple old scars, EOMI, PERRL, masklike faces, tardive
dyskinesia, protrudes tongue midline
NECK: Posterior cervical midline scar, limited extension, no LAD
CV: Regular, S1 + S2, no m/r/g appreciated
PULM: Coarse BS bilaterally with decreased air movement,
somewhat diminished over left lower lung field posteriorly,
bibasilar crackles and LLL egophony
ABD: Soft, NT, ND, BS+
EXT: WWP, no c/c/e
NEURO: CNII-XII intact w/ decreased smile, Strength ___,
sensation intact to light touch in distal ext, negative Romberg
Pertinent Results:
ADMISSION:
==========
___ 09:48PM URINE HOURS-RANDOM
___ 09:48PM URINE UHOLD-HOLD
___ 09:48PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:21PM ___ PO2-45* PCO2-32* PH-7.48* TOTAL
CO2-25 BASE XS-0
___ 09:21PM LACTATE-2.5* K+-3.7
___ 09:21PM O2 SAT-82
___ 09:20PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 09:13PM GLUCOSE-58* UREA N-15 CREAT-0.9 SODIUM-133
POTASSIUM-6.3* CHLORIDE-100 TOTAL CO2-20* ANION GAP-19
___ 09:13PM estGFR-Using this
___ 09:13PM cTropnT-<0.01
___ 09:13PM proBNP-31
___ 09:13PM D-DIMER-1000*
___ 09:13PM LITHIUM-0.5
___ 09:13PM WBC-10.0 RBC-4.58* HGB-14.5 HCT-42.6 MCV-93
MCH-31.7 MCHC-34.0 RDW-15.5 RDWSD-53.0*
___ 09:13PM NEUTS-90.3* LYMPHS-5.8* MONOS-3.1* EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-9.06*# AbsLymp-0.58* AbsMono-0.31
AbsEos-0.03* AbsBaso-0.02
___ 09:13PM PLT COUNT-388
OTHER LABS:
===========
___ 05:16AM BLOOD WBC-13.6* RBC-4.10* Hgb-12.9* Hct-38.9*
MCV-95 MCH-31.5 MCHC-33.2 RDW-15.6* RDWSD-54.8* Plt ___
___ 06:00AM BLOOD WBC-15.4* RBC-3.91* Hgb-12.2* Hct-36.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-16.0* RDWSD-55.4* Plt ___
___ 05:16AM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
___ 06:00AM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-108 HCO3-22 AnGap-14
___ 09:13PM BLOOD cTropnT-<0.01
___ 05:16AM BLOOD cTropnT-<0.01
___ 09:13PM BLOOD D-Dimer-1000*
___ 09:20PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICRO:
======
___ 11:08 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
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.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 11:00 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 7:50 am Rapid Respiratory Viral Screen & Culture
Source: Nasal swab.
Respiratory Viral Culture (Pending):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 11:53 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
___ 7:51 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING:
=========
___ 9:10 ___
CHEST (PORTABLE AP)
IMPRESSION:
Patchy ill-defined bibasilar opacities may reflect areas of
aspiration or
infection. Probable mild pulmonary vascular congestion.
___ at 09:56
Portable TTE (Complete)
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 60 %). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta and aortic arch are 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. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified. Mildly dilated thoracic
aorta.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
___ 3:05 ___
VIDEO OROPHARYNGEAL SWALLOW
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is aspiration of thin
consistency barium, which is
improved by chin-tuck maneuver. There is intermittent
aspiration of nectar consistency barium. No aspiration or
penetration is seen with solid consistency barium.
DISCHARGE:
==========
___ 06:18AM BLOOD WBC-9.2 RBC-3.59* Hgb-11.2* Hct-34.2*
MCV-95 MCH-31.2 MCHC-32.7 RDW-16.1* RDWSD-57.1* Plt ___
___ 06:18AM BLOOD Glucose-202* UreaN-7 Creat-0.8 Na-141
K-4.4 Cl-107 HCO3-21* AnGap-17
Brief Hospital Course:
Mr. ___ is a ___ y/o M with past medical history of Type 1
diabetes mellitus, hypothyroidism, COPD, history of aspiration
pneumonia, and bipolar disorder on lithium/ziprasidone,
presenting with fever, cough and CXR found to have PNA.
Initially, admitted to ICU w/ tachycardia to 147; started on
vanc/cefepime. Condition was stable and transferred to the
floor. Continued on vanc/cefepime. Video swallow study
demonstrated silent aspiration. Flue -ve, MRSA swab -ve, Urine
legionella -ve. Patient was instructed in safe swallowing
procedures and discharged home with speech therapy. He also was
instructed to complete oral levofloxacin for a 7d course. He had
an episode of hypoglycemia on day prior to discharge ___
inadequate PO, and was advised to eat regularly.
Brief MICU Course (___)
===============================
Patient was admitted to the MICU for persistent tachycardia in
the emergency department during the night of ___. Symptoms
seemed most likely related to a possible aspiration pneumonia
secondary to history of aspirations, fever, chills, fluid
responsive tachycardia, and mild pleuritic pain. Patient is
allergic to IV contrast and V/Q scan was decided against at this
time even in the setting of elevated D dimer with negative
cardiac markers and a normal echo. Patient was covered with
Cefepime, Vancomycin, and Azitrhomycin with ___ being day 1 of
antibiotics. Plan was to cover broadly for 48 hours while we
awaited culture data. Patient was stable overnight and his heart
rate improved. He was slowly weaned of his oxygen. He was called
out to the floor on the morning of ___.
MEDICINE COURSE:
================
# Sepsis secondary to PNA: As above, likely mechanism
aspiration. Treated with vanc/cef and narrowed to levoflox on
___ after MRSA swab returned negative. As below, levoflox was
then switched to clindamycin to complete the course.
# possible history of levofloxacin allergy: patient has a
history of a possible allergy to levofloxacin, reaction listed
as rash but that the rash was present before levoflox (thought
___ contrast he received earlier) and the rash reportedly
worsened after getting the levofloxacin. He was sent home with a
dose of levofloxacin to complete his course as above. He
tolerated that single dose on day of discharge (at home) well
but given concern that further problems could result, this was
switched to clindamycin out of an abundance of caution. He is
therefore to complete the course of abx with clindamycin for 4
more days.
# History of Aspiration: Patient currently being worked up for
___ Body Dementia which may be contributing to aspiration
events. He was seen by speech and swallow and underwent a video
swallow. He had oropharyngeal dysphagia and silent aspiration.
Chin tuck reduced risk but still had some aspiration even with
this. Additionally, the patient was noted not to use this
strategy consistently unless cued. Of note, the patient was
obsereved to have tremulous movements of tongue and laryngeal
musculature at rest. Given that any diet would be risky, he was
given teaching on ways to reduce risk (as below). He should
follow up with neurology and can consider ENT evaluation as
well.
# Dilated ascending aorta: TTE on ___ showing a mildly
dilated ascending aorta.
# Depression with ? ___ Body Dementia:
# Bipolar Disorder:
Symptoms well controlled at home, however patient appeared to be
having flushing reaction w/ ziprasidone. He was also noted to
have some tardive dyskinesia on exam. Spoke w/ Dr. ___
___ who recommended discontinuing ziprasidone given concern
that he may have had some swelling in his face after taking this
medication, so this was discontinued and also listed as
allergy--patient and wife both aware of such. Seen by PACT in
house who recommended other medication reconciliation
corrections.
# Hypertension: Initially held amlodipine, okay to restart on
discharge.
# T1DM (lantus 10QAM, 24QPM and ISS): Patient wa hypoglycemic to
48 o/n from ___. This was in the setting of low PO intake
after the barium swallow study. Decision made not to adjust
insulin regimen because patient was going home to resume normal
diet and reports checking his BS levels 10x/d.
# Chronic conditions for which home medications were continued:
Hypothyroidism, COPD, Hyperlipidemia, GERD, Pain management
TRANSITIONAL:
=============
[] Antibiotics - complete 7d course for PNA (day 1: ___, day 7:
___
[] Swallow recommendations on discharge:
-CHIN TUCK. MUST be used with all liquids
-Swallow 2x per bolus with head in a chin tuck position
-Avoid straws
-Sit upright for all PO
-Small bites/sips
3. Medications whole in pureed solids
4. TID oral care
[] Med changes: ziprasidone discontinued and listed as allergy,
abx as above
[] Insulin titration: 1 episode of hypoglycemia (48) o/n
___, please consider if patient needs further adjustment
[] Consider medication titration of gabapentin for neuropathy
[] Mildly dilated ascending aorta - f/u chest imaging in ___ yrs
___ or later)
[] Consider ENT referral for swallow evaluation
[] Ensure neurology evaluates swallow as well
[] Ensure patient follows up with psychiatry to consider a new
medication in place of previous ziprasidone
[] Consider allergy testing given his several allergies,
including a questionable allergy to levofloxacin
---------------
# Communication: HCP: Wife
# Code: Full Code (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4-6H:PRN wheezing
2. amLODIPine 5 mg PO DAILY
3. DULoxetine 60 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Glargine 10 Units Breakfast
Glargine 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Levothyroxine Sodium 175 mcg PO 6X/WEEK (___)
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Lithium Carbonate 300 mg PO BID
9. Pravastatin 10 mg PO QPM
10. Ranitidine 150 mg PO BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. ZIPRASidone Hydrochloride 20 mg PO QAM
13. ZIPRASidone Hydrochloride 20 mg PO NOON
14. ZIPRASidone Hydrochloride 40 mg PO QPM
15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
16. Aspirin 81 mg PO DAILY
17. Docusate Sodium 100 mg PO BID:PRN constipation
18. Loratadine 10 mg PO DAILY:PRN allergies
19. Simethicone 120 mg PO QID:PRN gas
20. LORazepam 1 mg PO QHS:PRN anxiety, insomnia
21. LORazepam 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
2. Glargine 10 Units Breakfast
Glargine 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler 1 PUFF IH Q4-6H:PRN wheezing
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. DULoxetine 60 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Levothyroxine Sodium 175 mcg PO 6X/WEEK (___)
11. Lidocaine 5% Patch 1 PTCH TD DAILY
12. Lithium Carbonate 300 mg PO BID
13. Loratadine 10 mg PO DAILY:PRN allergies
14. LORazepam 1 mg PO QHS:PRN anxiety, insomnia
15. LORazepam 0.5 mg PO DAILY:PRN anxiety
16. Pravastatin 10 mg PO QPM
17. Ranitidine 150 mg PO BID
18. Simethicone 120 mg PO QID:PRN gas
19. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Aspiration pneumonia
SECONDARY DIAGNOSES:
=====================
Type 1 diabetes mellitus
Hypothyroidism
Bipolar disorder on lithium
Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
pneumonia.
What was done during this hospitalization?
- You were admitted to the Intensive Care Unit because you had a
very fast heart rate
- You were treated with antibiotics and fluids, and your
condition improved
- You left the ICU and continued intravenous antibiotics
- You had a swallow study that showed you are aspirating when
you eat
- The swallow specialists have made specific recommendations
about safe eating for you
- Your condition is stable and you are safe to go home
What should you do now that you are leaving the hospital?
- Tuck you chin with every swallow, and always swallow twice
- Take your medications as prescribed
- Attend your follow-up appointments
- Work with the swallowing specialist at home to improve your
swallowing
- Return to the hospital if you develop new or concerning
symptoms
It was a pleasure taking care of you. Wishing you the best in
health!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10497215-DS-12 | 10,497,215 | 28,865,662 | DS | 12 | 2209-11-10 00:00:00 | 2209-11-10 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ y/o F with PMH significant for severe AS,
HTN, DM II, Fe deficiency anemia, advanced dementia who is
presenting for worsening hyperglycemia and hypertension.
Of note, patient was recently admitted from ___ for
hypertension. Her antihypertensives were uptitrated (regimen of
amlodipine 5 mg in the morning, metoprolol succinate 50 mg in
the
morning, lisinopril 30 mg in the evening). TTE demonstrated
severe aortic stenosis and preserved ejection fraction. After
discussions with her healthcare proxy, it was clear that the
procedure was not within the patient's goal of care.
She presents to ED from her day facility with hyperglycemia and
hypertension. Today her day nurse reports BPs 200's/100's wth
FSBG >500. She had received her normal meds in the morning,
including 5mg glipizide, 20mg Lasix, 5 mg amlodipine. At 10AM
she
received 10mg lisinopril.
In the ED, she was found hypertensive, although less
hypertensive
than reported at home. She also was found to have significant
hyperglycemia with blood sugars greater than 400. Workup
revealed a urinalysis that was concerning for infection, she
received 1 dose of cefpodoxime. She was also found to have a
lactate of 3.9, but was otherwise hemodynamically stable and had
no evidence of shock.
- Initial vitals: 97.8 76 167/70 16 100% RA
- Labs/studies notable for: WBC 12, lactate of 3.9
- Patient was given:
___ 14:28 IV Insulin Regular 10 units
___ 17:35 PO/NG Cefpodoxime Proxetil 200 mg
___ 18:15 IVF LR 500 cc
On the floor, the patient was seen with her daughter at bedside.
The patient has no current complaints outside of minor pain in
her legs. She denies any significant chest pain or shortness of
breath. She denies any symptoms of dysuria. Daughter notes
that
outside of being sleepier than usual on the evening of ___,
mental status is at baseline.
REVIEW OF SYSTEMS:
10 point ROS completed and negative except as above
Past Medical History:
-Diabetes
-Hypertension
-Dyslipidemia
-Dementia
-Angioectasias of the cecum
-Hepatitic C
-GERD
Social History:
___
Family History:
no known family history of CAD
Physical Exam:
ADMISSION PHYSICAL:
VITALS: ___ 2241 Temp: 98.1 PO BP: 179/73 R Lying HR: 77
RR: 18 O2 sat: 94% O2 delivery: Ra
GEN: NAD
HEENT: Conjunctiva clear, PERRL, MMM, eyelid drooping on right
(baseline per daughter)
NECK: No JVD noted
LUNGS: CTAB
HEART: RRR, nl S1, S2. III/VI SEM
ABD: NT/ND, no suprapubic tenderness
EXTREMITIES: No edema. WWP.
SKIN: No rashes.
NEURO: AOx1-2 (person, sometimes place, not date). ___ Strength
in UE and ___.
DISCHARGE PHYSICAL:
97.7 PO 162 / 63 R Sitting 77 20 94 ra
Gen: elderly women, curled in bed, NAD
CV: RRR, III/VI systolic murmur at USB
PULM: Mild crackles at bases b/l, normal work of breathing, no
wheezes
ABD: soft, NT, ND
EXT: no ___ edema, WWP
Neuro: alert, interactive, oriented to person but not place or
date
Pertinent Results:
ADMISSION LABS:
===========
___ 10:36AM BLOOD WBC-11.6* RBC-3.35* Hgb-9.5* Hct-31.0*
MCV-93 MCH-28.4 MCHC-30.6* RDW-13.1 RDWSD-44.6 Plt ___
___ 01:53PM BLOOD ___ PTT-27.9 ___
___ 10:36AM BLOOD Glucose-487* UreaN-38* Creat-1.0 Na-143
K-4.1 Cl-104 HCO3-21* AnGap-18
___ 10:36AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.4
___ 02:30PM BLOOD Lactate-3.9*
___ 05:16PM BLOOD Lactate-3.8*
___ 07:29AM BLOOD Lactate-2.3*
___ 02:30PM BLOOD pO2-100 pCO2-43 pH-7.39 calTCO2-27 Base
XS-0 Comment-GREEN TOP
INTERVAL LABS:
=========
___ 05:44AM BLOOD ALT-20 AST-29 AlkPhos-123* TotBili-0.3
DISCHARGE LABS:
===========
___ 10:14AM BLOOD WBC-8.2 RBC-3.57* Hgb-10.0* Hct-33.5*
MCV-94 MCH-28.0 MCHC-29.9* RDW-13.1 RDWSD-44.8 Plt ___
___ 10:14AM BLOOD Glucose-286* UreaN-27* Creat-0.8 Na-142
K-4.6 Cl-107 HCO3-22 AnGap-13
___ 10:14AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9
MICROBIOLOGY:
==========
___ 3:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
=======
CXR ___
No acute cardiopulmonary process.
Brief Hospital Course:
Ms ___ is a ___ y/o F with PMH significant for severe AS,
HTN, DM II, Fe deficiency anemia, advanced dementia presenting
with hyperglycemia and hypertension, found to have sepsis from
UTI, dehydration, and hypertensive urgency.
ACUTE ISSUES:
=============
# Sepsis
# UTI
# Dehydration
# Hx ESBL E coli in urine
Patient presenting with + urinalysis (leuk esterase, WBC,
bacteria), in the setting of leukocytosis and hyperglycemia.
Patient unable to report any urinary symptoms but has dementia.
Question of encephalopathy initially. She remained hypertensive
but initially with elevated lactate of 3.9, normalized with IVF,
treatment of
hyperglycemia, and holding diuretics. Initially she was on
ceftriaxone, then on cefpodoxime. Discharged with Cefpodoxime
for 7d total course starting ___ to end ___.
#New HFpEF:
EF 59% likely ___ hypertension and valvular dysfunction. Lasix
20 mg was held as above for infection. Lasix held on discharge,
with plan for close volume ___ with ___ at home, and also
has close PCP ___. Amlodipine/Lisinopril as above,
continued metoprolol succinate 25 mg daily.
# DM II with Hyperglycemia
# c/f HHS
A1c 5.9% ___. Hyperglycemia to 500 on presentation most likely
related to infection, however could be having highs/lows with
glipizide. Held home PO anti-hyperglycemics initially and used
ISS and hydration. Transitioned back to glipizide day prior to
discharge.
# Hypertensive Urgency
SBPs were elevated on recent admission to 180s at times. Was
over 200s this admission. She remained asymptomatic. Home
regimen was recently uptitrated on her prior admission
(Lisinopril 20 mg to 30 mg daily) so unclear if this had time to
take effect. Given continued hypertensive, amlodipine was
increased from 5 to 7.5 mg daily.
# Insomnia
Due to concern for encephalopathy, her zolpidem was held. She
experienced some insomnia which was treated with ramelteon and
trazodone PRN. Delirium precautions were instituted. Zolpidem
held as well on discharge due to concern for deliriogenic
effect.
CHRONIC ISSUES:
===============
# Severe AS
The patient's most recent admission she was found to have severe
aortic stenosis. After discussion with family, it was determined
that no intervention is within her goals of care, so she was
discharge on medical management.
# Advanced Dementia
Per family, patient's baseline mental status is AOx1-2, she is
completely dependent of all ADLs. Her mental status remained
close to her baseline soon after admission.
# CAD: Continued atorvastatin
# Fe Deficiency Anemia: Held iron for infection, please resume
after completion of antibiotics.
# GERD: Continued omeprazole
# CODE STATUS: DNR DNI
# Contact ___, Relationship: daughter Phone:
___
TRANSITIONAL ISSUES:
===============
Antibiotics: Cefpodoxime 100 mg Q12H, D1 = ___, last day = ___
[] ___: please check labs ___ to ensure renal function stable,
and fax to ___., MD ___: ___)
[] Consider resuming diuretics at ___ ___
[] Consider discontinuing zolpidem permanately given age and
advanced dementia.
[] Amlodipine was increased from 5 to 7.5 mg daily.
[] Held iron supplement for infection, consider resume after
completion of antibiotics.
[] Creon tablets held on discharge as unclear indication, please
resume if indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lisinopril 30 mg PO QPM
7. Omeprazole 20 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Creon (lipase-protease-amylase) 3,000-9,500- 15,000 unit
oral BID
11. GlipiZIDE 2.5 mg PO DAILY
12. melatonin 5 mg oral QHS:PRN insomnia
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 3 Days
Last day ___
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*5 Tablet Refills:*0
2. amLODIPine 7.5 mg PO DAILY
RX *amlodipine 5 mg 1.5 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
4. Atorvastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO DAILY
6. GlipiZIDE 2.5 mg PO DAILY
7. Lisinopril 30 mg PO QPM
8. melatonin 5 mg oral QHS:PRN insomnia
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. HELD- Creon (lipase-protease-amylase) 3,000-9,500- 15,000
unit oral BID This medication was held. Do not restart Creon
until speaking to your PCP
12. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until you finish
antibiotics
13. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until speaking to your physician
14. HELD- Zolpidem Tartrate 5 mg PO QHS This medication was
held. Do not restart Zolpidem Tartrate until speaking to your
physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
UTI, complicated, sepsis
T2 DM with hyperglycemia
Dehydration
Hypertensive urgency
Secondary:
chronic diastolic heart failure
dementia
severe AS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with high blood sugar, high blood
pressure, and a urinary tract infection. You were very
dehydrated from your infection and from taking Furosemide.
While you were here, you received antibiotics to treat the
infection and fluids through an IV. Your blood sugar got better
with insulin and treating the infection. Your blood pressure
medicine was increased to help with blood pressure.
After you leave the hospital, please:
- see below for your appointments
- see below for your medicines
- keep a close eye on your blood pressure at home and call your
doctor if it the top number is above 160 routinely
- keep an eye on your weight and your legs. If your weight
starts to go up and your legs look puffy, call your doctor
- check your blood sugar before meals and call your doctor if it
goes below 70 or above 200
It was a pleasure caring for you and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
10497215-DS-13 | 10,497,215 | 24,692,761 | DS | 13 | 2209-11-27 00:00:00 | 2209-11-27 22:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough, dyspnea, leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMH significant for severe AS, HTN, DM II, Fe
deficiency anemia, advanced dementia with a recent admission for
hyperglycemia and hypertension secondary to urosepsis presenting
today with cough, dyspnea, leg swelling. Patient is unable to
provide any history, but per the daughter, the patient has had
worsening leg swelling over the past few days with a
nonproductive cough and mild subjective shortness of breath. She
denies fevers, vomiting diarrhea. The daughter is unable to
describe any additional symptoms.
In the ED, vitals were: temp 97, HR 63, BP 167/64, RR 20, 99% RA
Exam:2+ edema to the knees bilaterally, 2+ DP pulses. Crackles
at the bilateral bases, left greater than right.
Labs: Hg 10.3, proBNP ___, AP 117, BUN 25, Cr 0.7, Lactate 2.5
flu A positive
Studies:
UA: large leuks, positive nitrite, moderate bacteria, 62 WBC
CXR: Mild pulmonary edema with bibasilar streaky atelectasis.
EKG: RBBB, slight peaked Ts but otherwise not largely changed
They were given: ceftriaxone, lasix 20mg IV x1
On admission to the floor, the patient's daughter explains the
patient has been short of breath for several days. Daughter
notes that following last hospitalization, she noted worsening
___ and ___ PCP recommended restarting home lasix so she has
been on her home lasix for over a week with ongoing worsening of
___ and dyspnea. She does not believe the patient was having
fever,
chills or urinary symptoms at home.
Past Medical History:
-Diabetes
-Hypertension
-Dyslipidemia
-Dementia
-Angioectasias of the cecum
-Hepatitis C
-GERD
Social History:
___
Family History:
No known family history of CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 97.3 PO BP: 177/73 HR: 62 RR: 20 O2
sat: 97% O2 delivery: RA
GENERAL: Alert but not oriented.
HEENT: PERRL. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. III/VI
systolic murmur.
LUNGS: crackles at lung bases bilaterally. Expiratory wheezing
diffusely. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: ___ dependent pitting edema in ___ ___.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
========================
Temp: 97.8 Axillary BP: 147/73 R Lying HR: 76 RR: 18 O2 sat: 95%
ra
GENERAL: Asleep, easily arousable.
HEENT: MMM. JVP not visible at 30 degrees
CARDIAC: RRR. III/VI systolic murmur.
LUNGS: CTAB anteriorly with poor effort
ABDOMEN: S/NT/ND.
EXTREMITIES: no pitting edema in BLE.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS
==========================
___ 02:04PM BLOOD WBC-7.8 RBC-3.71* Hgb-10.3* Hct-34.0
MCV-92 MCH-27.8 MCHC-30.3* RDW-12.7 RDWSD-42.2 Plt ___
___ 02:04PM BLOOD Neuts-52.1 ___ Monos-9.7 Eos-2.4
Baso-0.8 Im ___ AbsNeut-4.08 AbsLymp-2.70 AbsMono-0.76
AbsEos-0.19 AbsBaso-0.06
___ 02:20PM BLOOD ___ PTT-32.6 ___
___ 02:04PM BLOOD Glucose-335* UreaN-25* Creat-0.7 Na-135
K-4.7 Cl-102 HCO3-22 AnGap-11
___ 02:04PM BLOOD ALT-17 AST-30 AlkPhos-117* TotBili-0.2
___ 02:04PM BLOOD proBNP-2131*
___ 02:04PM BLOOD cTropnT-<0.01
___ 02:04PM BLOOD Albumin-3.6 Calcium-9.2 Phos-4.0 Mg-1.8
___ 02:32PM BLOOD Lactate-2.5*
RELEVANT IMAGING
==========================
___ CXR PA/LAT
Mild pulmonary edema with bibasilar streaky atelectasis.
RELEVANT MICRO
==========================
___ URINE CULTURES
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ BLOOD CULTURES X2: NO GROWTH
DISCHARGE LABS
==========================
___ 04:32AM BLOOD WBC-9.8 RBC-3.56* Hgb-9.7* Hct-32.3*
MCV-91 MCH-27.2 MCHC-30.0* RDW-12.9 RDWSD-42.5 Plt ___
___ 04:49AM BLOOD Glucose-165* UreaN-37* Creat-0.9 Na-145
K-4.3 Cl-109* HCO3-23 AnGap-13
___ 04:49AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8
Brief Hospital Course:
====================
PATIENT SUMMARY
====================
The patient is a ___ with h/o critical aortic stenosis, HTN, DM
II, Fe deficiency anemia, advanced dementia who is presenting
with cough, dyspnea and leg swelling found to have influenza A,
presumed UTI and HFpEF exacerbation. Course c/b concern for
significant GIB, however repeat CBCs were relatively stable. She
was treated with oseltamivir for the flu, ceftriaxone for her
presumed UTI, and gentle IV Lasix for her HFpEF exacerbation.
Goals of care discussion were initiated given her poor prognosis
from her critical AS and advanced dementia. She was discharged
to rehab with plan to potentially transition to hospice.
====================
TRANSITIONAL ISSUES
====================
[] Goals of care: Discussion was initiated given critical aortic
stenosis (based on development of HFpEF recently) and advanced
dementia. The patient's HCP, her daughter, agreed with potential
transition to hospice. Please continue to assess her clinical
status and assist in transition to hospice when clinically
appropriate. Palliative Care involvement may be appropriate.
[] MOLST: Patient is DNR/DNI. The daughter/HCP had noted that
she would like her mother to not be given artificial nutrition
or be put on hemodialysis, but she is amenable to artificial
hydration. Please continue to discuss goals of care; there is
interest in potential transition to hospice.
[] During prior hospitalization, patient's oral furosemide was
discontinued. By discharge, she was not on standing oral
diuretics given poor PO intake. Please continue to monitor
volume exam and restart Lasix 20 mg PO as needed.
[] Mirtazapine: The patient was started on mirtazapine for
insominia and poor appetite. Her prior zolpidem tartrate 5mg at
night was stopped. Please continue to assess for her clinical
status and determine whether her mirtazapine should be increased
in dose vs. switching back to zolpidem.
[] Iron deficient anemia: Given 500mg IV ferric gluconate this
admission. She may benefit from additional IV iron repletion
depending on clinical status for a total of 1g.
====================
ACUTE ISSUES
====================
# HFpEF exacerbation
# Critical aortic stenosis
# Hypertension
# Coronary artery disease
Presented with mildly elevated JVP, mild pulmonary edema, ___
bilateral lower extremity edema in the setting of not being
discharged on an oral diuretic previously and increasing leg
swelling at home which was not controlled with oral furosemide.
Weight and I/O could not be tracked reliably. Given IV Lasix
20mg with good result, then transitioned to PO Lasix 20mg
briefly. Home antihypertensives were continued. Metoprolol was
stopped given HR in the ___ (and hence unlikely to provide
benefit for AS), atorvastatin stopped as well (given poor
prognosis). Patient was noted to have poor PO intake, and hence
oral diuretics were stopped toward the end of the admission. She
may benefit from PRN dosing of PO Lasix 20mg based on clinical
exam.
# Advanced dementia
Continued home zolpidem per daughter/HCP's strong preference, as
it calms down her mother. Replaced melatonin with Ramelteon
while admitted. Patient was noted to have poor PO intake, and
zolpidem 5mg home dose was switched to mirtazapine for sleep and
appetite stimulation.
# Chronic iron-deficiency anemia
# Concern for significant upper GI bleed
Patient has chronic iron deficiency anemia. This admission was
noted to have dark stool (in the context of being on oral iron)
which was guaiac positive. Repeat CBC stable. Per review of OMR
records, her daughter/HCP had previously declined endoscopy for
her mother given her poor health overall. Given 500mg IV ferric
gluconate this admission.
# Influenza A infection
Likely contributed to cough and dyspnea. Treated with renally
dosed oseltamivir for 5 days. No clinical evidence of bacterial
pneumonia.
# Presumed urinary tract infection
UA with large leuks, positive nitrites, 62 WBC, moderate
bacteria, 1 epithelial cell. Patient could not tell us whether
she had symptoms, though she was incontinent, unclear if worse
than baseline. Urine culture with mixed flora. Treated with 3d
ceftriaxone for uncomplicated UTI.
# T2DM
Had prior admission for hyperglycemia. Home oral antiglycemics
were held on admission. Was put on insulin sliding scale here
with sufficient glycemic control.
# Goals of care
Patient was felt to have a poor prognosis given critical AS and
advanced dementia. Had multiple hospitalizations recently and
significant functional decline. Had presented with home this
admission. Daughter/HCP did not want aggressive measures for her
mother. Confirmed that she was DNR/DNI. Additionally, patient's
daughter did not want her mother to have artificial nutrition or
dialysis. Did want future hospitalizations if indicated,
non-invasive ventilation, and IV hydration. HCP also agreed with
potential transition to hospice from rehab.
#CODE: DNR/DNI
#CONTACT:Name of health care ___
Phone ___
Cell ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 7.5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Docusate Sodium 100 mg PO DAILY
5. Lisinopril 30 mg PO QPM
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. melatonin 5 mg oral QHS:PRN insomnia
10. GlipiZIDE 2.5 mg PO DAILY
11. Creon (lipase-protease-amylase) 3,000-9,500- 15,000 unit
oral BID
12. Furosemide 20 mg PO DAILY
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Albuterol 0.083% Neb Soln ___ NEB IH Q6H:PRN wheezing
2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
3. Glucose Gel 15 g PO PRN hypoglycemia protocol
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
5. Mirtazapine 15 mg PO QHS
6. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
7. amLODIPine 7.5 mg PO DAILY
8. Creon (lipase-protease-amylase) 3,000-9,500- 15,000 unit
oral BID
9. Docusate Sodium 100 mg PO DAILY
10. Lisinopril 30 mg PO QPM
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
# Influenza A pneumonia
# Urinary tract infection
# Acute on chronic diastolic HF
# Severe aortic stenosis
# End-stage dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure taking care of you at the ___
___!
WHAT BROUGHT YOU TO THE HOSPITAL?
- You were having a cough, shortness of breath, and leg swelling
at home.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have the flu. You received a medication
(Tamiflu/oseltamivir) to treat it.
- You were found to have an exacerbation of your heart failure.
You received IV Lasix to treat it, before being transitioned to
oral Lasix as needed.
- You were found to have a urinary tract infection. You received
antibiotics for it.
- There was initial concern that you were having significant
bleeding from your gastrointestinal tract. However, your blood
counts were stable, so we felt this to be unlikely.
- We gave you iron through the IV to help improve your blood
counts.
- We and your daughter discussed the fact that your heart is
functioning poorly from your aortic stenosis. To maximize your
comfort, we will plan to transition your care to hospice.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- Please take your medications as prescribed.
- Please monitor the swelling in your legs. If your leg swelling
gets significantly worse, please call your doctor. You may need
to take some Lasix pills to help decrease the swelling.
- Please spend time with your loved ones.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10497294-DS-27 | 10,497,294 | 28,509,541 | DS | 27 | 2150-09-12 00:00:00 | 2150-09-12 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Iodine
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
___: Ureteral Stent removal
History of Present Illness:
___ PKD-ESRD HCV+ s/p cadaveric kidney transplant from high risk
donor ___ has been off HD for ~ 2 wks now with
hyperkalemia. Patient had routine labs today which demonstrated
a potassium of 6.8 (per report, no labs are with the patient).
He was sent to the ED. EKG demonstrated peak T waves in the
anterior leads. He was treated medically with calcium, insulin
and kayexelate. Nephrology and transplant were consulted.
Patient reports making ___ cc of urine a day. He remained on
HD after his transplant but reports being off HD for ~ 2 weeks
now. He still has a tunneled HD line. He is otherwise
asymptomatic. Denies chest pain, SOB, fevers, chills, nausea,
emesis, diarrhea, constipation. Denies burning with urination.
Past Medical History:
ESRD (dialysis since ___, (PD ___ complicated by
recurrent peritonitis, failed LUE AV fistula ___ now s/p
kidney transplant ___
Polycystic kidney disease s/p right nephrectomy ___
Hypertension ___ years
Hepatitis C dx ___ s/p failed interferon treatment ___
L5-S1 discitis, osteomyelitis, epidural abscess ___
enterococcus bacteremia, treated with 10 days of
ampicillin/gentamycin
Endocarditis (___)
Hyperparathyroidism, s/p subtotal parathyroidectomy ___,
revision ___ s/p thyroid lobectomy
Gout (questionable diagnosis but on treatment)
Carotid stenosis
Restless leg syndrome
Depression
Chronic pain syndrome
Social History:
___
Family History:
Mother - diagnosed with DM in her ___
Father - died of drugs and alcohol and pancreatic cancer at ___
3 of 4 or ___ healthy brother
2 children (estranged) - ___nd healthy ___ yo
Physical Exam:
VS: afvss
Gen: NAD, AOx3
___: RRR
Pulm: no disress
Abd: S/NT/ND Incision healing well, no drainage, erythema or
fluctuance.
___: no LLE
Chest: R chest with tunneled HD line, site clean no erythema or
fluctuance
Pertinent Results:
On Admission: ___
WBC-3.4*# RBC-3.21*# Hgb-10.0*# Hct-32.1*# MCV-100* MCH-31.2
MCHC-31.2 RDW-15.7* Plt ___ PTT-34.6 ___
Glucose-105* UreaN-41* Creat-3.7*# Na-135 K-6.5* Cl-111*
HCO3-17* AnGap-14
Calcium-11.3* Phos-1.7*# Mg-2.0
At Discharge: ___
WBC-3.2* RBC-3.28* Hgb-10.2* Hct-32.5* MCV-99* MCH-31.2
MCHC-31.5 RDW-15.8* Plt ___
Glucose-112* UreaN-33* Creat-3.5* Na-141 K-5.4* Cl-108 HCO3-26
AnGap-12
Calcium-10.6* Phos-3.5 Mg-2.2
.
Cholesterol and Triglycerides pending at discharge
Brief Hospital Course:
___ y/o male s/p kidney transplant on ___ with delayed graft
function, off HD for 2 weeks who now presents through the ED
from ___ with hyperkalemia.
The patient underwent transplant kidney ultrasound, findings
were normal vascular waveforms and resistive indices, no
hydronephrosis.
He was treated medically with insulin, dextrose, bicarb,
calcium, and also received kayexalate for the admission
potassium. EKG done on admission showed peaked T waves.
He was placed on telemetry and transferred to the surgical
floor.
Repeat potassium was 5.2
Nephrology was consulted who recommended discontinuing Bactrim
The following day the potassium was again 6.5. This was
medically treated, and patient received further doses of
Kayexalate.
On ___, the urology service came by to d/c the ureteral stent
placed at time of kidney transplant.
Due to continued hyperkalemia, the patient will be converted to
Sirolimus (Rapamycin) as Prograf can cause hyperkalemia. The
patient will be discharged on both agents, follow up potassium
tomorrow, and full labs with trough Prograf and sirolimus levels
on ___.
Patient received pentamidine inhalation on ___
Medications on Admission:
Tacro 8'' (per pt), MMF 250'', Allopurinol ___ mg',
amitriptyline 50 mg qhs, metoprolol 25 mg'', morphine SR 30
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
5. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
6. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(___).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a
day.
11. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig:
Thirty (30) grams PO As directed as needed for hyperkalemia.
12. pentamidine 300 mg Recon Soln Sig: Three Hundred (300) mg
Inhalation once a month: Monthly Inhalation. First dose ___.
13. sirolimus 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily):
First dose given ___.
14. Lasix 20 mg Tablet Sig: ___ Tablet PO once a day.
15. Neupogen 300 mcg/0.5 mL Syringe Sig: One (1) dose Injection
As directed as needed for neutropenia: As needed for
neutropenia.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyperkalemia
s/p kidney transplant with delayed graft function
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, decreased
urine output, dysuria, hematuria, pain over kidney graft, easy
bruising, inability to tolerate food fluids or medications,
increased cough or sputum production
.
Patient being converted off prograf and starting Sirolimus
(Rapamycin) as prograf can cause hyperkalemia. Additionally,
Bactrim is being held and he will start pentamadine inhalation
treatments for PCP ___.
Please have neupogen available as Sirolimus may cause
pancytopenia, and he has already been neutropenic.
The patient should avoid lifting greater than 10 pounds
The dialysis catheter will remain in place, and need will be
re-assessed at next transplant kidney appointment due to history
of delayed graft function in the new kidney transplant.
.
Labs are recommended as follows:
___ Potassium only
___ Full labs to include chem 10, AST, t bili, CBC,
Trough Prograf, Trough Sirolimus (___), urinalysis.
Please fax results to Transplant clinic at ___
.
Patient may take kayexalate PRN for hyperkalemia
He should avoid potassium containing foods to include, potatoes,
tomatoes (and sauce), orange juice, citrus, bananas, dark green
vegetables (broccoli, kale, spinach) nuts and chocolate. Dietary
restrictions will be reassessed once hyperkalemia is resolved.
.
Start on 10 mg lasix PO daily
.
Patient has received first Pentamadine treatment on ___, this
should be given as inhalation once monthly and Bactrim has been
d/c'd. This may be re-evaluated once ___ conversion is complete
and if hyperkalemia resolves.
.
Ureteral stent has been removed from time of kidney transplant
Followup Instructions:
___
|
10497294-DS-33 | 10,497,294 | 22,569,872 | DS | 33 | 2157-09-10 00:00:00 | 2157-09-12 19:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending: ___.
Chief Complaint:
Hand and foot wounds
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is as ___ incarcerated male with ESRD
secondary to PCKD s/p failed kidney transplant in ___ and on HD
___, Hepatitis C (treated), HTN, hx of osteomyelitis/
endocarditis per chart review, and carotid stenosis who is
presenting with approximately 4 months of worsening bilateral
hand and unilateral foot pain swelling and skin breakdown.
He reports no known antecedent trauma to his hands and his feet
but has had progressive pain and discoloration of two fingers on
his right hand, one finger on his left hand, and right big toe.
He reports trying to seek help earlier but was unable to get
medical attention at his ___ facility. The pain has
progressively gotten worse to now ___ pain, limiting his
ability to ambulate and use his hands.
Regarding his ulcers, per outpatient notes, Mr. ___ has a
long
history of manipulative and self-injurious behavior. The wound
on
the right hand started as a small cut likely from trimming his
finger nails. Without adequate wound care or dressing changes,
this progressed into a blister and then further progressed to
the
necrotic lesion.
He had an ultrasound of the right subclavian to rule out
thrombus
and an echo which showed no vegetations. ANCA panel and
cryoglobulins were negative. He had a period where the hand
became edematous and erythematous, with elevated ESR and CRP and
was treated with IV vanco and ceftaz with improvement in the
wound appearance, edema and erythema. Despite this, he continued
to be non-compliant with wound care.
He was seen by Vascular Surgery at ___ and on ___ an
arteriogram was done there showing:
The right subclavian artery axillary and brachial arteries were
all widely patent. The right ulnar artery was the primary
outflow to the hand as the radial artery occluded in the distal
forearm. On the left the subclavian axillary and brachial
arteries were all widely patent. There was reversal of flow
distal to the fistula, the fistula filled very quickly. With
fistula compression the ulnar artery had improved flow and was
the primary runoff to the hand as the radial artery occluded in
the mid forearm. Of note, there was significant sluggish flow
throughout all of his vessels concerning for a possible central
source.
Dr. ___ performed the study, had no good explanation
for the very sluggish flow in this patient whose last EF was
normal. There were no treatable lesions as above.
Dr. ___, the transplant physician who has been managing his
left upper extremity fistula, felt that ligating the fistula
would be recommended in this setting to optimize flow to the
left hand and help healing as much as possible, although patient
has declined in the past. This may be an elective option in the
future.
In the ED, initial vitals:
T 96.0 HR 88 BP 156/77 RR 20 O2 Sat 95% RA
- Exam notable for:
Con: In no acute distress
CV: 3 out of 6 holosystolic ejection murmur
MSK: Secondary digits of right hand, second digit of left hand,
first digit of right foot with ulcerations consistent with dry
gangrene, possible small amount of purulence of second digit of
right hand, swelling of feet bilaterally, all extremities cool
and tender to palpation, digits of hands are tender to palpation
and swollen however are not held in a flexed position can be
fully extended without pain
- Labs notable for:
Chem panel: Na 133, K 5.2, Cl 92, CO2 27, BUN 31, Cr 6.3, Glc
88,
AG 14; extended lytes are normal
CBC: WBC 6.2, Hgb 12.1 with MCV 86, Plt 180
Coags: Normal
LFTs: Normal
UA: 600 protein, 6 WBC
Lactate: 1.5
- Imaging notable for:
XR Bilateral Hands-
Loss of soft tissue at the tip of the right long finger,
possibly
reflecting necrotic changes, with subtle loss of bone at the
terminal phalangeal tuft concerning for focal osteomyelitis.
Left
hand grossly unremarkable.
XR Bilateral Feet-
No evidence of osteomyelitis or soft tissue gas. Soft tissue
swelling noted bilaterally slightly more pronounced on the right
than left.
RLE US:
No evidence of DVT in the right lower extremity.
CXR:
1. No acute intrathoracic process.
2. Dialysis catheter appears well positioned.
Hand surgery was consulted and felt that there was no need for
acute intervention particularly given that patient is afebrile
and does not have an elevated WBC. Recommended IV antibiotics.
- Pt given:
PO oxycodone 5mg
Tylenol 1g
Morphine IV 4mg x 2
IV Vancomycin 1g and Ciprofloxacin 400mg
- Vitals prior to transfer:
HR 74 BP 176/92 RR 16 O2 Sat 95% RA
On the floor, patient reports ___ pain in his right hand
(second and third fingers), left second finger, and right big
toe. He manages his medications by himself and does not have any
issues remembering his medications. He is very hypertensive on
arrival, as he did not get any of his BP medications on ___.
Metoprolol ER and nifedipine ER were given to him early on
arrival to the floor. He denies any headache, dizziness, visual
changes, chest pain, shortness of breath.
ROS:
Specifically denies any fevers, chills, sweats.
Has had some weight loss due to poor appetite.
Has had decreased urine output.
No visual changes, no chest pain, no shortness of breath or
cough.
No nausea, vomiting or diarrhea.
No mood changes.
Otherwise 10-point review of systems negative
Past Medical History:
ESRD due to polycystic kidney disease, on HD ___ to ___ s/p
SCD renal transplant ___
GERD
Hepatitis C, treated with interferon monotherapy then Harvoni
post-transplant
Hypertension
Hyperparathyroidism status post subtotal parathyroidectomy
revision ___, thyroid lobectomy.
Gout.
Carotid stenosis.
Restless legs syndrome.
Depression.
L5-S1 discitis, osteomyelitis, epidural abscess ___
enterococcus bacteremia, treated with 10 days of
ampicillin/gentamycin Endocarditis (___)
Social History:
___
Family History:
Father: ___, pancreatic cancer, alcohol and drug abuse
Mother: ___, diabetes
Sister: CAD
- Most sisters (___ or ___) with DM
Brother: healthy
Son: ___
Physical Exam:
ADMISSION PHYSCIAL EXAM:
========================
VITALS: T 98.1 BP 184 / 93 HR 75 RR 18 O2 Sat 96 ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. No
JVD.
Chest: Has HD catheter tunneled into right chest
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur heard throughout
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present.
Prior transplant scar on right abdomen.
Ext: Warm. Fistula in left arm is in process with scar tissue
proximally and distally. Mild pitting edema up to mid shin R >
L.
No erythema or tenderness to palpation over fistula.
-- RUE: Necrosis of distal tips of R ___ and ___ finger with
tenderness to palpation; pain with passive ROM and active ROM.
Significant nail changes, detached from underlying skin. 2+
radial pulse. Sensation intact.
-- LUE: Necrosis of distal tip of L ___ finger with tenderness
to palpation and again, pain with passive ROM and active ROM.
Radial artery not palpable.
-- RLE: Necrosis of distal R big toe, significant tenderness to
palpation; pain with passive and active ROM. Sensation intact.
Neuro: CNII-XII intact. ___ strength distal extremities but
limited by pain.
DISCHARGE PHYSICAL EXAM:
======================
___ 0707 Temp: 98.3 PO BP: 186/94 HR: 85 RR: 17 O2 sat: 96%
O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Chest: Has HD catheter tunneled into right chest
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur heard throughout
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present.
Prior transplant scar on right abdomen.
Ext: Warm. Fistula in left arm. Several fingers with dressing.
Necrosis of distal R big toe. Several other fingers seem to be
forming discoloration.
Neuro: CNII-XII intact. ___ strength distal extremities but
limited by pain.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:30PM BLOOD WBC-6.2 RBC-4.29* Hgb-12.1* Hct-36.8*
MCV-86 MCH-28.2 MCHC-32.9 RDW-16.6* RDWSD-51.7* Plt ___
___ 07:30PM BLOOD Neuts-78.9* Lymphs-12.5* Monos-7.7
Eos-0.6* Baso-0.0 Im ___ AbsNeut-4.91 AbsLymp-0.78*
AbsMono-0.48 AbsEos-0.04 AbsBaso-0.00*
___ 08:00PM BLOOD ___ PTT-33.4 ___
___ 07:30PM BLOOD Glucose-88 UreaN-31* Creat-6.3*# Na-133*
K-5.2 Cl-92* HCO3-27 AnGap-14
___ 08:00PM BLOOD Albumin-3.5 Calcium-9.8 Phos-4.3 Mg-2.4
___ 10:16PM BLOOD TotProt-5.4*
___ 08:19PM BLOOD Lactate-1.5
PERTINENT/DISCHARGE LABS:
=========================
___ 10:16PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 10:16PM BLOOD ANCA-NEGATIVE B
___ 08:00PM BLOOD CRP-45.5*
___ 10:16PM BLOOD C4-21
___ 10:16PM BLOOD HIV Ab-NEG
___ 10:16PM BLOOD HCV Ab-POS*
___ 10:09AM BLOOD SerVisc-1.6
___ 10:16PM BLOOD Lupus-NOTDETECTE dRVVT-S-1.11 SCT-S-1.12
___ 08:40AM BLOOD b2micro-19.4*
___ 10:16PM BLOOD PEP-NO SPECIFI IFE-NO MONOCLO
___ 10:09AM BLOOD C3-119
IMAGING:
========
XR Bilateral Hands: ___
Loss of soft tissue at the tip of the right long finger,
possibly
reflecting necrotic changes, with subtle loss of bone at the
terminal phalangeal tuft concerning for focal osteomyelitis.
Left
hand grossly unremarkable.
XR Bilateral Feet: ___
No evidence of osteomyelitis or soft tissue gas. Soft tissue
swelling noted bilaterally slightly more pronounced on the right
than left.
RLE US: ___
No evidence of DVT in the right lower extremity.
CXR: ___
1. No acute intrathoracic process.
2. Dialysis catheter appears well positioned.
TTE ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild aortic stenosis. Moderate mitral regurgitation
(may be UNDERestimated due to shadowing). No 2D
echocardiographic evidence for endocarditis. If
clinically suggested, the absence of a discrete vegetation on
echocardiography does not exclude the diagnosis of endocarditis.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
MR ___ Hand ___
Limited study. Nonspecific marrow edema in the distal phalanges
of the index, long, and ring fingers. Although these findings
could represent early osteomyelitis, given the patient's
clinical presentation, the findings are more likely related to
the patient's peripheral vascular disease.
Lower extremity ABIs ___
Noncompressible distal vessels bilaterally with diminished toe
pressures
consistent with significant obstructive arterial disease.
Doppler and pulse volume recordings consistent with tibial
disease
bilaterally, with significantly diminished left digit PVR.
DISCHARGE LABS
=============
___ 04:31AM BLOOD WBC-6.4 RBC-3.83* Hgb-10.7* Hct-34.9*
MCV-91 MCH-27.9 MCHC-30.7* RDW-17.0* RDWSD-55.5* Plt ___
___ 04:31AM BLOOD Glucose-99 UreaN-50* Creat-6.8* Na-137
K-5.2 Cl-96 HCO3-27 AnGap-14
___ 04:31AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.8*
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of ESRD ___ PCKD s/p
deceased donor renal transplant (___) c/b chronic allograft
dysfunction, now back on HD since ___, HCV s/p Harvoni, and
HTN who presented with bilateral digital ulcers, with imaging
concerning for possible osteomyelitis. Broad workup sent to rule
out vasculitic process and embolic source. Presentation
ultimately thought secondary to peripheral vascular disease with
associated dry gangrene of the digits.
ACUTE/ACTIVE PROBLEMS:
# Foot/Hand ulcers
# Concern for osteomyelitis
Patient presented with worsening pain, swelling, and necrotic
changes of the R index/middle and L index fingers in the setting
of progressively worsening chronic hand ischemia. Duration seems
likely ___ months, as not noted on prior admission discharged in
___. Per outpatient notes, injury was apparently incurred and
resulted in worsening appearance and apparent concern for
superinfection which was treated with IV Vanc/Ceftaz at ___
additionally, reportedly ANCA and Cryoglobulins were sent and
were negative. When not improved, patient was sent to ___
where arteriogram shows sluggish flow without evidence of a flow
limiting lesion. This may be seen in the presence of a central
lesion or can also be seen in advanced heart failure, however EF
was noted to be preserved. Broad differential was considered for
decreased perfusion and vasculopathy including peripheral
arterial disease, embolic (hypercoagulability, infectious,
central lesion) vasculitis(small/medium/large vessel
involvement, cryoglobulinemia) with work up unrevealing. He also
underwent CTA chest which did not show a central lesion in his
aorta. He had ABIs of the lower extremities which showed
significant vascular occlusive disease. Calciphylaxis was
considered, dermatology was consulted but thought unlikely given
isolated involvement of fingertips. For potential benefit of
increased perfusion via vasodilation, nifedipine was uptitrated.
Tacrolimus was discontinued after discussion with renal given
limited benefit to graft and known side effect of
vasoconstriction. Admission radiographs concerning for R digit
osteomyelitis and as such MR was obtained which was not fully
completed, but did not show osteomyelitis. Repeat MRI was not
pursued as hand surgery did not think it would change
management. Vascular surgery and hand surgery were consulted.
Vascular surgery did not recommend intervention. Hand surgery
felt his presentation was most likely consistent with dry
gangrene related to his peripheral vascular disease and the
fingers would likely self-demarcate/self-amputate. Pain was
aggressively controlled with OxyCODONE (Immediate Release) 15 mg
PO Q8H:PRN Pain on discharge. He was also started on gabapentin
100 mg daily as adjuvant medication which discussed with the
nephrology team.
#Atypical pneumonia
Found to incidentally have multifocal opacities on CTA chest per
above. He was asymptomatic without leukocytosis, fever, cough.
Differential diagnosis for the opacities included vasculitis
given the above workup, however was ultimately felt to be most
consistent with an atypical pneumonia. He received azithromycin
#ESRD ___ PCKD s/p DDRT ___ c/b chronic allograft dysfunction
(antibody-mediated rejection ___, biopsy-confirmed chronic
transplant glomerulopathy, interstitial fibrosis & tubular
atrophy ___
Patient maintained on HD ___ schedule for dialysis. Discharge
weight was around
148lb on prior admission. On admission 140lbs. Discharge weight
140.1 lbs.
- Continued home nephrocap daily, Mg oxide 800mg daily, Calcium
Carbonate 500 mg PO BID, and Cinacalcet 30 mg PO DAILY, EPO shot
once weekly, renal diet, fluid restriction 1.5L daily.
Tacrolimus was discontinued given limited benefit to graft and
known side effect of vasoconstriction.
# Immunosuppression
Continued prednisone 5mg daily. Prior to admission tacrolimus
2.5mg BID which is vasoconstrictive, held after discussion with
renal. Continued PCP ppx with ___ Suspension 750 mg PO
DAILY.
#Hypertension
Uptitrated nifedipine to 30 daily.
#Afib:
Labetolol switched to metoprolol succinate 50 daily last
admission. Downtitrated metoprolol to 25 mg daily to decrase
potential vasoconstriction.
CHRONIC/STABLE PROBLEMS:
========================
#Normocytic anemia
Hemoglobin stable from prior, felt to be ___ anemia of chronic
disease ___ ESRD and iron deficiency. Continued ferrous
gluconate 324mg BID.
# Left-sided L4-L5 neural foraminal narrowing
On past admission, patient presented with left flank/hip/back
pain. MRI L-spine and pelvis were done, demonstrating L5-S1
changes c/w chronic spondyloarthropathy ___ ESRD vs. sequela of
prior discitis, as well as severe left-sided L4-L5 neural
foraminal narrowing. Continued pain management: APAP 1000mg Q8h,
amitriptyline 100mg QHS, lidocaine patch.
# GERD
Continued home ranitidine daily, simethicone for gas.
# Hyperlipidemia:
Continued home atorvastatin 80mg daily.
# Health maintenance
Continued home Vitamin D weekly (___), aspirin 81mg daily.
GENERAL/SUPPORTIVE CARE:
#CODE: Full confirmed
#CONTACT: ___ (Son) - No number on file
For emergency contact, patient requests ___ (mom) be called
___
TRANSITIONAL ISSUES
===================
[] Continue azithromycin 250 mg daily for treatment of atypical
pneumonia (end date = ___
[] Recommend outpatient referral to vascular medicine for
further evaluation of non-operative management of vascular
disease
[] Consider repeat CT chest imaging to evaluate for resolution
of multifocal opacities
[] Follow up with hand surgery in two weeks for further
management of dry gangrene
[] Follow up with Dr. ___ surgery) at ___ in
approximately 1 month
[] Gabapentin 100 mg daily started for pain control. Consider
dosing with additional 100-200 mg post-dialysis on HD days.
[] Discharge pain regimen: oxycodone 15 mg TID PRN pain. Please
consider weaning off as acute pain resolved.
[] Wound care recs:
1. Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
2. Right great toe:
- Apply betadine, may cover with DSD. Change daily.
3.Bilateral pointer finger and right second finger:
- Apply Betadine over necrotic ulcers, cover with DSD. Change
Daily.
- Elevate right hand
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Amitriptyline 100 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atovaquone Suspension 750 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium Carbonate 500 mg PO BID
7. Cinacalcet 30 mg PO DAILY
8. Ferrous GLUCONATE 324 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD QPM
10. Furosemide 80 mg PO 4X/WEEK (___)
11. Epoetin ___ ___ unit/ml SC 1/WEEK
12. Magnesium Oxide 800 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Morphine SR (MS ___ 10 mg PO DAILY
15. NIFEdipine (Extended Release) 30 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chset pain
17. nutri.supp,lacto-free,iron-soy 0.04 gram- 1 kcal/mL Other
3X/WEEK
18. PredniSONE 5 mg PO DAILY
19. Ranitidine 150 mg PO DAILY
20. Simethicone 80 mg PO TID:PRN bloating
21. Tacrolimus 2.5 mg PO Q12H
22. Vitamin D ___ UNIT PO 1X/WEEK (___)
23. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*1
Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Gabapentin 100 mg PO DAILY
RX *gabapentin 100 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
4. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
5. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 15 mg 1 tablet(s) by mouth Every 8 hours Disp #*21
Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice daily Disp
#*30 Tablet Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
8. NIFEdipine (Extended Release) 60 mg PO DAILY
RX *nifedipine 60 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
10. Amitriptyline 100 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. Atovaquone Suspension 750 mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
15. Cinacalcet 30 mg PO DAILY
16. Epoetin ___ ___ unit/ml SC 1/WEEK
17. Ferrous GLUCONATE 324 mg PO BID
18. Furosemide 80 mg PO 4X/WEEK (___)
19. Lidocaine 5% Patch 1 PTCH TD QPM
20. Magnesium Oxide 800 mg PO DAILY
21. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chset pain
23. nutri.supp,lacto-free,iron-soy 0.04 gram- 1 kcal/mL Other
3X/WEEK
24. PredniSONE 5 mg PO DAILY
25. Ranitidine 150 mg PO DAILY
26. Simethicone 80 mg PO TID:PRN bloating
27. Vitamin D ___ UNIT PO 1X/WEEK (___)
28. HELD- Morphine SR (MS ___ 10 mg PO DAILY This
medication was held. Do not restart Morphine SR (MS ___
until you are told to do so by your doctor.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Dry gangrene of digits
Chronic vascular insufficiency secondary to peripheral vascular
disease
SECONDARY DIAGNOSES
===================
ESRD ___ PCKD s/p failed transplant
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 caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had ulcers on your fingers that became very painful
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by our specialists for your ulcers. Your ulcers
developed due to poor blood flow.
- There was concern you had a bone infection of your finger.
- Our vascular surgeons recommended no surgery.
- Our hand surgeons recommended waiting until the tips of your
fingers broke off on their own.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10497657-DS-14 | 10,497,657 | 25,747,398 | DS | 14 | 2176-07-07 00:00:00 | 2176-07-09 20:52:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zestril / Penicillins
Attending: ___.
Chief Complaint:
s/p Fall, R Arm Swelling, L Knee Pain
Major Surgical or Invasive Procedure:
Upper endoscopy
Intubation
Right ankle arthrocentesis
Bedside incision and drainage of right upper extremity abscess
History of Present Illness:
HPI:
___ w/ HTN, HLD, DM, heart failure (LVEF 20%) and bicuspid
aortic valve presents with fall today, also with RUE swelling
and L knee pain, found to have RUE cellulitis.
Per admission note, patient slipped on his own urine, had a
mechanical fall, hitting his right side. ___ denies have LOC. ___
has been having urinary urgency with episodes of voiding before
reaching the bathroom related to diuretics for heart failure,
and had difficulty getting up off the floor, for which ___ was
brought to the ___ ED. Over the past ___ days, ___ has noticed
mild speech slurring, intermittent ___ weakness (esp of R
proximal leg) and with numbness over bilateral arms. ___ denies
ever having any symptoms like this is the past. ___ also noted
RUE and L knee swelling and redness for the past week. ___ went
to see his dermatologist 2 days PTA and was started on keflex.
Endorses significant weight loss for which ___ had a CT torso,
reportedly negative. Patient denies fevers, dyspnea, dysuria,
black/bloody/loose stools, n/v prior to admission.
Admission labs notable for Glucose 536. WBC 9.5, Hgb 12.8, trop
0.03, BNP 18955, Cr 1.3, lactate 3.2. UA neg for bac, leuk. 1
WBC. 1000 glucose, trace ketone. Imaging notable for: RUE U/S:
neg for DVT with subcutaneous edema. NCHTC with possible chronic
subdural hematoma or hygroma. No acute intracranial hemorrhage.
R elbow, R forearm and L knee xrays performed, soft tissue
swelling present. No DVT on RUE Doppler.
On HD2 patient became increasingly agitated (baseline is normal
and high functioning), triggered for hypotension w/ BP ___ ___
and HR ___ 120s. Poor access so missed vanc dose. Got 1L IVF. Had
2 large bloody bowel movements. Patient missed AM dose of
prednisone.
On transfer, vitals were: 105/67 137 100/RA
On arrival to the MICU, patient is agitated
Review of systems: Limited by patient agitation
Past Medical History:
- Severe systolic dysfunction (EF 25%), prior history of waxing
waning LV dysfunction
- smoking (15 pack-year history; just quit 2 weeks ago)
- HTN
- HLD
- ETOH use
- cachexia/weight loss
- anemia
- asthma
- gout
- CKD (baseline Cr 1.5)
- back pain
- hip OA
- unspecified hypersensitivity puritis
Social History:
___
Family History:
Mother with CHF - age ?___; Father with CABG surgery (>___).
Sister with "cardiomyopathy" ___ years). There is no history of
sudden cardiac death, death under unexplained circumstances, or
cardiovascular genetic diseases, as reported by the patient.
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals: 87/67 75 13 100/RA
GENERAL: Alert, agitated, confused
HEENT: Scleral edema present, periorbital edema present,
anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. R forearm with extensive skin breakdown, swelling, and
erythema(appears improved from yesterday). L knee with warmth,
swelling right over patellar area. full ROM. PD pulses intact.
Mild pedal edema ___ dependent region.
Skin: erythema as above, ___ addition to diffuse chronic skin
changes
NEURO: Grossly intact on nonfocal exam due to patient agitation
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.7 ___ 126-130 ___ 97-100%RA
Weight: 76.6 kg -> 75.9 -> 77 -> 76 -> 73.9 -> 70.7 -> 68 ->
70.3 -> 71.5 -> 72
General: AAOx1-2.
HEENT: Moist mucus membranes, oropharynx clear
Neck: JVP 6-7 cm at 45 degrees
Lungs: Lungs clear to auscultation bilaterally with good air
movement. No rales.
CV: RRR, no audible murmurs
Abdomen: soft, nontender, nondistended
Ext: WWP. Trace ___ edema. Lg right toe is swollen, not tender to
palpation. Pain is limiting movement about toe
Neuro: Grossly intact, not oriented to place or time, only
person. ___ continues to have delusions, thinking that ___ needs
to get to court or ___ be late for meetings.
Pertinent Results:
ADMISSION LABS:
======================
___ 05:00PM BLOOD WBC-9.5# RBC-4.32* Hgb-12.8* Hct-38.8*
MCV-90 MCH-29.6 MCHC-33.0 RDW-17.1* RDWSD-56.4* Plt ___
___ 05:00PM BLOOD Neuts-96* Bands-0 Lymphs-1* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-9.12*
AbsLymp-0.10* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00*
___ 10:52PM BLOOD ___
___ 05:00PM BLOOD Glucose-536* UreaN-32* Creat-1.3* Na-134
K-3.3 Cl-86* HCO3-33* AnGap-18
___ 05:00PM BLOOD ALT-45* AST-45* CK(CPK)-49 AlkPhos-217*
TotBili-1.2
___ 05:00PM BLOOD cTropnT-0.03* ___
___ 07:02AM BLOOD Calcium-8.8 Phos-1.0* Mg-1.4*
___ 07:02AM BLOOD VitB12-1157*
___ 03:52AM BLOOD %HbA1c-11.9* eAG-295*
___ 04:39AM BLOOD Ammonia-29
___ 03:46AM BLOOD TSH-1.8
___ 07:02AM BLOOD TSH-0.61
___ 01:07PM BLOOD CRP-47.5*
___ 10:49PM BLOOD ___ pO2-37* pCO2-44 pH-7.48*
calTCO2-34* Base XS-8
___ 06:23PM BLOOD Lactate-3.2*
___ 11:55PM BLOOD O2 Sat-75
___ 08:30PM BLOOD freeCa-0.98*
___ 08:30PM URINE Color-Straw Appear-Clear Sp ___
___ 08:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:30PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
MICROBIOLOGY
===================
___ 8:30 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
FINAL SENSITIVITIES.
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
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.
Daptomycin AND LINEZOLID Sensitivity testing per ___
___
(___), ON ___.
Daptomycin MIC: 0.38 MCG/ML (SENSITIVE).
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
DAPTOMYCIN------------ S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Reported to and read back by ___, ___ @
01:56AM (___).
___ 8:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:38 am SEROLOGY/BLOOD Source: Line-cordis.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
___ 10:50 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
___ 5:20 am ABSCESS Source: RUE.
Fluid should not be sent ___ swab transport media. Submit
fluids ___ a
capped syringe (no needle), red top tube, or sterile cup.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
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.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
___ 7:15 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:51 pm JOINT FLUID Source: Right Ankle.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
IMAGING
=======
___ RUE US
IMPRESSION:
No evidence of deep vein thrombosis ___ the right upper
extremity.
Subcutaneous edema overlying the right upper extremity is noted
___ FOREARM/ELBOW XR
IMPRESSION:
Soft tissue swelling overlying the proximal forearm, most
notably at its
dorsal aspect.
___ L KNEE XR
IMPRESSION:
Soft tissue swelling overlying the patella. No fracture.
___ ___
IMPRESSION:
A 3 mm low-density left frontoparietal subdural collection,
potentially
chronic subdural hematoma or hygroma. No acute intracranial
hemorrhage.
___ MRI/MRA brain
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Incidental 2 mm outpouching arising from the right anterior
cerebral artery
(19;121). A CTA of the head is recommended for further
evaluation.
Otherwise, unremarkable MRA of the head.
3. Dominant left vertebral artery, with a asymmetrically
hypoplastic right
vertebral artery. Otherwise, unremarkable MRA of the neck
without evidence of
stenosis by NASCET criteria.
___ R UE US
IMPRESSION:
Extensive is right forearm abscess measuring more than 6 x 2 cm
with multiple
loculations.
___ TTE
The left atrium is moderately dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis.. Quantitative
(biplane) LVEF = 16 %. The estimated cardiac index is depressed
(<2.0L/min/m2). A small thrombus is seen ___ the left ventricle.
Right ventricular chamber size is normal with severe global free
wall hypokinesis. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Severe
(4+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Biventricular cavity dilation with severe global
hypkinesis. Severe mitral regurgitation. Mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the left ventricular cavity is slightly larger with similar
systolic function; the severity of mitral regurgitation has
increased, and there is pulmonary artery systolic hypertension.
___ BILAT ___ US
IMPRESSION:
No evidence of deep venous thrombosis ___ the right or left lower
extremity
veins.
___ L ANKLE XR
IMPRESSION:
___ comparison with the study of ___, the bony structures
again joint
spaces remain essentially within normal limits with an the ankle
mortise is
intact. Linear opacification knee anteriorly could reflect
dystrophic
calcification.
No evidence of erosive changes.
___ R UE US
IMPRESSION:
Subcutaneous edema, without evidence of a residual fluid
collection.
___ CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Severe cardiomegaly, small pleural effusions. Patchy
ground-glass
opacities ___ both upper lobes that are likely due to pulmonary
edema, however
an infectious process cannot be completely exclude. Please
correlate
clinically.
___ TTE
There is severe global left ventricular hypokinesis (LVEF = 15 -
20 %). No masses or thrombi are seen ___ the left ventricle. The
right ventricular cavity is dilated with moderate global free
wall hypokinesis. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. There is no
pericardial effusion.
IMPRESSION: No LV clot was visualized using ultrasound contrast.
___ CT HEAD WO CONTRAST
1. No acute intracranial findings. ___ particular, no
hemorrhage. No subdural
collection identified.
___ CXR
1. Mild central vascular congestion without overt pulmonary
edema.
2. Stable moderate cardiomegaly, which could represent
cardiomyopathy or
pericardial effusion. Echocardiography can be performed for
further
evaluation, if desired.
___ TTE
The estimated right atrial pressure is at least 15 mmHg. There
is severe global left ventricular hypokinesis (LVEF = 15%). No
masses or thrombi are seen ___ the left ventricle. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. Severe (4+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction.
Severe mitral regurgitation. No pericardial effusion.
___ RENAL ULTRASOUND
1. No sonographic evidence of hydronephrosis bilaterally.
2. Mild abdominal ascites within the pelvis.
___
Normal sinus rhythm at a rate of 80 beats per minute. No change
___ ongoing ST segment changes. There is some straightening of
the ST segments laterally.
The tracing is poor quality, ___ some leads it looks like there
may be slight J point elevation, but clinical correlation
required to rule out injury.
___ CXR: With the study of ___, there is little
interval change. Again there is stable moderate enlargement of
the cardiac silhouette without appreciable vascular congestion.
This discordance raises the possibility of pericardial effusion
or cardiomyopathy. No evidence of pleural effusion or acute
focal pneumonia.
___ CT HEAD W/OUT CONTRAST: 1. There is no acute
intracranial abnormality. 2. There is left facial, infraorbital
soft tissue swelling.
___ CT SINUS/MANDIBLE/MAXILLA: 1. Subtle nasal bone
fracture, likely chronic, clinically correlate. 2. Periodontal
disease. Periapical lucency surrounding left maxillary tooth
14, may represent periapical cyst, granuloma or infection.
Dental consult recommended. 3. Paranasal sinus disease as
described.
___ CT C-SPINE W/OUT CONTRAST: 1. There is no acute
fracture.
2. There are multilevel degenerative changes as described.
___ ECHO: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 15%). Right ventricular chamber
size is normal with mild global free wall hypokinesis. 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. Moderate (2+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction. Moderate functional mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
PROCEDURES
==========
___ EGD
Impression:Gastric ulcer (injection, thermal therapy)
Blood ___ the stomach
Duodenal ulcer
Otherwise normal EGD to third part of the duodenum
Recommendations:- continue IV PPI BID x 72hrs
- avoid NSAIDs
- check H. pylori stool antigen
DISCHARGE LABS
==============
___ Digoxin 0.4
___ WBC 6.8, H/H ___, Plts 199
___ Na 138 K 3.5 Cl 94 HCO3 29 BUN 51 Cr 1.7 Glc 114 Ca
9.5 Phos 3.5 Mg 1.9
Brief Hospital Course:
Mr. ___ is a ___ year old man with PMHx of sCHF (EF 15%), on
chronic steroids for dermatitis of unclear etiology, who
presents with mechanical fall with altered mental status, found
to have cellulitis, MRSA bacteremia, and hyperglycemia,
transferred to MICU for hypotension ___ the setting of GI bleed
where ___ required intubation and received EGD, RUE abscess
drainiage, and pressor support, with a complicated hospital
course where ___ was managed for acute on chronic systolic heart
failure, ___, and persistent altered mental status attributed to
protracted delirium.
ICU COURSE: ___ had altered mental status and required intubation
and sedation upon ICU transfer.
# GI Bleed
# Acute Blood loss anemia:
# Hypovolemic/Septic Shock:
Patient presenting with hypotension requiring pressors and acute
drop ___ hemoglobin with frank blood ___ BMs x4. ___ ultimately
required 2 units PRBCs. GI did bedside endoscopy with multiple
ulcers ___ gastric fundus, s/p sclerotherapy and epinephrine
injection with apparent improvement ___ bleed. H pylori was
negative and ___ was started on pantoprazole 40 BID. Anemia
stabilized with no further signs of bleeding during his floor
course.
#MRSA Bacteremia:
#RUE Abscess:
His MRSA bacteremia was treated with IV vancomycin (started on
___ When ___ was stable and off pressors ___ was successfully
extubated but required ongoing precedex for severe agitation and
delirium. ___ was noted to have a large RUE abscess that required
bedside incision and drainage by surgery. Although etiology of
wound was unclear, cultures from the abscess were positive for
MRSA making it likely source of MRSA bacteremia, vancomycin was
continued to complete a four week course on ___.
His ICU course was complicated by the following:
# Severe ICU delirium: Post-extubation patient exhibited waxing
and waning agitation with delirium and hallucinations. Organic
causes were addressed (i.e. bacteremia, CHF, GI bleed) and head
CT and MRI were both negative. His high dose prednisone, which
was thought to be a contributor, was tapered over the course of
2 weeks as planned per his outpatient dermatologist (was started
for unspecified pruritus, work up for parasitic, allergic, and
malignant etiologies were negative). ___ was consistently trying
to get out of bed (despite deconditioning and instability with
ambulation), swinging or kicking at staff, pulling at lines
/tubes and dressings. Initially ___ was continued on precedex at
night to help keep him calm and safe. When attempts were made to
wean the precedex ___ would again become agitated despite
scheduled Seroquel with Haldol and Olanzapine PRN. Psychiatry
was consulted who recommended Depakote and olanzapine. These
were titrated up over the course of several days to help the
patient remain calm and keep him safe. When ___ was called out to
the floor ___ was on Depakote 500mg Q8H and olanzapine ___
PRN.
# Question of LV thrombus: the patient was noted to have a left
ventricular thrombus on ECHO ___. Per GI and cardiology
recommendations ___ was started on a heparin drip to treat the
thrombus. Shortly thereafter a drop ___ his hemoglobin was noted
and the heparin drip was stopped. Repeat ECHO on ___ showed
absence of the LV thrombus. LV thrombus initially seen on echo
is thought to be artifact when discussed with heart failure
team. Repeat echo showed no evidence of clot. After discussion
with heart failure team, they recommend no anticoagulation at
this time. CTA did not show any evidence of pulmonary embolus.
# Gout: patient complained of gout ___ his ankles bilaterally.
Rheumatology was consulted and recommended increasing
allopurinol from 100mg to 300mg daily. Arthrocentesis of the
right ankle was done and synovial fluid showed needle like
crystals. One dose of Colchicine 0.6mg was given with
improvement. ___ was
FLOOR COURSE
============
On ___ the patient was called out to the floor. His course
there was uneventful, and after < 24 hours ___ was transferred to
the heart failure service for further management. On the floors,
patient continued to be agitated and pulled out PICC line x 2
for which ___ was getting Lasix and vancomycin. ___ was continued
on these medicines through a peripheral line. ___ was transferred
to the medicine service for management after ___ was felt to be
euvolemic from diuresis.
# Acute on chronic systolic heart failure: LVEF 16%. Became
hypervolemic ___ MICU following 7L fluid resuscitation ___ setting
of sepsis. Remained tachycardic with BP 90-110/70s. ___ was
continued on diuresis with Lasix gtt @ 5 and metoprolol
Succinate XL 12.5 mg PO BID (increased from 12.5 po qd).
Sacubitril-Valsartan (24mg-26mg) was discontinued and replaced
with hydralazine 10mg TID and isosorbide dinitrate 10mg TID. ___
was continued on aspirin and statin. ___ continued to be very
agitated and pulling out his lines, and as ___ approached
euvolemia, ___ was diuresed with torsemide 100mg BID and
metolazone 2.5mg instead of IV lasix given his lack of IV
access. ___ continued to diurese well with this regimen. ___ was
stablized on 100mg torsemide daily to maintain euvolemia while
on the medicine service. Repeat ECHO again showed LVEF 15% with
severe MR. ___ was briefly transferred to the CCU after multiple
hypotensive episodes to the SBP ___ with lactate elevated to 4.6
and rising creatinine but no intervention was performed as his
mental status would not permit a safe procedure of right heart
catheterization and ___ was assessed to be euvolemic/mildly
volume overloaded. Lactate improved after transfer out of CCU.
___ was restarted on BID torsemide due to increased lower
extremity edema. Bicarbonate increased and ___ was given a one
time dose of oral acetazolamide with improvement ___ bicarbonate
level. On ___, ___ was found to be cool on exam with rising
lactate and was transferred to the heart failure service for
diuresis. Dopamine gtt was initiated with IV Lasix boluses to
which the patient responded well. Although ___ has been
tachycardic throughout his stay, his HRs were sustained to
130-140s during this time frame of unclear etiology (likely some
contribution from dopamine gtt and reflex tachycardia ___ the
setting of beta-blocker discontinuation). ___ was transitioned
off dopamine gtt and onto po Torsemide 60 mg BID. HRs on
discharge were 120-130s with SBP 90-110s; patient remained
clinically asymptomatic. On the day of discharge, his regimen is
as follows: Torsemide 60 mg po BID, Digoxin 0.125 mg daily,
Hydralazine 25 mg TID, Isosorbide dinitrate 20 mg TID. Of note,
___ is not on a beta-blocker or ___ at this time, which is
to be discussed with his outpatient cardiologist.
# ___ on CKD (baseline Cr 1.3): Initially thought to be
cardiorenal ___ setting of hypervolemia though his creatinine
continued to increase with aggressive diuresis suggesting an
element of intravascular volume depletion, however, ___ did not
respond to diuretic holiday for 2 days with creatinine remaining
elevated and two episodes of hypotension. No ATN seen on
sediment. FeUrea 26%. Renal ultrasound with cysts but without
any evidence of hydronephrosis. Creatinine did improve with
dopamine gtt and diuresis and had improved to 1.7 on discharge.
___ will be continued on Torsemide 60 mg BID.
# Toxic metabolic encephalopathy/Altered mental status/Delirium:
___ was altered on admission, worsened after
intubation/extubation. Contributions include infection, possible
benzodiazepine withdrawal, and high dose steroid use. Neurology
was consulted; CT head negative, and MRI/MRA which showed no
acute cause of encephalopathy. ___ continued to be agitated for
an extended period of time, despite trials of Seroquel,
Depakote, olanzapine, precedex. ___ was treated with Trazodone
and Ramelteon given his insomnia. Despite his improving medical
problems, his altered mental status continued. ___ was given a
trial of high does thiamine without improvement of his symptoms.
___ continued to have delusions, thinking that ___ needed to go to
court, or to exercise classes, as well as hallucinations that
his parents were ___ the room with him. A repeat head CT was done
which showed no abnormalities. An EEG was done which showed no
seizures. Neurology and psychiatry both agreed that this
appeared to be a protracted delirium with a very prolonged
recovery course ahead. Per the wife, the patient was a fully
functioning ___ prior to this admission, making dementia less
likely. His medication regimen was adjusted to include standing
haldol (12.5mg QHS) and Depakote (1500 mg QHS); olanzapine was
slowly tapered off per psychiatry recommendations. His agitation
improved, but ___ continued to require a sitter for exit seeking
behavior. ___ was persistently confused and disoriented despite
attempts to regulate the sleep wake cycle and to frequently
reorient; this continued on discharge. Neurology was
re-consulted and felt that his symptoms were due to protracted
delirium with no further imaging recommended.
# Ankle Pain/Gout: Rheumatology consulted, thought to be due to
gout. Joint aspiration performed ___ the right ankle showed
crystals consistent with monosodium urate. One dose of
Colchicine 0.6mg was given with improvement. Continued on
colchicine 0.6mg every other day for active gout flare. When
pain improved, allopurinol ___ mg daily was restarted and
colchicine was held.
# Steroid-induced DM: Patient with new diagnosis of DM. HgbA1c
5.8% ___ ___, increased to 11.9. Likely ___ setting of
prednisone use and infection. ___ was continued on HISS as
needed.
# Dermatitis NOS: Per ___ derm records, dermatitis of unclear
etiology with significant itching. Biopsy unrevealing. Concern
for malignancy, CT torso unrevealing. Was on prednisone 60 mg,
which was tapered as discussed above. Strongyloides IgG
negative. ___ completed a prednisone taper (end ___ with
plans to follow up with dermatology as outpatient
===========================
TRANSITIONAL ISSUES
===========================
[ ] Mental status remained altered on discharge as ___ was
persistently confused and disoriented despite attempts to
regulate the sleep wake cycle and to frequently reorient
[ ] Patient is not on beta-blocker or ___ at this time, due
to borderline low blood pressure. This issue to be readdressed
with his outpatient cardiologist
[ ] Cr improved to 1.7 on discharge, should have repeat Cr drawn
at follow-up. ___ need to consider uptitration of his Torsemide
60 mg BID dosing.
[ ] Patient has had intermittent hyperphosphatemia, most likely
___ setting of kidney disease. It had normalized on discharge to
3.5
[ ] Continued discussion of goals of care: With protracted
altered mental status changes and end-stage heart failure,
limited therapeutic options at this time.
[ ] Discussion of ICD for end-stage heart failure ___ setting of
uncertain etiology and prognosis of altered mental status.
[ ] Patient will have scheduled neurology follow-up (being
pursued at time of discharge), ___ will require neurocognitive
assessment to have further assessment of altered mental status.
[ ] Close follow up with psychiatry as outpatient is very
important, to continue to titrate medications and monitor mental
status, patient needs to be seen by a psychiatrist ___ order to
titrate Haldol/Divalproex. Mental status is severely altered and
___ will have a prolonged recovery course
[ ] Patient will require repeat EGD if ___ line with GOC as
outpatient given that not all areas of the stomach were visible
due to bleeding. Follow-up appointment with gastroenterology has
been scheduled for ___.
[ ] Follow up with dermatology for dermatitis, NOS. Completed
prednisone taper on ___.
[ ] Consider repeat A1c ___ the setting of steroid administration
(detailed above). A1c ___ ___ was 5.8
Weight on discharge: 72kg
Cr on discharge: 1.7
Hgb on discharge: 9.0
#CODE: Full Code
#PROXY: ___ Wife ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Torsemide 40 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Temazepam 30 mg PO QHS:PRN insomnia
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. PredniSONE 40 mg PO DAILY
7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
8. Atorvastatin 40 mg PO QPM
9. Colchicine 0.6 mg PO DAILY:PRN gout attack
10. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Divalproex (DELayed Release) 1500 mg PO QHS
RX *divalproex ___ mg 3 tablet(s) by mouth at bedtime Disp #*90
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID:prn Disp
#*30 Capsule Refills:*0
4. Haloperidol 10 mg PO QHS
RX *haloperidol 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
6. Isosorbide Dinitrate 20 mg PO TID
RX *isosorbide dinitrate 20 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*3
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
9. Potassium Chloride 10 mEq PO EVERY OTHER DAY
RX *potassium chloride [K-Tab] 10 mEq 1 tablet(s) by mouth EVERY
OTHER DAY Disp #*15 Tablet Refills:*3
10. Ramelteon 4 mg PO QHS
RX *ramelteon [Rozerem] 8 mg 0.5 (One half) tablet(s) by mouth
at bedtime Disp #*15 Tablet Refills:*0
11. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth BID:prn Disp #*15
Tablet Refills:*0
12. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
13. TraZODone 100 mg PO QHS insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
14. Torsemide 60 mg PO BID
RX *torsemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
15. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild
16. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
17. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
19.Outpatient Lab Work
PLEASE DRAW NA/K/CL/HCO3/BUN/Cr/GLC/CA/MG/PHOS on ___
ICD-9 428.0
PLEASE FAX RESULTS TO ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute systolic heart failure
Sepstic shock MRSA Bacteremia
Acute blood loss anemia
Upper gastrointestinal bleed
Delirium, Protracted of unclear etiology
Secondary:
Toxic metabolic encephalopathy
Gout
Acute on chronic renal failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic intermittently
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized after a fall. You were found to have an
infection of the right arm, which was drained. You had a
bacterial infection ___ the blood and were treated with
antibiotics. You were transferred to the ICU after you developed
low blood pressures related to bleeding from stomach ulcers. The
gastroenterology doctors performed ___ and gave
medicines to help stop the bleeding. You were given medications
to treat low blood pressure during your time ___ the ICU.
You were transferred out of the ICU and were treated for a heart
failure with diuretics. Imaging of your heart was done and
showed that the heart function is very weak, which was treated
with a variety of medications to reduce the strain on the heart.
Your kidney function slowed down while we were treating your
heart failure but it slowly improved before you were discharged.
During your hospital course your mental status was altered. We
believe a large part of this is related to a process called
delirium that can be caused from any type of significant illness
(infection, heart failure, bleeding, electrolyte imbalance) and
from being ___ the unfamiliar environment of the hospital. Lack
of sleep is also a cause of delirium. The psychiatry and
neurology teams evaluated you. Head CT and MRI were done that
did not show a clear reason (related to brain structure) for the
mental status change. You were given medications to help control
agitation and confusion. You mildly improved through your course
but your mental status was not back to your normal when you were
discharged. You should continue to take the Depakote and
Haloperidol unless instructed differently by a neurologist or
psychiatrist. Trazodone can be discontinued with a slow taper if
you don't feel that it is helping; please discuss this with your
PCP.
Weigh yourself every morning, call MD if weight goes up more
than ___ lbs, as this may indicate a problem with the heart
function. Please call your doctor or return to the emergency
department if you develop shortness of breath, worsening leg
swelling, black or bloody stools, fevers or chills.
It is very important that you attend your follow-up appointments
listed below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10497675-DS-14 | 10,497,675 | 21,862,357 | DS | 14 | 2171-05-06 00:00:00 | 2171-05-06 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Odynophagia
Major Surgical or Invasive Procedure:
- Machidoscopy of pharynx
- Laryngoscopy
History of Present Illness:
Ms. ___ is a ___ with history a history of GERD,
epidermolysis bullosa and esophageal stricture s/p dilatation on
___ who presents to the ED with esophageal pain. Patient
underwent treatment of dysphagea ___ to esophageal stricutre
catheter dilatation using ___ catheter to ___ catheter on ___.
The patient tolerated the procedure well and was instructed to
continue a liquid diet with plan for repeat dilatation in 2
weeks.
She has had persistent pain in her throat after the procedure.
The pain is worsened by swallowing. She is able to tolerate
popsicles, but when she tries drinking fluids or eating soft
foods (mashed potatoes) she has substernal and epigastric pain
that persists for several minutes; it does not radiate anywhere
else.
Denies fever, chills. Mild headache. No cough or pain with deep
inspiration. No chest pain or tightness. No abdominal pain other
than epigastric pain, n/v, diarrhea, BRBPR, melena.
Initial VS in the ED were 98.7 84 173/84 16 100%. Labs were
notable for lactate 1.0, Na 142, K 4.1, Cr 0.6, Gluc 116, Alt
44, Ast 38, Lip 23, AP 101, Tbili 0.5, Alb 4.4, WBC 7.3, and HCT
37.6. UA was notable for 13 WBC and otherwise WNL.
The patient received 1L NS IV, Morphine 5mg IV, Zofran 4mg IV,
and 10ml Viscous lidocaine swish/spit. CXR, Neck X-ray and
single contrast upper GI showed no evidence of perforation. She
was admitted to medicine for pain control and hydration.
Past Medical History:
1. GERD.
2. Epidermolysis bullosa.
3. Hypercholesterolemia.
4 Osteoporosis.
Social History:
___
Family History:
Family History: Negative for colorectal cancer and esophageal
cancer. Mother had breast cancer at age ___. Father died at age
___. The cause of his death is not clear.
Physical Exam:
Physical Exam on admission:
Vitals: T: 98.2 BP:150/82 P:72 R:20 O2: 99/RA
General: NAD
HEENT: Sclera anicteric, slightly dry MM, oropharynx clera
Neck: supple, no JVD, no LAD
Lungs: CTAB, no w/r/r
CV: RRR, II/VI apical systolic murmur.
Abdomen: +BS, soft, NTND.
Ext: WWP, 2+ distal pulses, no c/c/e
Neuro: Alert and oriented to conversation
Exam on discharge:
VS: 98.8 97.7 104/48 63 18 99/RA
General: Sitting comfortably in bed
HEENT: Sclera anicteric, MMM
Neck: supple, no JVD
Lungs: CTAB, no w/r/r
CV: RRR, I/VI apical systolic murmur
Abdomen: +BS, soft, NTND.
Ext: WWP, no c/c/e
Neuro: Alert and oriented to conversation
Pertinent Results:
CBC:
___ 08:47AM BLOOD WBC-4.0 RBC-3.93* Hgb-11.2* Hct-34.9*
MCV-89 MCH-28.4 MCHC-32.0 RDW-12.5 Plt ___
___ 06:55AM BLOOD WBC-7.3 RBC-4.24 Hgb-12.6 Hct-37.6 MCV-89
MCH-29.7 MCHC-33.5 RDW-12.5 Plt ___
___ 06:55AM BLOOD Neuts-80.5* Lymphs-13.8* Monos-4.4
Eos-0.9 Baso-0.4
Chem:
___ 08:47AM BLOOD Glucose-134* UreaN-4* Creat-0.6 Na-142
K-3.9 Cl-109* HCO3-27 AnGap-10
___ 08:47AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.0
___ 06:55AM BLOOD Glucose-116* UreaN-9 Creat-0.6 Na-142
K-4.1 Cl-108 HCO3-22 AnGap-16
LFTs:
___ 06:55AM BLOOD ALT-44* AST-38 AlkPhos-101 TotBili-0.5
Brief Hospital Course:
Ms. ___ is a ___ with a history of epidermolysis bullosa c/b
esophageal strictures who preseneted with odynophagia two days
after endoscopic dilation of stricture. She was admitted to
___ for pain control and hyrdation. She remained in stable
condition through her admission, and was discharged when she had
adequate pain control to tolerate PO fluid intake.
Active issues:
# Odynophagia: Ms. ___ was admitted to ___ with
odynophagia that began on ___ after attemepted serial
dilation of esophageal stricture from ___ to ___. The pain
persisted and she was unable to tolerated PO. Pharyngeal exam in
the ED with Machidoscope showed no pharyngeal injury.
Gastrograffin swallow study showed no evidence of active
perforation, and CT confirmed no healing perforation. Her
symptoms were attributed to post-procedural pain.
She was initially kept NPO except for ice chips and popsicles.
She was started on ___ for hydration. Her oral home
medications were held to prevent further irritation of the
procedure site. We substituted pantoprazole IV for omeprazole.
We initially treated her pain with morphine, which had limited
effect. Given her history of gastritis, we initially avoided
NSAIDs and started her on Roxicet (oxycodone-acetaminophen
syrup) and Benadryl/Lidocaine/Maalox 1:1:1 solution, which
partially alleviated her symptoms. Bronchoscopy by ENT on
___ confirmed no serious injury to pharynx. Given the slow
improvement of her symptoms, she was started on ibuprofen
solution, and given sucralfate to decrease the risk of stomach
irritation on ___.
A midline catheter was placed in the left arm in anticipation of
discharge on ___. She had a marked improvement of her symptoms
and tolerated a liquid diet that evening, and the decision was
made to remove the midline catheter on the following day. She
received 20mg of prednisone for additional anti-inflammatory
effect and she was discharge to home in stable condition on a
liquid diet, with Roxicet, ibuprofen, sucralfate, and
lansoprazole disintegrating tablets.
Inactive issues:
#GERD - avoided oral meds, d/c'd home omeprazole
- Pantoprazole IV 40mg while admitted, discharged on
lansoprazole disintegrating tabs
# Osteoporosis - held oral raloxifene
# HLD - held home simvastatin
Transitional issues:
# GERD: On lansoprazole, patient will discuss restarting
omeprazole with PCP when tolerating PO
# Osteoporosis - Raloxifene be restarted when tolerating pills.
# HLD - Simvastatin to be restarted when tolerating pills.
Patient is scheduled for followup with PCP on ___ and
with GI on ___.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. raloxifene *NF* 60 mg Oral daily
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Vitamin D Dose is Unknown PO DAILY
5. Vitamin B Complex Dose is Unknown PO DAILY
6. Chlorhexidine Gluconate 0.12% Oral Rinse Dose is Unknown
ORAL HS
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
2. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL four times a day Disp #*300
Milliliter Refills:*0
3. OxycoDONE-Acetaminophen Elixir 10 mL PO TID QAC
Please give before every meal
RX *Roxicet 5 mg-325 mg/5 mL three times a day Disp #*220
Milliliter Refills:*0
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg daily Disp #*30 Tablet Refills:*0
5. Ibuprofen Suspension 600 mg PO Q6H
RX *ibuprofen 100 mg/5 mL Every six hours Disp #*850 Milliliter
Refills:*0
6. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL take twice a day as needed Disp
#*1 Bottle Refills:*0
7. ___ *NF* 200-25-400-40 mg/30 mL
Mucous Membrane QID pain
Take every six hours as needed for pain
RX *FIRST-Mouthwash BLM 400 mg-400 mg-40 mg-25 mg-200 mg/30 mL
Every six hour as needed Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Odynophagia after stricture dilation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
with painful swallowing after a procedure to dilate a stricture
obstructing your esophagus.
Several studies were done to see if there was a serious injury
after the procedure. The gastroenterologists and ENT (head and
neck doctors) did not see any evidence injury to the throat. In
addition X-ray and CT studies of the neck did not show any
evidence of a tear in the esophagus. We treated you with two
antibiotics, ciprofloxacin and metronidazole, until the results
of these studies came back, to treat any infection may have
resulted from a potential tear.
We stopped all your home pills while you were in the hospital to
prevent any irritation of the dilation site. We treated your
pain initially with intravenous morphine, and then switched to
an oral solutions of oxycodone-acetaminophen and ibuprofen,
which provided adeuqate pain control. You were kept intravenous
fluids to keep you hydrated while you were not able to drink
liquids.
Given that your pain has been improving and you are now able to
drink enough liquid to not require IV fluids, we are comfortable
sending you home with pain medication.
We held your home pills while you were admitted to ___:
1. STOPPED Raloxifene
2. STOPPED Simvastatin
3. STOPPED Omperazole
We have started the following medications:
1. START Roxicet syrup 10 mL (5mg oxycodone-325mg acetaminophen
per 5mL)
2. START Ibuprofen suspension 600mg
3. START Maalox/diphenylhyrdamine/lidocaine solution 15mL
4. START lansoprazole oral disintegrating tab 30mg (replaces
omeprazole)
5. Sucralfate 1gm four times a day, to protect stomach while
taking ibuprofen
6. Docusate - take as needed for constipation that may develop
with oxycodone
Please speak with your gastroenterologists and primary care
physician before starting your home medications again.
It was a pleasure to participate in your care at ___.
Followup Instructions:
___
|
10498472-DS-7 | 10,498,472 | 21,568,271 | DS | 7 | 2189-02-01 00:00:00 | 2189-02-13 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, ST depressions
Major Surgical or Invasive Procedure:
US-guided Liver Mass Biopsy (___)
History of Present Illness:
___ with history of hypertension presenting with acute on
chronic abdominal pain found to have new pancreatic and liver
lesions. Patient reports that she has had chronic abdominal pain
for many months, more acutely worsened over the last several
weeks. The pain is a "gassy" pain, located in the epigastic
region with radiation to RUQ and LUQ. It is not changed with
food. Not crampy in nature. No associated vomiting or diarrhea
though has had some mild nausea. She denies recent fevers but
has had occasional chills. Overall, having poor PO intake
related to the pain and notes a weight loss over the last few
months though cannot quantify the loss. Has also noted mild
abdominal distention in addition to the pain.
On the day of admission, she presented to ___ with
epigastric pain and was found to have diffuse ST segment
depressions on EKG prompting transfer to ___.
In the ED, initial vitals were: ___ 142/76 16 97%RA
Exam notable for no stool in rectal vault, no change in pain
with palpation of abdomen.
EKG with ST depressions in V3-V6 and in II
Labs notable for WBC 15K with 81% polys, H/H 10.9/32 1, plt 445,
Na 127, Cr 0.6, ALT 35, AST 47, AP 247, tbili O.6, and alb 3.2.
Trops x2 negative.
INR 1.3. Lactate 1.4, UA with ___ RBCs.
Imaging was notable for: RUQ US with 4.7 cm hypoechoic mass from
mid-body of pancreas with multiple associated hepatic masses
highly suspicious for metastatic pancreatic
cancer.
Patient was given: 4mg IV morphine and 1L NS
Vitals prior to transfer· 99.1 97 151/64 20 96%RA
On the floor, patient reports her pain is worsening again, an
___ on my examination
ROS:
+/- per HPI
Full 10 point ROS otherwise negative in detail
Past Medical History:
Hypertension
Social History:
___
Family History:
Hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs. 98 7 PO 138/59 R Lying 98 18 98% RA
General Alert, oriented. mildly uncomfortable appearing thin
woman
HEENT: Sclera anicteric, MM dry, OP clear, no LAD, no JVD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
ABDOMEN: Soft, non-distended, no increased tenderness to
palpation, hypoactive bowel sounds
GU: No foley
EXT:. Warm, well perfused, I+ DP pulses, no edema
NEURO: CNII-XII intact. ___ strength lower extremities
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 99.6 119/66 95 18 98%RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MM dry
Neck: No LAD, no JVD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, distended, no increased tenderness to palpation,
hypoactive bowel sounds
Ext: Warm, well perfused, pulses 2+ bilaterally, no edema
Neuro: CNII-XII intact, ___ strength lower extremities
Pertinent Results:
ADMISSION LABS:
===============
___ 10:15AM WBC-15.9* RBC-3.88* HGB-10.9* HCT-32.1*
MCV-83 MCH-28.1 MCHC-34.0 RDW-12.4 RDWSD-37.5
___ 10:15AM NEUTS-81.7* LYMPHS-6.8* MONOS-10.0 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-13.01* AbsLymp-1.08* AbsMono-1.59*
AbsEos-0.01* AbsBaso-0.05
___ 10:15AM ___ PTT-29.1 ___
___ 09:40AM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Hazy SP
___
___ 09:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.5 LEUK-TR
___ 09:40AM URINE ___ BACTERIA-RARE
YEAST-NONE ___ 09:40AM URINE MUCOUS-RARE
___ 10:15AM ALBUMIN-3.2*
___ 10:15AM cTropnT-<0.01
___ 10:15AM LIPASE-17
___ 10:15AM ALT(SGPT)-35 AST(SGOT)-47* ALK PHOS-247* TOT
BILI-0.6
___ 10:15AM GLUCOSE-153* UREA N-14 CREAT-0.6 SODIUM-127*
POTASSIUM-3.5 CHLORIDE-84* TOTAL CO2-29 ANION GAP-18
___ 10:35AM LACTATE-1.4
___ 04:11PM cTropnT-<0.01
DISCHARGE/PERTINENT LABS:
=========================
___ 03:05PM BLOOD WBC-13.7* RBC-3.46* Hgb-9.4* Hct-29.7*
MCV-86 MCH-27.2 MCHC-31.6* RDW-13.1 RDWSD-40.1 Plt ___
___ 07:00AM BLOOD Parst S-NEGATIVE
___ 07:00AM BLOOD Glucose-130* UreaN-13 Creat-0.5 Na-133
K-4.3 Cl-95* HCO3-32 AnGap-10
___ 07:00AM BLOOD ALT-41* AST-41* LD(LDH)-282* AlkPhos-262*
TotBili-0.5
___ 07:00AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.0
___ 03:37PM BLOOD %HbA1c-6.4* eAG-137*
___ 08:10AM BLOOD Triglyc-93 HDL-33 CHOL/HD-3.7 LDLcalc-71
___ 08:10AM BLOOD HBsAg-Negative HBsAb-Negative IgM
HAV-Negative
CA ___: ___ H
MICROBIOLOGY:
=============
URINE CULTURE (Final ___: <10,000 organisms/ml.
Malaria Antigen Test (Final ___: Negative for Plasmodium
antigen.
IMAGING:
========
RUQ US:
1. 4.7 cm hypoechoic ill-defined vascular mass arising from the
mid body of pancreas with multiple associated hepatic masses,
highly suspicious for metastatic pancreatic cancer.
2. Normal gallbladder. No evidence of intrahepatic or
extrahepatic biliary ductal dilatation.
CXR:
No acute cardiopulmonary abnormality.
ABD/PELVIC CT:
Large pancreatic body/tail mass with innumerable hepatic
lesions,
concerning for metastatic pancreatic adenocarcinoma.
CHEST CT:
Numerous lung lesions measuring 2 cm or less are concerning for
lung metastasis, some demonstrating rim of surrounding
hemorrhage.
TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
PATHOLOGY:
==========
Poorly differentiated adenocarcinoma consistent with
pancreatobiliary origin.
Brief Hospital Course:
___ with history of hypertension presenting with acute on
chronic abdominal pain found to have new pancreatic and liver
lesions confirmed to be metastatic, poorly differentiated
adenocarcinoma.
# Metastatic Pancreatic Cancer/Abdominal Pain:
Patient with several months of chronic epigastric pain, that has
acutely worsened. Presented to ___ Urgent Care where
she was found to have ST depressions on EKG, and was transferred
to ___. On arrival, the patient was hemodynamically stable.
Exam was unremarkable. Labs notable for WBC 15, Na 127, AP 247,
trop x2 negative, and INR 1.3. Given negative cardiac work-up,
patient underwent a RUQ US that showed a 4.7cm hypoechoic mass
from mid-body of pancreas with multiple associated hepatic
masses highly suspicious for metastatic pancreatic cancer.
The patient then underwent CT Torso that confirmed a large
pancreatic body/tail mass with innumerable hepatic lesions, and
pulmonary nodules concerning for metastatic pancreatic
carcinoma. Oncology was consulted and recommended biopsy of a
metastatic site. ___ was then consulted, and the patient
underwent an US-guided biopsy of a liver lesion which she
tolerated well. Pathology of the liver mass biopsy showed poorly
differentiated adenocarcinoma consistent with a pancreatobiliary
origin. The patient was placed on oxycontin and oxycodone for
pain control with plans to follow-up with oncology for further
management.
# Leukocytosis:
Patient had leukocytosis on admission. Likely due to
malignancy-related inflammation Low suspicion for infection.
Downtrended in the hospital, but remained elevated. No
additional work-up at this time.
# Malnutrition
Patient has had significant weight loss and decreased PO intake
over the past 4 weeks. Mostly associated with increased
abdominal pain. Nutrition consulted, recommended nutritional
supplements and MVI. Patient's PO intake improved with better
pain control.
# ST depressions:
Patient intially presented to ___ Urgent Care where
she was found to have precordial ST depression. ECG at ___
unremarkable for ischemia. Troponin x2 negative. Low suspicion
for ACS. Patient did not develop any substernal chest pain while
in the hospital. Echocardiogram was grossly normal and showed
normal systolic function (LVEF >55%).
Transitional Issues:
=====================
-Patient has suspected new diagnosis of pancreatic cancer with
mets to the liver and lung
-Follow-up final pathology results from hepatic lesion biopsy
-Patient is uninsured and needs Oncology follow-up. Number given
to the family to arrange upon discharge.
-Needs to establish primary care physician as an ___ as
patient is from ___ and does not have coverage in the ___.
-Started on oxycontin 10mg BID and oxycodone 5mg q6h for pain
control
-Code: Full
-Contact: Sister ___, ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. NIFEdipine CR 30 mg PO DAILY
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [Tylenol] ___ mg ___ tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30
Suppository Refills:*0
4. Hydrocortisone Cream 1% 1 Appl TP QID:PRN Rash on Back
RX *hydrocortisone 1 % apply moderate amount to back twice a day
Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q6H
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*0
9. Simethicone 40-80 mg PO QID:PRN indigestion
RX *simethicone [Gas Relief] 80 mg 1 tab by mouth four times a
day Disp #*60 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
11. NIFEdipine CR 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Pancreatic mass
Multiple liver masses
Multiple lung nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you. You were admitted to the
___ because you were having
abdominal pain and abnormalities on electrocardiogram. You were
not having any acute problem with your heart, but ultrasound of
your abdomen showed a mass in the pancreas with multiple masses
in the liver. CT scan of the abdomen and chest was done that
confirmed the findings of the ultrasound and showed multiple
nodules in the lung. We did a biopsy of one of the liver masses
under ultrasound guidance to identify the nature of the masses.
We will contact you once we have the results of the biopsy. You
will have to schedule a follow-up appointment one week after
your discharge at the ___ by calling ___.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10498557-DS-21 | 10,498,557 | 21,197,551 | DS | 21 | 2187-11-10 00:00:00 | 2187-11-13 14:35:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Latex
Attending: ___
___ Complaint:
pain, swelling, redness in ___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ lady with with a history of thyroid cancer
in remission, diffuse large B-cell lymphoma in remission s/p
radiation to left groin with ___ edema and h/o recurrent
cellulitis who prtesented to the ED due to ___
swelling/pain/erythema.
She has had recurrent cellulitis in the past. Usually spikes
fevers to 104 and feels very ill, with leg swelling and redness.
Does not recall any h/o MRSA, but she has gotten Vancomycin in
the past. Has needed a PICC line for Abx in the past. She takes
suppressive Penicillin V potassium 500 mg BID and is happy to
report that her last cellulitis was in ___ when she was living
in ___.
She was feeling well until early ___ when she got bad tooth
pain. She went to her dentist who said that she had a dental
infection in a fractured tooth. She stopped her PCN and took
Amoxicillin instead. For tooth pain, she was offered Vicodin but
was worried about getting drowsy so she took ibuprofen.
Accidentally took 18 ibuprofen in 8 hours and started to feel
lightheaded, nauseated so she called EMS.
She was admitted to ___ from ___ for NSAID-induced
renal failure. Per verbal report, she was febrile to 101 there,
but thought to be due to the dental infection. She does not know
which antibiotics she was on while she was admitted, but she was
discharged yesterday on Flagyl which she has been taking.
When she returned home, noticed pain in her left medial calf.
Developed worsened swelling, as well as new erythema throughout
the day. No fevers/chills since getting home. She called HCA and
was referred to the ED.
In the ED, initial VS were: 8 98.5 82 129/76 16 97%. Labs were
notable for WBC 12.9 (N:80, Band:2, Metas: 1). Hct 28.2
(baseline ~36), BUN/Cr ___ (baseline Cr 0.9). ___ was
negative for DVT. She received Vancomycin 1g IV. Also for pain
control was given two Hydrocodone-Acetaminophen ___ Tablets,
as well as Dilaudid 0.5mg IV. She was admitted to Medicine for
IV antibiotics. VS prior to transfer were 99.2PO 88 16 131/76
92RA.
On arrival to the floor, she feels OK. The pain is much better
after receiving Dilaudid in the ED. She is upset about the idea
of having cellulitis again, because it had been so long since
her last episode.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
B cell Lymphoma of the left groin ___
--treated with combination of CHOP x 5 cycles plus radiation
therapy
Massive ___ edema as a result of the XRT
--h/o recurrent cellulitis, takes prophylactic PCN BID
Papillary follicular thyroid cancer ___
--treated with surgery (left thyroid lobectomy and isthmectomy)
Depression/Anxiety
--on Cymbalta, Buspirone
Hypertension
--on propranolol, HCTZ, Losartan
Social History:
___
Family History:
FAMILY HISTORY:
Father had resected colon cancer.
Paternal grandmother died of a stroke in her ___.
Maternal grandfather died at age ___, cause unknown.
Paternal grandfather died of heart disease at age ___.
Aunt died of sudden cardiac death in the ___.
Paternal aunt died of ___ Cancer.
Family history of heart disease.
Physical Exam:
Admission PE:
Physical exam:
VS T 99.1 HR 95 BP 140s/80s 144/88 RR 18 SaO2 95 RA
GEN Alert, oriented, no acute distress
HEENT NCAT EOMI grossly
NECK supple
PULM Good aeration, CTAB no wheezes, rales, rhonchi
CV Tachycardic to ___ (resolving leg pain) RRR normal S1/S2, no
mrg
ABD soft NT ND normoactive bowel sounds
EXT Right leg WWP 2+ pulses palpable, no c/c/e. Left leg
edematous, warmer than R leg, erythema advancing beyond drawn
from nightfloat. Skin breakdown on ___, corresponding to
edematous region. Skin intact on RLE
SKIN no ulcers or lesions
DISCHARGE PE:
Physical exam:
VS T 99.1 Tm 99.7 HR 76 BP 106/59 RR 18 SaO2 95 RA
GEN Alert, oriented, no acute distress
HEENT NCAT EOMI grossly. swelling and wrythema near back tooth
NECK supple
PULM Good aeration, CTAB no wheezes, rales, rhonchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds
EXT Right leg WWP 2+ pulses palpable, no c/c/e. Left leg
edematous, warmer than R leg, erythema resolving now closer to
ankle within line drawn from nightfloat. Continued skin
breakdown/flaking on ___, corresponding to edematous region.
Skin not tight or shiny. Skin intact on RLE
SKIN no ulcers or lesions
Pertinent Results:
Admission labs:
___ 10:13PM LACTATE-0.9
___ 08:25PM LACTATE-1.7
___ 07:50PM GLUCOSE-83 UREA N-16 CREAT-1.2* SODIUM-137
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
___ 07:50PM estGFR-Using this
___ 07:50PM WBC-12.9* RBC-3.26*# HGB-9.6*# HCT-28.2*
MCV-87 MCH-29.4 MCHC-34.0 RDW-14.5
___ 07:50PM NEUTS-80* BANDS-2 LYMPHS-7* MONOS-5 EOS-5*
BASOS-0 ___ METAS-1* MYELOS-0
___ 07:50PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
___ 07:50PM PLT COUNT-226
Micro:
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
Blood culture ___: No growth
Urine culture ___: No growth
Discharge labs:
___ BLOOD WBC-16.2* RBC-3.44* Hgb-10.0* Hct-29.8* MCV-87
MCH-29.0 MCHC-33.4 RDW-14.0 Plt ___
___ BLOOD Neuts-76* Bands-3 Lymphs-9* Monos-8 Eos-1 Baso-0
___ Metas-2* Myelos-1*
___ BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL
___ BLOOD Plt Smr-HIGH Plt ___
___ 06:05AM BLOOD Glucose-87 UreaN-10 Creat-0.8 Na-136
K-3.7 Cl-96 HCO3-30 AnGap-14
IMAGING:
CXR ___:
Mild progression of cardiac enlargement with mild degree of
pulmonary congestion. Consider dehydration therapy, possible
chest x-ray
followup to confirm the official results.
US L Lower extremity ___:
No evidence of DVT, however, the peroneal veins of the left calf
cannot be evaluated.
US L Lower extremity ___:
Diffuse edema in the left lower leg with no abscess identified.
Brief Hospital Course:
Ms ___ is a ___ with PMHx of multiple cellulitis infections
after L groin lymph node resection, XRT for B cell lymphona in
___, resulted in subsequent ___ lymphedema, who presented new
onset edema, erythema, pain c/f new ___ cellulitis.
# ___ cellulitis: Pt presented with fever, erythema, swelling,
and tenderness in ___. Prior to admission, she had recently had
a significant tooth infection for which she stopped taking her
prophylactic penicillin and started staking Flagyl. She
developed this pain in ___ after discontinuing penicillin. She
was diagnosed with ___ cellulitis. Initial, L lower extremity US
were negative for abscess and DVT, though due to edema it may
have been hard to assess the full ___ depth. She was treated
with IV vancomycin, metronidazole, and cephalexin to treat both
her cellulitis and tooth abscess. Pt improved clinically,
continued to be afebrile with decreasing swelling and erythema
in her leg. Her WBC peaked on ___ transiently, though she
was improving clinically, so L lower extremity US was repeated
to assess for abscess; however, no abscess was appreciated.
Since her WBC started to trend down and she improved clinically,
we transitioned her from IV vanc to bactrim and continued
metronidazole and cephalexin on discharge.
#Leukocytosis with left shift/WBC Differential: Pt's WBC
differential was significant for metas and myelos during her
stay, which may be consistent with her infection. However, given
her h/o lymphoma, it will be important for these to be trended
to resolution on an outpatient basis. She is already scheduled
for f/u with heme-onc in ___ and will see her PCP on ___.
# ___ s/p NSAIDs: Pt reports accidentally taking ___ NSAIDs
for tooth pain and developed nausea and vomitting at home. She
was taken to an OSH, where her creatinine was found to be 3.4 in
OSH on ___. On admisstion to ___ for her cellulitis, her Cr
had improved to 1.2. During her hospitalization, her Cr returned
to baseline 0.8 and we resumed her antihypertensives.
# HTN: BPs have been elevated in hospital, likely ___ to holding
antihypertensive medication for NSAIDs induced ___. Once, we
resumed losartan, propranolol, and hctz, BPs returned to
appropriate range.
# Dental infection: Treated with cephalexin and flagyl for tooth
infection. Will need dental follow-up
CHRONIC ISSUES:
# Anemia: Hct 28.2 w/ baseline in ___ ~36 and was 3.1 on ___
at OSH. Thus we checked guaiac, iron studies, and trended hct.
Fe studies revealed anemia of chronic disease. CBC was stable
during hospitalization.
# Depression/Anxiety: stable. continued home cymbalta and
buspirone. Gave ativan 0.25mg prn anxeity. Stable
TRANSITION ISSUES:
[ ] f/u on her tooth infection
[ ] f/u restarting PCN ppx against cellulitis in ___
[ ] continue to trend WBC differential, consider peripheral
smear and heme/onc referral if not improved
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Duloxetine 120 mg PO DAILY
2. BusPIRone 10 mg PO TID
3. Propranolol LA 80 mg PO DAILY
ON HOLD SINCE RECENT HOSPITALIZATION
4. Hydrochlorothiazide 25 mg PO DAILY
ON HOLD SINCE RECENT HOSPITALIZATION
5. Losartan Potassium 100 mg PO DAILY
ON HOLD SINCE RECENT HOSPITALIZATION
6. Penicillin V Potassium 500 mg PO Q12H
ON HOLD SINCE RECENT HOSPITALIZATION
7. MetRONIDAZOLE (FLagyl) 500 mg PO TID
STARTED UPON DISCHARGE FROM RECENT HOSPITALIZATION
Discharge Medications:
1. BusPIRone 10 mg PO TID
2. Duloxetine 120 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Propranolol LA 80 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Cephalexin 500 mg PO Q6H cellulitis Duration: 9 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*36 Bottle Refills:*0
7. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 9 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*36 Bottle Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H diarrhea and tooth
infection Duration: 9 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*27 Bottle Refills:*0
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:
Dear Ms. ___,
You were admitted for increased pain, redness, and swelling of
your left leg. You were found to have cellulitis of your left
lower extremity. We treated you with vancomycin, metronidazole,
and cephalexin for your cellulitis and partially for your tooth
abscess. You improved, so we switched IV vancomycin to oral
bactrim, while keeping the other antibiotics (metronidazole and
cephalexin). You will complete a 14 day course. You should have
your tooth evaluated by your dentist as the antibiotics will not
cure a tooth infection.
.
While you're taking these antibiotics, please discontinue your
prophylactic penicillin. When you follow-up with your PCP,
please discuss reinitiating this medication once antibiotic
treatment of your cellulitis is complete.
Followup Instructions:
___
|
10498985-DS-14 | 10,498,985 | 28,774,731 | DS | 14 | 2153-12-20 00:00:00 | 2153-12-20 22:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
frontal headache, diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with hx of asthma and seasonal allergies presented with
headaches and diplopia iso recent tx for sinusitis.
Pt was seen in her PCP's office today for ___ for
which she has had symptoms of nasal congestion and frontal
headache for the last month. She has been treated with
Augmentin for 10 day course. however, symptoms persisted so her
PCP treated her again for additional 5 days. She was then seen
again in ___ ED on ___ for ongoing frontal headache and
discharged home. She has been taking Tylenol and ibuprofen at
home without much relief.
Today, she noted worsening diplopia for a few hours and
worsening headache. On review, pt states that she was cutting
onions which made her tear up and she rubbed her eyes which made
her symptoms worse. Diplopia self-resolved after 2 hours.
However, given history of persistent sinusitis iso new diplopia
and worsening HA, pt was referred to ED for evaluation for
possible complicated sinusitis with orbital involvement.
On arrival to the ED, VS: 97.0, 79, 113/71, 18, 100% RA
Labs largely unremarkable but were hemolyzed.
Pt seen by Neuro who recommended MRI with contast to r/o
cavernous sinus thrombosis and MRV to r/o CSVT. MRI was
obtained and only showed severe paranasal sinus disease with
acute sinusitis with pus. Otherwise no sinus thrombosis or CSVT
Pt also seen by Ophtho who performed dilated eye exam and this
was wnl
Pt also seen by ENT who recommended starting IV unasyn, saline
nasal rinses, Flonase, and Afrin.
Pt admitted to medicine for further management of sinusitis.
Past Medical History:
Asthma
Seasonal allergies
PAST SURGICAL HISTORY:
Foot and toenail surgeries
Social History:
___
Family History:
no family history of immunodeficiencies
Physical Exam:
VITALS: 98.2PO ___ 18 100 RA
GEN: young F, sitting in bed in NAD
EYES: no scleral icterus, EOMI with no pain on movement
ENT: mild sinus tenderness, no active drainage, MMM, clear OP
NECK: supple, no LAD
RESP: CTA b/l, no respiratory distress
CV: RRR, no m/r/g
GI: Soft, NT/ND
EXT: wwp, no edema
NEURO: AOx3, CN's grossly intact
PSYCH: pleasant, normal mood and affect
SKIN: no lesions, no rashes
Exam on discharge:
Vitals: 98.3 BP: 106 / 78 HR 791897RA
GEN: laying in bed in NAD
EYES: no scleral icterus, EOMI
ENT: mild sinus tenderness, no active drainage, MMM, clear OP
NECK: supple, no LAD
RESP: CTA b/l, no respiratory distress
CV: RRR, no m/r/g
GI: Soft, NT/ND
EXT: wwp, no edema
NEURO: AOx3, CN's grossly intact
PSYCH: pleasant, normal mood and affect
SKIN: no lesions, no rashes
Pertinent Results:
ADMISSION LABS:
___ 08:21PM K+-3.8
___ 03:25PM URINE HOURS-RANDOM
___ 03:25PM URINE UCG-NEGATIVE
___ 03:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:25PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 03:25PM URINE MUCOUS-RARE
___ 03:18PM LACTATE-0.9 K+-5.9*
___ 03:11PM GLUCOSE-74 UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-6.4* CHLORIDE-104 TOTAL CO2-20* ANION GAP-19
___ 03:11PM WBC-9.5 RBC-3.81* HGB-11.9 HCT-35.5 MCV-93
MCH-31.2 MCHC-33.5 RDW-14.0 RDWSD-47.2*
___ 03:11PM NEUTS-53.6 ___ MONOS-5.4 EOS-1.6
BASOS-0.3 IM ___ AbsNeut-3.93 AbsLymp-2.86 AbsMono-0.40
AbsEos-0.12 AbsBaso-0.02
___ 03:11PM PLT COUNT-289
MRI head W/ and W/out Contrast:
1. Severe paranasal sinus disease with restricted diffusion of
frontal sinus
and sphenoid sinus contents indicating acute sinusitis with pus.
Edema and
enhancement within the clivus and superficial frontal calvarium
overlying the
frontal sinus may be reactive, but cannot exclude infectious
involvement.
Recommend ENT consultation for consideration of definitive
treatment, pus
drainage.
2. No evidence of cavernous sinus thrombosis.
3. No evidence of infarction or intracranial hemorrhage.
The findings were discussed with ___, M.D. by ___
___, M.D.
on the telephone on ___ at 9:57 pm, approximately 15
minutes after
discovery of the findings.
CT Sinuses: ___
IMPRESSION:
1. Opacification of all paranasal sinuses without evidence of
osseous erosion
or hyperostosis.
2. Complete station of the left and severe narrowing of the
right infundibulum
of the ostiomeatal units. The frontoethmoidal recesses are also
opacified.
Brief Hospital Course:
___ F with history of asthma and seasonal allergies p/w
recurrent sinusitis and diplopia.
# Sinusitis
# Frontal Headaches
The patient presented with headache and diplopia due to subacute
sinusitis. The patient was seen by ophthalmology in the ED and
was found to have no abnormalities. She was also seen by
neurology given her reports of vision changes. Otolaryngology
evaluated the patient and recommended a CT sinus which confirmed
sinusitis but without osseous involvement. ID was consulted and
recommended chaining antibiotics to Levaquin, although it is not
clear that the patient failed Augmentin . ENT also recommended
saline nasal spray, intranasal steroids. The patient will be
discharged on Levaquin to complete a 3 week course. She has
follow up scheduled with ENT. Would consider evaluation by
allergy per ID recommendations as the patent seems to have
poorly controlled allergic symptoms which may have contributed
to her presentation.
Transitional issues:
- Per ID: would recommend close f/u with PCP/allergy for closer
management of atopy, seasonal allergies, and likely asthma
(could c/s CF testing should she continue to have this issue
after improved allergic atopy management)
Medications on Admission:
Tylenol and ibuprofen prn
Discharge Disposition:
Home
Discharge Diagnosis:
Sinusitis
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 admission to
___. You were admitted with sinusitis. You were seen by the
opthalomologists who found no problems with your eyes. You were
seen by the ___ doctors, the neurologists and the infectious
disease doctors.
You will be discharged on a new antibiotics, Levofloxacin. You
should take this medication once daily. It is important that you
take this medication every day. You will continue this
medication for 3 weeks. You should also take Flonase for two
weeks. You should continue saline nasal rinses. You can use
Afrin for one more day. You can take Tylenol for your headache.
Do not take more than 4 grams (8 extra-strength Tylenol) in one
day.
Please ask your PCP about following up with an allergy doctor.
You should also follow up with an ENT at the appointment below.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10499159-DS-10 | 10,499,159 | 27,492,501 | DS | 10 | 2129-06-05 00:00:00 | 2129-06-05 19:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
Ertapenem / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
R foot infection
Major Surgical or Invasive Procedure:
___: R foot Incision and Drainage
History of Present Illness:
Mr. ___ is a ___ year old patient who presents for evaluation of
his R foot redness and drainage. The patient had surgery
preformed by Dr. ___ 2 weeks ago. He states that he
noted increased drainage as well as redness to his wound over
the past 2 days. The patient had been visiting his family ___
___ and returned early this morning. He had called the
podiatry resident on call last night who recommended that he
present to the ED for evaluation once landing ___ ___. A
prescription for clindamycin and ciprofloxacin was also sent to
a pharmacy ___ ___ for the patient. The patient denies recent
N/V/F/C/SOB/CP. Podiatric surgery was consulted to assess for
potential intervention.
Past Medical History:
L foot ulcer excision and debridement with closure ___
Reconstructive R foot surgery and hardware removal ___
Aortic Dissection and Valve replacement ___
Shoulder Sx ___
Wrist Sx
Social History:
___
Family History:
Mother DM
Physical ___:
PHYSICAL EXAM ON ADMISSION
VS: 97.2 80 120/72 16 98% RA
GEN: NAD, pleasant
CV: RRR
Pulm: No respiratory distress
GI: Soft, NT, ND
RLE: ___ pulses palpable. Cap refill <3 seconds to all digits.
Increase ___ temperature gradient to R medial forefoot. Dehisced
incision site to dorsal ___ metatarsal with fibro-granular base
and sero-purulent drainage. Erythema extending from hallux to
medial midfoot. No streaking noted. Gross sensation is
diminished.
NEURO: A&Ox3
PHYSICAL EXAM AT DISCHARGE:
VSS
GEN: NAD, pleasant
CV: RRR
Pulm: No respiratory distress
GI: Soft, NT, ND
RLE: C/D/I dressing to R foot. Cap refill <3 seconds to all
digits. Wound VAC intact at ___ mm Hg. Pt able to flex and
extend all toes and ankles.
NEURO: A&Ox3
Pertinent Results:
___ 06:50AM BLOOD WBC-11.1* RBC-3.80* Hgb-12.1* Hct-36.0*
MCV-95 MCH-31.8 MCHC-33.6 RDW-12.8 RDWSD-44.0 Plt ___
___ 06:42AM BLOOD WBC-6.5 RBC-3.81* Hgb-12.1* Hct-37.2*
MCV-98 MCH-31.8 MCHC-32.5 RDW-13.0 RDWSD-46.3 Plt ___
___ 07:50AM BLOOD WBC-7.0 RBC-4.06* Hgb-12.9* Hct-39.7*
MCV-98 MCH-31.8 MCHC-32.5 RDW-12.7 RDWSD-45.7 Plt ___
___ 08:10AM BLOOD WBC-7.2 RBC-4.12* Hgb-13.0* Hct-39.8*
MCV-97 MCH-31.6 MCHC-32.7 RDW-12.5 RDWSD-44.1 Plt ___
___ 06:50AM BLOOD Neuts-73.7* Lymphs-14.0* Monos-9.8
Eos-1.3 Baso-0.5 Im ___ AbsNeut-8.20* AbsLymp-1.56
AbsMono-1.09* AbsEos-0.15 AbsBaso-0.06
___ 06:50AM BLOOD ___ PTT-39.1* ___
___ 06:42AM BLOOD ___
___ 07:50AM BLOOD ___
___ 07:45AM BLOOD ___
___ 08:10AM BLOOD ___
___ 08:15AM BLOOD ___
___ 06:50AM BLOOD Glucose-123* UreaN-16 Creat-1.0 Na-136
K-4.2 Cl-102 HCO3-23 AnGap-15
___ 06:42AM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-137
K-4.7 Cl-103 HCO3-26 AnGap-13
___ 07:50AM BLOOD Glucose-161* UreaN-13 Creat-1.1 Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
___ 08:10AM BLOOD Glucose-100 UreaN-11 Creat-1.0 Na-140
K-4.5 Cl-101 HCO3-30 AnGap-14
___ 06:42AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
___ 07:50AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
___ 08:10AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.3
___ 05:18PM BLOOD Vanco-11.4
___ 07:06AM BLOOD Lactate-1.4
___ 9:23 am TISSUE Site: HEMATOMA
INFECTED HEMATOMA, RIGHT FOOT.
**FINAL REPORT ___
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 SINGLY.
TISSUE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
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.
ESCHERICHIA COLI. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). MODERATE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
BLOOD CULTURES x2 ___: Negative to date
R foot x-ray ___:
1. Diffuse soft tissue swelling about the forefoot centered on
the great toe. No radiographic evidence of osteomyelitis
however, comparison for prior postoperative radiographs is
recommended to evaluate whether there has been any interval
change.
2. Postsurgical changes involving the first, second, third and
fourth digits of the right foot, as above.
PATHOLOGY ___: P
Brief Hospital Course:
The patient was admitted to the podiatric surgery service on
___ for a left foot infection. On admission, he was started
on broad spectrum antibiotics. He was taking to the OR for right
foot incision and drainage on ___. Pt was
evaluated by anesthesia and taken to the operating room. There
were no adverse events ___ the operating room; please see the
operative note for details. Afterwards, pt was taken to the PACU
___ stable condition, then transferred to the ward for
observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with oral ciprofloxacin based on his OR cultures. His
intake and output were closely monitored and noted to be
adequate. The patient was supertherapeutic on admission with an
INR of 3.7. His Coumadin was held on admission and restarted on
___ when his INR was back to therapeutic range; early and
frequent ambulation were strongly encouraged while remaining
partial weightbearing to his R heel. He was evaluated by
physical therapy who deemed him safe to return home with his
current weightbearing restrictions.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with his current weightbearing restrictions,
voiding without assistance, and pain was well controlled. The
patient was discharged home with a wound VAC ___ place and home
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
-Bactrim DS 800 mg-160 mg 1 tab daily
-Coumadin 5 mg tablet on M/F
-Coumadin 7.5 mg tablet ___
-Cymbalta 60 mg capsule,delayed release
-Multivitamin
-Lyrica 225 mg capsule TID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain, fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
3. Duloxetine 60 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pregabalin 225 mg PO TID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q 4 hours Disp #*20
Tablet Refills:*0
7. Warfarin 5 mg PO M/F
Given ___ and ___
8. Warfarin 7.5 mg PO TUES/W/THURS/SAT/SUN
9. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R foot infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Partial weightbearing to R heel. Avoid placing weight
on the front part of foot.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service due to a right foot infection.
You were given IV antibiotics while here and taken to the
operating room for an incision and drainage. You are being
discharged home with a wound vac and with the following
instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
to your heel of right foot until your follow up appointment. Do
not place weight to the front part of your right foot. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub. You will need to have your wound VAC changed every 3
days by home nursing.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
10499159-DS-13 | 10,499,159 | 25,168,114 | DS | 13 | 2131-05-21 00:00:00 | 2131-05-22 08:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
Ertapenem / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Right Foot Infection
Major Surgical or Invasive Procedure:
___:
Right Foot I&D
Right Foot Removal of hardware
History of Present Illness:
___ with pmh ___ neuropathy, hx of multiple ___ ulcerations,
s/p R foot reconstruction ___, recent admission in ___ for
infection to the right foot. During his last admission he went
to the OR for debridement and wound VAC application and was
started on long term abx with suppressive therapy for retained
hardware in the right foot. He was on doxycycline and
ciprofloxacin per OPAT on admission. He presented to the ED
with complaints of acute worsening signs and symptoms of
infection in the right foot. He noticed increased erythema,
pain, and drainage to the right foot prior to arrival. He
reported fevers prior to admission. No nausea, vomiting, chills,
chest pain, cough, abdominal pain, diarrhea recently.
Past Medical History:
- Polymicrobial foot ulcer infections/?osteomyelitis as
described
in HPI
- denies DM despite documentation
- L foot ulcer excision and debridement with closure ___
- Reconstructive R foot surgery and hardware removal ___
- Aortic Dissection and mechanical Valve replacement ___ -
-coumadin
- shoulder surgery ___
- wrist surgery
- right foot Achilles tendon lengthening and medial column
fusion
- Right foot debridement ___
Social History:
___
Family History:
Mother DM
The Family History was reviewed and is non-contributory for a
past history of infection or immunocompromised state.
Physical Exam:
On Admission:
VITALS: 100.4 67 138/79 16 95% RA
General: [x]NAD [x]A/Ox3 []intubated/sedated
Cardiac: [x}RRR []no MRG []NL S1S2 [] abnormal-
Lungs: [x]CTA bil [x]No respiratory distress []abnormal -
Abd: [x]NBS [x]soft [x]nontender [x]nondistended [x]no rebound/
guarding
Vascular: [x]CRT<3 seconds []warmth []erythema []abnormal
Pulses: dp/pt Left: [p/p] Right: [p/p]
Right Lower Extremity: Right foot with prior surgical wound to
the medial aspect of foot with a small wound 1x1cm. There is a
moderate amount of serous drainage from the wound and the wound
probes deep, likely to underlying hardware. No direct
visualization of the underlying hardware. erythema and warmth to
the right foot. Patient reports increased pain with palpation to
the right foot. Decreased sensation b/l.
On Discharge:
VITALS: AVSSGeneral: [x]NAD [x]A/Ox3 []intubated/sedated
Cardiac: [x}RRR []no MRG []NL S1S2 [] abnormal-
Lungs: [x]CTA bil [x]No respiratory distress []abnormal -
Abd: [x]NBS [x]soft [x]nontender [x]nondistended [x]no rebound/
guarding
Vascular: [x]CRT<3 seconds []warmth []erythema []abnormal
Pulses: dp/pt Left: [p/p] Right: [p/p]
Right Lower Extremity: Dry surgical dressing in place
Pertinent Results:
On Admission:
___ 03:34PM BLOOD WBC-10.4* RBC-4.04* Hgb-12.5* Hct-37.5*
MCV-93 MCH-30.9 MCHC-33.3 RDW-13.9 RDWSD-47.5* Plt ___
___ 03:34PM BLOOD Neuts-78.1* Lymphs-8.6* Monos-11.8
Eos-0.8* Baso-0.3 Im ___ AbsNeut-8.10*# AbsLymp-0.89*
AbsMono-1.22* AbsEos-0.08 AbsBaso-0.03
___ 03:34PM BLOOD ___ PTT-31.1 ___
___ 03:34PM BLOOD Glucose-133* UreaN-21* Creat-1.3* Na-134*
K-5.0 Cl-97 HCO3-25 AnGap-12
___ 03:34PM BLOOD CRP-252.4*
___ 03:32PM BLOOD Lactate-1.4
.
On Discharge:
.
Imaging:
Right Foot Xray ___: AP, lateral, oblique views of the
right foot were provided. Medial plate and screw fixation again
seen spanning the right midfoot extending from the level of the
anterior body of the talus through the first metatarsal. Since
the prior exam, 1 of the 2 screws stabilizing the plate to the
anterior body of the talus has been removed. A second screw
remains in place. 2 screws are seen extending into the
navicular which appears somewhat fragmented. There is lucency
adjacent to the more proximal of the screws which may reflect
loosening or osseous destruction in the setting of
osteomyelitis. There is a lag screw extending through the base
of the first metatarsal and the medial
cuneiform into the navicular which appears unchanged in overall
position. 2 screws at the level of the first metatarsal appear
in stable position without signs of loosening. Tiny hyperdense
flecks within the soft tissues of the great toe are unchanged
representing postoperative changes. Unchanged changes related
to amputations are seen at the right toes without change. No
soft tissue gas. Midfoot subluxation is again noted on the
lateral view with dorsal subluxation of the metatarsals at the
tarsal metatarsal junction. Destructive bony changes of the
midfoot reflect Charcot arthropathy.
Right Foot Xray ___: s/p removal of all hardware on the
right foot
Chest Xray ___: Midline sternotomy wires and prosthetic
cardiac valve again noted. The lungs are clear bilaterally. No
focal consolidation, large effusion or pneumothorax. No signs
of congestion or edema. Cardiomediastinal silhouette is stable.
Bony structures are intact. Evidence of prior left distal
clavicular resection again noted. No free air below the right
hemidiaphragm.
.
Microbiology:
>>>>>>>
.
Pathology:
>>>>>>>>>>>
.
___ 04:03AM BLOOD WBC-8.9 RBC-3.57* Hgb-10.9* Hct-32.7*
MCV-92 MCH-30.5 MCHC-33.3 RDW-13.5 RDWSD-45.6 Plt ___
___ 03:34PM BLOOD Neuts-78.1* Lymphs-8.6* Monos-11.8
Eos-0.8* Baso-0.3 Im ___ AbsNeut-8.10*# AbsLymp-0.89*
AbsMono-1.22* AbsEos-0.08 AbsBaso-0.03
___ 04:03AM BLOOD Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have an infection to his right foot where he had prior foot
reconstruction. He was admitted to the podiatric surgery
service. He was started on broad spectrum antibiotics on
admission. The patient was taken to the operating room on
___ for right foot I&D as well as removal of the hardware
in the right foot which the patient tolerated well. A portion of
the incision was left open for drainage and later closed on the
floor. 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 taken off his coumadin
during the periop period and placed on a lovenox bridge. His
Coumadin was restarted POD#1. He will follow up with his
___ clinic on discharge for further testing. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with home ___ was appropriate. The ___
hospital course was otherwise unremarkable. Infectious disease
was consulted and recommended home on IV daptomycin and IV
cefepime with follow up in ___ clinic
He was seen by the Infectious Disease team during the hospital
stay. They recommended a 6 week IV abx course. He had a PICC
line placed and the position of the PICC line was verified using
chest xray. He will be set up for ___ on discharge for ___ line
care.
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
NWB to the lower extremity, and will be discharged on his
regular Coumadin dosing with lovenox bridging. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. DULoxetine 180 mg PO DAILY
3. Pregabalin 225 mg PO TID
4. Rosuvastatin Calcium 5 mg PO QPM
5. Fludrocortisone Acetate 0.2 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
8. Tamsulosin 0.4 mg PO QHS
9. alfuzosin 10 mg oral DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Bethanechol 25 mg PO TID
2. CefePIME 2 g IV Q12H
RX *cefepime [Maxipime] 2 gram 1 g IV twice a day Disp #*84 Vial
Refills:*0
3. Daptomycin 500 mg IV Q24H
RX *daptomycin 500 mg 600 mg iv Q24H Disp #*51 Vial Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. DULoxetine 240 mg PO QHS
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
7. Warfarin 5 mg PO DAILY16
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. alfuzosin 10 mg oral DAILY
10. Docusate Sodium 100 mg PO BID
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Fludrocortisone Acetate 0.2 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pregabalin 225 mg PO TID
15. Rosuvastatin Calcium 5 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Foot Osteomyelitis
Infected Hardware Right Foot
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:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of a right foot
infection. You were taken to the Operating Room on ___ for
an I&D with removal of the hardware in the right foot. You were
given IV antibiotics while here. You are being discharged home
with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your right foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
WOUND CARE:
Betadine Dressing to the Right Foot. Changed daily.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
FOLLOW UP:
Please follow up with your Podiatric Surgeon, Dr. ___. You
will have follow up in the Podiatric Surgery Clinic in ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge. If you are following up at one his
outside clinics please call the clinic to schedule an
appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills including your Coumadin dosing.
Followup Instructions:
___
|
10499421-DS-13 | 10,499,421 | 24,123,594 | DS | 13 | 2181-09-29 00:00:00 | 2181-09-30 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Amoxicillin / Penicillins
Attending: ___.
Chief Complaint:
"bowel issues"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of relapsing-remitting MS, neurogenic
bladder s/p 2 attempts at placing suprapubic catheter with
complications including entero-vesicular fistula and
entero-entero fistulas. She presents with complaint of "poop not
leaving body" and feeling like it is going up her rectum, as
well as "snakes in abdomen". She denies passing any fecal
material vaginally or in her urine. Pt does not have a
psychiatric history in the EMR, however exhibiting bizarre fixed
delusions and also stating if this problem is not resolved, she
will "end it all".
In the ED, initial vs were: 8 98.4 68 188/75 16 96% 0 Labs were
remarkable for WBC 4.8, Hct 33, BUN 25, creat 0.7, lactate 1, UA
with mod ___, pos nitrite, 25 WBC, many bacteria. CT A/P negative
for acute process. Patient was given lisinopril, carbamazepine,
oxycodone, baclofen, fioricet. Pt was seen by psych who
recommended ___ and medicine admission. Urine culture is
pending.
On the floor patient reported that her symptoms have worsened
over the past few weeks. She states that she is "defecating
inside her body" and knows because it "feels warm". She also
endorsed stool per vagina 3 days prior to admission. She stated
that the "snake" she described earlier was an analogy. She
cannot recall when her last bowel movement was. She denies any
blood in her stool or urine although she has had bloody stool
and urine previously. She denied any SI.
Past Medical History:
Bronchitis (patient denies)
Hypertension
Severe multiple sclerosis (b/l leg weakness and R hand weakness
at baseline; neurogenic bladder)
Rheumatoid-type arthritis (patient denies)
Lupus
Osteoarthritis
Constipation
Chronic back pain
gout
anemia
Sjo___'s
Social History:
___
Family History:
Coronary artery disease, atherosclerotic
cardiovascular disease and alcohol abuse.
Physical Exam:
Admission physical exam:
Vitals- Tc: 97.9 BP:158/74 HR: 74 18 97% RA
General- Alert, orientedx3, tearful as a result of her ___, speaks very slowly.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
GU- Indwelling foley present
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Alert and oriented, conversational. Reduced sensation to
fine touch in the bilateral legs > bilateral arms. Strength ___
in the bilateral legs and ___ in the bilater hands, but hands
significantly deformed from arthritis. Reflexes difficult to
assess.
LABS: Reviewed see below
Discharge physical exam:
Vitals- Tc 98.6, bp 118/47, HR 68, RR 22, SpO2 98% on room air
General- Alert, orientedx3, no apparent distress.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
GU- Indwelling foley present
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Psych- patient persistent in her thoughts that she has stool
leaking in her abdomen despite explanations that all of her
imaging studies were normal. Initially very tearful when told
her imaging studies were normal, but calmed with further
discussion. Thought process otherwise logical, able to
communicate clearly.
Neuro- Alert and oriented, conversational. Reduced sensation to
fine touch in the bilateral legs > bilateral arms. Strength ___
in the bilateral legs and ___ in the bilater hands, but hands
significantly deformed from arthritis. Reflexes difficult to
assess.
LABS: Reviewed see below
Pertinent Results:
Admission labs:
___ 09:08PM BLOOD WBC-4.4 RBC-3.30* Hgb-11.0* Hct-33.1*
MCV-100* MCH-33.3* MCHC-33.3 RDW-13.2 Plt ___
___ 09:08PM BLOOD ___ PTT-33.6 ___
___ 09:08PM BLOOD Plt ___
___ 09:08PM BLOOD Glucose-88 UreaN-25* Creat-0.7 Na-138
K-4.2 Cl-98 HCO3-29 AnGap-15
Discharge labs:
___ 11:00AM BLOOD Hct-29.0*
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD ___ PTT-31.8 ___
___ 07:35AM BLOOD WBC-3.9* RBC-2.77* Hgb-9.5* Hct-26.8*
MCV-97 MCH-34.2* MCHC-35.4* RDW-12.5 Plt ___
___ 07:35AM BLOOD Glucose-78 UreaN-17 Creat-0.7 Na-137
K-4.0 Cl-98 HCO3-33* AnGap-10
___ 07:35AM BLOOD LD(LDH)-194 TotBili-0.1
___ 07:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.7
___ 07:35AM BLOOD Hapto-100
Imaging studies:
___ CT abd/pelvis (oral contrast)
IMPRESSION:
1. No acute pathology within the abdomen or pelvis. No
evidence of fistula
or intra-abdominal abscess.
2. Ventral abdominal wall hernia contains a loop of transverse
colon, with no
evidence of strangulation or obstruction.
Brief Hospital Course:
Ms. ___ is a ___ yo female with history of
relapsing-remitting MS, neurogenic bladder s/p 2 attempts at
placing suprapubic catheter with complications including
entero-vesicular fistula and entero-entero fistulas, presenting
with concern for possible colovaginal fistula and also with a
fixed delusion of stool leaking into her abdomen.
Active problems:
# Fixed delusion/concern for colovaginal fistula - Patient with
delusions of defecating inside herself initially concerning for
delirium, not consistent w/ new psychosis per psych. She was
admitted to medicine on a ___ as a result of her suicidal
ideation and for concerns that she had delirium from a suspected
medical cause. Upon interview, however, it was determined that
the patient seemed oriented and was able to give a history. Her
___ was reversed upon her arrival to the medicine floor
and her 1:1 sitter was discontinued. No urinary symptoms
endorsed. Her UA was not overly concerning for infection given
her indwelling foley. She was insistent that she was
experiencing stool per vagina, and given her history of
abdominal surgeries, a fistula needed to be ruled out. Surgery
felt that suspicion for a fistula was low based on her CT
imaging but requested that Ob/Gyn perform a speculum exam, which
was unremarkable. Both surgery and Ob/Gyn concluded that no
additional follow-up would be necessary. Although no fistula was
noted on exam, significant stool buildup was seen inside the
colon and so an aggressive bowel regimen was started. The
patient ultimately had several large bowel movements with a
fleet enema.
Ms. ___ was discharged on ___ after an extensive
discussion with her regarding the normal results of her studies
while in the hospital. She was extremely upset and tearful about
these results given her conviction that stool is indeed leaking
into her abdomen. It was explained that her imaging studies and
speculum exam did not reveal a fistula and that she would have
been extremely ill and would need emergency surgery if her
bowels were perforated. She ultimately became more calm and was
able to speak to social work regarding her living situation and
___ services. She was discharged on a bowel regimen consisting
of bisacodyl ___aily pen, docusate 100 mg po bid, miralax
1 packet daily, senna 1 tab bid, and fleet enemas 3x weekly to
prevent further constipation upon discharge.
#UTI: Ms. ___ initially presented with asymptomatic bacturia
and so was not treated with antibiotics per IDSA guidelines. On
the day of discharge, she began to complain of some back pain,
and she was ultimately given a 7 day course of bactrim due to
concerns that her UTI might be becoming symptomatic. Her urine
culture ultimately grew out Klebsiella pneumoniae sensitive to
Bactrim.
#HTN: Received lisinopril in the ED, BP improved. Continued home
lisinopril, metoprolol, nifedipine, terazosin.
#Anemia: Patient gives a history of bleeding hemorrhoids
diagnosed on colonoscopy in ___. Patient experienced an acute
drop in HCT on the morning of ___ from 33 to 26; a repeat Hct
was 29 and hemolysis labs were normal, suggesting a lab
abnormality for the Hct of 26.
Chronic problems:
#Severe multiple sclerosis (b/l leg weakness and R hand weakness
at baseline; neurogenic bladder): continued home baclofen,
carbamazepine, citalopram
# Rheumatoid arthritis/OA/lupus: Continued home acitaminophen,
salsalate, hydroxychloroquine
#Chronic back pain: Continued home gabapentin, tizanidine
#gout: Patient currently not on prophylactic medications
#Sjogren's: bowel regimen continued per above, as Sjogren's
contributing to patient's constipation.
Transitional issues:
- please give fleet enema three times a week
- please check cardiopulmonary function three times a week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO BID
2. Spironolactone 25 mg PO DAILY
3. NIFEdipine CR 90 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Terazosin 5 mg PO ONCE
6. Hydroxychloroquine Sulfate 400 mg PO DAILY
7. Tizanidine 4 mg PO QHS
8. Baclofen 10 mg PO QHS
9. Carbamazepine (Extended-Release) 300 mg PO BID
10. Lisinopril 40 mg PO DAILY
11. Furosemide 10 mg PO BID
12. Salsalate 1500 mg PO BID
13. Gabapentin 100 mg PO HS
14. Levothyroxine Sodium 50 mcg PO DAILY
15. calcium citrate 800 mg Oral BID
16. modafinil 200 mg Oral BID
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Ascorbic Acid ___ mg PO BID
20. Acetaminophen 1000 mg PO DAILY
21. Calcium Carbonate 1250 mg PO BID
22. Fluticasone Propionate NASAL 2 SPRY NU DAILY
23. Baclofen 30 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Calcium Carbonate 1250 mg PO BID
4. Carbamazepine (Extended-Release) 300 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Furosemide 10 mg PO BID
7. Gabapentin 100 mg PO HS
8. Hydroxychloroquine Sulfate 400 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. Metoprolol Tartrate 12.5 mg PO BID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. NIFEdipine CR 90 mg PO DAILY
14. Salsalate 1500 mg PO BID
15. Spironolactone 25 mg PO DAILY
16. Terazosin 5 mg PO ONCE
17. Tizanidine 4 mg PO QHS
18. Vitamin D 1000 UNIT PO DAILY
19. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 Suppository(s) rectally daily Disp #*7
Suppository Refills:*0
20. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*14 Capsule Refills:*0
21. Fleet Enema ___X/WEEK (___) constipation
RX *sodium phosphates [Fleet Enema] 19 gram-7 gram/118 mL 1
Enema(s) rectally three times weekly Disp #*7 Each Refills:*0
22. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 (One) packet by
mouth daily Disp #*7 Each Refills:*0
23. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*7
Tablet Refills:*0
24. Sulfameth/Trimethoprim DS 1 TAB PO BID
Continue for 7 days (Day 1 = ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*13 Tablet Refills:*0
25. calcium citrate 800 mg ORAL BID
26. modafinil 200 mg Oral BID
27. Baclofen 10 mg PO QHS
28. Baclofen 30 mg PO TID
29. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Active problems:
# Fixed delusion/concern for colovaginal fistula
#UTI
Chronic problems:
#HTN
#Anemia
#Severe multiple sclerosis (b/l leg weakness and R hand weakness
at baseline; neurogenic bladder)
# Rheumatoid arthritis/OA
# Lupus
#Chronic back pain
#gout
#Sjogren's
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
concerns about abdominal fistulas causing stool leakage. We
evaluated you with a CT scan and a speculum exam, and after
talking to the surgical team and Ob/Gyn team, we determined that
you did not have a fistula. You also were extremely constipated,
and so we treated you with a number of medications for
constipation including an enema. In addition, you were found to
have some bacteria in your urine. We did not treat you initially
because you did not have any symptoms, but you later began to
have some back pain and so we started you on antibiotics.
Please keep your follow-up appointments upon discharge.
Followup Instructions:
___
|
10499421-DS-14 | 10,499,421 | 24,026,025 | DS | 14 | 2182-02-13 00:00:00 | 2182-02-13 20:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Amoxicillin / Penicillins / CT IV contrast
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with severe MS, neurogenic bladder, HTN, h/o delusions,
Sjogren's who presents with constipation and no BM for 1 week.
Patient reports that for the past week she has been unable to
have a bowel movement. She is taking senna, colace and bisacodyl
at home. Has been receiving Fleet enemas from a ___, but these
were stopped since last admission because they were felt not to
be effective. She has also stopped miralax as she doesn't think
it was helping. The patient feels that she is defecating inside
herself, with stool going into her abdomen, inside her legs, and
into her lungs. She has reported similar belief in the past and
seems to realize that others find this hard to believe. She also
reports fatty material in her GI tract which has been blocking
the stool from leaving her body.
Notably, her last admission note documents h/o entero-vesicular
fistula after failed suprapubic catheter placement as well as
entero-enteric fistulae. She did have a partial small bowel
resection in ___ after small bowel injury during suprapubic
tube placement in the OR, however I see no documentation of
fistulae and none noted on recent CT from ___. However, she
did have a ventral hernia containing non-strangulated loop of
colon on CT abd/pelvis ___.
In the ED initial vitals were: 97.6 76 169/67 18 96% ra. Labs
were significant for Hct 33 (baseline), otherwise nl. Patient
was given no meds. Manual disimpaction attempted per report, no
stool in rectal vault. KUB without e/o obstruction, but showed
large amount of fecal loading. Vitals prior to transfer were:
98.5 86 150/76 16 94% RA.
On the floor, patient reports frustration with her ongoing
constipation. Denies abd pain.
Review of Systems:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Hypertension
-Severe multiple sclerosis (b/l leg weakness and R hand weakness
at baseline; neurogenic bladder)
-Neurogenic bladder s/p failed appendicovesicostomy
-Rheumatoid-type arthritis (patient denies)
-Lupus
-Osteoarthritis
-Constipation
-Chronic back pain
-gout
-anemia
-Sjogren's
-Fixed delusion regarding defecating inside her body
Social History:
___
Family History:
Coronary artery disease, cardiovascular disease and alcohol
abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T 98 BP 134/57 HR 72 RR 20 SpO2 94/RA
General- Awake, alert
HEENT- MMM
Lungs- CTAB
CV- RRR, no m/r/g
Abdomen- hypoactive BS, soft/NT/obese
Rectal- No stool in rectal vault
GU- Foley in place
Ext- 3+ ___ edema bilaterally
Neuro- A&Ox3, normal affect but perseverating on idea of stool
not leaving her body. Decreased sensation and strength in her
legs. Strength ___ in hands, but significant joint
deformities noted.
DISCHARGE PHYSICAL EXAM:
VS- T98.4, BP139/56, HR64, RR18, 95RA
General- Awake, alert, pleasant
Lungs- Soft expiratory wheezes R>L, no crackles
CV- RRR, normal S1 S2, no murmurs
Abdomen- hypoactive BS, soft, nontender, nondistended
GU- Foley in place
Ext- 2+ ___ edema bilaterally; 6x6 cm erythematous area on RLE
without open lesions, drainage, warmth
Neuro- A&O. Decreased sensation and strength in her legs.
Pertinent Results:
=========================
LABS ON ADMISSION:
=========================
___ 07:50PM BLOOD WBC-4.7 RBC-3.31* Hgb-10.6* Hct-33.6*
MCV-102* MCH-32.1* MCHC-31.6 RDW-12.7 Plt ___
___ 07:50PM BLOOD Neuts-69.2 ___ Monos-7.3 Eos-3.1
Baso-0.6
___ 07:50PM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-140
K-3.5 Cl-101 HCO3-28 AnGap-15
___ 06:45AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
___ 07:56PM BLOOD Lactate-1.0
=========================
LABS ON DISCHARGE:
=========================
___ 07:35AM BLOOD WBC-4.8 RBC-3.10* Hgb-10.3* Hct-31.7*
MCV-102* MCH-33.2* MCHC-32.4 RDW-12.8 Plt ___
___ 07:35AM BLOOD Glucose-77 UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-97 HCO3-32 AnGap-13
___ 07:35AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.0
=========================
IMAGING:
=========================
___ CXR
In comparison with the study of ___, there is persistent
elevation of the right hemidiaphragmatic contour. No evidence
of acute
pneumonia or appreciable vascular congestion or pleural
effusion.
___ KUB
A large amount of stool is seen throughout the colon and rectum.
No dilated loops of small bowel, air-fluid levels, or free
intraperitoneal gas is demonstrated. Phleboliths are noted
within the pelvis. Marked
dextroscoliosis of the thoracolumbar spine with associated
degenerative
changes are re- demonstrated.
IMPRESSION:
Large amount of fecal loading. No evidence of small bowel
obstruction.
Brief Hospital Course:
___ with severe MS, neurogenic bladder, HTN, fixed delusions,
Sjogren's syndrome, and chronic constipation who presents with
constipation and no BM for 1 week.
# Constipation: Appears to be a chronic issue for her, worsening
over the past week. No evidence of obstruction on KUB, but does
show large amount of fecal loading. No nausea or vomiting. She
is passing flatus and has benign abdominal exam. No fecal
impaction present within reach on rectal exam. Despite her
delusions about fistulae and stool going other places in her
body, no evidence of this on exam or imaging. Persistent
constipation is likely result of progressive MS and bowel
regimen noncompliance. She was treated with lactulose and
promptly had many bowel movements. She was discharged on
lactulose, milk of magnesia, senna, and colace.
# Multiple sclerosis: MS symptoms seem to be worsening, and
patient is feeling hopeless about condition at home. States she
and her husband are exhausted from the work of caring for her.
She currently has home health aides 4hr/day for 5 day/week, but
states this is not nearly enough. Continue home tizanidine,
baclofen. Patient will consider assisted group home living.
# Hypertension: Stable. Continue home Lasix, nifedipine,
lisinopril, spironolactone, metoprolol. Given severe leg edema,
would consider stopping CCB and changing to another agent.
# Fixed delusions: These are not new and she does not appear
frankly psychotic. Has been seen by Psychiatry in the past for
this issue. No immediate identifiable threats to self or others.
Continue home meds.
# URI: She was started on 10d course of azithromycin per PCP.
Not reporting symptoms at this time. Azithromycin was stopped
due to low concern for bacterial infection and given resolution
of symptoms.
# Inflammatory arthritis and Sjogren's: Continue
hydroxychloroquine.
### TRANSITIONAL ISSUES ###
- New bowel regimen: milk of magnesia, senna, colace. Lactulose
as PRN rescue med
- Patient likely needs more assistance at home or possibly
placement at more permanent assisted facility
- Patient continues to have persistent fixed delusion regarding
stool building up in unusual places in her body; she would
likely benefit from further uptitration of her aripiprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Carbamazepine (Extended-Release) 300 mg PO QAM
4. Citalopram 40 mg PO DAILY
5. Furosemide 10 mg PO BID
6. Gabapentin 100 mg PO HS
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. NIFEdipine CR 90 mg PO DAILY
12. Salsalate 1500 mg PO BID
13. Spironolactone 25 mg PO DAILY
14. Terazosin 5 mg PO HS
15. Tizanidine 4 mg PO QHS
16. Vitamin D 1000 UNIT PO DAILY
17. Calcitrate (calcium citrate) 800 mg oral BID
18. modafinil 200 mg oral BID (AM , NOON)
19. Baclofen 20 mg PO QHS
20. Azithromycin 250 mg PO Q24H
21. Aripiprazole 2 mg PO QAM
22. Baclofen 30 mg PO QAM
23. Baclofen 25 mg PO QNOON
24. Baclofen 25 mg PO QPM
25. Carbamazepine (Extended-Release) 400 mg PO QPM
26. Calcium Carbonate 1250 mg PO BID:PRN reflux
27. Hydroxychloroquine Sulfate 400 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO DAILY
2. Aripiprazole 2 mg PO QAM
3. Ascorbic Acid ___ mg PO BID
4. Calcium Carbonate 1250 mg PO BID:PRN reflux
5. Carbamazepine (Extended-Release) 300 mg PO QAM
6. Carbamazepine (Extended-Release) 400 mg PO QPM
7. Citalopram 40 mg PO DAILY
8. Furosemide 10 mg PO BID
9. Gabapentin 100 mg PO HS
10. Hydroxychloroquine Sulfate 400 mg PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lisinopril 40 mg PO DAILY
13. Metoprolol Tartrate 12.5 mg PO BID
14. Multivitamins W/minerals 1 TAB PO DAILY
15. NIFEdipine CR 90 mg PO DAILY
16. Salsalate 1500 mg PO BID
17. Spironolactone 25 mg PO DAILY
18. Terazosin 5 mg PO HS
19. Tizanidine 4 mg PO QHS
20. Vitamin D 1000 UNIT PO DAILY
21. Docusate Sodium 100 mg PO BID
22. Milk of Magnesia 30 mL PO QAM
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth every morning Disp #*3 Bottle Refills:*0
23. Senna 17.2 mg PO BID
24. Baclofen 30 mg PO QID
25. Calcitrate (calcium citrate) 800 mg oral BID
26. modafinil 200 mg oral BID (AM , NOON)
27. Lactulose ___ mL PO EVERY OTHER DAY constipation
use if more than 2 days without bowel movement
RX *lactulose 10 gram/15 mL ___ mL by mouth every other day
Disp ___ Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Constipation
SECONDARY:
Multiple sclerosis
Chronic constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to constipation likely because
you were not taking your bowel medicines at home. We gave you
lactulose and you were able to have several bowel movements. We
restarted several of your bowel medications and you were able to
have bowel movements.
Please take all medications as prescribed and keep all follow up
appointments. It was a pleasure taking care of you. We wish you
all the best.
Followup Instructions:
___
|
10500002-DS-5 | 10,500,002 | 20,014,934 | DS | 5 | 2184-01-08 00:00:00 | 2184-01-08 13:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ R hip arthrocentesis ___
History of Present Illness:
Mr. ___ is a ___ paraplegic since ___ s/p T8 spinal injury
due to ___ who presents with fevers. Pt states for the past 2
days he has had fevers/chills, and cough productive of clear
sputum. Fever at home was to 101.0. He denies pain (but has no
sensation below his umbilicus). Straight caths at home and has
h/o recurrent UTIs, but has not noticed change in his urine.
Also had nausea with emesis ___ yesterday, non-bloody
non-bilious. His wife was concerned that he looked unwell and
called his PCP, who recommended he present to the Ed.
.
In the ED, initial VS were Temp: 99.1 HR: 130 BP: 137/76 Resp:
18 O2sat 98% on RA. He later spiked fever to 101 and had
rigors. Labs were notable for Hct 33.3 (last Hct 44.3 in
___. CXR and UA showed no e/o infection. CT
chest/abdomen/pelvis showed dislocated right femoral head with
respect to the acetabulum and adjacent soft with high-density
fluid attenuation within the joint. He was evaluated by the
orthopedic service who recommended ___ aspiration of the
joint to assess for septic arthritis in absence of other
explanation for his fever. He received 1g vanc, 1g ceftriaxone,
diazepam 5mg x2, levoflox 750mg x1, and flagyl 500mg x1. He was
admitted to medicine for further eval.
.
Upon transfer to the floor, he was febrile to 101.1, BP 106/64,
HR 118, RR 20, O2 sat 95% RA. He states that he feels like he
has "a cold", occ cough but no SOB. Mild nausea today but no
vomiting since yesterday. Denies HA, visual changes, neck
pain/stiffness, CP/SOB, abdominal pain, change in stool.
.
ROS: per HPI, denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Paraplegia ___ T8 spinal injury from motor cycle accident ___ s/p rod placement
Neurogenic bladder
Gout
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Exam:
VS - Temp 101.1, BP 106/64, HR 118, RR 20, O2 sat 95% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tachycardic, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
R hip - no erythema/warmth, leg soft with occ spasm
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Admission Labs:
___ 11:20AM WBC-8.6# RBC-3.70* HGB-11.6* HCT-33.3* MCV-90
MCH-31.4 MCHC-35.0 RDW-12.6
___ 11:20AM PLT COUNT-172
___ 11:15AM GLUCOSE-126* UREA N-24* CREAT-1.2 SODIUM-136
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
___ 11:15AM ___ PTT-33.5 ___
___ 11:20AM ALT(SGPT)-28 AST(SGOT)-28 LD(LDH)-156 ALK
PHOS-66 TOT BILI-0.6
___ 11:32AM LACTATE-2.2*
U/A:
___ 10:55AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:55AM URINE RBC-2 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-1
___ 10:55AM URINE HYALINE-2*
___ 10:55AM URINE MUCOUS-RARE
Micro:
Imaging:
CXR ___: Portable chest radiograph demonstrates unremarkable
mediastinal, hilar and cardiac contours. Streaky atelectasis is
again noted in the bilateral lung bases without definitive
opacity concerning for pneumonia. Nodular projection over the
posterior right fifth rib correlates with deformity due to prior
trauma, better depicted on the ___ second
opacity projects in the right upper lung adjacent to the
overlying lead and may relate to the medical device though
cannot definitively separate from the lung parenchyma. Please
correlate with direct visualization of lead. No pleural effusion
or pneumothorax evident. Stable thoracic spine fusion hardware.
IMPRESSION:
1. No focal opacification concerning for pneumonia.
2. Nodular opacity over the fifth right posterior rib correlates
with
deformity due to fracture seen on chest CT.
3. Second nodular focus in the right upper lung likely relates
to overlying medical device/EKG lead though cannot definitively
separate from lung parenchyma. Please correlate with visual
inspection. No definite correlate seen in the lung on subsequent
chest CT from this same date, ___.
CT CHEST ABDOMEN PELVIS ___:
CHEST: Subtle linear opacities at both lung bases likely
represent
atelectasis. There may be mild bronchial wall thickening,
suggestive of
inflammation. No pneumothorax or pleural effusion is seen. No
pericardial
effusion is seen. Prominence of the main pulmonary artery is
again noted; the heart and great vessels are otherwise
unremarkable. No axillary, mediastinal, or hilar lymphadenopathy
is detected. The visualized portion of the thyroid is
homogeneous.
ABDOMEN: A 1.7 cm hypodensity in the right lobe of the liver is
stable, but incompletely evaluated on this study. There is no
intra- or extra-hepatic biliary ductal dilation. The
gallbladder, spleen, pancreas, adrenal glands, and left kidney
are unremarkable. Right upper pole renal scarring is again
noted. The stomach and visualized loops of small and large bowel
are within normal limits. The appendix is normal. Note is made
of an inferior vena cava filter. There is no free
intraperitoneal air or ascites.
PELVIS: The bladder is decompressed with a Foley catheter.
Intravesicular
air is likely secondary to instrumentation. The prostate and
seminal vesicles are within normal limits. Apparent rectal wall
thickening without adjacent stranding may relate to collapsed
state.
There is postero-lateral dislocation of the right femoral head
with respect to the acetabulum. There is adjacent soft tissue
thickening and density within the joint space which measures 26
Hounsfield units, suggestive of hyperdense fluid or hemorrhage.
There is adjacent heterotopic ossification. A small amount of
left hip joint fluid may be present.
Thoracic spine hardware is again seen with a focus of
hyperdensity to the
right of the spinous process above the superior end of the
hardware;
ossification was present in this location previously, and
therefore this
likely represents evolving post-surgical change. Healing rib
fractures are
again noted.
IMPRESSION: Dislocated right hip with adjacent soft tissue
thickening and
possible intraarticular fluid; infection cannot be excluded.
Clinical
correlation is recommended for chronicity. Further evaluation
could be
performed with MRI or joint aspiration.
HIP 2-VIEWS ___:
AP view of the pelvis and AP and lateral views of the right hip
were obtained. On the AP view of the pelvis, the right femoral
head is not
within the acetabulum and is located superolaterally. However,
the imaging of the right hip demonstrates the right femoral head
to be in alignment with the acetabulum. Heterotopic ossification
is seen around the right hip versus soft tissue calcification
from possibly myositis ossificans. Soft tissue calcification is
seen along the left hip as well. There is a Foley catheter.
Residual contrast is seen in the bladder from recent CT. No
definite acute fracture is seen.
Brief Hospital Course:
Primary Reason for Hospitalization:
___ paraplegic since ___ s/p T8 spinal injury due to ___ who
presents with fevers, N/V, cough x2 days and found to have right
hip subluxation with high density fluid collection. The initial
differential was viral versus septic joint. He had an ___ guided
aspiration of the hip which was negative and antibiotics were
discontinued. His nasopharyngeal aspirate was positive for
influenza A. He did not meet criteria for oseltamivir and had
already begun to defervesce. He was advised that he was
contagious to contacts until he was afebrile for 24 hours.
Orthopedics recommended keeping a knee imobilizer on the right
leg to prevent subluxation of the hip but he does not require
intervention.
Chronic issues:
# Neurogenic bladder: Stable, no e/o UTI. He was continued on
his home baclofen.
Transitional issues:
- He maintained full code status.
Medications on Admission:
Baclofen 10 mg Oral Tablet take 1 to 3 tablets a day for spasms
Alendronate (FOSAMAX) 70 mg Oral Tablet Take 1 tablet once a
week, on ___
Nitrofurantoin Macrocrystal 100 mg Oral Cap 1 capsule every
other day
ASCORBIC ACID ___ MG TAB 500 mg Oral Tab 1 by mouth 4 times a
day
Discharge Medications:
1. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
___.
3. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
4. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Influenza A
Secondary Diagnosis:
Fluid collection in right hip
Paraplegia
Neurogenic bladder
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
for fevers. There was the initial concern that your hip was
infected because of a fluid collection, however labs show that
there is no evidence of active infection in the joint. You
tested positive for influenza A however, this is most likely the
reason you've been having fevers. This is a viral process and
so will resolve on its own with time. It is recommended that
you stay home for at least 24 hours after your last fever is
gone.
Your medications have not changed. Please continue to take them
as originally prescribed.
Followup Instructions:
___
|
10500002-DS-7 | 10,500,002 | 25,994,031 | DS | 7 | 2189-09-11 00:00:00 | 2189-09-11 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide / reserpine / hydralazine
Attending: ___.
Chief Complaint:
Fever, weakness, DKA
Major Surgical or Invasive Procedure:
Several sacral wound debridements
History of Present Illness:
___ year old M with paraplegia s/p T8 spinal injury ___ ___
MVC, neurogenic bladder with hx recurrent UTIs who intermittent
straight caths, prediabetes, known coccygeal pressure ulcer who
presents with 2 days of fevers, weakness, DOE suspected to be
from infected ulcer. Subsequently with development of DKA.
Pt reports feeling weak with poor appetite for a few days and
development of fevers at ___ (unknown to how high) for 1 day
prior to admission. Of note, patient has been paraplegic with no
sensation below umbilicus from T8 spinal cord injury. He is
functionally independent ___ wheelchair at baseline. Several
weeks ago he noted coccygeal ulcer based on foul smelling odor
and drainage. He was seen ___ ___ ED on ___ at which point
wound was evaluated and per patient he was discharged with plan
for surgical follow up for debridement. Per patient he had an
appointment at ___ on ___.
He denies cough, chest pain, leg swelling, endorses mild nausea
but denies vomiting. No change ___ urinary or stool output. Of
note he is incontinent of feces and has urinary retention
requiring q2h straight caths at ___ which has been treated with
botox injections to the bladder ___ the past.
___ the ED, initial vitals were: ___ 16 96% RA
Exam was notable for: Patient no acute distress, malodorous,
Stage III to stage IV sacral decubitus ulcer which did not
appear to probe to bone.
Labs notable for: WBC elevated to 18.8, Hgb 13.1, Plt 306. Cr
baseline at 0.8, K 4.9, blood glucose 400s, Bicarb 23, AG
elevated to 19. LFTs notable for albumin of 3.1. After 8 hours
electrolytes retrended and demonstrated AG 19 --> 22, Bicarb 23
--> 18. VBG 7.42/48 -> 7.31/48. Urine notable for trace
leukocyte esterase, 9 WBC, few bactereia, neg nittrites, and 80
ketones.
Patient was given:
___ 00:50 IVF NS
___ 00:50 IV Piperacillin-Tazobactam
___ 00:59 PO Acetaminophen 1000 mg
___ 02:40 IV Vancomycin
___ 03:59 IVF NS
___ 03:59 SC Insulin Regular 10 units
___ 06:44 IVF NS 1000 mL
___ 08:14 IV Piperacillin-Tazobactam
___ 08:14 IVF NS ___ Started 250 mL/hr
A R IJ CVL was placed due to difficult access. The patient was
noted to develop a worsening anion gap and metabolic acidosis
and was started on an insulin drip for treatment of DKA. He was
started on vanc/zosyn for presumed skin and soft tissue
infection. Urinary and blood cultures were sent.
Past Medical History:
Gout
Paraplegia
Recurrent UTIs
Fracture of thoracic vertebra, T8 with cord injury, neurogenic
bladder
Tachycardia
PSA elevation
LVH (left ventricular hypertrophy)
Traumatic brain injury, closed
Adjustment disorder
Pre-diabetes
Social History:
___
Family History:
Mother alive with arthritis. Father died, had diabetes.
Physical Exam:
ADMISSION EXAM:
VITALS: Reviewed ___ Metavision, T 37.1, HR 110, BP 99/58, RR
20, O2 99%
GENERAL: WDWN, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular tachycardic rate and rhythm, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: L itergluteal ulcer with eschar 9cmx5xm. Coccygeal ulcer
5cmx2cm with depth 2cm and undermining at ___ of 1-2cm.
Foul smelling, necrotic appearing tissue. No apparent probe to
bone over the coccygeal ulcer.
NEURO: No sensation below umbilicus, no mobility of lower
extremities.
ACCESS: RIJ CVL
DISCHARGE EXAM:
VITALS: 98.3 PO 131 / 78 87 18 98 Ra
General: NAD, resting ___ bed comfortably
Abd: S/NT/ND +BS
GU: foley ___ place
Pertinent Results:
ADMISSION LABS:
___ 11:48PM BLOOD WBC-18.8*# RBC-4.30* Hgb-13.1* Hct-40.1
MCV-93 MCH-30.5 MCHC-32.7 RDW-12.3 RDWSD-42.1 Plt ___
___ 11:48PM BLOOD Neuts-81.6* Lymphs-7.5* Monos-9.0
Eos-0.3* Baso-0.2 Im ___ AbsNeut-15.34*# AbsLymp-1.42
AbsMono-1.69* AbsEos-0.06 AbsBaso-0.03
___ 11:48PM BLOOD Plt ___
___ 11:48PM BLOOD Glucose-430* UreaN-12 Creat-0.8 Na-137
K-4.9 Cl-95* HCO3-23 AnGap-19*
___ 11:48PM BLOOD ALT-24 AST-14 AlkPhos-106 TotBili-0.7
___ 11:48PM BLOOD Lipase-34
___ 06:40AM BLOOD cTropnT-<0.01 proBNP-53
___ 11:48PM BLOOD Albumin-3.1*
___ 06:40AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
___ 09:00AM BLOOD %HbA1c-12.2* eAG-303*
___ 09:00AM BLOOD CRP-GREATER TH
___ 02:41AM BLOOD ___ pO2-70* pCO2-30* pH-7.42
calTCO2-20* Base XS--3 Intubat-NOT INTUBA
___ 11:57PM BLOOD Lactate-1.9
___ 09:57AM BLOOD Glucose-295* Lactate-1.4 Na-136 K-3.5
Cl-107
___ 09:57AM BLOOD O2 Sat-69
IMAGING
-------
KUB ___:
Persistent dilatation of small bowel loops with multiple
air-fluid levels grossly unchanged from prior abdominal
radiographs from ___, consistent with ongoing
small bowel obstruction.
RUE ultrasound ___:
1. There is a right brachial vein PICC. No evidence of PICC
associated deep venous thrombosis.
2. The cephalic vein was not visualized. Within this limitation,
no evidence of deep vein thrombosis ___ the right upper extremity
veins.
CT A/P ___:
1. Small-bowel obstruction withabrupt transition zone ___ a mid
ileal loop (series 5, image 56), possibly secondary to
adhesions. If the patient has not had previous abdominal
surgery, small-bowel obstruction due to internal/pericecal
hernia would be a consideration.
RECOMMENDATION(S): General surgery consultation is recommended.
MICROBIOLOGY
------------
___ 1:52 pm TISSUE COCCYX WOUND TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
PREVOTELLA SPECIES. RARE GROWTH. BETA LACTAMASE
POSITIVE.
___ 12:25 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CHAINS.
Reported to and read back by ___ ON
___ AT
22: 50 ___.
Blood culture x ___: negative
Blood culture x ___: negative
C. diff PCR ___: negative
DISCHARGE LABS
--------------
___ 03:38AM BLOOD WBC-7.2 RBC-2.63* Hgb-8.5* Hct-28.2*
MCV-107* MCH-32.3* MCHC-30.1* RDW-18.0* RDWSD-71.2* Plt ___
___ 03:38AM BLOOD Neuts-53.9 ___ Monos-10.4 Eos-2.3
Baso-0.3 Im ___ AbsNeut-3.91# AbsLymp-2.35 AbsMono-0.75
AbsEos-0.17 AbsBaso-0.02
___ 03:38AM BLOOD Glucose-129* UreaN-7 Creat-0.7 Na-141
K-3.3 Cl-104 HCO3-25 AnGap-12
___ 03:38AM BLOOD ALT-12 AST-12 AlkPhos-59 TotBili-0.4
___ 05:10AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ year old M with paraplegia s/p T8
spinal injury ___ ___ MVC, neurogenic bladder with hx
recurrent UTIs who intermittent straight caths, prediabetes,
known coccygeal pressure ulcer who presents with 2 days of
fevers, weakness, DOE suspected to be from infected ulcer, also
with diabetic ketoacidosis and development of small bowel
obstruction.
# Sepsis
# Bacteremia
# Stage 4 Coccygeal Ulcer with likely Osteomyelitis:
Source is felt to be coccygeal ulcer given presence of foul
drainage and necrotic tissue. Due to eschar unable to stage but
at least Stage 3, now s/p debridement ___ OR with ACS and tissue
debrided down to periosteum. Unclear if positive blood cultures
are secondary to wound vs. contamination. He is on nafcillin
and metronidazole and needs at least six weeks of antibiotics,
OPAT intake performed. He has a pouch for fecal control. ACS
performed several debridements, then proceeded to place wound
vac on ___. He should continue antibiotics until ___. He
should follow up with ID.
#Fever
After several stable days, he also developed a fever and soft
blood pressures. His infectious work up did not reveal UTI or
PNA. BCX were negative. He primary noted rhinorrhea and
non-productive cough. After one day with no additional
intervention, he completely defervesced; this was thought to be
due to a viral URI, and at time of discharge he had been stable
for five days.
# Diabetic ketoacidosis:
# New diabetes with previous prediabetes: marked hypoglycemia to
400s with ketonuria and increasing anion gap. Of note,
patient's last A1c ___ ___ was 6.1 and he has no history of
severe hyperglycemia or DKA. Confirmed DKA with serum ketones
and repeat A1c as previously patient without significant
diabetes. Volume status appears euvolemic and patient already
s/p 2L. Gap closed, ___ has been following. He was
discharged the following insulin regimen: glargine 12 units QHS.
# Small bowel obstruction
# Diarrhea: patient complained of constipation over admission
however on ___ developed acute n/v. CT A/P demonstrated SBO
likely secondary to adhesions. Patient was made NPO and started
on IV fluids. NGT was placed on ___ for worsening distention.
He began having loose BMs after relief of small bowel
obstruction. NGT removed, patient advanced diet, with pouch ___
place for fecal control. C. diff PCR was negative.
# Malnutrition
He required TPN, but was able to be weaned off as his
obstruction improved.
#Prolonged QTc
514ms on EKG at time of admission; not on any QTc prolonging
meds, no electrolyte abnormalities at time of admission.
==============
CHRONIC ISSUES
==============
#T8 spinal cord injury
#Neurogenic Bladder.
#Spasticity
#Recurrent UTIs.
Resulted from ___ ___ ___. No sensation below the umbilicus.
Continued ___ baclofen and intermittent straight caths. He
takes methenamine at ___ for prevention of urinary tract
infections; however, as he is on broad spectrum antibiotics,
this was held, and should be restarted after the antibiotics are
finished on ___.
TRANSITIONAL ISSUES:
- patient should have methenamine restarted on ___, after
nafcillin and metronidazole are stopped
- patient should follow up with ID after he finishes his
antibiotics. An appointment is pending and the office will
contact him.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. methenamine hippurate 1 gram oral QID
3. Baclofen ___ mg PO DAILY:PRN Muscle Spasms
Discharge Medications:
1. Glargine 12 Units Bedtime
2. MetroNIDAZOLE 500 mg PO Q8H
3. Nafcillin 2 g IV Q4H
4. Ascorbic Acid ___ mg PO DAILY
5. Baclofen ___ mg PO DAILY:PRN Muscle Spasms
6. HELD- methenamine hippurate 1 gram oral QID This medication
was held. Do not restart methenamine hippurate until you finish
your other antibiotics on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis
Osteomyelitis
Sacral decubitus ulcer
Bacteremia
SBO
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted for fevers and weakness related to an infected
sacral wound and an underlying bone infection. You were also
found to have bacteria ___ your blood. You were given fluids as
well as antibiotics with improvement ___ your fevers. You were
taken to the OR for debridement of your wound which reaches the
bone. You also developed a small bowel obstruction ***
The diabetes specialists were seeing you for your high sugar
levels as well. You were diagnosed with diabetes. ***
Followup Instructions:
___
|
10500002-DS-8 | 10,500,002 | 26,008,542 | DS | 8 | 2190-04-15 00:00:00 | 2190-04-15 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide / reserpine / hydralazine
Attending: ___.
Chief Complaint:
___ is a ___ man with a history of paraplegia
and stage IV decubitus sacral ulcer, recent UTI presented to the
ED with nausea/vomiting and worsening fatigue.
In the ED, he was febrile to 101.8 with HR 125 BP 100-131/44-98.
He triggered in the ED for HR 135. Blood work showed WBC 19.3,
H&H 7.9/29.0, BUN/Cr ___. Lactate 3.4 -> 2.5 after IVF
resuscitation. CXR showed left basilar opacification. He was
given 2L IVF, zosyn, and vancomycin. He was also given Tylenol.
Urology saw the patient and a 16fr catheter was placed. He was
seen by ACS with plan for bedside debridement of his sacral
wound.
On arrival to the floor, he reports he felt that he was getting
a
UTI about 10 days ago and took his macrobid PRN x 4 days with
improvement in his symptoms of sweats, foul smelling urine, and
cloudy urine. He was feeling well after the macrobid but then
developed nausea/vomiting on ___. He had some mild nausea up
until arrival to the floor and had about 6 total episodes of
non-bloody emesis. He has also had loose stools over the last
several days. He denies any sick contacts or unusual foods. He
denies any abdominal pain.
Of note he has no sensation below his umbilicus.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with a history of paraplegia
and stage IV decubitus sacral ulcer, recent UTI presented to the
ED with nausea/vomiting and worsening fatigue.
In the ED, he was febrile to 101.8 with HR 125 BP 100-131/44-98.
He triggered in the ED for HR 135. Blood work showed WBC 19.3,
H&H 7.9/29.0, BUN/Cr ___. Lactate 3.4 -> 2.5 after IVF
resuscitation. CXR showed left basilar opacification. He was
given 2L IVF, zosyn, and vancomycin. He was also given Tylenol.
Urology saw the patient and a 16fr catheter was placed. He was
seen by ACS with plan for bedside debridement of his sacral
wound.
On arrival to the floor, he reports he felt that he was getting
a
UTI about 10 days ago and took his macrobid PRN x 4 days with
improvement in his symptoms of sweats, foul smelling urine, and
cloudy urine. He was feeling well after the macrobid but then
developed nausea/vomiting on ___. He had some mild nausea up
until arrival to the floor and had about 6 total episodes of
non-bloody emesis. He has also had loose stools over the last
several days. He denies any sick contacts or unusual foods. He
denies any abdominal pain.
Of note he has no sensation below his umbilicus.
Past Medical History:
Stage IV Sacral decubitus ulcer, 16cm^2
T8 Paraplegia ___ MVC
Recurrent UTIs
Strep anginosus bloodstream infection ___
Gout
PSA elevation
TBI
Diabetes
LVH (left ventricular hypertrophy)
Traumatic brain injury, closed
Social History:
___
Family History:
Mother alive with arthritis. Father died, had diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
98.0 114/79 97 18 97%RA
GENERAL: Well- appearing, in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
GU: foley in place draining yellow urine
EXT: Warm, well perfused. No erythema or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. T8 paraplegia without feeling and
strength in ___
SKIN: large 10cmx 12cmx 3cm decubitus ulcer on his sacrum that
appears clean without drainage or granulation tissue, 4cm x 5cm
right scrotal/perineal ulcer, 3cm x 4cm left perineal/lower
gluteal fold ulcers both with necrosis and drainage
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen softly distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: indwelling foley catheter
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: 12cm stage IV sacral decubitus ulcer s/p debridement of
necrotic tissue with healthy surrounding tissue, two small
ulcers
overlying the ischial tuberosities, no active purulent drainage.
NEURO: Alert, oriented, face symmetric, insensate below the
waist
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
==============
___ 12:46PM BLOOD WBC-19.3* RBC-3.48* Hgb-7.9* Hct-29.0*
MCV-83 MCH-22.7* MCHC-27.2* RDW-17.0* RDWSD-51.2* Plt ___
___ 10:55AM BLOOD ___ PTT-27.6 ___
___ 12:46PM BLOOD Glucose-155* UreaN-21* Creat-1.3* Na-144
K-4.8 Cl-102 HCO3-24 AnGap-18
___ 10:55AM BLOOD ALT-20 AST-15 LD(LDH)-162 AlkPhos-91
TotBili-0.2
___ 12:46PM BLOOD Calcium-8.9 Phos-4.7* Mg-1.9
___ 10:55AM BLOOD calTIBC-173* VitB12-297 Folate-13
Ferritn-618* TRF-133*
___ 06:26AM BLOOD CRP-241.0*
___ 01:00PM BLOOD Lactate-3.4*
___ 04:28PM BLOOD Lactate-2.5*
IMAGING
=======
___ CXR
Persisting left basilar opacity which ___ reflect atelectasis or
aspiration/pneumonia.
___ CXR
Left basilar opacification, potentially atelectasis, with
infection or
aspiration not excluded, and likely a small left pleural
effusion.
MICROBIOLOGY
============
___ BLOOD CULTURE, x2: no growth to date
___ URINE CULTURE: negative
___ SPUTUM CULTURE: no growth to date
DISCHARGE LABS
==============
___ 05:40AM BLOOD WBC-9.9 RBC-3.16* Hgb-7.4* Hct-27.0*
MCV-85 MCH-23.4* MCHC-27.4* RDW-16.9* RDWSD-52.4* Plt ___
___ 05:40AM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-146
K-4.6 Cl-108 HCO3-22 AnGap-16
Brief Hospital Course:
Mr. ___ is a ___ male with past medical history of T8
paraplegia after ___ MVA, recurrent UTIs, Stage IV sacral
decubitus ulcer presents with fatigue, diarrhea and 6
episodes of NBNB emesis found to be febrile with leukocytosis to
18k and tachycardia on arrival.
Acute / Active Problems:
========================
# Sepsis due to
# Viral gastroenteritis, suspected norovirus
Presented with nausea, vomiting & diarrhea, with WBC elevated to
___, and tachycardic. Given empiric antibiotics x24 hours and
aggressive IVF and WBC normalized the following day. Surgery
evaluated decubitus ulcer, and had low concern for
superinfection. Culture data all negative. GI symptoms resolved
within 1 day; unable to send stool studies for further testing
(as solidified).
#Chronic, Necrotic Stage IV sacral decubitus ulcer - he is s/p
bedside wound debridement by ACS x3 since admission. ACS has low
suspicion for active infection involving his chronic sacral
ulcer based on exam. ___ RN also given recommendations for
further care (see note in OMR). Continue with Santyl and
dressing changes daily.
#Dehydration #Acute Kidney Injury - Cr up to 1.3 from 0.5,
likely in the setting of sepsis. Improved with IV hydration.
#Acute on chronic blood loss anemia #Anemia of chronic
inflammation - course has been complicated by acute on chronic
anemia with Hgb down to 6.2 morning of ___ after fluids,
transfused 1 unit with appropriate response. GI following but
likely combination of chronic inflammation with slow blood loss
in sacral wounds and now with superimposed acute inflammation.
No signs of active GI bleed. Continue with supportive care,
trend CBC daily, maintain active T&S and transfuse to Hgb > 7.
Chronic / Stable Problems:
==========================
#Type 2 Diabetes Mellitus on insulin - with initial
hyperglycemia
on presentation which has since resolved, suspect in the setting
of acute infection as above.
Greater than 30 minutes spent on coordination of care &
discharge planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID:PRN Muscle Spasms
2. methenamine hippurate 1 gram oral QID
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ASDIR UTI sx
4. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Ascorbic Acid ___ mg PO QID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Collagenase Ointment 1 Appl TP DAILY
3. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Ascorbic Acid ___ mg PO QID
5. Baclofen 10 mg PO TID:PRN Muscle Spasms
6. methenamine hippurate 1 gram oral QID
7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ASDIR UTI sx
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Sepsis
# Viral gastroenteritis
# Chronic, stage IV sacral decubitus ulcer
# Acute renal failure
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 nausea, vomiting &
diarrhea and signs of a severe infection. You recovered very
quickly, and we suspect you had a viral infection, like
"NOROVIRUS" that caused this.
It was a pleasure caring for you!
Please follow up with your primary care doctor, as scheduled
below.
We wish you the very best,
Your ___ Care Team
Followup Instructions:
___
|
10500002-DS-9 | 10,500,002 | 27,599,129 | DS | 9 | 2190-06-05 00:00:00 | 2190-06-05 15:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
hydrochlorothiazide / reserpine / hydralazine
Attending: ___.
Chief Complaint:
fever, chills
Major Surgical or Invasive Procedure:
___: right anticubital PICC line
___ Debridement, vac, diverting colostomy
___ debridement, Vac placement
History of Present Illness:
Mr. ___ is a ___ year old gentleman with h/o T8 paraplegia,
stage IV sacral decub, and recurrent UTIs who presents with
fevers, rigors, and worsening sacral wounds.
Mr. ___ notes that he started developing fevers ~1 days PTA,
with fevers as high as ___. Of note, has chronic sacral
wounds and per report from one of his family members, one of the
smaller ulcers has smelled worse recently and developed yellow
drainage from it. Of note, at baseline has a chronic cough and
rhinorrhea which is stable. Denies shortness of breath or chest
pain.
Of note, has history of multiple UTIs. Notes that when he gets a
UTI, he develops darker malodorous urine. Notes that recently
his urine has been darker than usual, although not malodorous
like when he gets a UTI. Denies flank pain, sacral pain, or
lower abdominal pain - but of note cannot feel below his
umbilicus due to paraplegia.
___ ED initial VS: T 99.0, HR 84, BP 102/60, RR 16, SO2 100% RA
Labs significant for:
-CBC notable for: WBC 19.8 (88.5% N0, 1.1% bands), Hgb 7.3, Plts
427
-BMP notable for: HCO3 19, AG 21, Cr 0.9; PO4 4.7
-LFTs notable for: AP 145, Alb 2.8
-Lactate: 4.5
-U/A: Hazy, Urobili 4, Small ___, Trace blood, 100 Protein, 5
WBC, Few bacteria, 7 Epi, 4 Hyaline casts, Occ mucous
-VBG: 7.44/31
-Repeat Lactate: 1.1
Patient was given: 3L NS, 1g Vancomycin (___), 2g Cefepime
(___), 1g APAP, started Norepinephrine gtt due to persistent
hypotension
Imaging notable for:
-CT A/P w/ Contrast:
1. Interval worsening of sacral/coccygeal decubitus ulcers with
resultant bilateral soft tissue abscesses inferior to bilateral
ischial tuberosities, as described above. Left abscess extends
into left adductor musculature. Right abscess demonstrates
partially imaged external cutaneous sinus tract.
2. Severe, right greater than left, bilateral hip degenerative
joint disease.
3. Possible new right heterogeneous 1.8 cm cystic lesion.
Nonurgent renal ultrasound is recommended for further
evaluation.
4. Relatively hyper perfusing wedge-shaped regions ___ the right
kidney, near an area of cortical scarring, may represent
pyelonephritis ___ the appropriate clinical setting. Correlation
urinalysis is recommended.
5. New splenomegaly.
-CXR IMPRESSION: Left base atelectasis without definite focal
consolidation.
-CXR #2 IMPRESSION: Right central venous catheter tip overlies
the patient's thoracic spinal hardware and is not seen. No
pneumothorax.
Consults:
-ACS: "Pt seen and examined, discussed with attending. R ischial
ulcer debrided at bedside. sacral ulcer with appropriate
granulation tissue. L ischial ulcer needs additional
debridement. Will follow for additional debridement if found
while inpatient."
VS prior to transfer: HR 70, BP 119/61, RR 24, SO2 100%
On arrival to the FICU, endorses the above history. States that
he feels much better than earlier ___ the day. No current
complaints.
Past Medical History:
Stage IV Sacral decubitus ulcer, 16cm^2
T8 Paraplegia ___ MVC
Recurrent UTIs
Strep anginosus bloodstream infection ___
Gout
PSA elevation
TBI
Diabetes
LVH (left ventricular hypertrophy)
Traumatic brain injury, closed
Social History:
___
Family History:
Mother alive with arthritis. Father died, had diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
VITALS: Reviewed ___ metavision
GENERAL: Alert, oriented, middle-aged man ___ no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally on anterolateral
auscultation - no wheezes, rales, or rhonchi
CV: RRR, 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: +Large sacral decubitus ulcer ~12 x 9cm with clean margins
and non-exudative, +two smaller ___ ~3 x 3cm ulcers with
the R ulcer w/ black eschar base
NEURO: Alert, oriented, unable to move legs, no sensation below
umbilicus.
DISCHARGE PHYSICAL EXAM:
vital signs: 98.3, hr=100, bp=100/64, rr= 18 99% room air
GENERAL: NAD
CV: ns2, s2, no murmurs
LUNGS: clear
ABDOMEN: mild distention, soft, ostomy right side abdomen with
yellow stool and flatus, staples lower aspect of wound ( to be
removed when patient returns to clinic)
EXT: flaccid lower ext bil.., full ROM upper ext.
NEURO: alert and oriented x 3, speech clear, no tremors
WOUND: Wet to dry dressing to buttock/ischial bil., ___
wound erythematous, peripheral pink, fibrous tissue on sacrum,
no odor
Pertinent Results:
___ 10:34AM BLOOD WBC-10.4* RBC-3.54* Hgb-9.2* Hct-30.4*
MCV-86 MCH-26.0 MCHC-30.3* RDW-18.1* RDWSD-57.6* Plt ___
___ 05:30AM BLOOD WBC-10.3* RBC-3.50* Hgb-9.1* Hct-30.1*
MCV-86 MCH-26.0 MCHC-30.2* RDW-18.2* RDWSD-57.4* Plt ___
___ 05:05AM BLOOD WBC-10.3* RBC-3.48* Hgb-9.0* Hct-30.1*
MCV-87 MCH-25.9* MCHC-29.9* RDW-18.3* RDWSD-58.2* Plt ___
___ 04:37AM BLOOD WBC-9.1 RBC-3.48* Hgb-9.1* Hct-30.5*
MCV-88 MCH-26.1 MCHC-29.8* RDW-18.4* RDWSD-59.2* Plt ___
___ 05:24PM BLOOD WBC-19.8* RBC-3.08* Hgb-7.3* Hct-26.2*
MCV-85 MCH-23.7* MCHC-27.9* RDW-17.0* RDWSD-52.7* Plt ___
___ 03:54AM BLOOD Neuts-86.2* Lymphs-6.1* Monos-6.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.92* AbsLymp-1.12*
AbsMono-1.24* AbsEos-0.00* AbsBaso-0.03
___ 10:34AM BLOOD Plt ___
___ 02:56AM BLOOD ___ PTT-30.3 ___
___ 10:34AM BLOOD Glucose-93 UreaN-18 Creat-0.5 Na-135
K-4.6 Cl-95* HCO3-27 AnGap-13
___ 05:30AM BLOOD Glucose-107* UreaN-18 Creat-0.5 Na-137
K-5.0 Cl-98 HCO3-27 AnGap-12
___ 05:05AM BLOOD Glucose-113* UreaN-17 Creat-0.5 Na-136
K-4.8 Cl-97 HCO3-27 AnGap-12
___ 02:00AM BLOOD ALT-12 AST-13 LD(LDH)-105 AlkPhos-145*
TotBili-0.9
___ 02:54AM BLOOD ALT-10 AST-21 LD(LDH)-228 AlkPhos-166*
TotBili-0.7
___ 10:34AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.8
___ 05:30AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
___ 02:54AM BLOOD calTIBC-144* Hapto-418* Ferritn-628*
TRF-111*
___ 03:19AM BLOOD Hapto-470*
___ 03:19AM BLOOD CRP-265.6*
___ 05:50AM BLOOD Vanco-18.0
___ 07:35AM BLOOD Vanco-14.0
___ 05:44AM BLOOD Vanco-17.6
___ 11:52AM BLOOD Lactate-2.1*
___: CT abdomen/pelvis:
. Interval worsening of sacral/coccygeal decubitus ulcers with
resultant
bilateral soft tissue abscesses inferior to bilateral ischial
tuberosities, as described above. Left abscess extends into
left adductor musculature. Right abscess demonstrates partially
imaged external cutaneous sinus tract.
2. Severe, right greater than left, bilateral hip degenerative
joint disease.
3. Possible new right heterogeneous 1.8 cm cystic lesion.
Non-urgent renal ultrasound is recommended for further
evaluation.
4. Relatively hypo-perfusing wedge-shaped regions ___ the right
kidney, near an area of cortical scarring, may represent
pyelonephritis ___ the appropriate clinical setting. Correlation
urinalysis is recommended.
5. New splenomegaly.
___: 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 mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is suboptimal image quality to assess regional left
ventricular function. Global left ventricular systolic function
is normal. The visually estimated left ventricular ejection
fraction is 55-60%.
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) appear structurally normal. No masses or vegetations are
seen on the aortic valve. There is no aortic valve stenosis.
There is no aortic regurgitation.
The mitral leaflets are mildly thickened with no mitral valve
prolapse. No masses or vegetations are seen onthe mitral valve.
There is mild [1+] mitral regurgitation. The tricuspid valve is
not well seen. No mass/
vegetation seen, but cannot exclude due to suboptimal image
quality. There is trivial tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial pericardial effusion.
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global
biventricular systolic function. Mild mitral regurgitation. If
clinically suggested, the absence of a discrete vegetation on
echocardiography does not
exclude the diagnosis of endocarditis.
___: CXR:
Compared to chest radiographs since ___ most recently
___.
Lung volumes are lower exaggerating an increase ___ pulmonary
vascular caliber. There is no pulmonary edema. Small left
pleural effusion is likely. Heart size top-normal. No
pneumothorax.
Right jugular line ends ___ the low SVC.
___: US buttock:
1. Fluid and gas containing collection ___ the right buttock not
well imaged secondary to a bandage.
2. Complex left inferior gluteal gas-containing collection
measuring greater than 7.1 cm, located 6 mm from the skin
surface. However, deep portions of the collection are difficult
to visualize on ultrasound. Recommend further evaluation of the
left upper thigh with contrast enhanced CT or MRI to evaluate
the full extent of the collection.
___: CXR:
___ comparison with the study ___, there has been
placement of a left subclavian PICC line that extends to about
the level of the cavoatrial junction.
Cardiomediastinal silhouette is stable and there is no evidence
of appreciable vascular congestion. Bibasilar opacifications
most likely represent atelectatic changes. The right jugular
catheter is been removed.
___ 4:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set ___ the previous five days.
Susceptibility testing requested per ___
(___) ON
___.
Daptomycin Susceptibility testing requested by ___
___
(___) ON ___. FINAL SENSITIVITIES.
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.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Daptomycin MIC OF 0.5 MCG/ML test result performed by
Etest.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------<=0.25 S
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S <=0.25 S
DAPTOMYCIN------------ S
ERYTHROMYCIN----------<=0.12 S =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 0.5 S <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
GRAM POSITIVE COCCI ___ PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Reported to and read back by ___ (___), ___
@ 08:52AM.
___ 5:24 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). OF TWO COLONIAL
MORPHOLOGIES.
(formerly Peptostreptococcus species).
Isolated from only one set ___ the previous five days.
NO FURTHER WORKUP WILL BE PERFORMED.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON
___ -___.
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 11:46 am BLOOD CULTURE Source: Line-left radial.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:30 pm BLOOD CULTURE Source: Line-RIJ TLC 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:41 pm SWAB Source: Left buttock ulcer.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Ertapenem , Ceftolozane/tazobactam , AND
CEFTAZIDIME/AVIBACTAM
SUSCEPTIBILITIES REQUESTED BY ___ ___
___.
Ertapenem = SUSCEPTIBLE.
Ertapenem AND Piperacillin/Tazobactam test result
performed by
___.
CEFTAZIDIME/AVIBACTAM MIC = 0.5 MCG/ML = SUSCEPTIBLE;
test result
performed by Etest.
CEFTOLOZANE/TAZOBACTAM MIC = ___ MCG/ML = SUSCEPTIBLE
test result
performed by Etest.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
Daptomycin Susceptibility testing requested per ___
___
___. Daptomycin MIC <= .25 MCG/ML.
Daptomycin test result performed by Sensititre.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS)
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I).
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
___ 6:57 pm BLOOD CULTURE Source: Line-RIJ TLC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:10 am TISSUE LEFT ISCHIAL.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
___ year old male with a PMH of T8 paraplegia related to a
motorcycle crash. He has a reported history of sacral
decubitus ulcers previously complicated by Strep anginosus
bacteremia ___ ___. The patient had been followed ___ the Acute
care clinic for wound debridement. He was last seen ___ the
clinic on ___ where the ulcer was debrided and a VAC dressing
was applied. Prior to admission, the patient reported fever,
chills and a malodorous drainage from a sacral decubitus ulcer.
He presented to the hospital ___ septic shock.
Upon admission, the patient was reportedly hypotensive requiring
intravenous fluids and pressor support. He was admitted to the
intensive care unit for monitoring and started on a course of
vancomycin and zosyn for BSI. He underwent a cat scan which
showed bilateral soft tissue abscesses inferior to the ischial
tuberosities. The Acute care surgery service was consulted.
They performed a bedside debridement of the wound. Blood
cultures were obtained which grew Group B streptococcus and the
Infectious Disease service were consulted. After examination of
the patient, they recommended a change ___ the antibiotic
regimen. The vancomycin was discontinued and the patient
remained on zosyn. Per recommendations of Infectious disease,
the patient underwent an echocardiogram which showed no evidence
of endocarditis. The patient required up to 6 units of blood for
a decreased hematocrit. His hematocrit remained stable.
On HD #5, the patient was taken to the operating room where he
underwent debridement of bilateral ischial decubitus ulcers and
sacral decubitus ulcer. During the operative course, the patient
required neosynephrine for blood pressure support. A VAC
dressing was placed over the wound at the close of the
procedure. The patient was extubated and returned to the
intensive care unit for monitoring. Cultures from the fluid
collection grew MDR E.coli sensitive to meropenum. The zosyn
was discontinued and the patient continued on vancomycin and
meropenum.
The patient returned to the operating room on HD #8 where he
underwent a VAC change, left ischial wound biopsy/debridement
and a sigmoid colostomy. The operative course was stable with
minimal blood loss. The patient's vital signs remained stable
and he was transferred to the surgical floor.
The post-operative course remained stable. The patient began
to have return of flatus, but bowel function was slow to return.
The patient was started on a clear liquid diet. The Infectious
Disease service continued to monitor the patient's cultures and
___ blood cell count. Recommendations were made from for a 6
week course of Vancomycin and Meropenum necessitating placement
of a PICC line. The last day of medication will be ___. The
patient's foley catheter was removed and self catheterizations
were initiated. The ostomy nurse provided instruction and
supervision ___ the care of the ostomy ___ which family members
were present. ___ preparation for discharge, the patient was
evaluated by physical therapy and discharge measures were
undertaken.
At the time of discharge, the patient's vital signs were stable
and he was afebrile. He was tolerating a regular diet and self
catheterization of his bladder continued. Given that the sacral
and ischial wounds tracked to the periosteum, recommendations
were made for a 6 week course of IV vancomycin and meropenum at
discharge, through ___. He will also need MWF wound vac
changes as noted.
A follow-up appointment was made ___ the acute care clinic. The
Infectious disease service will follow-up with patient and
schedule appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO QID
2. Baclofen 10 mg PO TID:PRN Muscle Spasms
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Collagenase Ointment 1 Appl TP DAILY
5. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. methenamine hippurate 1 gram oral QID
7. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
2. Docusate Sodium 100 mg PO BID
3. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
4. Glucose Gel 15 g PO PRN hypoglycemia protocol
5. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
6. Heparin 5000 UNIT SC BID
7. Meropenem 500 mg IV Q6H
last dose ___. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. Vancomycin 1000 mg IV Q 12H
last dose ___. Zinc Sulfate 220 mg PO DAILY
13. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
15. Ascorbic Acid ___ mg PO QID
16. Baclofen 10 mg PO TID:PRN Muscle Spasms
17. methenamine hippurate 1 gram oral QID
18. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
septic shock
sacral wound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital ___ septic shock related to an
infected sacral ulcer. You were monitored ___ the intensive care
unit for a low blood pressure. You were taken to the operating
room for debridement of the sacral wound and placement of a
wound vac. You returned to the operating room for additional
debridement and diverting colostomy was performed. During your
hospitalization, you were evaluated by the Infectious Disease
service who recommended a course of antibiotic to cover the
infection ___ your sacral ulcer. It was recommended that you
complete a 6 week course. Your vital signs have been stable and
you are preparing for discharge to a rehabilitation facility to
further regain your strength and mobility. You are being
discharged with the following instructions:
Please replaced VAC dressing to sacral and bil. ischium wounds.
Your staples will be removed when you return to clinic for your
post-op visit. You will need to complete a 6 week course of
meropenum and vancomycin as per recommendations of infectious
disease. Blood work has been recommended results of which
should be faxed to the Infectious Disease Dept.
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/MEROPENUM: WEEKLY: CBC with differential, BUN, Cr,
Vancomycin trough, CRP, BUN, Cr, AST, ALT, Total Bili, ALK PHOS
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY CRP for patients with bone/joint
infections
and endocarditis or endovascular infections
FOLLOW UP APPOINTMENTS:
to be scheduled after discharge by ___ clinic.
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.
PLEASE NOTIFY THE ID SERVICE OF ANY QUESTIONS REGARDING THESE
RECOMMENDATIONS OR WITH ANY MEDICATION CHANGES THAT OCCUR AFTER
THE DATE/TIME OF THIS OPAT INTAKE NOTE.
Additional discharge instructions include:
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 ___ your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change ___ your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
10500167-DS-20 | 10,500,167 | 24,026,330 | DS | 20 | 2155-09-30 00:00:00 | 2155-10-03 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Latex / Iodine-Iodine Containing / Bactrim / Amoxicillin /
Clindamycin
Attending: ___
Chief Complaint:
speech disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ is a ___ right-handed WF w/PMH of
migraine w/aura, palpitations and an unspecified hypermobility
syndrome, who presents with a speech disturbance during a
headache. The pt has been experiencing some palpitations
recently, and is scheduled for a Holter monitor soon. Apart from
this, she was in her usual state of health until this morning,
when she went to a spin class, which she completed without
difficulty. She did, however, not drink much during class or for
the remainder of the morning. About an hour later, the pt
noticed
the onset of a typical aura of vision disturbance (described as
fuzzy and zig-zag sparkling) and R arm tingling, which was
followed by a mild headache, with a L retro-orbital tightness,
associated with photo- & phonophobia and mild nausea. Of note,
the pt has never had neurological symptoms with her auras
besides
the vision changes and arm tingling. She took ibuprofen 800 mg,
which she usally does when she feels a headache coming on. This
helped significantly. However, a little while later, as the pt
was in a store talking to a clerk, she suddenly noticed that her
speech was completely garbled. She knew what she wanted to say,
but the words that came out of her mouth were wrong; she doesn't
think they were slurred. Comprehension was never affected. She
called an ambulance, and by the time the EMTs arrived ___
minutes later, her speech had improved somewhat but she still
had
significant word-finding difficulties. Ms. ___ was brought to
___, where she had milder word-finding problems
that then resolved. Total duration of speech problem was about 1
hour. She was given alprazolam 0.5 mg at ___, as her
doctors thought she might be suffering from anxiety (although
she
denies feeling particularly anxious at any point during this),
and also metoclopramide. Head CT was read as normal. She does
admit, however, to significant stress recently, as her husband
just lost his job and thus their only source of income.
The headache has now resolved, and the pt is otherwise
completely
asymptomatic.
On neurologic ROS, no neck stiffness; no
lightheadedness/confusion/syncope/seizures;; no
amnesia/concentration problems; no diplopia; no
vertigo/tinnitus/hearing difficulty; no
dysarthria/dysphagia/drooling; no muscle weakness, no
clumsiness;
no difficulty with gait/balance problems/falls.
On general ROS, palpitations as above; no
fevers/chills/rigors/night sweats/anorexia/weight loss; no chest
pain/dyspnea/exercise intolerance/cough; no
vomiting/diarrhea/constipation/abdominal
pain/melena/hematochezia; no dysuria/hematuria, and no bowel or
bladder incontinence/retention/hesitancy; no
myalgias/arthralgias/morning
stiffness/Raynaud's/rash/photosensitivity/oral ulcers.
There is no history of easy bleeding/bruising/history of blood
clots.
Past Medical History:
- Migraine w/aura; usually gets mild headaches about every 10
days and migraine w/aura every 4 months
- Anxiety
- G6P3, with one elective abortion and 2 spontaneous early
pregnancy losses
- asthma, with frequent prednisone requirements
- Hypermobility syndrome, followed by rheumatology here, with
recurrent shoulder dyslocations
- Abdominal hernia x 2
- Cystocele & rectocele s/p surgical operation
- Cataracts s/p surgery, attributed to steroid use
- Easy bruisability, previously attributed to steroid use
Social History:
___
Family History:
Children: son ___
Siblings: sister w/migraine
Parents: mother w/severe peripheral neuropathy; father w/DVT
after operation
Grandparents: paternal grandmother w/migraine, AD; maternal
grandmother w/brain tumor
There is no history of early strokes or heart attacks, seizures,
movement disorders.
Physical Exam:
General: NAD, lying in bed comfortably.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions
- Fundoscopy: discs flat with crisp disc margins (no
papilledema), normal color. Cup-to-disc ratio normal.
Neuroretinal rim is normal without notching, thinning, or
atrophy. Arteries & veins normal without arteriolar narrowing or
venous engorgement, no crossing changes observed. On limited
exam, no other retinal or optic disc lesions seen
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
- Neurovascular: No carotid, vertebral or subclavian bruits
- Cardiovascular: carotids with normal volume & upstroke;
jugular
veins nondistended, RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Extremities: Warm, no cyanosis/clubbing/edema
- Skin was without rash, induration or neurocutaneous stigmata.
Intact hair, nails and nail folds.
Neurologic Examination:
Mental Status:
Awake, alert, oriented x 3.
Attention: Recalls a coherent history; thought process linear
without circumstantiality or tangentiality. No neglect to visual
or sensory double stimulation. Concentration maintained when
recalling months backwards.
Affect: euthymic
Language: Converses appropriately with fluent speech and good
comprehension. No dysarthria, dysprosody or paraphasias noted.
Follows two-step commands, midline and appendicular and crossing
the midline. High- and low-frequency naming intact. Intact
repetition. Normal reading.
Memory: Easily registers ___ objects and recalls ___ at 3
minutes.
Praxis: No ideomotor apraxia or neglect w/o bodypart-as-object
or
spacing errors.
Executive function tests:
Luria hand sequencing easily learned and performed repeatedly.
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light. No
RAPD.
Visual fields full to peripheral motion, tested individually,
and
to finger counting (including DSS) when tested together.
[III, IV, VI] EOM intact, no pathologic nystagmus.
[V] V1-V3 with symmetrical sensation to light touch. Pterygoids
contract normally.
[VII] No facial asymmetry at rest and with voluntary activation.
[VIII] Hearing grossly intact to finger rub bilaterally.
[IX, X] Palate elevates in the midline.
[XI] Neck rotation normal and symmetric. Shoulder shrug strong.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor: Normal bulk and tone. No pronation or drift. 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]
Interossei [R 5] [L 5]
Abductor Digiti Minimi [R 5] [L 5]
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]
Extensor Hallucis Longus [R 5] [L 5]
Sensory:
Intact proprioception at halluces bilaterally.
There is a gradient to cold sensation to about mid-shin.
Vibration intact at hallluces.
Cortical sensation: No extinction to double simultaneous
stimulation. Graphesthesia intact.
Reflexes
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
Coordination: No rebound. No dysmetria on finger-to-nose and
heel-knee-shin testing. No dysdiadochokinesia. Forearm orbiting
symmetric. Finger tapping on crease of thumb, and sequential
finger tapping symmetric.
Gait& station:
Stable stance without sway. No Romberg.
Normal initiation. Narrow base. Normal stride length and arm
swing. Intact heel, toe, and tandem gait.
Brief Hospital Course:
Mrs. ___ was admitted. Her symptoms resolved and she returned
back to baseline. Due to concern that this was a migraine with
aura and the fact that she has frequent migraines, she was
started on magnesium for migraine prophylaxis. She was given
Toradol and Reglan for headache control. She had a MRI that was
normal. She was discharged home with improved headache and no
focal neurological deficits.
Medications on Admission:
- Advair Diskus 250-50 mcg
- Escitalopram 20 mg daily
- alprazolam 0.25-0.5 mg qhs PRN
- ibuprofen 800 mg PRN at onset of headache
Discharge Medications:
1. ALPRAZolam 0.25-0.5 mg PO QHS:PRN insomnia, anxiety
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Ibuprofen 800 mg PO Q8H:PRN headache
5. Magnesium Oxide 400 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine with Aura
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for transient speech changes due to a MIGRAINE
WITH AURA. The symptoms resolved while you were in the hospital.
You had a MRI that was normal. The following changes were made
to your medications.
Started:
Magnesium 400mg by mouth twice a day
Followup Instructions:
___
|
10500251-DS-13 | 10,500,251 | 24,284,113 | DS | 13 | 2188-10-30 00:00:00 | 2188-10-31 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
confusion, encephalopathy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ man with h/o of seizure disorder and
___ Disease (Spinal Muscular Atrophy type II)
presenting with progressive weakness and fatigue x 2 days with
fall on day of admission, referred to the ED by his PCP.
Neurology was asked to evaluate pt's weakness and possible
seizures. Pt is unable to relate much of the recent history and
so much information was obtained from OMR and sister, ___ (___)
Until this past ___, pt had been seizure-free since ___. He
Pt was admitted to ___ twice ___ and ___ for
weakness, falls, incontinence, and staring episodes. These
symptoms were attributed to Tegretol toxicity (level was 16) or
partial seizures. He then went to rehab for several days after
his last discharge. Tegretol dose was decreased an repeat level
on ___ was 5.6. Pt had been feeling well since discharge from
rehab until yesterday when family again noticed that pt seemed
tired, lethargic, weak, and was slurring speech. He was unable
to
get out of the chair using his normal assistance devices
(crutches/walker/braces). Yesterday he also had several episodes
of loose stools and has actually had new-onset intermittent
fecal
and urinary incontinence over several weeks. Due to these
symptoms, pt presented to his PCP, who sent him to ___.
Per medicine team, on arrival to the floor, pt was lethargic
with
mild slurring and slowed speech, but communicative. Sister was a
bedside and relayed her concern that pt may have had partial
seizure en route in ambulance en route to the hospital due to a
"staring spell." Pt does not recall ambulance ride.
Pt was seeing a neurologist regularly until ___ years ago, when
his neurologist retired. He was scheduled to see Dr. ___
___
in ___ but was unable to attend because he was in the
hospital. Last neuro evaluation was on ___. At that time, he
was noted to have decreased strength in IPs ___ bilaterally).
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 numbness,
parasthesiae.
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, constipation or
abdominal
pain. Denies rash.
Past Medical History:
Seizure disorder since childhood- previously tonic clonic, but
now focal with "staring spells"
Spinal muscular atrophy type II ___ disease)-
developed progressive lower extremity weakness at age ___ or ___.
Cerebral Palsy
Peptic ulcer with hemorrhage
Peripheral neuropathy
Depression
Onychomycosis
Social History:
___
Family History:
Family Hx:
History of prostate cancer and DM2. No family history of
seizures.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.5 P: 72 R: 18/ BP:112/80 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM.
Neck: Supple
Neurologic:
-Mental Status: Alert, oriented x 3. Difficulty relaying
history.
Attentive to interview. Has difficulty naming days of week
backward and requires prompting, but does not appear distracted.
Language is fluent. Generally offers ___ word responses. Able to
repeat "no ifs, ands, or buts." but has difficulty with
"___." Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal tone throughout but decreased bulk. No pronator
drift bilaterally.
Bilateral resting tremor in upper extremities, more pronounced
on
right. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 4+ ___ 4+ 2 2 2 3 3 3 3
R 5 ___ ___ 2 2 2 3 3 3 3
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination: slight dysdiadochokinesia noted. Some dysmetria
on
FNF but generally accurate. Heel-to-shin not able to complete
secondary to weakness.
-Gait: Deferred due to weakness.
DISCHARGE PHYSICAL EXAM:
Mental status- improved to basline. Responding appropriately
Pertinent Results:
**********
Laboratory Data:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.5 4.15* 12.9* 37.5* 91 31.0 34.3 12.2 216
Glucose UreaN Creat Na K Cl HCO3 AnGap
75 5* 0.4* 128* 4.0 94* 26 12
Ca 8.1, Phos 3.3, Mg 1.8
Carbamazepine: 8.1
valproate 88
phenobarbital 21.1
Imaging:
NCHCT: normal
***************
EEG-
___
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: The patient progressed from wakefulness to stage II, then
slow wave
sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate of
60-80 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of a
mild diffuse slowing of background frequencies compatible with a
diffuse
disorder of cortical neuronal activity. This could be a very
mild
encephalopathic condition. No paroxysmal or epileptic features
were
identified.
___
QUANTITATIVE EEG: Trend analysis was performed with Persyst
Magic Marker
software. Panels included automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios. Segments showing
trends were
reviewed and showed normal activity.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: The patient progressed from wakefulness to stage II, then
slow wave
sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate of 70
bpm.
IMPRESSION: This is a normal continuous EEG monitoring. No focal
or
epileptic features were identified.
Brief Hospital Course:
Mr. ___ is a ___ year old man who presented with
lethargy and weakness in the setting of a seizure disorder
(complex partial, secondary generalized), Kugelburg-Wellander
Disease (SMA type II), peripheral neuropathy, and cerebral
palsy. One day prior to admission, he began feeling more
lethargic and generally weak after having made
improvements with physical therapy. He had difficulty
transferring from a chair; he normally ambulates with braces,
crutches, and a walker but was having difficulty with this. He
was noted at one point to have a high carbamazepine level of 16;
his dose was decreased with a normal repeat level. He was doing
reasonably well until two days prior to this admission when he
was noted to have "slurred speech," lethargy, and generalized
weakness again. He was brought to the ___ ED and was found to
have a Na of 125 (down from 137). He was admitted to medicine
for
treatment of this. Apparently, his family has also reported
"staring spells" when visiting him, and the concern for complex
partial seizures was raised. He was transferred to Neurology
for video EEG monitoring.
His hyponatremia was treated medically and improved to normal
range withing 2 days. His initial EEG showed diffuse slowing
consistent with encephalopathy but no electrographic seizures.
While on EEG his carbemazepine was discontinued and Keppra was
started to avoid prior difficulties with CBZ toxicity. One
possible etiology of his symptoms was thought to be epoxide
toxicity related to prior CBZ. His EEG resolved to normal by
___ and he had return to normal mental status.
Key Examination Findings:
Awake, alert, oriented, speech fluent but slow, follows
commands,
attends to examiner
PERRL, EOMI, no major facial movement asymmetry
Elevates both arms and legs, no drift
- Stopped Carbamazepine.
- continue Levetiracetam 1000 mg BID
- Continue Divalproex (delayed release) ___.
- Otherwise continue home medications
- ___.
- Likely followup with Dr. ___ (___, previously a
patient ___.
- To rehab facility: HE IS EXPECTED TO STAY AT REHAB LESS THAN
30 DAYS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine (Extended-Release) 600 mg PO QAM
2. Carbamazepine 400 mg PO QHS
3. Divalproex (DELayed Release) 1500 mg PO QAM
4. Divalproex (DELayed Release) 1000 mg PO QNOON
5. Divalproex (DELayed Release) 1500 mg PO QPM
6. PHENObarbital 60 mg PO QHS
7. Ascorbic Acid ___ mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Divalproex (DELayed Release) 1500 mg PO QAM
3. Divalproex (DELayed Release) 1000 mg PO QNOON
4. Divalproex (DELayed Release) 1500 mg PO QPM
5. Multivitamins 1 TAB PO DAILY
6. PHENObarbital 60 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. LeVETiracetam 1000 mg PO BID
9. Ascorbic Acid ___ mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
metabolic encephalopathy
hyponatremia
possible epoxide toxicity from carbemazepine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted on ___ with increased lethargy and
confusion. We found that you had low sodium which may have been
related to your seizure medicationt , carbemazepine, and can
cause increased confusion. We transitioned you off of
carbamazepine (which was one of the medications you took for
epilepsy) becasue we thought it might be leading to side effects
that make you confused. You were monitored with EEG which
initially showed slowing of brain activity but no seizures. In
3 days of recording there were no seizures. After 2 days the
repeat EEG was completely normal. We started you on a new
seizure medication called Keppra and your mental status improved
back to baseline. We scheduled you for a follow up appointment
with Dr. ___ would like for you to remain on all of the
medications listed below. Thank you for allowing us to
participate in your care.
Followup Instructions:
___
|
10500395-DS-13 | 10,500,395 | 20,720,800 | DS | 13 | 2184-07-22 00:00:00 | 2184-07-22 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 01:45PM BLOOD WBC-8.7 RBC-4.09 Hgb-13.4 Hct-37.5 MCV-92
MCH-32.8* MCHC-35.7 RDW-15.2 RDWSD-50.4* Plt ___
___ 01:45PM BLOOD Neuts-76.7* Lymphs-11.8* Monos-9.1
Eos-1.4 Baso-0.5 Im ___ AbsNeut-6.66* AbsLymp-1.02*
AbsMono-0.79 AbsEos-0.12 AbsBaso-0.04
___ 01:45PM BLOOD ___ PTT-30.2 ___
___ 01:45PM BLOOD Glucose-98 UreaN-19 Creat-1.1 Na-141
K-4.1 Cl-103 HCO3-27 AnGap-11
___ 01:45PM BLOOD ALT-16 AST-23 LD(LDH)-265* AlkPhos-79
TotBili-3.0* DirBili-0.5* IndBili-2.5
___ 01:45PM BLOOD Albumin-5.3*
OTHER RELEVANT LABS
=====================
___ 01:45PM BLOOD Lipase-50
___ 01:45PM BLOOD cTropnT-<0.01
___ 05:25PM BLOOD cTropnT-<0.01
___ 01:45PM BLOOD TSH-1.1
___ 01:45PM BLOOD CRP-29.3*
___ 05:38PM BLOOD SED RATE-PND
DISCHARGE LABS
==============
___ 07:35AM BLOOD WBC-4.7 RBC-3.43* Hgb-11.2 Hct-31.4*
MCV-92 MCH-32.7* MCHC-35.7 RDW-15.5 RDWSD-50.9* Plt ___
___ 07:35AM BLOOD Glucose-91 UreaN-19 Creat-1.0 Na-143
K-4.2 Cl-105 HCO3-26 AnGap-12
___ 07:35AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1
IMAGING/STUDIES
===============
___ CXR
Lungs are clear. Heart size is normal. There is no pleural
effusion. No
pneumothorax is seen. No evidence of pneumonia
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[] Discharged on omeprazole 40 BID, clarithromycin 500 BID,
flagyl 500 TID x 14 days for empiric H pylori treatment given
positive IgG and epigastric/lower substernal chest pressure.
[] Stool sample not obtained to assess for active H pylori
infection, but would consider stool sample as outpatient to
ensure clearance of presumed H pylori infection
[] Patient with mildly elevated total bilirubin while admitted.
Appears chronic. Consider further work-up of causes of elevated
bilirubin as outpatient.
[] Patient with elevated CRP while admitted, likely secondary to
presumed H pylori infection. Consider following up CRP to ensure
resolution of inflammatory process with triple therapy (or
pursue further work-up if still elevated). ESR pending at
discharge.
BRIEF SUMMARY:
=================
___ PMH HTN, choledocholithiasis, DCIS, s/p hysterectomy,
presenting with an episode of chest pressure. History notable
for previous episodes of the same pressure that are not related
to exertion and are intermittent without clear trigger. EKG and
trops negative in ED. Most likely diagnosis is H pylori
infection as patient apparently had symptoms after taking meds,
pain seems to be lower chest/epigastric, and had H pylori IgG
positive about a month prior to admission, though at that time
was not felt to have symptoms. We recommended stress echo, but
patient declined, opting to pursue as outpatient, which we felt
was an appropriate discharge plan. Discharged on omeprazole,
clarithromycin, and flagyl as patient has allergy to
penicillins.
ACUTE ISSUES:
=============
# Gastroesophageal reflux disease
# Peptic ulcer disease
# H pylori infection
# Atypical chest pain/pressure
Her story is not convincing for cardiac origin of chest pain,
was temporally associated with taking her pills and previously
with a stressful episode. Of note, on reclarification of history
patient has had these symptoms intermittently for ___ years. Her
EKG was non-ischemic and she also had two negative troponins,
thus low concern for ACS, especially as she is able to perform
physical activity without any chest pain or pressure or
shortness of breath. Given the lower pretest probability, we
recommended getting a stress echo, however patient wanted to
defer to outpatient and inpatient team was okay with this as a
safe discharge plan. With her history of breast cancer, would
avoid nuclear stress test which would expose to further
radiation. Most likely diagnosis is H pylori infection as
patient apparently had symptoms after taking meds, pain seems to
be lower chest/epigastric, and had H pylori IgG positive about a
month prior to admission, though at that time was not felt to
have symptoms. Differential also includes dyspepsia, anxiety,
esophageal spasm. Also with radiographic evidence of
choledocholithiasis from her MRI in ___, however this seems
less likely w/ only chronically elevated bilirubin. She was
discharged on omeprazole, clarithromycin, and flagyl as patient
has allergy to penicillins. Consider stool study to confirm
clearance of H pylori infection as outpatient, though of note
patient did not give stool study while inpatient.
# Headache:
Appears to be tension headache given band-like nature. No
associated aura or visual symptoms. Improved with fluids.
Treated with Tylenol PRN with good effect.
# Elevated CRP:
Nonspecific with broad differential and no localizing symptoms
aside from lower chest/epigastric pain. Most likely related to
presumed H pylori infection. TSH normal. ESR sent out. Would
follow up at outpatient.
CHRONIC ISSUES:
===============
# Elevated total bilirubin:
Seen on prior labs, primarily indirect hyperbilirubinemia. No
e/o hemolysis. ___ be inherited conjugation defect given the
persistence on prior labs, or reduced uptake. Not requiring any
emergent actions. ___ be ___. Consider further work-up as
outpatient.
# Hypertension:
Continued home valsartan
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Senna 8.6 mg PO BID
3. Valsartan 80 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Clarithromycin 500 mg PO BID
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*27 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*41 Tablet Refills:*0
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*27
Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
========
Helicobacter pylori infection
Peptic ulcer disease
Gastroesophageal reflux disease
SECONDARY
==========
Tension headache
Hypertension
Hyperbilirubinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We did some lab tests, which showed that your chest pain was
probably not related to your heart. We did not think you were
have a heart attack
- We tried to do a stress test while you were in the hospital,
but could not do it before you wanted to leave the hospital. We
recommend doing a stress test after you leave the hospital.
- We gave you medicine for H pylori, a bacteria that can cause
stomach ulcers and cause worsening heartburn, which we think is
the cause of your lower chest pain.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It's especially important to meet with your primary care
doctor soon to discuss a stress test for evaluation of your
chest pain
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10500420-DS-12 | 10,500,420 | 21,635,325 | DS | 12 | 2146-09-24 00:00:00 | 2146-09-24 10:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
lumbar puncture attempted, unsuccessful
History of Present Illness:
HPI: ___ ___ at 25w5d GA referred to ___ for further work up
of 4 day history of vertigo and headaches. Patient was in usual
state of health until ___ when she woke up with a headache
that she describes as starting in the back of her neck and
spreading up to the top of her head. This headache is associated
with photophobia and nausea, no phonophobia.This was also
accompanied by vertigo that she describes as "room spinning."
Vertigo is present regardless of what position she is in, but is
better when she lies down with her eyes closed. She was seen at
___ on ___ night where she was given meclizine and IV
fluids. Her vertigo improved after this, but was still
persistent.
Past Medical History:
PMH: Morbid obesity (BMI 43.5), T2DM vs gluc intolerance as
above. Iron deficiency anemia. H Pylori (diagnosed in ___, no
symptoms since then)
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam:
98.3 77 94/54 16 97% RA
Gen: NAD, lying down with eyes closed, opens eyes and able to
respond to questions.
CV: RRR
Pulm: CTAB anteriorly
Abd: soft, obese, ND, NT. No R/G, no fundal TTP
Extr: NT/NE
TAUS (performed after vasovagal episode): FHR 120bpm
Pertinent Results:
___ 06:36PM BLOOD WBC-12.2* RBC-4.33 Hgb-11.8* Hct-35.8*
MCV-83 MCH-27.2 MCHC-32.9 RDW-13.6 Plt ___
___ 06:36PM BLOOD Glucose-110* UreaN-7 Creat-0.6 Na-136
K-3.6 Cl-103 HCO3-21* AnGap-16
___ 02:05AM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-7
Brief Hospital Course:
Pt admitted ___ and seen by Neuro- benign positional
vertigo dx.
ASSESSMENT/PLAN:
___ year old woman, 5 months pregnant with a history of
gestational diabetes who presents with 4 days of headache,
vertigo, nausea and blurry vision. On reassessment in the
morning the patient appears to have more of a muscular tension
posterior headache without any signs concerning for meningitic
pain as her eye pain has since resolved. MRI/V also
demonstrated
no enhancement of the meninges nor any sinus thrombosis.
She demonstrates classic symptoms of benign vertigo, which
include episodic vertigo to one side, worse with head movements
and right head positioning, and right beating nystagmus.
- Please continue hydration and anti-vertigo/emetic medication;
recommend ativan/diazepam for acute management as this should
treat both her tension headache from neck spasm, as well as
treat
her nausea.
- No prophylactic medication should be necessary at this time to
control the patient's headaches. Recommend that she stay
adequately hydrated.
Case discussed, patient seen, and plan formulated with ___, MD, Neurology Attending.
Nl Nst ___
Stable and able to ambulate- did not take ativan
D/c ___ afte nl fetal doptone
f/u this week at ___
Medications on Admission:
1. NPH 20 Units Bedtime
2. Lorazepam 0.5 mg PO Q6H:PRN vertigo
3. Meclizine 25 mg PO Q8H:PRN vertigo
4. Ondansetron 4 mg PO Q6H:PRN nausea
5. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
no new meds- same as admission.
Discharge Disposition:
Home
Discharge Diagnosis:
pregnancy at 25 weeks gestation
vertigo
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the antepartum service for observation due
to your symptoms of vertigo and headache. The neurology team
followed you and felt that your symptoms and exam are most
consistent with a condition called Benign Positional Vertigo,
which is self-limited. You've been given medications to help
your symptoms. It is important that you stay hydrated.
Continue checking your fingersticks as you have been doing.
Followup Instructions:
___
|
10500792-DS-14 | 10,500,792 | 20,820,956 | DS | 14 | 2143-07-15 00:00:00 | 2143-07-15 20:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CT with pulmonary nodules
Major Surgical or Invasive Procedure:
___ right gluteal tissue biopsy
History of Present Illness:
Ms. ___ is a ___ y/o female with a h/o autoimmune hepatitis
on azothioprine, CKD (baseline Cr 1.3), subclavian artery
stenosis, and HTN who presented from PCP with chest CT today
which revealed multiple masses suggestive of possible lung CA
vs. obstructive PNA.
The history is taken from the patients daughters and review of
the chart as the patient is unable to provide history at this
time. The patient was in her usual state until she developed a
cough in ___ at which time a CXR was obtained which was normal,
however was treated for possible CAP with doxycycline. The
patient then had a mechanical fall on ___ where she fell
on her face. At that time she had a face hematoma and then
presented to PCP with rib pain and back pain. Per report no rib
fractures. The patient has had ongoing rib and back pain since
that time. The patient has been feeling generally unwell with
decreased energy, poor appetite, non-productive cough, and
increasing dyspnea developing over the last month.
She was then seen in ___ clinic on ___ at which time
labs revealed a positive UA with marked leukocytosis,
thrombocytosis, elevated AP and microcytic anemia with elevated
ferritin. Given her cough over the last couple of months a
repeat CXR was obtained by PCP that on ___ that showed RML
nodule. She was then started on cipro for positive UA done in
___ clinic and possible PNA. A CT scan was then ordered on
___ by PCP for lack of improvement and continued symptoms. This
revealed multiple lung masses and she was sent to ___ for
further management of failure to thrive and new findings on CT.
Her daughter reports that she is unable to walk more than a few
steps secondary to fatigue and also has audible wheezing and
continued cough productive of clear sputum. No leg swelling,
chest pain. No fevers/chills/NS. Continued poor appetitte and
almost no PO intake over the last 2 days.
In the ED, the patient was AAO x 2. She was given 2mg IV
morphine and a 500 cc bolus and sent to the medicine floor for
further management.
On arrival to the floor, the patient was noted to be AAO x 0 and
essentially non-verbal as only mumbling. Durring interaction
with overnight medicine resident she was noticed to have
twitching of her right mouth, right face and right arm. She had
3 episodes each lasting for about 1 minute. She was given 0.5 mg
IV ativan. Continuous O2 monitoring was started and during a
couple of episodes showed no desaturation. Possible leftward
gaze during episodes. She was given 500cc bolus and started on
Vanc + zosyn for possible pna. She was then sent for a STAT head
CT and transferred to the ICU for further care.
On arrival to the MICU, the patient mummbles only but is in NAD.
Per family no history of changes in vision, HA, focal weakness,
or numbness.
Past Medical History:
-Anxiety
-HYPERCHOLESTEROLEMIA
-VARICOSE VEINS
-Autoimmune Hepatitis
-Colonic polyp
-DIVERTICULOSIS
-Subclavian artery stenosis, left
-Hypertension
-Chronic Kidney disease, chronic, stage III (moderate, EGFR
___ ml/min)
Social History:
___
Family History:
-Daughter: seizures
-Mother: died of brain anerysm
-Brother: heart disease
Physical Exam:
ADMISSION PHYSICAL
General- awake, mumbling, unable to follow commands
HEENT- Sclera anicteric
Neck- supple, JVP not elevated
Lungs- ronchi throughout, decreased breath sounds at right base
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
Ext- warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro- awake, opens eyes spontaneously and to voice, unable to
follow most commands, however appears to give some effort when
asked to squeeze with left hand, moving all 4 extremities, tone
normal
DISCHARGE PHYSICAL
Vitals: T 97.8 BP 104-169/58-61 HR ___ RR 18 sat 96-98%
RA
General: Resting comfortably in bed. Alert and conversant.
HEENT: PERRL, Sclera anicteric. MMM
Neck: Supple
CV: Normal rate, regular rhythm. Nl S1, S2. No m/r/g
Lungs: Diffuse rales, L > R.
Abdomen: Soft, nontender, nondistended. Nl bowel sounds.
GU: no foley
Ext: wwp with no c/c/e
Neuro: CN ___ intact. AO to self, hospital, year. Responds
appropriately to questions.
Skin: No rash or jaundice
Pertinent Results:
ADMISSION LABS:
___ 07:00PM ___ PTT-33.7 ___
___ 07:00PM PLT COUNT-579*
___ 07:00PM NEUTS-90.2* LYMPHS-3.1* MONOS-5.0 EOS-1.3
BASOS-0.3
___ 07:00PM WBC-18.0* RBC-3.20* HGB-9.9* HCT-30.0* MCV-94
MCH-30.9 MCHC-32.9 RDW-13.4
___ 07:00PM ALBUMIN-3.4*
___ 07:00PM ALT(SGPT)-25 AST(SGOT)-35 ALK PHOS-305* TOT
BILI-0.5
___ 07:00PM estGFR-Using this
___ 07:00PM GLUCOSE-109* UREA N-33* CREAT-1.5*
SODIUM-125* POTASSIUM-4.6 CHLORIDE-85* TOTAL CO2-26 ANION GAP-19
___ 08:15PM LACTATE-1.7
IMAGING:
CT HEAD ___ brain metastases with surrounding cytotoxic
edema, as described above. If clinically indicated, more
definitive evaluation could be performed with MRI.
MR HEAD ___: FINDINGS: There are now multiple enhancing lesions
bilaterally in the cerebral hemispheres and right cerebellum,
with associated T2/FLAIR hyperintensity. In the superior aspect
of the left frontal lobe (image 74, series 100a) there are two
enhancing lesions measuring 4mm, and 6 mm respectively. In the
medial left parietal (image 64, series 100a) there is a 7 mm
enhancing lesion. In the left frontal lobe (image 49,
series100a) there is 11 x 11 mm enhancing mass, and in the right
frontal lobe there is enhancing lesion 11x1mm (image 52, series
100a). In the left basal ganglia there is a 5 mm enhancing
lesion (image 40, series 100a). In the medial aspect of the
right cerebellum there is a 8 mm enhancing lesion (image 22,
series 100a). Many of these lesions
have central susceptibility foci corresponding to the
hyperdensity seen on recent CT scan indicative of a hemorrhagic
metastasis.
In the posterior aspect of the left temporal lobe tears T2/FLAIR
hyperintensity (image 14, series 5) without a corresponding
enhancing lesion. However evaluation of this area on the
post-contrast images is limited by motion artifact. The
visualized paranasal sinuses and orbits are unremarkable. The
intracranial flow voids are present. There is no acute infarct,
or midline shift.
CXR ___: AP radiograph of the chest was compared to ___.
The nodule in the right mid lung is unchanged in appearance.
Cardiomegaly is re-demonstrated. Additional multiple small
pulmonary nodules are better assessed on the chest CT from
___. There is unchanged appearance of the
fullness of the right cardiophrenic angle due to the presence of
large necrotic lymph nodes. The appearance of the left lower
lung re-demonstrates consolidation but although might reflect
atelectasis, was not present on the chest CT from ___, can be seen on the CT abdomen from ___ and
might potentially reflect infected lung area.
OTHER PERTINENT LABS:
___ 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:00AM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-28.6* RBC-2.96* Hgb-8.8* Hct-28.9*
MCV-98 MCH-29.8 MCHC-30.6* RDW-13.5 Plt ___
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD Glucose-112* UreaN-40* Creat-1.0 Na-134
K-4.7 Cl-98 HCO3-26 AnGap-15
___ 07:10AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.4*
Brief Hospital Course:
Assessment and Plan: Ms. ___ is a ___ y/o female with a h/o
autoimmune hepatitis on azothioprine, CKD (baseline Cr 1.3),
aortic stenosis, and HTN who presented from metastatic disease
with unknown primary.
# Metastatic disease with unknown primary: Pt with diffuse
metastatic disease involving brain, lungs an abdomen and soft
tissue. She is up to date on cancer screening per family with
last ___ ___ and normal and yearly normal mammograms. A
biopsy of a right gluteal mass was performed ___ and results are
pending at time of discharge. She was evaluated by oncology,
neuro-oncology and radiation oncology and they will continue to
participate in her care as an outpatient. Radiation oncology
recommends whole brain irradiation as an outpatient.
# seizures: On arrival to the floor, the patient was noted to be
AAO x 0 and essentially non-verbal as only mumbling. During
interaction with overnight medicine resident she had twitching
of her right mouth, right face and right arm. She had 3 episodes
each lasting for about 1 minute. She was given 0.5 mg IV ativan,
sent for a STAT head CT and transferred to the ICU for further
care. Dexamethasone was started to reduce swelling surrounding
brain mets. Keppra was initated for seizure prophylaxis and
oncology and neuro-oncology were consulted. A 24 hour EEG on ___
showed no continued seizure activity. She is discharged on
keppra and dexamethasone.
# AMS: Pt AAOX0 at time of admission. Likely secondary to
seizures, hyponatremia, post-ictal state. Initially, there was
concern for an infectious etiology of her AMS. She was
subsequently started on vancomycin and zosyn in ER and continued
the day she was in the MICU. Antibiotics were discontinued upon
transfer to the floor
on ___ as pt was afebrile and physical exam not consistent with
PNA. Her mental status improved daily once she was transferred
to the floor and she is AAO X 3 at time of discharge.
# hypoxemia: Had LLL collapse ___ mucuous plug on ___ requiring
___ oxygen via NC. CXR ___ showed re-inflation of lung. She
was weaned off O2 and was able to ambulate with oxygen
saturation > 95% at time of discharge. She has persistent cough
and may be prone to mucous plugging given burden of lung diseae.
# Leukocytosis: Pt with leukocytosis of 18 to 33.7 during course
of admission. Most likely ___ malignancy (in one series tumor
associtated leukocytosis was seen in 15% of lung cancers). UA
here with no signs of infection and pt previously recieved cipro
x 4 days (___). No evidence of skin, pulmonary or GI
infection.
# Hyperglycemia: Secondary to steroid use. Pt given low dose
humalog ISS during admission. Upon discharge, pt/family advised
to check BG daily and talk to PCP about initiating insulin
therapy only if BG persistently > 300.
# Autoimmune hepatitis: : Discontinued home azothioprine
# anemia: Likely ___ chronic disease. Given diffuse metastatic
disease, a work-up was not pursued.
# HTN: Anti-hypertensive were initially held in setting of
hypotensive. Anti-hypertensives were held throughout admission
given metastatic disease and SBP consistently < 160 throughout
admission.
Transitional issues:
- metastatic disease with unknown primary: tissue biopsy is
pending
- oncology follow up
- radiation oncology follow up for brain metastases
- neuro-oncology follow up
- leukocytosis: no evidence of infection, likely related to pt's
cancer
- hyperglycemia ___ steroids: monitor and consider initiating
insulin for persistent fingersticks great than 300
- stopped anti-hypertensives, statin, azathioprine during this
admission
- brain metastases: whole brain irradiation recommended by
radiation oncology
- seizures: monitor and adjust keppra
- discharged on decadron 4mg twice daily for 3 more days and
then continue decadron 4mg daily throughout the course of whole
brain radiation. Neuro-oncology should take over management at
follow-up appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 150 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Azathioprine 50 mg PO EVERY OTHER DAY
5. Lisinopril 40 mg PO DAILY
6. Pravastatin 20 mg PO DAILY
7. Ciprofloxacin HCl 1000 mg PO Q12H
8. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
9. Azathioprine 25 mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every 8 hours Disp #*90 Tablet Refills:*0
2. LeVETiracetam 750 mg PO BID
RX *levetiracetam 750 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. rolling walker
please dispense one rolling walker
4. Dexamethasone 4 mg PO Q12H Duration: 3 Days
4mg twice daily for 3 more days & then 4mg daily going forward.
To be managed by Dr. ___.
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 12 hours Disp
#*30 Tablet Refills:*0
5. glucometer
secondary diabetes mellitus 249.1, V58.67
please check blood sugar once daily
6. glucometer test strips
secondary diabetes mellitus 249.1, V58.67
please check blood sugar once daily
7. lancets
secondary diabetes mellitus 249.1, V58.67
please check blood sugar once daily
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: metastatic disease of unknown primary,
seizures
Secondary diagnoses: steroid induced hyperglycemia, autoimmune
hepatitis, leukocytosis, hyponatremia, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___. You were
admitted for evaluation of lung masses found on a cat scan
ordered by your PCP that were concerning for cancer. Soon after
your admission, you had several brief seizures and were
transferred to the medical intensive care unit. You experienced
confusion for a couple days after these seizures. Neurology was
consulted and you were started on steroids and another
medication, called keppra, to prevent future seizures. Please
continue to take the keppra and steroid (dexamethasone) at home.
The steroids make your blood sugar high. Please check your
blood sugar once daily. If your blood sugar is consistently over
300, then you should discuss starting insulin with your PCP.
A cat scan showed that there was a cancer metastasis in your
right buttock. This metastasis was biopsied so that we can
determine what kind of cancer you have. Once we know what kind
of cancer you have, treatment options can be discussed.
Specialists in oncology, neuro-oncology and radiation oncology
were consulted and they will continue to participate in your
care going forward.
Followup Instructions:
___
|
10500891-DS-2 | 10,500,891 | 22,986,275 | DS | 2 | 2130-09-17 00:00:00 | 2130-09-18 21:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lopressor / Sulfa(Sulfonamide Antibiotics) / Verapamil
Attending: ___.
Chief Complaint:
Acute on chronic renal failure
Major Surgical or Invasive Procedure:
Cardioversion
TEE
History of Present Illness:
___ F w/ h/o CAD s/p CABG, HTN, CAD, AS, MS, Pulmonary HTN,
dyslipidemia, abnormal EKG (LBBB), stage III CKD, CVA (no
residual), PAD with atrial flutter, seen on ___ in
preparation for TEE and cardioversion, found to have new ARF
this AM after pre-procedure labs returned (Cr is 3.4, up from
baseline of 1.5 in ___. Patient reports that she has not
had an appetite during the last 4 days and that her fluid intake
has been half what it normally is. Further, she reports 50%
reduction in urine output over the last 4 days. She denies N/V,
diarrhea, f/c/ns. Denies NSAID use, no new medications
She also has an associated hct drop from 40 last year to 29
currently. Stool guiaic negative. Reports blowing her nose over
the weekend and finding a small blood clot. Denies any blood in
stool, melena, hematuria, hematemasis.
Recently having headaches and palps. Feels "tired", denies palps
or headache at this time.
Initial VS in the ED: 97.6 80 105/53 19 100% RA. Patient
recieved 1L NS, basic lab work and urinanalysis. Patient EKG
showed new 1mm STD in V6, otherwise, afib with IVCD, unchanged
from prior.
Past Medical History:
CABG x ___
Tachycardia induced cardiomyopathy EF 30%
atrial flutter ___
CVA ___ no residual
bilateral carotid artery disease s/p left carotid endarterectomy
___
vertebral artery stenosis
pulmonary hypertension
stage III chronic kidney disease
mild aortic stenosis with ___ 1.4cm2
mild mitral regurgitation
dyslipidemia
hypertension
peripheral vascular disease
breast cancer ___ years ago; s/p radiation therapy
Social History:
___
Family History:
Father: Passed due to MI at ___. Mother: Passed due to stroke at
___. CV disease common in extended family.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 97.5 BP: 119/74 P: 88 R: 18 O2: 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, cannon wave on R, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and irregular rhythm, normal S1 + S2,
pansystolic murmur II/VI along LLSB. No rubs or gallops
Abdomen: 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. Cap refill <1sec. Dry axillary b/l
PHYSICAL EXAM ON DISCHARGE:
Errythema and swelling in left antecubital fossa. Otherwsie,
exam unchaged on discharged.
Pertinent Results:
Admission Labs:
___ 05:21PM URINE HOURS-RANDOM UREA N-661 CREAT-61
SODIUM-68 POTASSIUM-24 CHLORIDE-54
___ 05:21PM URINE HOURS-RANDOM
___ 05:21PM URINE OSMOLAL-428
___ 05:21PM URINE UHOLD-HOLD
___ 05:21PM URINE GR HOLD-HOLD
___ 05:21PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 05:21PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:21PM URINE RBC-2 WBC-26* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:21PM URINE GRANULAR-25*
___ 03:05PM GLUCOSE-190* UREA N-80* CREAT-3.4*#
SODIUM-140 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
___ 03:05PM estGFR-Using this
___ 03:05PM cTropnT-0.04* ___
___ 03:05PM WBC-6.4 RBC-3.25*# HGB-9.6*# HCT-29.2*#
MCV-90 MCH-29.4 MCHC-32.8 RDW-14.2
___ 03:05PM NEUTS-80.3* LYMPHS-11.9* MONOS-6.8 EOS-0.6
BASOS-0.4
___ 03:05PM PLT COUNT-288
___ 03:05PM ___ PTT-33.3 ___
Discharge Labs:
___ 10:20AM BLOOD Glucose-194* UreaN-56* Creat-2.5* Na-144
K-3.3 Cl-101 HCO3-28 AnGap-18
Notable Labs:
___ 05:45AM BLOOD tTG-IgA-7
___ 05:40AM BLOOD TSH-1.2
___ 05:40AM BLOOD calTIBC-421 Ferritn-16 TRF-324
___ 03:05PM BLOOD cTropnT-0.04* ___
___ 05:40AM BLOOD Ret Aut-1.4
___ 03:05PM BLOOD ___ PTT-33.3 ___
___ 05:40AM BLOOD ___ PTT-32.4 ___
___ 05:45AM BLOOD ___ PTT-38.4* ___
___ 05:20AM BLOOD ___ PTT-37.7* ___
___ 07:50AM BLOOD ___ PTT-37.9* ___
___ 06:30AM BLOOD ___ PTT-36.6* ___
___ 03:32PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:21PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:32PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:21PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:32PM URINE RBC-4* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
___ 05:21PM URINE RBC-2 WBC-26* Bacteri-FEW Yeast-NONE
Epi-<1
___ 03:32PM URINE CastHy-1*
___ 05:21PM URINE CastGr-25*
___ 03:32PM URINE AmorphX-RARE
___ 03:32PM URINE Mucous-RARE
___ 03:32PM URINE Hours-RANDOM UreaN-474 Creat-41 Na-49
K-31 Cl-63
___ 05:21PM URINE Hours-RANDOM UreaN-661 Creat-61 Na-68
K-24 Cl-54
___ 03:32PM URINE Osmolal-350
___ 05:21PM URINE Osmolal-428
.
ECG Study Date of ___ 2:49:02 ___
Atrial fibrillation with moderate ventricular response.
Intraventricular
conduction delay of the left bundle-branch block type. Compared
to the previous tracing of ___ atrial fibrillation is new.
ECG ___:
Sinus rhythm. Left axis deviation. Intraventricular conduction
delay. Loss of R waves in the anterior leads suggests anterior
wall myocardial infarction of indeterminate age. Lateral ST-T
wave changes which are non-specific. Compared to the previous
tracing of ___ atrial fibrillation has now converted to
sinus rhythm. Other findings appear to be persistent. Clinical
correlation is suggested.
CHEST (PA & LAT) Study Date of ___ 3:42 ___
No acute intrathoracic process. Possible trace effusion on the
right.
TEE (Complete) Done ___ at 9:00:17 AM
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. Moderate AR and mild
MR. ___ tricuspid regurgitation. Complex aortic atheroma.
UNILAT LOWER EXT VEINS Study Date of ___ 1:20 ___
CONCLUSION: No evidence of DVT in the right lower extremity.
RENAL U.S. Study Date of ___ 1:20 ___
CONCLUSION:
1. Normal size and normal-appearing right kidney, limited, but
relatively
normal, color flow Doppler.
2. Atrophic left kidney which has occurred since ___ and is
most likely a
result of renal artery stenosis.
3. Small right pleural effusion.
RUE DOPPLER ULTRASOUND ___:
Thrombus is seen in a short segment of the cephalic vein in the
antecubital fossa where the IV catheter was placed. This vein is
considered
as a superficial vein. No deep vein thrombus is seen.
Brief Hospital Course:
___ F w/ h/o CAD s/p CABG, HTN, CAD, AS, MS, Pulmonary HTN,
dyslipidemia, abnormal EKG (LBBB), stage III CKD, CVA (no
residual), PAD. Admitted for acute on chronic renal failure
likely in the setting of ATN. Also admitted for cardioversion
for atrial flutter
ACTIVE ISSUES:
1) ACUTE ON CHRONIC RENAL FAILURE: Initially though to be
pre-renal azotemia given her recently reduced intake and urine
output in days prior to admission (Cr:3.4 and BUN/Cr>20). Given
a poor response to IV fluid challenge, slow renal recovery with
low urine output, and an abundance of granular casts on urine
sediment, she probably had acute tubular necrosis. Potential
post-renal obstruction or embolic disease unlikely given normal
renal u/s. The renal service followed along. We suspect that she
had prolonged renal hypoperfusion that eventually converted to
ATN, with possible contribution from a potentially decreased
forward flow from her atrial arrhythmia. Urine output slowly
increased. After 6 days of hospitalization her Cr dropped to
2.5. We initially held all BP meds to permit hypertension and
renal perfusion- we restarted amlodipine prior to discharge,
electing to hold the thiazide/lisinopril. She was euvolemic
with even inputs/outputs on discharge.
2) ATRIAL FIBRILLATION: Patient was succesfully
TEE/cardioverted on ___. Post cardioversion she was continued
on coumadin anticoagulation (CHAD2 score: 5). INR goal of
2.0-3.0 reached prior to discharge and patient was sent home on
coumadin 4mg PO. Toprol XL decreased from 150mg to 100mg daily
following restoration of sinus rhythm, which was maintained
throughout the hospitalization. Was on digoxin prior to
admission which was held according to her cardiologist's
recommendation.
3) ANEMIA: HCT is a few points lower than baseline. Iron studies
suggest iron deficiency with low ferritin, high TIBC and low
iron. Recieved IV iron x1 and started on oral iron repletion
with iron sulfate 365mg once daily. She had an episode of
colitis in years past which may have contributed. Celiac ruled
out with normal anti TTG. Will f/u with PCP and
gastroenterologist as outpatient.
4) UNCOMPLICATED CYSTITIS: UA on admission work up was
suggestive of UTI. While she had no dysuria or frequency, she
complained of weakness and general malaise, and was therefore
treated with cipro x 3 days, completed in house. Her energy
level substantially improved with fluids and rest.
5) SUPERFICIAL THROMBOPHLEBITIS: Her right antecubital IV caused
a superficial thrombus with local inflammation. No evidence of
cellulitis. Treated symptomatically with warm packs and
elevation.
6) HYPERTENSION: Her blood pressure medications were held upon
being admitted to allow for permisive hypertension (SBP goal of
140-150) with the purpose of increasing renal perfusion. The
amlodipine was eventually restarted as SBP went above 150;
however, ACEi and Triamterene-hydrochlorothiazide due to ARF.
INACTIVE PROBLEMS:
7) CORONARY ARTERY DISEASE: Patient was asymptomatic throughout
hospitalization. Aspirin initially held and later restarted.
Toprol XL dose reduced as above. Rosuvastatin continued.
8) CHRONIC SYSTOLIC HEART FAILURE: not exacerbated, euvolemic
PENDING RESULTS:
None
TRANSITIONAL CARE:
-f/u Cr
-warfarin/INR management
Medications on Admission:
Amlodipine 5mg PO daily
Calcitriol 0.25mcg PO Qweek
Metoprolol succinate 150mg Extended Release PO daily
Quinapril 40mg PO daily
Rosuvastatin 40mg PO daily
Triamterene-hydrochlorothiazide 37.5mg-25mg PO 3x/wk
Warfarin 5mg PO in AM daily
Aspirin 81mg PO daily
Coenzyme Q10 100mg PO daily
Digoxin (started ___ currently held by cardiologist since
___
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 1X/WEEK
(MO).
3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
8. Outpatient Lab Work
please have chem7 and INR drawn on ___ and fax to:
Dr. ___ ___
Dr. ___ ___
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day:
Your warfarin dose will likely need to be adjusted over the next
few days; use these 1 mg tabs to allow for easy adjustment.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute on chronic renal failure (Acute tubular necrosis)
Anemia
Atrial fibrillation
Urinary Tract Infection
Chronic systolic and diastolic heart failure
SECONDARY DIAGNOSIS:
Hypertension
Coronary artery disease
Chronic systolic and diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital with: 1) Acute on chronic
renal failure 2) Atrial fibrillation 3) Anemia. ___ were found
to be in renal failure after pre-procedure test by your
cardiologist found an elevated creatinine of 3.4 and a blood
level (hematocrit) of 29. ___ were then admitted to ___ for
treatment of renal failure and anemia. The procedure your
cardiologist planned to do, cardioversion, was also planned for
during your admission.
With regards to your renal failure, we advise that ___ take in
enough oral fluids to ensure that your urine output is at or
above its normal amount. We also suggest that ___ weigh yourself
daily and record the values. This information may be useful to
your primary care provider during followup.
It will also be important to also continue to take your iron
pills as prescribed to ensure an adequate store of iron is built
up in your system.
Please continue to take your home medications and please
continue to take the Coumadin 4mg once daily. It is crucial that
___ see your PCP for followup within ___ days of discharge to
have your blood tested to ensure the coumadin is working
correctly.
The following changes were made to your medications:
1. START Coumadin 4mg once daily
2. CHANGE Metropolol 150mg to 100mg once daily
Please see PCP if symptoms do not improve or go away.
It was truly a pleasure taking care of ___, I wish ___ the best.
Followup Instructions:
___
|
10500891-DS-3 | 10,500,891 | 25,742,351 | DS | 3 | 2131-10-24 00:00:00 | 2131-11-15 20:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Verapamil
Attending: ___.
Chief Complaint:
decreased urine output, increased facial swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with complicated PMHx including CAD s/p CABG, PAD, PAF,
stage III-IV CKD (baseline Cr 1.5), HTN, dyslipidemia, and CVA
(no residual deficit) who presents with decreased urine output
overnight and facial swelling. Patient states that she normally
urinates frequently overnight, and noted that on ___ night,
she did not. Denies dysuria or fevers. Also noted facial
swelling in the morning. Does note that she has had decreased
appetite for the past ___ days, but reports that she has been
drinking fluids as normally and that her urine output was normal
until last night ___ night).
In the ED, initial VS were 97.8 58 133/36 18 96% RA. Labs were
significant for Cr 2.0 (up from baseline 1.5), stable anemia,
INR 3.4 (on coumadin). UA was positive with <1 epis, >182 WBC,
large leuk, few bacteria. Patient was given ceftriaxone 1g IV
and admitted to medicine for further management. Vital signs on
transfer were 98.6 58 136/54 14 95% RA.
On arrival to the floor, patient states that she started
urinating normally after arrival to the ED, and that her facial
swelling has improved. She currently has no complaints.
REVIEW OF SYSTEMS:
(+) Per HPI, decreased appetite over the past ___ days but
currently improving
(-) Denies fever, chills, night sweats. Denies headache or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Denies dysuria. Denied arthralgias or myalgias.
Past Medical History:
Stage III-IV CKD (baseline Cr 1.5)
CAD s/p 3-v CABG ___
Tachycardia induced cardiomyopathy EF 30%
Atrial fibrillation
Renovascular hypertension
CVA ___ no residual deficit
Bilateral carotid artery disease s/p left carotid endarterectomy
___
Vertebral artery stenosis
Pulmonary hypertension
Mild aortic stenosis with ___ 1.4cm2
Mild mitral regurgitation
Dyslipidemia
Peripheral vascular disease
Breast cancer ___ years ago; s/p radiation therapy
Collagenous colitis
Social History:
___
Family History:
Father passed due to MI at ___. Mother passed due to stroke at
___. CV disease common in extended family.
Physical Exam:
ADMISSION EXAM
VS: T 98.0, BP 116/37, HR 65, RR 20, SpO2 95% RA. 60.3kg
GEN: A+Ox3, NAD
HEENT: NCAT. EOMI, PERRL, sclerae anicteric. MMM. no LAD. no
JVD. neck supple. face with some erythematous patches but no
appreciable edema, hard of hearing
CV: RRR, normal S1/S2, III/VI systolic murmur heard best at
RUSB, rubs or gallops.
LUNG: CTAB, no wheezes, rales or rhonchi
ABD: soft, NT/ND, +BS. no rebound or guarding. neg HSM.
EXT: W/WP, no edema (compression stockings in place). 2+ ___
pulses bilaterally.
SKIN: W/D/I
NEURO: CNs II-XII intact. sensation intact to LT.
PSYCH: appropriate affect
DISCHARGE EXAM
VS: T 98.4, BP 158/48, HR 60, RR 20, SpO2 95% RA
GEN: A+Ox3, NAD
HEENT: NCAT. EOMI, PERRL, sclerae anicteric. MMM. no LAD. no
JVD. neck supple. face with some erythematous patches but no
appreciable edema, hard of hearing
CV: RRR, normal S1/S2, III/VI systolic murmur heard best at
RUSB, rubs or gallops.
LUNG: CTAB, no wheezes, rales or rhonchi
ABD: soft, NT/ND, +BS. no rebound or guarding. neg HSM.
EXT: W/WP, trace bilateral lower extremity edema (compression
stockings in place). 2+ ___ pulses bilaterally.
SKIN: W/D/I
NEURO: CNs II-XII intact. sensation intact to LT.
PSYCH: appropriate affect
Pertinent Results:
Admission Labs
___ 10:43AM BLOOD WBC-6.4 RBC-3.42* Hgb-10.2* Hct-33.0*
MCV-97 MCH-29.8 MCHC-30.8* RDW-15.2 Plt ___
___ 10:43AM BLOOD Neuts-80.3* Lymphs-10.6* Monos-7.6
Eos-1.1 Baso-0.3
___ 10:43AM BLOOD ___ PTT-45.2* ___
___ 10:20AM BLOOD Glucose-137* UreaN-63* Creat-2.0* Na-139
K-4.3 Cl-105 HCO3-22 AnGap-16
___ 10:20AM BLOOD Phos-3.4 Mg-2.2
___ 12:31PM BLOOD Lactate-1.0
Discharge Labs
___ 07:15AM BLOOD WBC-7.6 RBC-3.38* Hgb-10.2* Hct-32.8*
MCV-97 MCH-30.2 MCHC-31.1 RDW-15.2 Plt ___
___ 07:15AM BLOOD ___ PTT-41.6* ___
___ 07:15AM BLOOD Glucose-111* UreaN-54* Creat-1.9* Na-143
K-3.7 Cl-107 HCO3-25 AnGap-15
___:15AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
Imaging
___ CXR (PA/Lat)
FINDINGS: The patient is status post coronary artery bypass
graft surgery. The cardiac, mediastinal and hilar contours
appear unchanged. Trace pleural effusions are suspected. The
chest is hyperinflated. There is mild peribronchial cuffing and
a slight interstitial process.
IMPRESSION: Slight suspected interstitial process, although not
striking, probably mild fluid overload.
Microbiology
___ Blood Culture, Routine (Final ___: NO GROWTH.
___ Blood Culture, Routine (Final ___: NO GROWTH.
___ URINE CULTURE (Final ___:
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ with complicated PMHx including CAD s/p CABG, PAD, PAF,
stage III-IV CKD (baseline Cr 1.5), HTN, dyslipidemia, and CVA
(no residual deficit) who presents with transient decreased
urine output overnight and facial swelling, found to have
acute-on-chronic renal failure.
# Acute-on-chronic renal failure: Patient has stage III-IV CKD
and was found to have Cr 2.0 from baseline 1.5. FENa > 1%, but
urine osms somewhat elevated and indicative of volume depletion.
Patient had decreased urine output overnight and facial swelling
when she woke up in the morning; she then reports that ___ hours
after getting to the ED, she started to urinate a lot and the
facial swelling improved. Unclear why UOP was decreased and then
resolved; it does not appear that she received IVF in the ED.
Received 1L NS while in-house. Found to have asymptomatic
bacteriuria; received ceftriaxone 1g IV in the ED, and will
complete a 3-day course of antibiotics with ciprofloxacin.
Creatinine trended down slightly to 1.9 on discharge.
# Renovascular hypertension: Patient has significant vascular
disease and hypertension. Continue home Quinapril 10 mg PO
DAILY, Metoprolol Succinate XL 100 mg PO BID, Amlodipine 10 mg
PO DAILY, and Hydralazine 37.5 mg PO TID.
# Atrial fibrillation: Patient is on coumadin alternating daily
taking 2mg or 4mg. INR was supratherapeutic at 3.4 on admission;
last took 4mg on ___. Held coumadin and monitored INR.
# CAD s/p CABG: Continued aspirin, rosuvastatin, metoprolol, and
quinapril.
# DVT prophylaxis: Systemic anticoagulation with warfarin (INR
3.4).
# Code status: Patient was confirmed full code during this
admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quinapril 10 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO BID
3. Warfarin ___ mg PO DAILY16
4. Amlodipine 10 mg PO DAILY
5. HydrALAzine 37.5 mg PO TID
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Aspirin EC 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. coenzyme Q10 *NF* 100 mg Oral DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. HydrALAzine 37.5 mg PO TID
4. Metoprolol Succinate XL 100 mg PO BID
5. Quinapril 10 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. coenzyme Q10 *NF* 100 mg Oral DAILY
9. Warfarin ___ mg PO ___
You should take only 2mg on ___. Get INR rechecked on ___
___ and then take dose as directed.
10. Ciprofloxacin HCl 250 mg PO ONCE Duration: 1 Doses Take on
___.
RX *ciprofloxacin 250 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute kidney injury
Urinary tract infection
SECONDARY DIAGNOSIS:
Stage III-IV chronic kidney disease
Paroxysmal atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital for acute-on-chronic kidney
injury and found to have an asymptomatic urinary tract
infection. You received 1 liter of IV fluid and your kidney
function is slowly improving. You also received antibiotics for
your infection.
Your INR was supratherapeutic, so your coumadin was held while
you were in the hospital. You should take 2mg on ___.
Have your INR rechecked on ___, and then take your next
coumadin dose as directed by your PCP.
It is important that you take your medications as prescribed and
keep all of your follow up appointments.
Followup Instructions:
___
|
10501162-DS-11 | 10,501,162 | 27,141,230 | DS | 11 | 2190-09-03 00:00:00 | 2190-09-04 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegretol / Ibuprofen / Bactrim
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
CT-guided biopsy of T8 paravertebral collection/hematoma
(___)
History of Present Illness:
This is a ___ with CMML, type I diabetes, spinal stenosis,
adrenal insufficiency, grave's disease, who presents with back
pain.
He has been having intermittent paroxysms of pain since last
week, which have been increasing in frequency and intensity
since
Thurday. The pain was typically with movement. At it's worst, he
was having severe back pain at rest. The pain became so
unbearable that he presented to the ED for management. The pain
is in the mid-to-low thorax.
He has experienced no acute weakness or sensory deficits in the
upper or lower extremities. He feels generally weak since his
hospitalization wish PNA/sepsis requiring an ICU stay last year.
He has had urge incontinence for the last year, and complains of
decreased rectal tone for ___ year as well, with only one episode
of fecal incontinence months ago.
He has had no fevers or chills. He has had no changes to his
bowels or bladder. He has not had recent weight loss or gain. He
has had no chest pain, SOB, heart palpitations, or headache.
At home he took aspirin and oxycodone for relief.
Patient took valium x2 prior to presentation.
In the ED, initial vitals: 97.8 84 127/60 16 95% RA
- ED Exam notable for:
Somnolent, though oriented. Obvious discomfort upon moving.
Point
vertebral tenderness ~T9-10. Strength/sensation to light touch
is
intact throughout. No saddle anesthesia. Mildly reduced rectal
tone.
- Labs were notable for:
139 / 100 / 19
-----------------< 228, AGap=14
4.3 / 25 / 1.0
WBC 31.2 Hgb 12.4 plt 112
- Imaging:
IMPRESSION:
MR ___ &W/O CONTRAST Study Date of ___ 8:42 AM
1. T8 osteomyelitis with a mild compression deformity and
paraspinal inflammatory change/phlegmon. No epidural or
drainable paraspinal abscess is identified.
2. Lumbar degenerative disc disease and a chronic L1 vertebral
body compression fracture as detailed above.
CXR IMPRESSION:
1. No acute intrathoracic process.
2. Diffuse osteopenia with no definite acute fracture identified
within limitations of chest radiography. Please note that
cross-sectional imaging is more sensitive for acute fracture
- Consults: SPINE:
No emergent or urgent neurosurgical intervention indicated at
this time. Would recommend admission to Medicine, ___ biopsy and
ID consult for antibiotic regimen. Neuro exam stable with no
motor deficit (has baseline L foot weakness). There is no
epidural collection that would require surgical intervention.
Pt was given:
___ 09:30 IV Morphine Sulfate 2 mg ___
Partial Administration
___ 09:50 IV Morphine Sulfate 2 mg ___
Partial Administration
___ 12:54 IV Vancomycin ___ Started
___ 12:54 IV CefePIME ___ Started
___ 13:58 IV CefePIME 2 g ___ Stopped (1h
___
___ 14:00 IV Vancomycin 1000 mg ___ Stopped
(1h ___
- Vitals prior to transfer were
T 98.7 HR88 BP140/111 RR18 95% 2L NC
On arrival to the floor, the patient shares the above history.
He
requests urological, neurological, and endocrine consult.
Past Medical History:
ADRENAL INSUFFICIENCY, ANEMIA, DIABETES MELLITUS, GRAVE'S
DISEASE, HYPOTHYROIDISM, OSTEOARTHRITIS, PAIN, VENOUS
INSUFFICIENCY, MONILIAISIS, HYPERTENSION, SPINAL STENOSIS, NECK
PAIN, GRAVE'S DISEASE, SPINAL STENOSIS
DERMATOHELIOSIS, SEBORRHEIC DERMATITIS, IRRITABLE BOWEL SYNDROME
Social History:
___
Family History:
A son has DM1
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.7 BP 165/79 HR 71 RR18 96% Ra
GENERAL: Pleasant, lying in bed comfortably
HEENT: notable for proptosis
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, lungs clear to
auscultation
ABD: Normal bowel sounds, obese, soft, continuous glucose
monitor in place
EXT: Warm, well perfused, 1+ lower extremity edema in LLE.
NEURO: Alert, oriented, cranial nerves grossly intact by
observation, exam limited by pain, but BLLE with 4+/5 in all
domains, full strength in upper extremities
SKIN: scattered ecchymoses and purpura on ___ forearms
DISCHARGE EXAM:
===============
VS:
___ 0929 Temp: 97.5 PO BP: 138/75 HR: 61 RR: 19 O2 sat:
___ O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Pleasant, lying in bed comfortably
HEENT: notable for proptosis
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, lungs clear to
auscultation
ABD: Normal bowel sounds, obese, soft, continuous glucose
monitor
in place
EXT: Warm, well perfused, 1+ lower extremity edema in LLE.
NEURO: Alert, oriented, cranial nerves grossly intact by
observation, exam limited by pain, but BLLE with 4+/5 in all
domains, full strength in upper extremities
SKIN: scattered ecchymoses and purpura on ___ forearms
Pertinent Results:
ADMISSION LABS:
===============
___ 06:14AM BLOOD WBC-31.2* RBC-4.93 Hgb-12.4* Hct-41.4
MCV-84 MCH-25.2* MCHC-30.0* RDW-15.6* RDWSD-47.0* Plt ___
___ 06:14AM BLOOD Neuts-46 Bands-0 ___ Monos-26*
Eos-0 Baso-0 ___ Metas-2* Myelos-1* AbsNeut-14.35*
AbsLymp-7.80* AbsMono-8.11* AbsEos-0.00* AbsBaso-0.00*
___ 06:14AM BLOOD Plt Smr-LOW* Plt ___
___ 06:14AM BLOOD Glucose-228* UreaN-19 Creat-1.0 Na-139
K-4.3 Cl-100 HCO3-25 AnGap-14
___ 06:14AM BLOOD CRP-4.8
CHEST X-RAY (___):
========================
FINDINGS:
PA and lateral views of the chest provided.
Bibasilar atelectasis is visualized. There is no focal
consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is unchanged. Diffuse osteopenia is visualized
throughout the thoracic spine limiting assessment for fracture
with no definite acute fracture identified.
IMPRESSION:
1. No acute intrathoracic process.
2. Diffuse osteopenia with no definite acute fracture identified
within
limitations of chest radiography. Please note that
cross-sectional imaging is more sensitive for acute fracture.
MRI SPINE (___):
======================
FINDINGS:
Cervical spine:
Vertebral body height is preserved. There is mild degenerative
the cysts at several levels.
There is cervical degenerative disc disease with mild spinal
canal and severe neural foraminal narrowing at several levels.
No suspicious bone marrow signal abnormalities identified.
The cervical spinal cord appears normal in morphology and signal
intensity. No abnormal intradural enhancement is identified.
Thoracic spine:
There are mild chronic compression fractures of the T3 and T6
vertebral
bodies. There are a few healed posterior rib fractures.
There is mild loss of height and abnormal enhancement within the
T8 vertebral body. There is associated paraspinal inflammatory
change, left more than right. There is minimal prevertebral
edema. No epidural abscess or drainable paraspinal abscess is
identified. The adjacent intervertebral discs appear spared.
Thoracic vertebral body alignment is preserved.
The thoracic spinal cord appears normal in morphology and signal
intensity. There is no abnormal intradural enhancement.
There is signal abnormality within the basilar lower lobes,
possibly
atelectasis or infection.
There is a few small probable hepatic cysts.
Lumbar spine:
There is a moderate chronic anterior wedge compression fracture
of the L1
vertebral body. There is mild degenerative spondylolisthesis at
several
levels.
Th there is intervertebral disc height loss and degenerative
endplate change at several levels, most advanced L3-4.
The conus medullaris terminates at the T12-L1 level. The conus
medullaris and cauda equina appear normal in morphology and
signal intensity. No abnormal intradural enhancement is
identified.
T12-L1: There is mild bilateral neural foraminal narrowing due
to facet
arthropathy. There is mild spinal canal narrowing due to
prominent dorsal
epidural fat.
L1-2: There is a minimal disc bulge without spinal canal
narrowing. There is mild bilateral neural foraminal narrowing
due to facet arthropathy.
L2-3: Spinal canal narrowing due to a disc bulge, intervertebral
osteophytes, ligamentum flavum thickening, and facet
arthropathy. There is suspected impingement on the traversing
left L3 nerve root. There is moderate bilateral neural
foraminal narrowing.
L3-4: There is no spinal canal narrowing post laminectomy.
There is moderate bilateral neural foraminal narrowing due to
facet arthropathy.
L4-5: The spinal canal is decompressed post L4 laminectomy.
There is no bony or disc impingement on the traversing nerve
roots. There is mild bilateral neural foraminal narrowing due
to facet arthropathy.
L5-S1: There is no spinal canal narrowing. There is mild right
and moderate left neural foraminal narrowing due to facet
arthropathy and intervertebral osteophytes.
There is mild edema within the dorsal subcutaneous soft tissues.
IMPRESSION:
1. Likely T8 osteomyelitis with a mild compression deformity and
paraspinal inflammatory change/phlegmon. Differential
considerations also include the possibility of a pathologic
fracture. No epidural or drainable paraspinal abscess is
identified.
2. Lumbar degenerative disc disease and a chronic L1 vertebral
body
compression fracture as detailed above.
CT GUIDED SPINE BIOPSY (___):
===================================
FINDINGS:
1. Limited pre-procedure CT scan a small area of perivertebral
phlegmon with a 1cm abcess adjacent to the T8 vertebral body,
which was targeted for aspiration and biopsy. Postprocedure
scan did not demonstrate any adjacent hematoma or pneumothorax.
IMPRESSION:
Technically successful CT-guided aspiration and biopsy of a
perivertebral
phlegmon/abscess. Samples were sent for microbiology, Gram
stain, culture and sensitivity.
CT SPINE (___):
=====================
FINDINGS:
There is mild exaggerated kyphosis of the upper thoracic spine.
Moderate sclerosis throughout the T3 vertebral body with mild
loss of vertebral body height is allowing for technical
differences unchanged from MR ___. A mild anterior
compression deformity of the T6 vertebral body is also
unchanged.
There is mild height loss of the T8 vertebral body similar to ___. There is also buckling of the lateral aspect of the
cortex. Findings are suggestive of a compression fracture. A
thin rim of soft tissue is noted along the anterolateral aspects
of the T8 vertebral body.
Posterior, chronic rib fractures are noted involving the eighth,
ninth and tenth ribs on the left and the ninth and tenth ribs on
the right. An 11 mm lucent lesion in the distal right clavicle
has a nonaggressive morphology.
There is asymmetric ground-glass and consolidation at the left
lung base relative to the right, which could just represent
atelectasis but underlying infection or inflammation can't be
excluded. Right lung base demonstrates mild scarring and
atelectasis. Trace left pleural effusion is noted.
Mediastinal lymph nodes are mildly enlarged. For example a
right subcarinal lymph node measures up to 12 mm (series 301,
image 72). Additionally, there is posterior paraspinal nodes
(301:84) measuring 9 mm in short axis. The visualized thyroid
is unremarkable. There is a small hiatal hernia and there is a
duodenal diverticulum. A small hypodensity in the caudate lobe
of the liver likely represents a simple cyst. Otherwise,
limited assessment of the abdomen is unremarkable.
IMPRESSION:
1. Mild vertebral body height at T8 with buckling of the lateral
aspect of the cortex compatible with a compression deformity,
similar appearance compared to prior MR. ___ small rim of
perivertebral soft tissue likely represents hematoma.
Possibility of an underlying lesion or infection is not excluded
by this CT though no specific evidence is identified on this
exam.
2. Additional vertebral bodies with height loss including T3 and
T6 appear
unchanged from prior MR.
3. Asymmetric consolidation ground-glass at the left lung base,
relative to the right. This could be asymmetric atelectasis but
correlation for infection or inflammation is recommended.
4. Mediastinal lymphadenopathy, may be reactive.
DISCHARGE LABS:
===============
___ 05:15AM BLOOD WBC-28.7* RBC-4.65 Hgb-11.6* Hct-38.0*
MCV-82 MCH-24.9* MCHC-30.5* RDW-15.7* RDWSD-46.9* Plt ___
___ 05:15AM BLOOD Glucose-50* UreaN-21* Creat-0.9 Na-142
K-4.1 Cl-101 HCO3-24 AnGap-17
Brief Hospital Course:
This is a ___ with CMML, type I diabetes, spinal stenosis,
adrenal insufficiency, grave's disease, who presents with back
pain, found to have T8 compression fracture.
# T8 compression fracture:
Patient presented with atraumatic progressive back pain. Exam
notable for point tenderness along T8-T9 spine as well as
weakness on plantar flexion of left foot (___). ___ count
markedly elevated to 31.2, though baseline elevation given h/o
CMML (WBC 20.2 on ___ at discharge). CRP and ESR were normal.
MRI was notable for a T8 deformity that was concerning for
osteomyelitis. Underwent CT-guided aspiration and biopsy of a
perivertebral fluid collection (cultures have shown no growth).
Initially stared on ceftriaxone/vancomycin. Underwent CT
___, which showed mild vertebral body height at T8 with
buckling of the lateral aspect of the cortex compatible with a
compression deformity. The deformity was thought to be most
likely secondary to a compression deformity (rather than
osteomyelitis), so antibiotics were discontinued. Pain managed
with gabapentin, PO morphine and naproxen.
STABLE ISSUES:
==============
# Type I Diabetes
Patient was diagnosed with Type I diabetes at age ___. Pt with
continuous glucose monitor. Per recent ___ note "he gives
multiple small doses of insulin throughout the day ___
injections on average) based on BG and he continues to
occasionally inject insulin IV when he feels he needs it to
bring BG down more quickly. ___ was consulted while patient
was admitted and guided insulin therapy. He was discharged on
his home insulin regimen.
# Adrenal Insufficiency
Patient has a history of secondary adrenal insufficiency
secondary to chronic steroid usage. At home, the patient takes
varying doses of hydrocortisone 30 mg to 80 mg depending on his
symptoms. Endocrinology was consulted while the patient was
admitted. Despite the relatively benign nature of his biopsy,
the patient requested stress dose steroids prior to the
procedure, and so he was given 100mg hydrocortisone on the day
of his procedure before being weaned to his home hydrocortisone
30mg daily.
# Leukocytosis
Patient had persistent leukocytosis during admission, with WBC
in the ___. Felt to be multifactorial in the setting of
corticosteroid usage and patient's CMML.
CHRONIC ISSUES:
===============
# Hypertension: Pt does not take any medications for his
hypertension.
# Grave's disease: continue home Levothyroxine 150 mcg PO/NG
daily
# Chronic urinary frequency
# Urge urinary incontinence
Continued home Tolterodine
# Osteoarthritis
# Chronic Pain
Managed with morphine while inpatient
# Right Achilles avulsion
# H/o compound L ankle fracture
# Gait disorder
Pt walks with crutches at baseline. ___ consulted while patient
in-house.
# HLD: continued home rosuvastatin 20 mg.
TRANSITIONAL ISSUES:
====================
[] Patient needs to follow up with Dr. ___
neurosurgery in 1 month.
[] Patient will need to start bisphosphonate therapy on ___ for
osteoporosis therapy. Bisphosphonate was not started inpatient
given acute fracture.
[] Patient was started on high dose vitamin D while in hospital.
Please re-draw in ___ weeks to measure vitamin D levels.
[] Consider PCP prophylaxis if patient continues to take
corticosteroids a suprphysiological doses.
[] Patient has history of atrial fibrillation and
self-discontinued his rate control and anticoagulation
medications. Please readdress with the patient whether he will
take these medications.
[] Will need to redraw CRP/ESR in one week (by ___ to
confirm patient does not have osteoporosis.
[] Patient's home oxycodone was discontinued while he is being
treated with morphine.
# CODE: full (presumed)
# CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocortisone 10 mg PO TID takes ___ when ill
2. lactulose 10 gram/15 mL oral DAILY:PRN
3. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q4H:PRN diarrhea
4. Tolterodine 2 mg PO BID
5. Glucagon 1 mg Subcut ONCE:PRN as needed for hypoglycemia
6. Becaplermin Gel 0.01% 1 Appl TP DAILY
7. Rosuvastatin Calcium 10 mg PO 5X/WEEK (___)
8. Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humulin R U-100 8 Units Breakfast
Humulin R U-100 8 Units Bedtime
NPH U-100 12 Units Breakfast
NPH U-100 12 Units Bedtime
9. salicylic acid 6 % topical QOD
10. OxyCODONE (Immediate Release) 10 mg PO TID:PRN as needed
11. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___)
12. Levothyroxine Sodium 75 mcg PO 1X/WEEK (___)
Discharge Medications:
1. Alendronate Sodium 70 mg PO QWED
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Calcium Carbonate 1000 mg PO DAILY
4. Gabapentin 400 mg PO QHS
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth every 6 hours Disp #*12
Tablet Refills:*0
7. Naproxen 500 mg PO Q8H Duration: 3 Weeks
Stop by ___
8. Polyethylene Glycol 17 g PO DAILY
9. Vitamin D ___ UNIT PO 1X/WEEK (WE)
10. Becaplermin Gel 0.01% 1 Appl TP DAILY
11. Glucagon 1 mg Subcut ONCE:PRN as needed for hypoglycemia
12. Hydrocortisone 10 mg PO TID takes ___ when ill
13. Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humulin R U-100 8 Units Breakfast
Humulin R U-100 8 Units Bedtime
NPH U-100 12 Units Breakfast
NPH U-100 12 Units Bedtime
14. lactulose 10 gram/15 mL oral DAILY:PRN
15. Levothyroxine Sodium 150 mcg PO 6X/WEEK (___)
16. Levothyroxine Sodium 75 mcg PO 1X/WEEK (___)
17. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q4H:PRN diarrhea
18. Rosuvastatin Calcium 10 mg PO 5X/WEEK (___)
19. salicylic acid 6 % topical QOD
20. Tolterodine 2 mg PO BID
21. HELD- OxyCODONE (Immediate Release) 10 mg PO TID:PRN as
needed This medication was held. Do not restart OxyCODONE
(Immediate Release) until off of morphine
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Acute T8 compression fracture
Secondary:
- DM type I
- Atrial Fibrillation
- Secondary adrenal insufficiency
- Hypothyroidism
- CMML
- Likely CD5- CLL
- Hypertension
- Hyperlipidemia
- Spinal stenosis
- Prior Achilles rupture with chronic venous stasis ulcers
- Prior tibula/fibula compound c/b Yokenella osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
WHY WERE YOU ADMITTED:
- You were having severe back pain, and we did an MRI of your
back which showed that you had a possible infection in your
spine.
WHAT HAPPENED IN THE HOSPITAL:
- You were found to have a compression deformity in your spine
- You had a biopsy of your back which did not grow any bacteria.
- We had multiple specialists see you, including Diabetes,
Endocrine, Infectious Disease, and Neurosurgery, and they gave
us recommendations regarding your care.
WHAT SHOULD YOU DO AFTER LEAVING:
- Please follow-up with your doctors as ___.
- Please take your medications as prescribed.
- If you notice worsening back pain, numbness/weakness in your
legs, please call your doctor.
Thank you for allowing us to take part in your care!
Your ___ team
Followup Instructions:
___
|
10501162-DS-13 | 10,501,162 | 20,361,456 | DS | 13 | 2191-05-04 00:00:00 | 2191-05-09 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegretol / Ibuprofen / Bactrim / titanium
Attending: ___.
Chief Complaint:
left leg pain/swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Dr. ___ is a ___ male with a sig PMHX of DM2 on
insulin, hypothyroid, Addison's disease on cortisone, who
presents with left leg pain and swelling.
The patient was in his USOH until 2 days prior to admission.
Notably, he was recently admitted for RLE cellulitis on ___,
that was treated with IV cefazolin which was transitioned to PO
Keflex X 10 days (D10 = ___, after rapid improvement of
symptoms. Dermatology also evaluated given persistent pain and
erythema, who suspected this was likely ___ venous insufficiency
with superimposed cellulitis.
He was discharged home, and over the past 2 days, he began
developing worsening swelling and pain of his left leg. He took
Keflex and Augmentin, which he had at home without any
significant improvement. His pain became so significant that he
is now having difficulty ambulating.
Otherwise, he has no acute complaints. He denies any fevers,
chills, chest pain, dyspnea, abdominal pain, n/v/d,
claudication.
He has chronic urinary retention. He spoke to his PCP, who
referred him to ___ ED for further evaluation.
In the ED,
- Initial vitals:
T 98.3 HR 81 BP 124/55 RR 16 SPO2 97% RA
- Exam notable for:
General: comfortable
Lungs: CTAB
Cardiac: RRR, no murmur
Abdomen: Soft, nontender, nondistended
Extremities: ___ diffusely erythematous and swollen, TTP. Wounds
on lateral aspect of lower leg.
Neurologic: Awake, alert, moves all extremities. Speech fluent.
Dermatologic: Skin is warm and dry
- Labs notable for:
CBC: WBC 32.2 Hb 11.8 Plt 123
CHEM 7: Cr 0.8 K 3.8
Lactate: 1.2
- Imaging notable for:
+L Lower Ext Vein U/S:
Left peroneal veins were not visualized. Within that limitation
there is no evidence of DVT in the left lower extremity. Mild
subcutaneous edema in the left calf.
- Pt given:
IV Vancomycin 1500 mg
IV Hydrocortisone Na Succ. 100 mg
- Vitals prior to transfer:
T 98.6 HR 71 BP 121/63 RR 17 SPO2 93% RA
Upon arrival to the floor, the patient reports the above story.
He states that the pain in his left leg is worsening daily. He
has been keeping up with his wound care that was recommended by
dermatology. He denies any new trauma or disruption to his skin.
Otherwise, he has no acute complaints.
Past Medical History:
CMML
DM1
ADRENAL INSUFFICIENCY
ANEMIA
DIABETES MELLITUS
GRAVE'S DISEASE
HYPOTHYROIDISM
OSTEOARTHRITIS
PAIN
VENOUS INSUFFICIENCY
MONILIAISIS
HYPERTENSION
SPINAL STENOSIS
NECK PAIN
DERMATOHELIOSIS
SEBORRHEIC DERMATITIS
IRRITABLE BOWEL SYNDROME
Social History:
___
Family History:
A son has DM1
Physical Exam:
ADMISSION EXAM
================
VITALS: T 97.9 BP 111/62 HR80 RR20 SP___
General: pleasant obese male, sitting upright in bed. Alert,
oriented, no acute distress
HEENT: + large ecchymosis over R eye, healing (prior ___ in
___. ptosis in eyes b/l. Sclerae anicteric, MMM, oropharynx
clear, EOMI, PERRL, neck supple, JVP flat, 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. +CGM in LLQ c/d/i
Ext: warm extremities. minimal ROM in ___. RLE with full active
ROM. gait not assessed.
Skin: +erythematous and tense ___, ttp. healing 5X2 cm shallow
ulcer with granulation over L lateral malleolus. 1X1 cm shallow
ulcer on L medial malleolus c/d/I with granulation. RLE with
chronic venous stasis hyperpigementation with demarcation,
without erythema. 2 shallow based ulcers c/d/I on anterior RLE.
Neuro: CNII-XII intact, grossly normal sensation, 2+ patellar
reflexes bilaterally.
DISCHARGE EXAM
==================
VITALS: ___ 1123
Temp: 97.7 PO BP: 149/85 R Lying HR: 75 RR: 18 O2 sat: 94% O2
delivery: Ra FSBG: 109
General: sitting upright in bed. Alert, oriented, no acute
distress
HEENT: + large ecchymosis over R eye, healing (prior fall in
___. ptosis in eyes b/l. Sclerae anicteric, MMM, oropharynx
clear, EOMI
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. +CGM in LLQ c/d/i
Ext: Warm extremities. Minimal ROM in ___. RLE with full active
ROM. Gait not assessed.
Skin: +erythematous and tense ___, ttp. healing 5X2 cm shallow
ulcer with granulation over L lateral malleolus. 1X1 cm shallow
ulcer on L medial malleolus c/d/I with granulation. RLE with
chronic venous stasis hyperpigmentation with demarcation,
without
erythema. 2 shallow based ulcers c/d/I on anterior RLE.
Neuro: CNII-XII grossly intact, moving all extremities equally.
Pertinent Results:
ADMISSION LABS
================
___ 08:25PM WBC-32.2* RBC-4.81 HGB-11.8* HCT-40.7 MCV-85
MCH-24.5* MCHC-29.0* RDW-16.9* RDWSD-51.8*
___ 08:25PM NEUTS-63 BANDS-1 LYMPHS-12* MONOS-21* EOS-0*
BASOS-0 ATYPS-1* MYELOS-2* AbsNeut-20.61* AbsLymp-4.19*
AbsMono-6.76* AbsEos-0.00* AbsBaso-0.00*
___ 08:25PM PLT SMR-LOW* PLT COUNT-123*
___ 08:25PM GLUCOSE-89 UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
___ 08:31PM LACTATE-1.2
DISCHARGE LABS
================
___ 07:41AM BLOOD WBC-39.0* RBC-4.29* Hgb-10.7* Hct-36.4*
MCV-85 MCH-24.9* MCHC-29.4* RDW-16.7* RDWSD-51.6* Plt ___
___ 07:41AM BLOOD Glucose-80 UreaN-21* Creat-0.7 Na-141
K-3.9 Cl-101 HCO3-26 AnGap-14
___ 07:41AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
___ 07:41AM BLOOD TSH-0.39
MICROBIOLOGY
===============
___ 8:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
=============
___ ___ IMPRESSION:
Left peroneal veins were not seen. Otherwise, no evidence of
DVT elsewhere in the left lower extremity. Mild subcutaneous
edema in the left calf.
Brief Hospital Course:
___ w/ PMH T1DM on insulin, adrenal insufficiency on chronic
steroids, CMML, chronic venous stasis with recent RLE cellulitis
in ___ admitted for ___ cellulitis.
# ___ Cellulitis:
# Chronic Venous Stasis:
The patient was in his usual state of health until 2 days prior
to admission. Notably, he was recently admitted for RLE
cellulitis on ___ that was treated with IV cefazolin which
was transitioned to PO Keflex X 10 days (D10 = ___. He was
discharged home, and over the week prior to admission he began
developing worsening swelling and pain of his left leg. He took
Keflex that he had left over from a previous infection for three
days with no improvement in his symptoms. He then took two days
of Augmentin that he had from a previous infection and still saw
no improvement. The patient began to have difficulty ambulating
at which point he was referred to the ___ ED on ___ by his
PCP. In the ED, the patient was hemodynamically stable and
afebrile. His exam was normal except for a diffusely
erythematous and swollen ___. The leg was tender to palpation.
Wounds were noted on the lateral aspect of lower leg. CBC showed
a WBC count of 32.2 (consistent with his baseline given CMML).
LENIs were negative for DVT. The patient was started on IV
vancomycin and cefazolin. On the evening of ___ the patient was
admitted to the medicine floor. On ___ the ___ was less
painful, but still very red and swollen. IV vancomycin was
discontinued due to low suspicion for MRSA infection. The
patient continued on IV cefazolin through ___. On the morning
of ___, the patients leg had less swelling, receeding redness
and less pain. The infectious disease team was consulted
regarding antibiosis and felt that the patient would have the
same coverage on PO Keflex as he was getting from the IV
cefazolin. The patient was discharged on a 10 day course of PO
Keflex with instructions to return to the ED if he felt his
swelling, redness or pain worsened. Last day of antibiotics is
___.
#DM Type 1:
Patient requested to titrating his own insulin regimen while
hospitalized. The patient's home insulin regimen was continued
as an inpatient. The patient requested his insulin and it was
administered by a nurse. The ___ diabetes service was
consulted for their opinion on his regimen and felt that his
sugars had been well controlled on his home regimen. The patient
was maintained on the following regimen:
- NPH 12 units bid
- Regular 8 units bid
- Humalog ___ units before meals
#Adrenal insufficiency:
Prior notes describe secondary adrenal insufficiency. The
patient again requested to titrate his own regimen of cortisone
as he does at home. He was written to receive hydrocortisone
___ mg PO/NG QID:PRN. His usual dose was 12.5 mg PO QID based
upon his calculations. His sugars were relatively well
controlled on this regimen while he was an inpatient.
CHRONIC/STABLE PROBLEMS:
# CMML, likely CD5-negative CLL: Maintained near baseline WBC
___. Low risk disease per ___ CMML prognostic model. Patient
should continue to be followed by Heme/Onc as outpatient.
# Anemia / Thrombocytopenia:
Hb and Plt count remained near baseline as an inpatient. No
evidence of acute bleeding on exam, and no evidence of
hemolysis.
# Grave's disease:
Continued on home Levothyroxine
# Osteoarthritis
# Chronic Pain
Patient continued on home ___ mg oxycodone TID PRN.
# HLD: Continued on home rosuvastatin
TRANSITIONAL ISSUES
=======================
[ ] Complete 10 day antibiotic course with cephalexin 500mg PO
Q6H (last day ___
[ ] Follow up with PCP regarding blood sugar control and
management of adrenal insufficiency with chronic steroids.
[ ] Recommend on-going wound care follow up for management of
bilateral leg ulcers with frequent elevation and leg wrapping to
reduce swelling.
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. Becaplermin Gel 0.01% 1 Appl TP DAILY
2. Calcium Carbonate 1000 mg PO DAILY
3. Hydrocortisone ___ mg PO QID:PRN titrated per patient
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Opium Tincture (morphine 10 mg/mL) 10 mg PO DAILY:PRN
diarrhea
6. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Moderate
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Alendronate Sodium 70 mg PO QSAT
11. Furosemide 20 mg PO PRN edema
12. salicylic acid 6 % topical QOD
13. Selenium Sulfide 0 mL TP WEEKLY AND AS DIRECTED
14. TraZODone 50 mg PO QHS:PRN sleep
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
16. Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
NPH 12 Units Breakfast
NPH 10 Units Bedtime
Regular 6 Units Breakfast
Regular 6 Units Lunch
Regular 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth EVERY 6 HOURS Disp
#*32 Tablet Refills:*0
2. Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
NPH 12 Units Breakfast
NPH 10 Units Bedtime
Regular 6 Units Breakfast
Regular 6 Units Lunch
Regular 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Selenium Sulfide ___ mL TP WEEKLY AND AS DIRECTED
4. Alendronate Sodium 70 mg PO QSAT
5. Becaplermin Gel 0.01% 1 Appl TP DAILY
6. Calcium Carbonate 1000 mg PO DAILY
7. Furosemide 20 mg PO PRN edema
8. Hydrocortisone ___ mg PO QID:PRN titrated per patient
9. Levothyroxine Sodium 150 mcg PO DAILY
10. Opium Tincture (morphine 10 mg/mL) 10 mg PO DAILY:PRN
diarrhea
11. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
13. Rosuvastatin Calcium 10 mg PO DAILY
14. salicylic acid 6 % topical QOD
15. TraZODone 50 mg PO QHS:PRN sleep
16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Lower Extremity Cellulitis
Type 1 Diabetes Mellitus
Adrenal Insufficiency
Chronic Venous Stasis
Bilateral Venous Ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Dr. ___ was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had an infection of the skin on your left leg and needed
IV antibiotics.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received IV antibiotics and saw improvement in the
infection of your skin.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue taking your Keflex every 6 hours through ___
(for a total 10-day course).
- Keep your legs elevated.
- See your wound care clinic every two weeks.
- Continue to take all your other medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10501162-DS-14 | 10,501,162 | 29,961,239 | DS | 14 | 2191-06-03 00:00:00 | 2191-06-05 11:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegretol / Ibuprofen / Bactrim / titanium
Attending: ___.
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with T1DM on insulin, adrenal
insufficiency on chronic steroids, CMML, and chronic venous
stasis c/b cellulitis x2 (admissions ___ and ___ who
presented s/p unwitnessed fall, subsequently found to have TBI
and T8 compression fracture.
Per ED Dashboard: "Was walking down stairs at midnight when wife
heard pt fall to ground. Wife reports that patient was conscious
however briefly did not respond to verbal command, consistent
with prior episodes vasovagal episodes. No apparent head strike,
unable to recall if preceding chest pain, palpitations, light
headedness. Pt currently reports pain along L ribs cage, L arm,
L
hip, and worsening chronic back pain. Was unable to ambulate
following the incident. EMS was called and pt brought to ED."
In the ED, initial vitals: 97.7F, 79, 97/48, 16, 92% RA
- Exam notable for: +Chest wall TTP, +anterior L hip TTP,
limited
flexion of L hip, +diffuse ecchymosis along L thigh and L
abdomen
- Labs notable for:
---CBC: WBC 85.9, Hgb 8.9, Plts 105
---BMP: BUN 23, Cr 0.8
---Coags: INR 1.3
---Influenza: Negative
- Imaging notable for:
---CXR: Low lung volumes. Patchy left base opacity could be due
to atelectasis, pneumonia, aspiration, and/or pulmonary
contusion
in the setting of trauma. No large pleural effusion, though
trace
left pleural effusion be difficult to exclude. Subtle
irregularity of the posterior left seventh rib could represent a
fracture, although not definitely substantiated on CT.
---NCHCT:
1. Acute intraparenchymal hemorrhage in right paramedian frontal
lobe with right parafalcine subdural hematoma.
2. Hyperdensities along the bilateral paramedian sulci
consistent
with subarachnoid hemorrhage.
3. No mass effect.
4. No acute fracture.
---CT A/P w/ Contrast:
1. Likely acute on chronic compression fracture of T8 with
moderate retropulsion resulting in mild spinal canal narrowing.
2. Partially imaged hematoma measuring up to 7.7 cm within the
soft tissues along the left proximal femur.
3. Incompletely characterized 1.5 cm cystic lesion in body of
the
pancreas, for which MRCP in a non-emergent setting is
recommended.
---XR Pelvis/L Femur/: Knee: The oblique view of the knee is
suboptimal due to underpenetration and technique. Otherwise, no
evidence of acute fracture.
- Consults: Neurosurgery
"Patient examined and imaging reviewed by attending. Agree with
admission to medicine for complex medical issues. We recommend
the following:
# TBI: GCS 13 on evaluation. Not on any anticoagulation. Would
typically treat as a mild TBI with ED obs however the CT head
was
16 hours after his reported fall. There is no indication for
urgent or emergent neurosurgical intervention.
- q4h neuro checks
- Keppra 500mg BID x7 days
- Recommend MRI/MRA to ensure no underlying lesion
- No anticoagulation unless cleared by neurosurgery
- PTT has not resulted, recommend re-checking
- Please enroll patient in TBI pathway
- Please provide patient with TBI Education Packet
# T8 compression fracture (worsened since prior):
- Please place formal spine consult
- urgent MRI ___ to evaluate for cord compression given LLE
weakness
- NPO until MRI results
- log roll, bedrest
- TLSO brace"
- Pt given: 500cc NS, Gabapentin 300mg x1, Oxycodone 20mg x1, IV
Morphine Sulfate 4 mg IV, hydrocortisone 10mg PO, D10W @ 100/hr
x 1L
- Vitals prior to transfer:
75 |104/52| 15 | 92% (unsepcified amount) of Nasal Cannula
Patient sent to floor prior to inpatient team accepting patient
straight from MRI and was found to be on a non-rebreather. He
was
down-titrated to 4L nasal cannula with saturation of 92%. Upon
arrival to the floor, the patient was drowsy but arousable to
voice and answering some questions appropriately. He reports
that
he had unknown cause of fall. He replies not being in any acute
pain at this time. Reports limited mobility in left shoulder s/p
fall.
Past Medical History:
Chronic Myelomonocytic Leukemia
DM1
ADRENAL INSUFFICIENCY
ANEMIA
DIABETES MELLITUS
GRAVE'S DISEASE
HYPOTHYROIDISM
OSTEOARTHRITIS
PAIN
VENOUS INSUFFICIENCY
MONILIAISIS
HYPERTENSION
SPINAL STENOSIS
NECK PAIN
DERMATOHELIOSIS
SEBORRHEIC DERMATITIS
IRRITABLE BOWEL SYNDROME
Social History:
___
Family History:
A son has DM1
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: ___ 0148 Temp: 97.4 PO BP: 115/57 HR: 81 RR: 18 O2
sat: 94% O2 delivery: 4L Dyspnea: 0 RASS: -1 Pain Score:
___
General: Drowsy, rousable to voice, answers questions
appropriately, unwell appearing. Multiple ecchymoses.
HEENT: Multiple ecchymoses. Exopthalmos. R eyelid shut. Sclerae
anicteric, MMM, oropharynx clear, EOMI unable to be assessed
secondary to drowsiness, PERRL constricting from 2.5 to 2.0 mm
b/l, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended, no organomegaly, no rebound or guarding
GU: No foley
Ext: Diffuse ecchymoses over L shu___, forearm, flank. Warm,
well perfused, 2+ pulses, no clubbing, cyanosis. 1+ edema in b/l
___. LLE is wrapped.
Skin: Skin type III. Diffuse ecchymoses over L shulder, forearm,
flank. Scattered petechiae. Erythematous papules and plaques
over
chest and trunk.
Neuro: Mental Status: Alert to self, place. Drowsy.
Cranial Nerves:
Visual Fields: unable to assess, vision grossly intact.
Visual Acuity: Vision grossly intact
Eye Movements: Unable to assess, appear grossly intact.
V: Unable to assess.
VII: Facial expression is unable to be assessed.
VIII: Hearing intact to voice
IX, X: Uvula position unable to be assessed.
XI: Shoulder shrug and strength in sternocleidomastoid
diminished
on LUE, intact on RUE
XII: Slurred speech, unable to assess tongue protrusion.
Motor:
Bulk, tone: Appropriate for age, sex and body habitus. Without
rigidity.
RUE: 5+
LUE: 4+, ROM limited at shoulder
RLE: 5+
LLE: ___
Abnormal movements: Absent
Pronator drift: unable to assess
Sensory:
Light touch: Intact
Reflexes:
Patellar: 1+ b/l
DISCHARGE PHYSICAL EXAM:
======================
Vitals: 24 HR Data (last updated ___ @ 824)
Temp: 99.6 (Tm 99.6), BP: 97/59 (93-107/54-64), HR: 83
(81-92), RR: 18 (___), O2 sat: 91% (91-95), O2 delivery: 1 L
General: Sitting up in bed, no apparent distress
HEENT: Pale, no icterus, MMM. Multiple ecchymoses. Exopthalmos.
No cervical or supraclavicular LAD
CV: RRR normal S1 and S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anterolaterally, no wheezes, rales,
rhonchi
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended, no organomegaly, no rebound or guarding
Ext: Large, firm hematoma involving L lateral thigh. 2+ edema in
b/l ___ to thighs.
Skin: Diffuse ecchymoses over L shoulder, forearm, hip, flank.
Scattered
petechiae.
Neuro: Alert, oriented to person, place, ___, responding
appropriately. CN ___ grossly in tact, moving all 4 extremities
with purpose
Pertinent Results:
ADMISSION LABS:
=============
___ 01:42PM NEUTS-52 BANDS-4 LYMPHS-14* MONOS-26* EOS-0*
___ METAS-3* MYELOS-1* AbsNeut-48.10* AbsLymp-12.03*
AbsMono-22.33* AbsEos-0.00* AbsBaso-0.00*
___ 01:42PM WBC-85.9* RBC-3.57* HGB-8.9* HCT-31.2* MCV-87
MCH-24.9* MCHC-28.5* RDW-16.4* RDWSD-52.8*
___ 01:42PM POIKILOCY-1+* OVALOCYT-1+* ECHINO-1+*
RBCM-SLIDE REVI
___ 01:42PM CK(CPK)-104
___ 01:42PM GLUCOSE-143* UREA N-23* CREAT-0.8 SODIUM-136
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
___ 01:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIO:
========
-All blood and urine cultures negative throughout admission. C.
diff PCR negative
IMAGING:
=======
CT HEAD ___ CONTRASTStudy Date of ___ 4:09 ___
1. Focal 2.3 x 1.3 x 0.9 cm right frontal intraparenchymal
hematoma with
surrounding mild edema. Adjacent right parafalcine subdural
hematoma measures
up to 0.6 cm in width, 3.5 cm in length.
2. Bilateral parafalcine acute subarachnoid hemorrhage.
3. No acute fracture.
CHEST (SINGLE VIEW)Study Date of ___ 4:09 ___
Low lung volumes. Patchy left base opacity could be due to
atelectasis,
pneumonia, aspiration, and/or pulmonary contusion in the setting
of trauma.
No large pleural effusion, though trace left pleural effusion be
difficult to
exclude.
Subtle irregularity of the posterior left seventh rib could
represent a
fracture, although not definitely substantiated on CT.
CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 4:10 ___
1. Concern for acute on chronic compression fracture of the T8
vertebral body
with 3 mm of retropulsion resulting in mild spinal canal
narrowing.
2. Partially imaged hematoma measuring up to 7.7 cm within the
soft tissues
lateral to the proximal left femur.
3. Incompletely characterized 1.5 cm cystic lesion in body of
the pancreas,
for which nonemergent MRCP is recommended.
RECOMMENDATION(S): Nonemergent MRCP for further
characterization cystic
lesion in the body of the pancreas.
FEMUR (AP & LAT) LEFTStudy Date of ___ 4:13 ___
No definite acute fracture is seen. The oblique view of the
knee is limited
in and underpenetrated. There are mild to moderate bilateral
hip degenerative
changes. The pubic symphysis and sacroiliac joints are not
widened.
Multilevel degenerative changes of the partially imaged lower
lumbar spine are
partially imaged. Minimal to no suprapatellar joint effusion is
seen. There
is mild patellar enthesopathy and tiny posterior patellar spurs.
Vascular
calcifications are seen.
KNEE (AP, LAT & OBLIQUE) LEFTStudy Date of ___ 4:14 ___
The oblique view of the knee is suboptimal due to
underpenetration and
technique. Otherwise, no evidence of acute fracture.
MR THORACIC SPINE ___ CONTRASTStudy Date of ___ 12:38 AM
1. Recent T8 compression fracture with approximately 75%
vertebral body height
loss and evidence of 7 mm retropulsion resulting in severe
spinal canal
stenosis with compression of the spinal cord but no evidence of
definitive
cord signal abnormality. Severe bilateral T8-T9 neural
foraminal narrowing.
2. Diffuse low signal within the vertebral bodies could be due
to anemia or an infiltrative process. Prominence of paraspinal
soft tissues could be due to fat deposition or due to
extramedullary hematopoiesis at the site of compression fracture
(08:11).
3. Despite the abnormal appearance of the bony structures with
diffuse low
signal, the presence of a high intensity cleft within the
fractured vertebra suggest posttraumatic component. MRI with
gadolinium can help for further assessment if clinically
indicated.
4. Thin epidural hematoma along the right posterior aspect of
the T6 through T9 vertebral bodies.
5. Chronic T3, T6, L1 and L2 superior endplate compression
deformities.
6. Prevertebral soft tissue edema extending from T7 through T9.
RECOMMENDATION(S): MRI with gadolinium to further assess the
nature of T8
compression fracture.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFTStudy Date of
___ 4:40 ___
No evidence of fracture or dislocation.
T-SPINEStudy Date of ___ 4:41 ___
No definite change in moderate T8 compression fracture.
___ CT HEAD ___ CONTRAST:
1. Study is degraded by motion.
2. Grossly stable right frontal intraparenchymal and right
parafalcine
subdural hematomas with question interval increased edema, as
described.
3. Question interval increase in bilateral parietal subarachnoid
hemorrhage.
___ CTA ABD & PELVIS:
1. Interval increase in size of a large soft tissue hematoma in
the anterior compartment of the left thigh, now measuring 21.4 x
14.1 x 8.3 cm. No evidence of active bleed.
2. Interval increase in size of a layering nonhemorrhagic left
pleural
effusion with bibasilar atelectasis.
3. 12 mm hypodense lesion in the pancreatic head, statistically
likely
representing a side-branch IPMN. Further evaluation with
noncontrast MRCP in 6 months is recommended to ensure stability.
___ CT HEAD ___ CONTRAST:
1. New right hemispheric subdural hematoma measuring up to 3 mm
from the inner table without significant mass effect.
2. Otherwise unchanged right parafalcine subdural hematoma,
right frontal
intraparenchymal hematoma, left parietoccipital subarachnoid
hemorrhage.
___ MR HEAD W/ & ___ CONTRAST:
1. Grossly unchanged right parafalcine and frontal lobe subdural
hematoma and right frontal intraparenchymal hematoma. No
evidence of new intracranial hemorrahge.
2. No evidence of suspicious intracranial lesions, mass effect,
or
hydrocephalus.
3. Punctate hyperintense cortical focus in the right posterior
frontal lobe, likely related to blood products or tiny
infarction
4. No evidence of stenosis, occlusion, or aneurysm in the major
intracranial arteries.
5. No definite MRI signs of diffuse axonal injury within the
limitation of
motion limited GRE images.
___ MR ___/ & ___ CONTRAST:
1. Unchanged T8 vertebral body compression fracture and
retropulsion of the intervertebral disc without evidence of
abnormal cord signal or worsening cord compression.
2. Stable epidural hematoma extending from the T6-T8 vertebral
bodies.
3. Multilevel degenerative changes in the thoracic and lumbar
spine are
unchanged.
4. Chronic compression deformity of the L1 vertebral body,
unchanged
___ CTA ABD & PELVIS:
1. Increase in size of a left anterior thigh hematoma without
evidence of
active extravasation.
2. Enlarging subcarinal lymph node now measuring up to 16 mm in
short axis. Further evaluation with CT chest could be performed
for further evaluation if clinically indicated.
3. Cystic lesions within the pancreas are stable from prior, the
largest of which measures 12 mm possibly representing a
side-branch IPMN.
4. Colonic diverticulosis without evidence of diverticulitis.
5. Reactive pelvic and inguinal lymphadenopathy is stable from
prior.
6. Subacute T8 compression fracture and chronic L1 compression
fracture are stable.
___ CXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes are persistently low, but nevertheless greater
mediastinal venous engorgement and mild pulmonary edema are
recognizable and moderate cardiomegaly has increased. Pleural
effusion small if any. Healed fracture deformities left mid rib
should not be mistaken for lung lesions.
___ Ultrasound Face
IMPRESSION:
Scans show it appears to be just it diffuse enlargement of the
left parotid gland, without hypervascularity and without any
focal solid or cystic lesions. This may represent parotitis.
___ CXR
IMPRESSION:
In comparison with the study of ___, there again are low
lung volumes. The chin of the patient substantially obscures the
superior mediastinum. Cardiomediastinal silhouette is stable.
The degree of pulmonary edema has decreased. Given the low lung
volumes and size of the cardiac silhouette, it would be very
difficult to exclude a retrocardiac aspiration/pneumonia in the
appropriate clinical setting, especially in the absence of a
lateral view.
DISCHARGE LABS:
=============
___ 05:50AM BLOOD WBC: 67.9* RBC: 3.35* Hgb: 8.6* Hct:
30.1* MCV: 90 MCH: 25.7* MCHC: 28.6* RDW: 17.6* RDWSD: 56.9* Plt
Ct: 149*
___ 05:50AM BLOOD Glucose: 114* UreaN: 17 Creat: 0.5 Na:
143 K: 3.8 Cl: 104 HCO3: 25 AnGap: 14
___ 05:50AM BLOOD Calcium: 7.2* Phos: 2.6* Mg: 1.8
Brief Hospital Course:
SUMMARY:
========
Dr. ___ is a ___ year old man with T1DM on insulin, adrenal
insufficiency on chronic steroids, CMML, and chronic venous
stasis c/b cellulitis x2 (admissions ___ and ___ who
presented s/p unwitnessed fall, subsequently found to have TBI
and T8 compression fracture with impingement upon the cord. He
was evaluated by Neurosurgery on admission who felt that there
was no role for acute intervention. He was stable until ___
when he was noted to be progressively tachycardic with dropping
BPs, as well as rapidly expanding L thigh hematoma. CBC checked
with Hb 3.3 from 7.3 earlier in day. BPs as low as ___,
improved with fluids and blood. Massive transfusion protocol
initiated and patient transferred to ICU. His Hgb has stabilized
and his last transfusion was ___. No intervention was
necessary to stop the bleeding. He went into Afib during his ICU
stay and was started on amiodarone due to worsening hypotension
with trial of beta blockers. Patient transferred to medicine
service ___ again once stable and remained he remained
stable until ___ when he was again noted to be hypotensive
with SBP in ___, and tachypneic to ___, with concern for
re-expanding L thigh hematoma. SBP improved to ___ with ~1L IVF.
CTA in ICU revealed no active extravasation into left thigh and
a negligibly larger hematoma. Ultimately it was felt that his
hypotension this time was due to too rapid of tapering his
stress dose steroids. His steroid dose was increased and his
blood pressures stabilized. He was again transferred to a
medicine service where he remained stable until discharge. He
was worked up for a coagulopathy with elevated INR by our
hematology service. They felt that his coagulopathy was most
likely nutritional and patient was given 10mg po vitamin K for 4
days. ___ followed patient while hospitalized to assist with
titration of his insulin dosing while blood sugars labile in the
setting of stress dose steroids. Endocrinology followed after
second transfer back to medicine service to assist with taper of
stress dose steroids. Prior to discharge amiodarone was
discontinued due to long QTc. Patient remained in sinus rhythm
despite holding amiodarone and he was not started on an
alternative rate or rhythm control agent. ___ and OT evaluated
patient while admitted and felt that safest discharge plan would
be for him to go to rehab for further recovery before going
home.
TRANSITIONAL ISSUES:
-Continue steroid taper per endocrinology recommendations:
Decrease IV Hydrocortisone Dose Q8H by 5mg per day until stable
at 10mg Q8H. Once stable at this dose could then switch to PO:
10mg qAM AND 20mg in the mid-afternoon
(___). Steroid dose at discharge 20mg IV Q8H.
-New Medications: Acetaminophen 1000mg Q8H, Multivitamin with
minerals Daily, Bisacodyl 10mg PR Daily, Senna 8.6mg BID,
Lidocaine Patch 5% Daily
-Held Medications: Alendronate 70mg Q ___, Furosemide 20mg
PRN, Trazodone 50mg QHS,
-Follow up Appointments: Needs to follow up with neurosurgery
week of ___ for repeat imaging, PCP, ___
[]Next Hydrocortisone dose 20mg IV at 1600, then start 15mg IV
Q8H for 24H at midnight.
[]Patient is sensitive to tramadol, causing sedation and poor
emotional response. This medication should be avoided in the
future
[]Patient was on amiodarone for control of Afib with RVR.
Amiodarone discontinued in the setting of prolonged QTc and
stable heart rates in sinus rhythm.
[] Once able to stand should obtain stainding ___ x-rays for
neurosurgery follow up
[] Will require ongoing insulin dose titration with steroid dose
being tapered.
[] Hgb at discharge 8.6
ACUTE/ACTIVE PROBLEMS:
======================
# TBI
GCS 13 on ED evaluation. Not on any anticoagulation prior to
admission. NCHCT showed acute intraparenchymal hemorrhage in
right paramedian frontal lobe with right parafalcine subdural
hematoma and hyperdensities along the bilateral paramedian sulci
consistent with subarachnoid hemorrhage. He was assessed by
Neurosurgery who said that there was no indication for urgent or
emergent neurosurgical intervention. They recommended Keppra
500mg BID x7 days which was completed. He will need to follow up
in ___ clinic for continued evalauation ___.
#L thigh hematoma
#Hypotension
#Secondary ___
Transferred to MICU twice during admission for hypotension.
Initially concern both times was highest for bleed into thigh
causing hypotension as hematoma enlarging per nursing. On first
transfer he was noted to be progressively tachycardic with
dropping BPs, as well as rapidly expanding L thigh hematoma. CBC
checked with Hb 3.3 from 7.3 earlier in day. BPs as low as
___, improved with fluids and blood. Massive transfusion
protocol initiated and patient transferred to ICU. He ultimately
stabilized after 6 units of blood, 1 platelet transfusion, and
brief time on pressors. ON his second transfer to MICU he was
again noted to be hypotensive with SBP in ___, and tachypneic to
___, with concern for re-expanding L thigh hematoma. SBP
improved to ___ with ~1L IVF. CTA in ICU revealed no active
extravasation into left thigh and a negligibly larger hematoma.
Ultimately it was felt that his hypotension this time was due to
too rapid of tapering his stress dose steroids. Blood pressures
stabilized with stress dose steroids. Once transferred back to
medicine service Endocrine was consulted who assisted with
tapering steroids towards his pre-hospital doses. Patient was
stable on taper of 5mg per dose per day at time of discharge.
His discharge dose was 20mg IV Hydrocortisone Q8H. Discharge
steroid taper plan was to taper to 10mg IV Q8H then transition
to oral regimen of 10mg Hydrocortisone QAM and 20mg
Hydrocortisone Q Early Afternoon.
#Coagulopathy
Patient with multiple bleeds on presentation in the setting of
fall at home. However, also with history of CMML which can be
associated with acquired coagulopathies, elevated ___, labile INR
throughout admission. Hematology was consulted who felt that
most likely patient was vitamin K deficiency in the setting of
poor nutrition and recent antibiotic use. Possibility that he
had an acquired coagulopathy related to his heme malignancy was
also considered however after vitamin K supplementation INR and
___ downtrended and inhibitor screen was cancelled.
#Atrial Fibrilation
Per chart review patient has history of afib in the setting of
sepsis in ___ and at one point was on metoprolol and apixaban
but he self-d/c'd these medications. Patient was noted to be
having AF with RVR during first MICU stay this admission. He was
started on amiodarone due to hypotension with metoprolol and
subsequently converted to sinus. Patient remained in sinus
rhythm for duration of admission after initial conversion back
from afib. Once out of iCU and back on medicine floor patient
was noted to have persistently prolonged QTc and risk of
continued amiodarone therapy was felt to outweigh the benefits
as patient had been stable in sinus rhythm for multiple days.
Amiodarone was discontinued ___ and patient remained in sinus
rhythm without further rate or rhythm control on discharge.
#DM Type 1:
Patient has a unique home insulin regimen he was titrating
himself prior to admission. ___ followed while patient
admitted and assisted with insulin management while on increased
steroid doses and during taper.
#Facial Swelling
#Likely Sialoadenitis
Patient developed new onset swelling to right side of face near
angle of mandible/ear as of ___ evening. Overlying skin was not
red or warmto touch, no lesions or drainage. Swelling was tender
to palpation. Ultrasound of the area obtained with findings
concerning for enlarged parotid gland but without signs or
symptoms of active bacterial infection. Swelling felt to
possibly be in the setting of a salivary duct stone.
Swelling/tenderness
improved over subsequent days without intervention.
# Encephalopathy
Patient with waxing/waning mental status throhugout admission.
Felt to be likely multifactorial in the setting of high dose
steroids, epidural hematoma, ICU delirium. Overall low concern
for infection throughout admission, no obvious metabolic
derangements to explain altered mental status. Slowly improved
over the course of admission.
# CMML,
# Likely CD5-negative CLL:
Baseline WBC ___. Patient found to have WBC ___ on admission
most likely in the setting of recent trauma. Low risk disease
per ___ CMML prognostic model, and followed by Hem Onc as
outpatient. His WBC was labile due to stress dose steroids but
was overall downtrending at discharge with tapered steroid
dosing.
#Acute hypoxic respiratory failure
Patient with new O2 requirement in ED. CXR showed low lung
volumes. Patchy left base opacity felt to be most likely due to
atelectasis but unable to exclude pneumonia, aspiration, and/or
pulmonary contusion in the setting
of trauma. O2 requirement improved over the course of admission
but intermittently required supplemental nasal cannula
overnight.
# Acute Blood Loss Anemia
In the setting of fall and subsequent trauma. Required massive
transfusion protocol due to thigh hematoma as above. After
transfusions for thigh bleed hemoglobin remained stable
throughout admission. Hgb at discharge 8.6
#Left shoulder pain
Left shoulder ecchymotic. Range of active motion was diminished.
Left shoulder XR looked ok with no evidence of fracture.
CHRONIC/STABLE PROBLEMS:
========================
#Chronic venous stasis
Wound was consulted for the ulcers and recommended daily
dressing changes and wound care.
# Grave's disease:
Continued home Levothyroxine
# Osteoarthritis
# Chronic Pain
Pain control with tylenol, oxycodone. Patient became
increasingly somnolent and encephalopathic with increased doses
of opioid medications. Did not tolerate tramadol well.
# HLD:
Continued home rosuvastatin
# Osteoporosis
Home alendronate held as patient deconditioned and unable to sit
upright for long enough period to prevent esophageal irritation.
Home Vitamin D, Calcium continued.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 1000 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Moderate
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Selenium Sulfide ___ mL TP WEEKLY AND AS DIRECTED
7. TraZODone 50 mg PO QHS:PRN sleep
8. Vitamin D ___ UNIT PO DAILY
9. Alendronate Sodium 70 mg PO QSAT
10. Furosemide 20 mg PO PRN edema
11. Hydrocortisone ___ mg PO QID:PRN titrated per patient
12. Opium Tincture (morphine 10 mg/mL) 10 mg PO DAILY:PRN
diarrhea
13. salicylic acid 6 % topical QOD
14. NPH 12 Units Breakfast
NPH 12 Units Bedtime
Regular 8 Units Breakfast
Regular 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl ___AILY:PRN Constipation - Second Line
3. Hydrocortisone Na Succ. 20 mg IV Q8H Duration: 1 Dose
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Multivitamins ___ Chewable 1 TAB PO DAILY
6. Senna 8.6 mg PO BID
7. NPH 12 Units Breakfast
NPH 12 Units Bedtime
Regular 8 Units Breakfast
Regular 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*24 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Rosuvastatin Calcium 10 mg PO QPM
11. Calcium Carbonate 1000 mg PO DAILY
12. Furosemide 20 mg PO PRN edema
13. Levothyroxine Sodium 150 mcg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. HELD- Alendronate Sodium 70 mg PO QSAT This medication was
held. Do not restart Alendronate Sodium until you are told to do
so by a physician
16. HELD- Hydrocortisone ___ mg PO QID:PRN titrated per patient
This medication was held. Do not restart Hydrocortisone until
you are told to do so by a physician
17. HELD- Opium Tincture (morphine 10 mg/mL) 10 mg PO DAILY:PRN
diarrhea This medication was held. Do not restart Opium
Tincture (morphine 10 mg/mL) until you are told to do so by a
physician
18. HELD- salicylic acid 6 % topical QOD This medication was
held. Do not restart salicylic acid until you are told to do so
by a physician
19. HELD- Selenium Sulfide ___ mL TP WEEKLY AND AS DIRECTED
This medication was held. Do not restart Selenium Sulfide until
you are told to do so by a physician
20. HELD- TraZODone 50 mg PO QHS:PRN sleep This medication was
held. Do not restart TraZODone until you are told to do so by a
physician
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Intraparanchymal Hemorrhage
Subarachnoid Hemorrhage
T8 Compression Fracture
T6-T9 Epidural Hematoma
Left Thigh Hematoma
Secondary Adrenal Insufficiency
Hemorrhagic Shock
Sialoadenitis
Paroxysmal Atrial Fibrilation
Type 1 Diabetes
Encephalopathy
SECONDARY DIAGNOSIS:
====================
CMML
Chronic Venous Stasis Ulcers
Grave's Disease/Hypothyroidism
Osteoarthritis
HLD
Osteoporosis
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Dr. ___,
___ was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you fell at home and
were badly injured.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital you were diagnosed with a brain bleed, a
fracture of your spine, a bleed around your spinal cord, and a
bleed into your left thigh. You were evaluated by our
neurosurgery team who felt that there was no role for a surgical
intervention at this time. They followed along while you were
admitted to ensure that your bleeds were not progressing and
causing further issues
- You were transferred to the ICU twice because of low blood
pressures. The first time this was because of bleeding into your
thigh. The second time this was felt to be due to your steroids
being tapered too quickly.
- Our Endocrine specialists followed you while you were admitted
to help us manage your steroid dosing and safely bring it down
to your pre-hospitalization levels.
- Our diabetes specialists evaluated you and helped us to manage
your insulin dosing
- You worked with our physical therapists and our occupational
therapists to help you recover while you were in the hospital
- You were evaluated by our hematology team to help us manage
your abnormal clotting values seen on our lab tests. They felt
that this was due to poor nutrition while you were very sick and
had us give you vitamin K to help correct this.
- Our speech and swallow specialists evaluated you to help us
find a safe diet while you were acutely ill
- When you were very sick your heart went into a rhythm called
atrial fibrillation and was beating very fast. This was
controlled with a medication called amiodarone which was stopped
prior to you being discharged from the hospital
- We gave you pain medications as needed to help keep the pain
from your injuries under control.
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:
___
|
10501162-DS-17 | 10,501,162 | 23,571,321 | DS | 17 | 2191-08-11 00:00:00 | 2191-08-11 10:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegretol / Ibuprofen / Bactrim / titanium
Attending: ___.
Chief Complaint:
Pneumothorax
Major Surgical or Invasive Procedure:
PEG tube placed on ___
History of Present Illness:
___ with history of adrenal insufficiency, DM, hypothyroidism,
subdural after a fall, left thigh hematoma requiring drainage
then c/b superinfection, and recent lengthy admission in the
MICU
for hypoxic respiratory failure ___ HAP requiring intubation
with
difficult extubation, course c/b recurrent aspiration/HAP PNA,
E.
coli UTI, acute renal failure requiring CRRT, who now presents
from ___ with pneumothorax sustained during dobhoff
replacement.
Upon arrival to ___ ED, he was satting 95% on ___. Evaluated by
thoracic surgery who assessed radiographs of PTX. After
conferring with patient's family based on his goals of care, it
was decided to manage conservatively with O2. He was kept on
___ mask overnight, and CXR obtained ___ AM showed interval
decrease in size of the PTX.
- In the ED, initial vitals were: T 97.9, HR 110, BP 97/58, RR
18, 95% ___
- Exam was notable for: Uncomfortable, oriented to self,
- Labs were notable for:
- UA with large leuks, small blood, 100 protein, 53 WBC and few
bacteria.
- WBC 38.5, Hgb 8.3 (recent baseline ___
- Studies were notable for:
- The patient was given: Vanc/Cefepime/Flagyl, Insulin,
Hydrocortisone, IV levothyroxine
Thoracic Surgery was consulted: Patient seen and examined. With
ED physicians, we compared CXR's from ___, ___ and here.
The size of the pneumothorax was comparable. CT scan did not
demonstrate a large pneumothorax. Given patients current
hemodynamic stability, family wishes and other patient
comorbidities, it is reasonable to consider conservative
management with oxygen therapy and serial CXR's. Please have
early AM CXR. Thoracic Surgery will follow.
On arrival to the floor, the patient was lying in bed
comfortably, responding to voice by opening his eyes and
tracking
but does not follow commands. His son states that this is
consistent with his waxing and waning mental status and that in
general his mental status has been better since stopping
olanzapine at ___, but it still varies during the day.
Past Medical History:
- DM1
- Adrenal insufficiency
- Chronic Myelomonocytic Leukemia
- Anemia
- Grave's diasease
- Venous insufficiency c/b cellulitis
- Hypertension
- Spinal stenosis
- IBS
- OA
- HLD
- Osteoporosis
- Hx afib
- Diverticulosis
- Constipation
- Hx laminectomy ___
- Status post compound foot fracture ___ and status post
multiple debridement surgeries and complicated by localized
infection
- ___ Admission s/p unwitnessed fall with TBI, SAH, epidural
thoracic hematoma also c/b left thigh hematoma s/p drainage
superinfected with citrobacter
- Recurrent thigh hematoma infection
- Nonocclusive RUE thrombus not on anticoagulation
- Chronic T8 compression fracture
Social History:
___
Family History:
A son has DM1
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=============================
VITALS: ___ 1721 Temp: 99.5 AdultAxillary BP: 118/74 L
Lying
HR: 102 RR: 18 O2 sat: 98% O2 delivery: 15L FSBG: 103
GENERAL: Frail older male in no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Tachycardic, regular. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Audible ronchi throughout, patient breathing through open
mouth. No crackles or wheezes.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Chronic venous
stasis changes to BLEs
NEUROLOGIC: Opens eyes to voice and tracks, does not follow
commands. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAMINATION:
=============================
Temp: 98.0 (Tm 98.7), BP: 105/61 (105-123/61-72), HR: 101
(93-103), RR: 20 (___), O2 sat: 98% (98-100), O2 delivery: 40%
FT
GENERAL: Frail older male in no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. Right eye
ptosis
CARDIAC: Tachycardic, regular. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Audible ronchi throughout upper anterior lung fields. No
crackles or wheezes.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Chronic venous
stasis changes to BLEs
NEUROLOGIC: Opens eyes to voice and tracks. Right upper
extremity is flexed and adducted but able to move it.
Pertinent Results:
ADMISSION LABS:
==============
___ 09:10PM BLOOD WBC-38.4* RBC-3.19* Hgb-9.1* Hct-29.6*
MCV-93 MCH-28.5 MCHC-30.7* RDW-17.7* RDWSD-60.2* Plt ___
___ 09:17PM BLOOD ___ PTT-26.4 ___
___ 09:10PM BLOOD Glucose-293* UreaN-23* Creat-0.7 Na-131*
K-4.4 Cl-89* HCO3-28 AnGap-14
___ 03:44PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.9
DISCHARGE LABS:
===============
___ 06:30AM BLOOD WBC-37.6* RBC-3.02* Hgb-8.6* Hct-29.5*
MCV-98 MCH-28.5 MCHC-29.2* RDW-16.9* RDWSD-60.3* Plt ___
___ 06:30AM BLOOD Glucose-211* UreaN-16 Creat-0.4* Na-149*
K-3.5 Cl-107 HCO3-31 AnGap-11
___ 06:30AM BLOOD Calcium-8.4 Phos-1.7* Mg-1.7
MICROBIOLOGY:
=============
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Pending - ___: No growth to date.
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
========
CXR - ___
Moderate right-sided apical pneumothorax, new since ___.
No findings to suggest tension.
CT CHEST WITHOUT CONTRAST - ___
1. Small-moderate volume right-sided pneumothorax without
substantial midline shift or evidence of tension.
2. Interval decrease in left pleural effusion. Mild bibasilar
atelectasis. No pulmonary nodules or masses. The airways are
patent.
3. Chronic compression deformities of vertebral bodies T3, T6,
T8 and L1 are stable. Stable appearance of multiple chronic rib
fracture deformities without evidence of acute fracture.
4. Interval increase in prominence of a area of mesenteric
stranding with multiple prominent lymph nodes, measuring up to
1.8 cm previously 1.2 cm. Findings could represent mesenteric
adenitis, versus worsened Lymphadenopathy.
CXR - ___
Interval decrease in size of a small right pneumothorax without
evidence of tension.
CXR - ___
In comparison with study of ___, the chin of the patient
obscures the area where the small apical pneumothorax was noted
on the right. However, there is certainly no evidence any
increase in pneumothorax. Otherwise, little change with
continued increased opacification at the left base most likely
representing atelectasis..
CXR - ___
No pneumothorax. The increase in pronounced elevation right
hemidiaphragm reflects generally low volume in the right lung
with discrete atelectasis limited to the lower lobe. Aside from
mild subsegmental atelectasis, left lung is clear. No
pneumothorax or pleural effusion. Heart mildly enlarged. No
good evidence for cardiac decompensation.
CXR - ___
1. New left mid to lower lung opacification which probably
includes a pleural effusion and may reflect atelectasis versus
pneumonia.
2. No pneumothorax identified.
3. PICC line terminating in the right atrium.
CXR - ___
Tiny right apical pneumothorax. Although not visible on the
recent prior
radiograph, this is thought likely due to poor visualization of
the right
apical region on the recent prior film; new pneumothorax is very
doubtful. Improvement in left basilar opacification, probably
reflecting decrease in a small left-sided pleural effusion.
Brief Hospital Course:
Dr. ___ is a ___ year-old man with history of adrenal
insufficiency, DM, hypothyroidism, right-sided subdural hematoma
after a fall and recent lengthy admission in the MICU for
hypoxic respiratory failure ___ HAP requiring intubation with
difficult extubation, course c/b recurrent aspiration/HAP PNA,
E. coli UTI, acute renal failure requiring CRRT, who now
presents from ___ with pneumothorax sustained during
dobhoff replacement. Pneumothorax has resolved with oxygen
therapy. Patient now s/p PEG tube.
ACUTE ISSUES
============
# Pneumothorax (Improved):
Secondary to Dobhoff placement. Patient has been asymptomatic
and hemodynamically stable. After being evaluated by thoracic
surgery, patient was managed conservatively with oxygen therapy
given lack of symptoms along family/patient preferences. On CXR
from ___, showed very small apical pneumothorax that is
likely residual from the original one. We would recommend CXR in
one week.
# Oropharyngeal dysphagia:
# Enteral feeding:
# Severe protein calorie malnutrition:
Engagement with speech and swallow has been limited due to
mental status. Patient had G-tube placed by ___ on ___ and
tube feeds were started on ___.
# Hypernatremia: likely in the setting of water deficit.
Increased water flushes through the G-tube.
# Bacteruria:
UA showed bacteriuria with pyuria. Patient cannot communicate
his symptoms. No fevers or signs of sepsis. Patient was NOT
treated with antibiotics as he did not have fevers and WBCs were
stable.
# Type 1 Diabetes Mellitus:
Blood sugars are tenuous. Patient with hx hyperglycemia and
night hypoglycemia. ___ were consulted. Please check
medication list for updated insulin recommendations.
# Leukocytosis
# CMML
# Likely CD5-negative CLL
WBC on admission 38K up from baseline WBC ___, improved to
24K with IV fluids in the ED. Leukocytosis is likely due to
CMML. Heme/onc consult during prior hospital admission, there is
low likelihood of AML transformation. Patient received
hydroxyurea during his last hospitalization with good response.
WBC remained stable during this hospital stay. WBC trended up
prior to discharge with WBC of 37K.
# Goals of care:
Geriatric team and palliative team discussed goals of care with
wife ___ regarding G-tube and overall picture. ___
stated that
since G-tube is a relatively small procedure she felt inclined
to move forward with it. She felt that it is unlike intubation,
where he would be unlikely to recover if he were to need this
intervention. ___ believes that Dr. ___ accept a
quality of life where he had his mental functions and could do
some activities that he enjoyed. We shared that we unfortunately
did not anticipate that he would regain this level of function.
___ also shared that over the past few months, Dr. ___
___ better than they had expected on multiple occasions. For
example, when he was extubated in the ICU he was not anticipated
to do well, but he was accepted to acute rehab and did make some
progress. She stated that she is simply not ready to give up on
the hope that he could recover more function.
# Encephalopathy:
# Left-sided arm flexed/adducted:
Patient's mental status improved during his hospital stay.
Initially, he was non-verbal and opened eyes to sound. Prior to
discharge, patient was able to engage in conversation (though
confused at times). This however waxes and wanes. His right arm
is flexed and adducted. He has right ptosis. Patient has had
extensive work-up for his neurological status including NCHCT
and EEG during a prior hospital stay, which were negative. His
wife mentions that he became more interactive when olanzapine
was held in rehab. Toxic metabolic causes are unlikely as
lectrolytes are wnl and no signs of infection including fever.
CHRONIC ISSUES:
===============
# Traumatic brain injury (TBI):
# Chronic Compression T8 Fracture:
# Epidural T6-T9 hematoma s/p fall ___
# T8 compression fracture with cord impingement:
Patient with history of fall on ___, he was found to have
intraparenchymal hemorrhage in the right paramedian frontal
lobe, parafalcine subdural subdural hematoma, and subarachnoid
hemorrhage in the paramedian sulci. There was no indication for
surgery at that time. CT head without contrast on ___ no acute
changes, showed chronic subdural.
# History of paroxysmal Atrial Fibrillation:
Alternating a-fib and sinus rhythm. Rates in the ___.
Patient is NOT on anticoagulation given intracranial hematomas
and history of thigh abscess. Home metoprolol tartrate 25mg Q6H
were held while there was no enteral access and was NOT resumed
as his HR continued to be in the ___ 100s.
# Hyperlipidemia: Discontinued statin as it will not change
prognosis.
# History of anasarca/volume overload: Euvolemic on examination.
Holding home furosemide 40mg PO. ___ restart if looking volume
overloaded or has new oxygen requirement.
# History of hypoxic respiratory failure:
During last admission (___), patient had recurrent
aspiration pneumonia with hypoxic respiratory failure requiring
intubation. Patient was discharged on humidified face mask
without supplemental oxygen via nasal cannula. Per report, he
was able to be weaned off face mask as well in rahab. Patient
could maintain sats on ___ during this hospital stay.
# Chronic Anemia:
Baseline hemoglobin 8.0-9.0. Hemoglobin remained stable during
this admission. No obvious site of bleeding. Hemoglobin on
discharge 8.2.
# Thrombocytopenia:
Baseline 170K. Platelet counts 115-130K throughout this hospital
stay. Hemolysis labs were negative and patient was
hemodynamically stable.
# Hx non-occlusive thrombus RUE: Deferred anticoagulation as
above.
# Adrenal Insufficiency
History polyglandular endocrinopathy with adrenal insufficiency.
Patient received hydrocortisone IV 50mg daily while awaiting for
enteral access. Patient was switched to home dose of
hydrocortisone of a total of 45mg PO. No stress dose was needed.
# Hypotension:
It seems to be related vasoplegia independent of adrenal
insufficiency. Patient was started on midodrine during his last
hospital admission as he could not be weaned off levophed. BP is
in acceptable range (100s-120s/60s-70s) without the need for
midodrine. Patient was discharged off midodrine, it can be
re-initiated if there is a need for it.
# History of Graves Disease, now hypothyroid:
Initially, IV levothyroxine, then switched to home PO dose, once
enteral access.
# Osteoporosis/Vertebral Fractures:
- Discontinued vitamin D and Calcium
## Skin:
# Sacral/coccyx unstageable pressure injuries:
# Left lateral foot unstageable:
Sacral/coccyx ulcer, sized around 5 by 5 cm with black ___
eschar tissue with irregular borders and erythemic skin.
Continued wound care.
# Thigh hematoma (resolved):
In the setting of a fall since ___, had massive left thigh
hematoma that required massive blood transfusions (complicated
by adrenal insufficiency/see endocrine system) requiring I&D and
complicated by superimposed infection with Citrobacter,
sensitive to cefepime. During this hospitalization, left thigh
wound is healing appropriately without evidence of infection.
CORE MEASURES:
==============
CODE STATUS: FULL CODE
HEALTH CARE PROXY:
Name of health care ___
Relationship:wife
Phone ___
Cell ___
TRANSITIONAL ISSUES:
==================
DISCHARGE H/H: 8.___.5
DISCHARGE Na: 149
DISCHARGE K: 3.5
DISCHARGE Cr: 0.4
NEW MEDICATIONS:
- Erythromycin ointment for his right eye conjunctivitis.
- SC heparin 5000 UNITS SC BID for DVT prophylaxis.
DISCONTINUED MEDICATIONS:
- Alendronate
- Furosemide 40mg daily: patient is euvolemic and on ___
resume if this changes.
- Metoprolol tartrate 25mg Q6H: HR in the ___ off
medication. ___ resume if HR >120.
- Midodrine 7.5mg TID: BP in the 100s-120s/60s-70s. ___ restart
if SBP < 90.
=
=
=
=
=
=
=
=
=
=
================================================================
#$%PLEASE CHECK CBC AND ELECTROLYTES ON ___ AND WEEKLY THERE
AFTER%$#
=
=
=
=
=
=
=
=
=
=
================================================================
# Pneumothorax:
[] Repeat CXR within a week of discharge to ensure resolving of
his pneumothorax.
# Type one diabetes:
[] Please continue frequent checks (5x/day) of sugars as they
were elevated during hospital stay. Glargine was increased
during hospitalization.
# History of fluid overload:
[] Holding furosemide 40mg as patient was euvolemic and
maintaining sats on ___.
[] ___ restart if evidence of volume overload (weight increases
by more than 3 lbs in one day of 5 lbs in one week) or new
oxygen requirement.
# Leukocytosis/CMML:
[] Repeat CBC on ___ and weekly there after.
# History of hypotension:
[] Holding midodrine as his pressures were maintained without
it.
[] ___ restart midodrine if patient became orthostatic or his BP
goes down.
# Atrial fibrillation:
[] Metoprolol was held as HR was in the ___.
[] Can resume metoprolol if HR>120 or having atrial fibrillation
with RVR.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Calcium Carbonate 1000 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Miconazole Powder 2% 1 Appl TP TID:PRN rash/itching
6. OxyCODONE (Immediate Release) 2.5 mg PO Q12H
7. OxyCODONE (Immediate Release) 2.5 mg PO Q12H:PRN Pain -
Moderate
8. Ramelteon 8 mg PO QHS insomnia
9. Rosuvastatin Calcium 10 mg PO QPM
10. Vitamin D ___ UNIT PO DAILY
11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
12. Alteplase 1mg/2mL ( Clearance ie. PICC, midline, tunneled
access line, PA ) 1 mg IV ONCE PER LUMEN (3 LUMEN)
13. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
14. Collagenase Ointment 1 Appl TP DAILY
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
16. Metoprolol Tartrate 25 mg PO Q6H
17. Midodrine 7.5 mg PO TID
18. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
19. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H To improve
secretions
20. Alendronate Sodium 70 mg PO QSAT
21. Nystatin Oral Suspension 5 mL PO QID
22. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
23. Senna 17.2 mg PO BID
24. TraZODone 25 mg PO QHS:PRN insomnia
25. Bisacodyl ___AILY:PRN Constipation - Second Line
26. Hydrocortisone 10 mg PO BID
27. Hydrocortisone 20 mg PO QAM
28. Hydrocortisone 5 mg PO QPM
29. Glargine 9 Units Breakfast
Glargine 8 Units Bedtime<br> Regular 6 Units Q4H
Insulin SC Sliding Scale using REG Insulin
30. OLANZapine 1.25 mg PO QHS:PRN agitation
Discharge Medications:
1. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID
2. Heparin 5000 UNIT SC BID
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
5. Alteplase 1mg/2mL ( Clearance ie. PICC, midline, tunneled
access line, PA ) 1 mg IV ONCE PER LUMEN (3 LUMEN)
6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
7. Bisacodyl ___AILY:PRN Constipation - Second Line
8. Collagenase Ointment 1 Appl TP DAILY
9. Hydrocortisone 10 mg PO BID
10. Hydrocortisone 20 mg PO QAM
11. Hydrocortisone 5 mg PO QPM
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
13. Levothyroxine Sodium 150 mcg PO DAILY
14. Miconazole Powder 2% 1 Appl TP TID:PRN rash/itching
15. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
16. Nystatin Oral Suspension 5 mL PO QID
17. OxyCODONE (Immediate Release) 2.5 mg PO Q12H:PRN Pain -
Moderate
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
19. Ramelteon 8 mg PO QHS insomnia
Should be given 30 minutes before bedtime
20. Senna 17.2 mg PO BID
21. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H To improve
secretions
22. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
# Pneumothorax
# Dysphagia
# Ecephalopathy
SECONDARY DIAGNOSES:
====================
# Traumatic brain injury (TBI)
# Type 1 diabetes
# History of paroxysmal atrial fibrillation
# Hyperlipidemia
# Bacteruria
# CMML
# Chronic anemia
# Thrombocytopenia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure caring for you at the ___.
- WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were transferred from rehab as you had pneumothorax (air
around your lungs) while a feeding tube (called dobhoff) was
being inserted.
- WHAT HAPPENED WHILE YOU WERE ADMITTED?
- Your pneumothorax was resolved with high levels of breathed
oxygen.
- While awaiting for the gastric tube placement, you receive IV
fluids.
- After talking you wife ___, a gastric tube was placed on
___.
- WHAT SHOULD YOU AFTER LEAVING THE HOSPITAL?
- Please continue to work with physical therapy at rehab to get
stronger.
- Please follow-up with your doctors as ___.
- Please take your medications as prescribed.
We wish you all the best!
Your ___ team
Followup Instructions:
___
|
10501214-DS-6 | 10,501,214 | 29,443,739 | DS | 6 | 2126-10-26 00:00:00 | 2126-10-27 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with chronic abdominal pain and
diarrhea who presents with acute worsening of her abdominal pain
and reported expression of suicidal ideation. Patient had been
experiencing almost daily cramping/stabbing abdominal pain since
___. She states that when the pain started it was worse in AM
after a bowel movement and worse after eating but over time
became more persistent in nature though was still worse
post-prandially and after a bowel movement. She has also had
frequent diarrhea that only recently decreased in frequency
after starting Amitriptyline. She has not had any nausea,
vomiting, bloody stools, fevers but has had occasional chills.
Nothing makes the pain better other than narcotic pain
medications and anxiolytics. She has lost more than 20 lbs due
to avoidance of food. Per a recent GI note, she has undergone
multiple extensive workups including multiple endoscopies,
colonoscopies, MR enterography, colonic biopsies and several
imaging studies of her abdomen, which have all been negative to
indicate any anatomic pathology to explain these symptoms. On
the day of admission, a call in was placed by her PCP's coverage
as the patient had acute worsening of her pain and had
reportedly expressed SI during the highest acuity of her pain.
Per GI note from ___:
She had previously had a colonoscopy in ___, which suggested
microscopic colitis and also esophagitis at endoscopy at that
time.
Recent endoscopy and colonoscopy with biopsies throughout were
normal.
In the ED, initial VS were 99.7, 79, 116/74, 18, 100% RA.
Patient denied any SI. CBC, chemistries and LFTs were within
normal limits and did not point to any particular etiology. UA
was negative. She received Morphine 5 mg IV once without relief.
No imaging studies were obtained. Vital signs on transfer were
98.8, 68, 18, 143/80, 100% RA.
.
ROS: per HPI.
Past Medical History:
- Migraine headaches
- Anxiety disorder
- Burning feet syndrome/plantar fascitis
- Burning mouth syndrome
- Osteoporosis
Social History:
___
Family History:
No family history of IBS, colon cancer or GI issues.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.0, 160/92, 78, 16, 100% on RA
GENERAL - uncomfortable, sitting at edge of bed, holding stomach
HEENT - MMM, no JVD
CV - RRR, normal S1 and S2, no m/r/g
RESP - unlabored, CTAB
ABD - BS+, thin, S/NT/ND, mild TT deep palpation
EXT - WWP, no edema
NEURO - CN grossly intact, sensation intact to light touch,
normal gait
.
DISCHARGE PHYSICAL EXAM:
VS - 99.7, 122/70, 70, 18, 96% on RA
GENERAL - comfortable, walking around in room and applying
makeup
HEENT - MMM, no JVD
CV - RRR, normal S1 and S2, no m/r/g
RESP - unlabored, CTAB
ABD - BS+, thin, S/NT/ND, mild TT deep palpation
EXT - WWP, no edema
NEURO - CN grossly intact, sensation intact to light touch,
normal gait
Pertinent Results:
ADMISSION LABS:
___ 08:20PM BLOOD WBC-5.1 RBC-4.13* Hgb-13.2 Hct-38.9
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.1 Plt ___
___ 08:20PM BLOOD Neuts-45.3* Lymphs-45.4* Monos-5.7
Eos-0.6 Baso-3.0*
___ 08:09AM BLOOD ___ PTT-33.4 ___
___ 08:20PM BLOOD Glucose-85 UreaN-10 Creat-0.9 Na-142
K-3.8 Cl-106 HCO3-30 AnGap-10
___ 08:20PM BLOOD ALT-25 AST-28 AlkPhos-93 TotBili-0.2
___ 08:20PM BLOOD Lipase-34
___ 08:20PM BLOOD Albumin-4.4 Calcium-8.7 Phos-4.1 Mg-2.2
___ 08:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
___ 08:26PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 08:26PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
.
DISCHARGE LABS:
___ 08:09AM BLOOD WBC-4.2 RBC-3.93* Hgb-12.5 Hct-36.9
MCV-94 MCH-31.8 MCHC-33.9 RDW-12.9 Plt ___
___ 08:09AM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-142
K-3.6 Cl-108 HCO3-28 AnGap-10
___ 08:09AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1
.
IMAGING:
___ MRCP:
FINDINGS:
The liver is not nodular in contour and does not demonstrate any
loss of
signal on out-of-phase compared to in-phase T1-weighted images
to suggest the presence of hepatic steatosis. No concerning
focal liver lesions are seen.
The hepatic arterial anatomy is conventional. The portal vein
and hepatic
veins are patent. No biliary duct dilatation. The gallbladder
is
unremarkable in appearance, the common bile duct measures 4 mm.
The spleen is not enlarged, measuring 9 cm. There is a tiny
cyst in the upper pole of the right kidney (3:15). No solid
renal mass is seen. The renal arteries are solitary
bilaterally. Both adrenal glands are unremarkable in appearance.
The pancreas is normal in signal intensity and morphology.
Normal
enhancement. No MR imaging features to suggest chronic
pancreatitis. No mass lesions seen. No upper abdominal
lymphadenopathy. Visualized osseous
structures are unremarkable.
Although this study is not tailored for the evaluation of the
mesenteric
vasculature, limited images demonstrate patency of the celiac
and superior
mesenteric arteries with no specific evidence to suggest SMA
syndrome
(1650:1,2).
IMPRESSION: Normal MRCP, no MR evidence for pancreatic
insufficiency.
Brief Hospital Course:
___ y/o female with acute on chronic abdominal pain most likely
due to a functional disorder as no anatomic or organic
etiologies have yet been identified despite extensive evaluation
to date.
.
#. Acute on Chronic Abdominal Pain: As above, her abdominal pain
is likely due to a functional disorder as evaluation has not
pointed to any anatomic/organic pathology. Labs this admission
were unremarkable; previous imaging and endoscopic studies have
also been unremarkable.
.
As to her pain management, the pt had received morphine in the
ED and IV dilaudid after initial admission overnight, and the
morning after admission expressed her expectation that she was
going to be "made comfortable". We continued her home Donnatol,
and offered APAP or ibuprofen for pain relief. Multiple times,
the pt c/o 100/10 or ___ excruciating pain, and requested pain
medications while noting that the IV dilaudid had helped her
pain resolve. After rounding and formulating the plan, the
medical team's assessment was that there was no current
indication for narcotic analgesia, and that further w/u of her
abdominal pain could be pursued with the MRA, MRCP, and her
upcoming breath test. The primary team spoke with her GI
specialists, who agreed with this plan and recommended
proceeding with the already-scheduled MRCP (results
preliminarily normal at time of discharge). There was no as-yet
identified organic cause of her abdominal pain, and there was a
marked discrepancy between her subjective pain and her observed
activity. Therefore, the team did not believe that
administration of opioid narcotics would be in the patient's
long-term best interest. The pt's physical exam was
unremarkable, and she was noted to be walking around the medical
floor in no apparent discomfort or difficulty while talking to
nursing staff, without tachypnea, diaphoresis, or vital sign
abnormalities. The pt was tolerating PO pills and was tolerating
PO liquids and solids. These findings did not correlate with her
c/o ___ excruciating pain, and there was no medical indication
for narcotic administration. Without an identified underlying
source for the pain, opioids carry the risk of dependence,
narcotic bowel syndrome, altered mental status, constipation,
delay of diagnosis, and other side effects.
.
This reasoning and the side effects of narcotics were explained
multiple times to the patient, who continued to request relief
of her pain with narcotics, stating that nothing else would
work. The patient exhibited splitting behavior by identifying
various providers who had provided IV narcotics as good doctors,
and members of the primary team as inhumane and lacking
understanding of her pain. The primary team spoke with the pain
mgmt service, by whom the pt had been previously seen in clinic.
Due to anticholinergic SE's reported by the pt from
amitriptyline, they agreed with starting celexa in place of
amitriptyline. The pt had reported resolution of a prior period
of abdominal pain in ___ after she had taken celexa, and she
desired to try taking celexa in lieu of amitriptyline.
Per report, the patient had voiced suicidal ideation prior to
admission. However, upon arrival to the medical floor she denied
any SI, and denied any recent life stressors or fear for her
personal safety. She further denied current or past abuse.
By the morning of discharge home, the pt reported that her
abdominal pain had improved since the night before. She was
discharged home on prn Tylneol and Ibuprofen, with instructions
on how to take them safely.
.
#. Migraine Headaches:
- Continued PRN Fiorcet
.
TRANSITIONS OF CARE:
-MRCP results were pending at time of d/c. Appt was made for pt
to f/u with pain psychology, per previous pain ___ clinic
recommendations.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amitriptyline 25 mg PO HS
2. FioriCET 1 TAB PO DAILY: PRN headache
3. Donnatol 1 tablet PO TID - QID: PRN pain
Discharge Medications:
1. FioriCET 1 TAB PO DAILY: PRN headache
2. Donnatol 1 tablet PO TID - QID: PRN pain
RX *Donnatal 16.2 mg-0.1037 mg-0.0194 mg-0.0065 mg four times a
day Disp #*60 Tablet Refills:*0
3. Citalopram 20 mg PO DAILY
RX *Celexa 20 mg once a day Disp #*30 Tablet Refills:*2
4. Acetaminophen 650 mg PO Q6H:PRN pain
Do not exceed 3grams per day
5. Ibuprofen 400 mg PO Q8H:PRN pain Duration: 1 Weeks
Take with food. Do not exceed 3200mg/day.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you were
having abdominal pain. You received an MRA/MRCP scan, and the
results will take a few days to come back. Your condition has
improved and you can be discharged to home.
The following changes were made to your medications:
NEW:
-Celexa
-Tylenol and ibuprofen as needed for pain (take according to
instructions)
STOPPED:
-Amitriptyline
Please keep your follow-up appointments as scheduled below. You
are on the waiting list for an earlier appointment with Dr.
___.
Followup Instructions:
___
|
10501258-DS-16 | 10,501,258 | 24,182,688 | DS | 16 | 2149-06-29 00:00:00 | 2149-06-30 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
___: Right burr holes for ___ evacuation
attach
Pertinent Results:
ADMISSION LABS:
=================
___ 10:49PM GLUCOSE-125* UREA N-14 CREAT-0.9 SODIUM-144
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
___ 10:49PM CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-2.4
___ 10:49PM ___ PTT-31.0 ___
___ 09:50PM GLUCOSE-147* UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
___ 09:50PM estGFR-Using this
___ 09:50PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-2.4
___ 09:50PM URINE HOURS-RANDOM
___ 09:50PM URINE UHOLD-HOLD
___ 09:50PM URINE COLOR-Colorless APPEAR-CLEAR SP
___
___ 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-7.5
LEUK-NEG
DISCHARGE LABS:
=================
___ 07:15AM BLOOD WBC-4.4 RBC-3.48* Hgb-11.6* Hct-35.3*
MCV-101* MCH-33.3* MCHC-32.9 RDW-13.8 RDWSD-51.0* Plt ___
___ 07:15AM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-143
K-4.3 Cl-109* HCO3-22 AnGap-12
___ 07:15AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
MICROBIOLOGY:
==============
___ 5:13 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
_
_
_
_
________________________________________________________________
___ 9:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMGINAG:
=========
- ___ CT head w/o contrast
Status post placement of subdural drain. Subdural hematoma is
decreased in size with 18 mm predominantly hypodense subdural
and subdural air are
identified. No acute hemorrhage.
- ___ CT head w/o contrast
1. Interval removal of right-sided subdural drain.
Predominantly hypodense subdural hematoma measures 1.8 cm,
unchanged from prior exam.
2. New 7 mm left subdural hematoma.
3. No acute hemorrhage.
- ___ Video oropharyngeal swallow
Deep penetration with thin liquids. Likely trace aspiration.
One episode of penetration with nectar thick liquids during
consecutive sips only.
- ___ CT head w/o contrast
1. Stable chronic right subdural hematoma.
2. No evidence of interval acute large territorial infarction or
new
intracranial hemorrhage.
3. Stable 3 mm rightward midline shift. The ventricles are
unchanged in
configuration without hydrocephalus.
- ___ CT head w/o contrast
1. Unchanged size of a predominantly chronic right subdural
hematoma. A
hyperdense focus posteriorly within the subdural collection
likely reflects acute blood products.
2. No evidence of interval acute large territorial infarction or
intraparenchymal hemorrhage.
3. Stable 3 mm rightward midline shift. The ventricles are
unchanged in
configuration without hydrocephalus.
- ___ CXR
Minimal bibasilar atelectasis.
Brief Hospital Course:
Mr. ___ is a ___ with history of ___ dementia and
CAD s/p CABG who initially presented as a transfer from
___ on ___ with altered mental status secondary to an
acute on chronic right subdural hematoma, s/p burr hole
evacuation ___ with neurosurgery, ultimately transferred to
the medicine service for management of hypertension, course c/b
toxic metabolic encephalopathy/delirium.
ACTIVE ISSUES:
==============
# Right acute on chronic subdural hematoma with midline shift
# Left subdural hematoma
No reported history of trauma preceding acute altered mental
status that prompted presentation to ___. Found to have
right SDH for which transfer to ___ for neurosurgical
evaluation was initiated. Underwent burr hole evacuation of R
SDH on ___, with repeat imaging ___ showing stable R SDH and
new small L SHD, felt to be an expected post-surgical change per
neurosurgery. Home aspirin discontinued (to be held until
outpatient follow-up with neurosurgery). Monitored with q4hr
neuro checks and received 7d course of Keppra (___) for
seizure ppx. Maintained SBP < 160 (see below).
# Hypertension
Persistently hypertensive in the setting of subdural hematoma,
as above. Required aggressive up-titration of antihypertensive
regimen, ultimately stabilized on lisinopril 40mg daily and
amlodipine 10mg daily. Was receiving labetalol during this
admission, but discontinued due to development of asymptomatic
bradycardia with low doses.
# Orthostatic Hypotension
Long-standing history of orthostatic hypotension in the setting
of autonomic dysfunction secondary to ___ disease, for
which he follows with his outpatient neurologist. Has been
maintained on fludricortisone and pyridostigmine in the
outpatient setting. Home fludricortisone discontinued during
admission in order to meet SBP goal, as above. Continued home
pyridostigmine 60mg BID.
# Toxic metabolic encephalopathy
Developed waxing/waning mentation with episodes of
hyperactivity, complicated by fall out of bed (see below).
Etiology felt to be multifactorial in the setting of
hospital-induced delirium, constipation, insomnia, subdural
hematoma, and underlying ___ dementia. No evidence of
active infection was identified on work-up, and no evidence of
metabolic abnormalities. Required Seroquel 25mg qhs to ensure
safety overnight. Also managed with delirium precautions,
standing bowel regimen, and ramelteon for sleep. Continued home
carbidopa-levodopa ER 25mg/100mg TID.
# Mechanical fall
Suffered from unwitnessed fall out of bed on ___ overnight.
Felt to be mechanical in nature, secondary to delirium and
trying to get out of bed without assistance. Reassuringly, CT
head stable and no evidence of other trauma on exam. Treated
with delirium precautions and medications for sleep, as above.
# Aspiration
Evaluated by SLP early in admission, who recommended modified
diet. Underwent video swallow which showed improvement, and diet
subsequently upgraded to ground solids with nectar-thickened
liquids.
# Pre-diabetes
Noted to be hyperglycemic during admission, and found to have
HbA1c 6.2% consistent with pre-diabetes. Maintained on Humalog
insulin sliding scale while inpatient.
CHRONIC ISSUES
===============
#?CAD s/p CABG
Unclear history but reportedly with CABG approximately ___ years
ago. No former documentation at ___. Unclear why patient is on
325 of aspirin, but this medication was held in the setting of
subdural hematoma, as above. Continued home atorvastatin 40mg
daily.
# Macrocytic anemia
Unclear baseline, but Hgb remained stable between ___ mg/dL
throughout admission. Repeat B12 level above normal limits so
home B12 supplementation discontinued ___.
# Urinary Incontinence: Home ___ NF so held during
admission and re-started on discharge.
TRANSITIONAL ISSUES:
=======================
[] Will need repeat video swallow in 2 weeks
[] Started on seroquel 25mg qhs inpatient due to delirium/fall
risk at night. Please re-evaluate delirium/agitation on a daily
basis, and discontinue this medication as soon as safely able
to.
[] Will need weekly QTc monitoring while on seroquel
[] Check BP q8hrs and maintain SBP < 160. If persistently above
SBP 160, would resume labetalol at 50mg BID. Please down-titrate
antihypertensive regimen as able if significantly below goal.
[] Holding home fludricortisone in setting of strict SBP goal of
< 160. Continue to hold until follow-up with neurosurgery and
discuss with outpatient neurologist/neurosurgeon regarding
timing of reinitiation (will depend on when SBP goal can be
liberalized).
[] Please follow precautions for orthostatic hypotension at all
times (sit up in bed slowly, sit at the side of the bed for
several minutes prior to rising, ambulate with walker and
assistance at all times, if patient reporting dizziness have him
sit down immediately)
[] Unclear why patient is on full-dose aspirin at home; hold
until follow-up with neurosurgery and re-evaluate indication for
full-dose.
[] Diagnosed with pre-diabetes this admission; monitor blood
glucose QACHS and consider initiation of metformin
[] Consider referral to palliative care per request of patient's
son/HCP once acute delirium has resolved and patient more able
to participate in discussion about goals of care
#CONTACT: ___ ___
#CODE: DNR/DNI (confirmed, MOLST completed prior to discharge)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO TID
2. Pyridostigmine Bromide SR 60 mg PO BID
3. Fludrocortisone Acetate 0.05 mg PO NOON
4. Fludrocortisone Acetate 0.1 mg PO QAM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
8. Aspirin 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ramelteon 8 mg PO QPM:PRN bedtime
11. Atorvastatin 40 mg PO QPM
12. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. Senna 17.2 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Carbidopa-Levodopa (___) 1 TAB PO TID
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. Multivitamins 1 TAB PO DAILY
10. Pyridostigmine Bromide SR 60 mg PO BID
11. Ramelteon 8 mg PO QPM:PRN bedtime
12. Vitamin D ___ UNIT PO DAILY
13. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until talking to your neurosurgeon
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
======================
Right acute on chronic subdural hematoma
Hypertension
Toxic metabolic encephalopathy
Delirium
Dysphagia
SECONDARY DIAGNOSIS:
=====================
___ dementia
Orthostatic hypotension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted to the hospital because you were confused, and
imaging showed that you had bleeding in the brain.
You were seen by the neurosurgeons who performed a procedure
called a craniotomy to remove the blood from your brain. After
this procedure, you had sutures and staples placed in your head
and were monitored very closely. Your blood pressure was very
high, so you received medications to help lower your blood
pressure.
Being in the hospital caused you to become a little confused. We
gave you medications to help you sleep at night and keep you
calm, which should help you feel less confused.
When you leave the hospital, please continue taking all your
medications as prescribed and follow-up with your doctors
___ information below). Please avoid heavy lifting,
running, climbing, or other strenuous activities until you
follow up with the neurosurgeons. Do not take your home aspirin
until the neurosurgeons tell you it is okay to take it again.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
It was a privilege caring for you, and we wish you well!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10501308-DS-18 | 10,501,308 | 20,658,471 | DS | 18 | 2122-05-01 00:00:00 | 2122-05-07 09:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation done at outside hospital on ___
extubated on ___
History of Present Illness:
Mrs. ___ is a ___ F who presents with repeat seizure
episodes in the setting of recent tooth infection/abscesses on a
background of a remote history of epilepsy.
Patient has no documented record at our hospital and arrives
intubated. history is obtained primarily from her daughter.
She was in her usual state of health until yesterday when her
daughter noted that she appeared more tired than usual. her
mother did not appear particularly weak simply drained from the
workday (she works in a ___) and her responsibilities at
home (she takes care of her husband who apparently requires
constant care). She is under almost constant stress and gets
home very
late and gets perhaps only 4 hours of sleep per night.
She got up at her usual time and went to work at 4am. At some
point while at work she suffered a generalized seizure (no
description available at this time) and EMS called. She was
taken to ___. Her daughters were alerted and actually
arrived prior to the patient who, on arrival, continued to have
seizure
activity. This was described by the daughters as stiffened arms
with rapid shaking with head shaking back and forth. Eyes were
describes as open during one event and closed during the other.
On arrival she was able to interact but appeared confused and
"was not making sense". She had perhaps 4 discrete episodes and
received 4mg ativan total and then 1g Keppra. She was intubated
for sedation and airway protection and placed on propofol and
sent to ___. Intubation was somewhat traumatic and blood was
noted to come from her nares.
In general, she is described as being very compliant with her
medications and never misses her doses of antiepileptic
(lamictal 100mg BID) however her daughter was unsure of exact
doses of other medications. She apparently is well controlled on
this dose and does not take other antiepileptics.
She has no other history of neurological problems such as
migraine or stroke. She does not have a history of cancer. She
does have a remote history of head trauma secondary to domestic
abuse that was supposedly the cause of her initial seizure
episode.
Of note, over the past few weeks, she has been complaining of
tooth pain and 2 teeth pulled (with a remaining tooth fragment
that required additional extraction). She complained of ongoing
pain until the day prio to admission although there was no clear
facial swelling or tenderness, fevers chills or other overt
signs of infection.
Her daughters describe a large degree of stress and exhaustion
although deny ongoing abuse or other clear psychosocial
stressors.
Past Medical History:
Epilepsy: She had one GTC ___ years ago. There were no seizures
from that time until this admission. She remained on Lamictal
and was not followed by a Neurologist.
Social History:
___
Family History:
No seizures in parents or offspring, no cancer in the family
either
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
GEN:intubated and sedated on propofol, held for several minutes
for the exam
MS: intubated and sedated
CN: pupils 3-2mm b/l, grimace symmetric, +doll's eyes, +gag,
Motor: no adventitious movements, tone normal and symmetric,
brisk withdrawal to noxious in all extremities,
Reflexes: 2+ and symmetric in uppers and lowers except ankles
which were absent, toes downgoing b/l
Sensory: withdraws to noxious in all ext
coord/gait: deferred
Discharge Physical Exam:
Awake, alet and oriented x3. Walks independently.
Pertinent Results:
Admission Labs:
___ 01:00PM BLOOD WBC-8.7 RBC-4.16* Hgb-13.1 Hct-37.3
MCV-90 MCH-31.5 MCHC-35.1* RDW-12.1 Plt ___
___ 01:00PM BLOOD Neuts-72.1* ___ Monos-5.2 Eos-1.6
Baso-0.8
___ 01:00PM BLOOD ___ PTT-28.6 ___
___ 01:00PM BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-143
K-3.5 Cl-107 HCO3-26 AnGap-14
___ 01:00PM BLOOD ALT-21 AST-22 AlkPhos-48 TotBili-0.7
___ 01:00PM BLOOD Lipase-29
___ 02:08AM BLOOD Albumin-3.8 Calcium-8.3* Phos-4.4 Mg-1.8
___ 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:12PM BLOOD Lactate-1.8
Discharge Labs:
___ 01:00PM URINE Color-Straw Appear-Clear Sp ___
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
============================================================
Imaging:
MRI ___: Normal MRI of the brain using seizure protocol
CTA Head and Neck ___: No evidence of occlusion, flow-limiting
stenosis, or dissection of the principal arteries of the head
and neck. No intracranial vascular malformation or aneurysm
greater than 2mm. Final read pending 3D reconstructions.
EEG ___: This is an abnormal portable EEG because of occasional
bursts of
slowing in the left posterior quadrant indicative of focal
cerebral
dysfunction in this region. However, no clear epileptiform
discharges or
electrographic seizures are seen. During brief periods of
wakefulness, the
background reaches alpha frequency. The generalized beta
activity is likely a medication effect, commonly from agents
such as benzodiazepines and barbituates.
Brief Hospital Course:
Mrs. ___ is a ___ year-old woman with a seizure disorder on
lamictal (no seizure in ___ years) who presented as a transfer
from ___ after approximately 5 generalized seizures. At
the OSH, she was intubated for airway protection and started on
Keppra 750mg BID after a 1gm bolus and Ativan 4mg.
At ___, a STAT EEG in the ED showed left posterior quadrant
slowing, but no electrographic seizures or epileptiform
discharges.
She was admitted to the Neuro ICU, where she remained intubated
until the morning of ___. Continuous video EEG was reassuring
with only episodic generalized slowing that was most suspicious
of encephalopathy, possibly med related. MRI and NCHCT were
reassuring. The etiology of her seizures was unclear. There was
no clear infectious trigger (no leukocytosis, no fever, negative
urinalysis). Keppra was stopped as of ___ am and she was
restarted on her home Lamictal.
After she was transfered to the floor she was seen by physical
therapist and cleared for home.
THe lamictal dose was increased and she will be followed in
neurology clinic.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. LaMOTrigine 100 mg PO BID
2. Hydrochlorothiazide 25 mg PO DAILY
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
4. Simvastatin 20 mg PO DAILY
5. Niaspan Extended-Release (niacin) ___ mg oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 600 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. LaMOTrigine 100 mg PO BID
RX *lamotrigine [Lamictal] 100 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*6
5. Niaspan Extended-Release (niacin) ___ mg oral QPM
6. Simvastatin 20 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. LaMOTrigine 25 mg PO PER INSTRUCTION
1 tab twice/day for 2 weeks then 2 tab twice a day. 125 MG
lamictal bid for 2 weeks then 150 mg bid
RX *lamotrigine [Lamictal] 25 mg 1 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*6
Discharge Disposition:
Home
Discharge Diagnosis:
1. Recurrence of seizure in the setting of suboptimal medication
dose and sleep deprevation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You have been admitted to ___ after you had clusters of
seizures.
You were admitted to ICU intubated as you were transferred
intubated here, at ___ you were started on keppra.
You did not have any seizure here and your EEG recorded in ICU
did not show seizure.
After extubation you were transferred to the regular floor.
Our physical therapy service evaluated you and confirmed that
you are independent and can be discharged home safely.
We changed the lamictal dose per instruction:
1. please take one 100mg tablet with one 25 mg tablet for 2
weeks, at the beginning of week 3 please continue with taking
one 100 mg tablet plus two 25 mg tablet twice a day. If you
develop any rash in your skin, mouth, eyes or genital area
please stop the tablet and present to the closest emergency
department.
Per MA law you should not drive for 6 month after seizure.
Please avoid swimming or taking shower when you are alone as
seizure in these situation can be fatal.
If you have further questions or concern, please contact
___
And I will reach you as soon as possible.
***Please have your PCP draw ___ lamotrigine blood level in 2
weeks, approximately ___. Please ask that these be faxed to
Dr. ___ office at ___
Followup Instructions:
___
|
10501705-DS-8 | 10,501,705 | 28,282,816 | DS | 8 | 2164-01-25 00:00:00 | 2164-01-25 18:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___ Thoracentesis
___ Left-sided pleural pigtail catheter placement
History of Present Illness:
___ yo M with afib on coumadin, hypertension, HL and
hypothyroidism sent in from PCP to the ___ today for an INR
elevated to 10.7. He has newly found metastatic disease with
bony lesions on hip MRI. Planned to see oncology soon with
likely biopsy, but was brought in due to INR. He has had hip and
groin pain for a couple months. Imaging was obtained by PCP
recently showing multiple bony lesions.
.
In the ___ inital vitals were, 98.0 100 100/75 16 94% RA. He was
given 10mg PO vitamin K. CXR showed large left sided pleural
effusion suspicious for lung mass. Bedside cardiac echo shows no
pericardial effusion but large left pleural effusion. Given
levaquin for question of pneumonia. Given a 500cc bolus for SBP
79. On transfer, SBP85 HR102 RR16 O2 95% on 4L.
.
On arrival to the ICU, he is comfortable and feeling well. He
has no complaints.
.
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:
1. Anxiety
2. Depression
3. Osteoarthritis
4. Sciatica
5. Hypothyroidism
6. Hypertension
7. Hypercholesterolemia
8. Question of atrial fibrillation - The patient is on Coumadin
but is unclear why. This is managed through the ___.
Social History:
___
Family History:
sister - unknown cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: minimal lung sounds on left, clear lungs on right
CV: Irregularly irregular no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ edema bilaterally
Skin: warm and dry
DISCHARGE PHYSICAL EXAM:
breathing comfortably, no acute distress
distant L lung sounds, crackles R lung
patient is comfort measures only, minimal exam
Pertinent Results:
___ 09:15AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:15AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 09:15AM URINE RBC-160* WBC-38* Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:45PM PLEURAL WBC-575* ___ Polys-69*
Lymphs-19* Monos-0 Eos-1* Macro-11*
___ 03:45PM PLEURAL TotProt-3.3 Glucose-83 LD(LDH)-286
Cholest-58
MICRO:
Blood (___): NGTD
___ 3:44 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Urine (___): NGTD
Preliminary cytology: Pleural fluid adenocarcinoma cells,
pending more detailed analysis. Scant cells, so difficult to
get special stains.
STUDIES:
ECG (___):
Atrial fibrillation with rapid ventricular response. Diffuse low
voltage.
No previous tracing available for comparison. Clinical
correlation is
suggested.
CXR (___):
Large left pleural effusion with left upper lobe collapse and
left central adenopathy. Left-sided mass is presumed.
ECHO (___):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size is
normal. with normal free wall contractility. 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. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is a trivial/physiologic pericardial effusion.
CT Abd/Pelvis (___):
1. Aggressive central left upper lobe lesion that invades the
left pulmonary
artery, superior left pulmonary vein and occlude the left upper
pulmonary
bronchus.
2. Extensive mediastinal lymphadenopathy.
3. Multiple pleural deposits.
4. Bone metastases and pathological fracture of the right eighth
rib.
5. Tense left pleural effusion.
CXR (___):
In comparison with the study of ___, the degree of
opacification
in the left hemithorax has increased. However, this could relate
to a
redistribution of pleural fluid in the supine position, when
compared to the upright PA view in the comparison study.
Nevertheless, there certainly does not appear to be any
substantial reduction in the degree of pleural fluid. No
pneumothorax is seen.
CXR (___):
Right basal atelectasis has nearly cleared and small right
pleural effusion is stable. Because of rightward patient
rotation, it is hard to say whether there has been interval
rightward mediastinal shift, but I believe there has been,
suggesting an increase in the volume of the already large left
pleural effusion that nearly completely collapses the left lung,
and obscures extensive intrathoracic malignancy as seen on the
torso CT earlier today. Bleeding into the left pleural space is
certainly possible. No pneumothorax.
CXR (___):
A modest decrease in the large left pleural effusion is
reflected in a slight increase in the small region of apical
lung aeration and return of the trachea to the midline. Small to
moderate right pleural effusion is larger. No pneumothorax.
CXR (___):
As compared to the previous radiograph, there is no relevant
change. Extensive left pleural effusion, occupying approximately
two-thirds of the left hemithorax, with displacement of the
mediastinal and cardiac structures towards the right. On the
right, there is unchanged evidence of a small pleural effusion
and an otherwise normal lung parenchyma.
MRI Head w/ and w/out ___
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of metastatic disease.
3. Sequelae of chronic small vessel ischemic disease, with
chronic lacunar
infarct in the left centrum semiovale.
CT Chest w/ contrast (___):
IMPRESSION:
1. Status post left pleural pigtail catheter placement with
improvement in
the volume of left pleural effusion and minimally improved
aeration of the
left lower lobe. Left lower lobe bronchus shows short segment
occlusion,
likely reflective of a mucus plug.
2. Continued large left upper lobe mass with mass effect on the
adjacent
bronchus and artery; mediastinal lymphadenopathy, most prominent
in the
subcarinal stations.
3. New small consolidation in the anterior portion of the right
lung apex may represent residual atelectasis versus a new focus
of pneumonia; small right simple pleural effusion with minimal
associated atelectasis.
4. Ascites.
5. Bone metastases as described above.
CXR ___
Upright portable view of the chest demonstrates left lower lobe
consolidation. Diffuse opacification of the left hemithorax is
not significantly changed since study obtained five hours prior.
The right lung is clear without pleural effusion or
pneumothorax. The hilar and mediastinal silhouettes are
unremarkable. Heart size is difficult to discern due to adjacent
opacities.
IMPRESSION:
Persistent left lower lobe consolidation and large left pleural
effusion,
unchanged.
Brief Hospital Course:
Patient Summary:
==============
___ yo M with HTN, HL, hypothyroid and significant smoking
history found to have a large left lung mass, as well as
multiple bony lesions. Admitted to the MICU with
hypercoaguability and hypotension. On discussion with patient,
family and medical teams, pursued Comfort Measures Only.
Active Issues:
==============
# Malignancy
Primary lung malignancy is most likely given large lung mass on
CT. Also with significant smoking history. Mets in R pelvis, rib
and thoracic spine. Thoracentesis was performed with specimens
sent for cytology confirming adenocarcinoma. Given his advanced
disease and poor functional status, no treatment options beyond
palliative care were available. Elected to undergo some
palliative radiation of right pelvis. Patient decided that he
preferred to go home with hospice and spend time with family. He
was made CMO with plan to transfer back home with hospice.
.
# Hypotension
Resolved. Pt had hypotension upon arrival to ___ w/ SBP nadir
79, very responsive to fluids. Pt received ___ IVF w/in first
24 hours of hospital stay, complicated by pulmonary edema,
worsening effusions and increased work of breathing (nasal
cannula to 6L. SBP in the 120s. Lactate improved. Most likely
etiology was poor PO intake. He was transferred to the medical
oncology floor on ___, however had recurrent hypotension and
was transferred back to MICU on ___.
.
# Supratherapeutic INR: Question secondary to poor PO intake
versus cirrhosis by CT abdomen. Improved with Vitamin K 20g
total and FFP. Lovenox stopped due to CMO.
.
# Atrial fib: Stopped metoprolol for CMO.
Stable Issues
==============
# Anxiety/depression: continued citalopram
.
# Hypothyroid: stopped levothyroxine for CMO
.
# HL: stopped simvastatin for CMO
.
# BPH: stopped finasteride, foley remained in place
Transitional Issues:
=====================
- will need to return for chest tube replacement via IP on
___
- PCP ___
- oncology ___
- one suture in L axilla --> to be taken out ___
- ___ ___ blood and pleural fluid cultures
Medications on Admission:
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth daily
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily
WARFARIN [COUMADIN] - 5 mg Tablet - 1 tab ___ tab other
days
ACETAMINOPHEN - 500 mg Tablet - 1000 mg by mouth three times a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600 mg-400
unit Tablet - 1 Tablet(s) by mouth twice a day
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (OTC) - Dosage
uncertain
Discharge Medications:
1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
3. prochlorperazine 25 mg Suppository Sig: One (1) Rectal every
twelve (12) hours as needed for nausea.
Disp:*10 supp* Refills:*0*
4. Levsin/SL 0.125 mg Tablet, Sublingual Sig: ___ Sublingual
every ___ hours as needed for increased secretions.
Disp:*10 tablets* Refills:*0*
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every ___ hours as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
___ mg PO q1hr as needed for discomfort, shortness of breath.
Disp:*40 mL* Refills:*0*
7. acetaminophen 650 mg Suppository Sig: One (1) supp Rectal
every four (4) hours as needed for ___.
Disp:*10 supp* Refills:*0*
8. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.25-2 mg PO
every four (4) hours as needed for nausea/anxiety/agitation.
Disp:*10 mL* Refills:*0*
9. Hospice
- Admit to ___
- Oxygen via nasal cannula 3L-10L titrate as needed for comfort
10. Tessalon Perles 100 mg Capsule Sig: Two (2) Capsule PO three
times a day.
Disp:*180 Capsule(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
12. senna 8.8 mg/5 mL Syrup Sig: One (1) PO three times a day.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic adenocarcinoma, likely lung primary
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital and found to have a large
metastatic lung cancer. After discussions with your medical
teams and your family, you elected to go home with hospice.
Followup Instructions:
___
|
10501909-DS-13 | 10,501,909 | 21,899,527 | DS | 13 | 2126-11-14 00:00:00 | 2126-11-15 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Myrbetriq / carvedilol / tele stickers / shrimp
Attending: ___.
Chief Complaint:
Headache, concern for stroke (L face and leg numbness)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of present illness:
Patient is a ___ year old right handed female with past medical
history most pertinent for stroke (___) and ___
disease whom presented because of episode of left sided facial
and leg numbness.
Patient stated that ___ at bedtime she was at baseline and
went
to sleep with no concerns. Patient awoke ___ at her normal
time of 05:30 AM and immediately noticed that she did not feel
well. Patient could not describe how she did not feel well
beyond a feeling of general weakness which she could not
localize
to a particular portion of the body. Patient while getting up
out of bed noticed a sudden and abrupt sensation of left sided
facial numbness and heaviness that was appreciated along the
mandibular portion of the face. Patient also concomitantly had
numbness of her left lower portion of our neck. Patient did not
appreciate numbness or heaviness on the right side of the body.
Patient stated that this sensation lasted for about five minutes
and then resolved completely.
Patient was brought to the emergency department with complaints
of headache, but stated that she never experienced a headache.
Patient when visited by myself expressed that she was concerned
that she had a stroke, but that she currently felt at her
baseline. Patient denied persistent change in sensation or
other
neurologic concerns including focal weakness.
Past Medical History:
R ACA/MCA ischemic stroke (___)
___ disease
thyroid cancer with a thyroidectomy in the ___.
Appendectomy.
Three C-sections.
Hysterectomy.
L4-L5 back problems, but no surgery.
Labile blood pressures.
Urinary Incontinence
Cervical spondylosis.
History of coronary artery disease with a stent placement.
History of cataract surgery.
Social History:
___
Family History:
Family History of HTN, DM. No stroke history
Physical Exam:
ADMISSION EXAM:
Presentation vitals:
Heart rate: 78
Blood pressure: 130/94
Respiratory rate: 20
Oxygen saturation: 96%
General examination:
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
Neurologic examination:
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, increased tone in the right upper and lower
extremity. Patient with resting oral tremor and bilateral upper
extremity tremor that is most pronounced on the right side.
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, proprioception throughout.
No extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination:
No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
Gait:
Deferred.
================
DISCHARGE EXAM:
VS: T 97.5, HR 87, BP 138/77, RR 18, SpO2 93% (RA)
General examination:
General: Comfortable and in no distress
Head: NCAT, MMM, no conjunctival injection
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic examination:
Mental Status: Oriented to person, place, date. Speech is fluent
with normal prosody. Able to fully cooperate with interview and
exam.
Cranial Nerves: PERRL 2->1.5, EOM full, face symmetric at rest
and with activation. Palate elevation symmetric. Tongue midline.
Motor:
Normal bulk, +paratonia bilaterally. Cogwheel rigidity at
bilateral wrists. Patient with resting bilateral upper extremity
tremor that is most pronounced on the left side.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 4* 5 5 5
*limited by tenderness R calf
Sensory:
No deficits to light touch throughout
Reflexes: As above.
Plantar response was flexor bilaterally.
Coordination:
No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
Gait:
Deferred.
Pertinent Results:
LABS:
___ 08:10AM GLUCOSE-105* UREA N-19 CREAT-0.8 SODIUM-141
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
___ 08:10AM ALT(SGPT)-9 AST(SGOT)-22 ALK PHOS-97 TOT
BILI-0.6
___ 08:10AM cTropnT-<0.01
___ 08:10AM ALBUMIN-4.0 CALCIUM-9.9 PHOSPHATE-3.3
MAGNESIUM-2.0
___ 08:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 08:10AM WBC-10.2* RBC-5.09 HGB-15.8* HCT-47.8* MCV-94
MCH-31.0 MCHC-33.1 RDW-13.9 RDWSD-48.0*
___ 08:10AM NEUTS-64.5 ___ MONOS-8.8 EOS-5.1
BASOS-0.6 IM ___ AbsNeut-6.61*# AbsLymp-2.11 AbsMono-0.90*
AbsEos-0.52 AbsBaso-0.06
___ 08:10AM PLT COUNT-355
___ 08:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
MICRO:
Urine culture ___: No growth
IMAGING:
CT Head ___:
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema,or new
mass. Again demonstrated, is a 1.5 cm left parietal extra-axial
calcified lesion (02:20). Prior areas of right MCA/ACA
infarctions identified on MRI from ___ arenot well
visualized on current CT. 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 of bilateral vertebral and cavernous portions of internal
carotid arteries.
There is no evidence of fracture. There is a mucous retention
cyst in the
left sphenoid sinus and right maxillary sinus, similar prior.
Otherwise, the remaining the visualize portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. Additional findings described above.
MRI Brain ___:
IMPRESSION:
No acute infarct.
No intracranial hemorrhage.
Normal evolution of the previously noted small punctate right
ACA and MCA
infarct.
Involutional changes of the brain with associated ex vacuo
dilatation of
ventricular system. Periventricular T2 and FLAIR hyperintense
signal changes are most likely sequela of microangiopathy.
Moderate atherosclerotic disease of the left V4 vertebral artery
segment.
Left posterior parietal extra-axial partially calcified
meningioma is
unchanged.
Brief Hospital Course:
Ms. ___ is a lovely ___ year old woman with with past
medical history most pertinent for stroke (___) and
___ disease whom
presented because of transient episode of left sided facial and
leg numbness. Upon further history, patient endorsed generalized
weakness and sensory changes extending forn the neck to
mandible, that was different from numbness, which was felt to be
due to underlying cervical spine DJD. MRI done after admission
was negative for evidence of acute infarction. It was felt that
due to the location of her symptoms (neck/face and leg
numbness), a TIA was also unlikely as the symptoms do not
localize to a vascular territory. We continued her home
medications and did not make any changes to them prior to
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 10 mg PO QPM
2. Omeprazole 20 mg PO DAILY
3. Oxybutynin 10 mg PO DAILY
4. Midodrine 2.5 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Carbidopa-Levodopa (___) 1.5 TAB PO TID
8. Atenolol 25 mg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Carbidopa-Levodopa (___) 1.5 TAB PO TID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Midodrine 2.5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Oxybutynin 10 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Transient sensory changes, generalized weakness
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 for symptoms of generalized
weakness and transient feeling of numbness of her neck and lower
face. Your sensory symptoms have resolved, and the MRI of your
brain shows no new strokes. We do not think you had a TIA due to
the location of the sensation changes. It is possible you also
have had a mild viral illness that would explain the generalized
weakness you have been having.
In order to prevent your risk for future strokes, please
continue to take all your medications as prescribed. We are not
making any changes to your home medication regimen. Please
follow up with your PCP and neurologist as instructed 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
It was our pleasure to take care of you.
Sincerely,
___ Neurology Team
Followup Instructions:
___
|
10501909-DS-14 | 10,501,909 | 28,905,562 | DS | 14 | 2128-01-02 00:00:00 | 2128-01-02 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Myrbetriq / carvedilol / tele stickers / shrimp
Attending: ___.
Chief Complaint:
Transient seeing red, like blood
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a lovely ___ year old woman with past medical
history most pertinent for TIA in ___ (p/w 45 mins of
L arm and face numbness in V1 distribution), stroke ___ (p/w
dysarthric speech, minimal verbal output, not following
commands,
right facial droop, R > L sided weakness) and ___
disease
who presents to the ED with complaints of an episode of vision
changes this morning.
Briefly, she states she felt tired the other day, which is not
unusual for her. She went to be early and woke up at around 4 am
to use the bathroom. She got to the bathroom and when she turned
on the light she saw the whole bathroom in red. She states like
it looked like the whole bathroom was covered in blood. This
lasted three minutes and then resolved. She denies any other
associated neuro deficits. She ahs baseline intermittent
diplopia, blurry vision and intermittent parasthesia and
generalized weakness. This never happened to her before. She
denies any headache associated with the episode.
Regarding her ___ disease, this started at approximately
age ___ with symptoms of tremor and writing difficulties. At her
last visit with Dr. ___ in ___, the following was
noted:
" No hallucinations except once when she woke up and had a
feeling like her mother was in the room. She does have vivid
dreams. Occasional lightheadedness but no syncope. She also
reports feeling "dizzy" when she first gets up in the morning
and
so she sits on the edge of the bed for a minute after which this
feeling stops. She described a feeling as if the room was
moving
before this resolves each morning."
Her stroke occurred in ___. She was originally admitted
to the hospital for a syncopal episode, but then later on had an
acute onset of right facial droop and dysarthria. Blood pressure
at the time was 70 systolic. She received IV fluids. An MRI
showed a late acute/subacute infarct in the right ACA/MCA
territory, which was believed to be due to hypoperfusion.
Past Medical History:
R ACA/MCA ischemic stroke (___)
___ disease
thyroid cancer with a thyroidectomy in the ___.
Appendectomy.
Three C-sections.
Hysterectomy.
L4-L5 back problems, but no surgery.
Labile blood pressures.
Urinary Incontinence
Cervical spondylosis.
History of coronary artery disease with a stent placement.
History of cataract surgery.
Social History:
___
Family History:
Family History of HTN, DM. No stroke history
Physical Exam:
Admission Physical Exam:
Vitals: 97.9 70 148/90 18 99% RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Pt was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
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: She had mild diffuse dyskinesias.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4 ___ 5 5 5- 5 5 4 4
R 4 ___ 5 5 4 4 4 4 4
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Deferred
=======================================================
Discharge Physical Exam:
24 HR Data (last updated ___ @ 1217)
Temp: 97.9 (Tm 98.5), BP: 132/67 (132-175/67-90), HR: 83
(70-94), RR: 16 (___), O2 sat: 94% (93-96), O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic:
-Mental Status: Alert. Attentive to exam. Language is fluent
with
no paraphasic errors. Able to follow both midline and
appendicular commands.
-Cranial Nerves: PERRL 3->2. VFF to confrontation with chronic
peripheral diplopia (chronic per pt and family). EOMI without
nystagmus. Face symmetric at rest and with activation. Hearing
intact to conversation. Palate elevates symmetrically. Mild
dysarthria.
-Motor: Normal bulk. Increased tone in b/l UE, LLE. Mild
bilateral pronation without drift. R worse than L pill rolling
tremor. Jaw/tongue tremor present.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ 5 5 4+ 5 5 4
R 4+ 5 4+ 4+ 5 4+ 4 5- 4 4
-Sensory: Intact to LT throughout.
-Coordination: No dysmetria on FNF bilaterally.
Pertinent Results:
___ 05:15AM BLOOD WBC-8.4 RBC-4.51 Hgb-14.0 Hct-43.6 MCV-97
MCH-31.0 MCHC-32.1 RDW-14.6 RDWSD-52.1* Plt ___
___ 05:15AM BLOOD ___ PTT-29.0 ___
___ 05:15AM BLOOD Glucose-123* UreaN-21* Creat-0.8 Na-145
K-4.5 Cl-106 HCO3-27 AnGap-12
___ 06:25AM BLOOD ALT-<5 AST-14
___ 05:15AM BLOOD Phos-3.7 Mg-2.0
___ 06:25AM BLOOD %HbA1c-6.2* eAG-131*
___ 06:25AM BLOOD Triglyc-112 HDL-40* CHOL/HD-3.7
LDLcalc-87
___ 06:25AM BLOOD CRP-1.4
___ 12:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
CT Head wo cont ___ IMPRESSION:
1. No acute intracranial abnormalities. Please note MRI of the
brain is more sensitive for the detection of acute infarct.
2. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
3. Grossly stable 1.5 cm left parietal extra-axial calcified
mass since ___, again suggestive of meningioma.
4. Paranasal sinus disease , as described.
CTA head/neck ___ IMPRESSION:
1. Dental amalgam and venous contrast pooling streak artifact
limits study.
2. Interval progression of long segment moderate narrowing of
the left P2/P3 segment compared ___ prior exam.
3. Grossly stable focal moderate narrowing of right A2, right
M2, right V4 and left P2 segments.
4. Atherosclerotic changes of the bilateral cavernous and
supraclinoid ICAs without narrowing.
5. Otherwise, patent circle of ___ without definite evidence
of
stenosis,occlusion,or aneurysm.
6. Nonocclusive atherosclerotic calcifications of bilateral
carotid
bifurcations without definite moderate or high-grade internal
carotid artery doses by NASCET criteria.
7. Otherwise, patent bilateral cervical carotid and vertebral
arteries without definite evidence of stenosis, occlusion, or
dissection.
8. Grossly stable right upper lobe 8 mm pulmonary nodule
compared to ___ chest CTA. Please see recommendation
below.
9. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule
measuring 6 to 8 mm, a CT follow-up in 6 to 12 months is
recommended in a
low-risk patient, optionally followed by a CT in ___ months.
In a high-risk
patient, a CT follow-up in 6 to 12 months, and a CT in ___
months is
recommended.
See the ___ ___ Guidelines for the Management
of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
MRI Head ___:
IMPRESSION:
1. Study is mildly degraded by motion.
2. Right corona radiata punctate probable subacute infarct
without definite evidence of hemorrhagic transformation.
3. Grossly stable 2 cm left parietal probable meningioma.
4. Chronic microvascular angiopathy changes.
5. Subcentimeter lacunar infarct in the bilateral deep gray
nuclei.
Brief Hospital Course:
Ms. ___ is a ___ yo F with PMH of TIA in ___ (p/w 45 mins
of L arm and face numbness in V1 distribution), stroke ___
(p/w dysarthric speech, minimal verbal output, not following
commands,right facial droop, R > L sided weakness) and
___ disease who presented to the ED with an episode of
transient vision change, described as seeing red "streaks of
blood" that lasted 3 minutes. Unclear if monocular or binocular.
No other associated neuro deficits. No headache. This never
happened to her before. CTH showed left parietal meningioma and
atrophy but nothing acute. CTA showed intracranial athero in
posterior and anterior circulation.
Brain MRI showed a small late subacute infarct involving the
right corona radiata. If we were to consider the hallucination
as potentially vascular in etiology, this would localize to the
occipital pole rather than the right corona radiata. This is
therefore favored to represent an incidental infarct.
Overall, the episode of seeing streaks of blood was favored to
represent an atypical ___ disease hallucination, though
we cannot completely rule out transient cerebral ischemia.
Her stroke risk factors include the following:
1) DM: A1c 6.2%
2) CTA showed intracranial athero in posterior and anterior
circulation.
3) Hyperlipidemia: LDL 87. Goal LDL<70
She was continued on ASA 81mg daily as there is a lack of
evidence showing benefit of increasing/transitioning
antiplatelet for secondary stroke prevention after stroke
occurring on low dose aspirin. Increasing statin was considered,
but deferred given relatively low LDL and high risk for myalgias
with high intensity statin therapy.
Transitional Issues:
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 = 87) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given: Initially started on atorvastation 40 but
continued home dose of rosuvastatin due to high risk of
myopathy.
[ ] Statin medication allergy
[ ] Other reasons documented by physician/___ practice
___/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO TID ___, 1600, ___
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Rosuvastatin Calcium 10 mg PO QPM
4. Atenolol 25 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Midodrine 2.5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Donepezil 5 mg PO QHS
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Ditropan XL (*NF*) 10 mg Other DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Loratadine 10 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
16. B Complex-Vitamin B12 (vitamin B complex) oral DAILY
17. Carbidopa-Levodopa (___) 1.5 TAB PO DAILY 0700
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. B Complex-Vitamin B12 (vitamin B complex) oral DAILY
4. Carbidopa-Levodopa (___) 1.5 TAB PO Q7AM
5. Carbidopa-Levodopa (___) 1 TAB PO 1100, 1600, ___
6. Ditropan XL (*NF*) 10 mg Other DAILY
7. Donepezil 5 mg PO QHS
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Midodrine 2.5 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Omeprazole 20 mg PO DAILY
14. Oxybutynin 5 mg PO BID
15. Rosuvastatin Calcium 10 mg PO QPM
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic stroke of the right corona radiata
___ disease
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of seeing red/blood which
was initially concerning for transient ischemic attack (TIA) vs
hallucination. Overall, we think this episode was more likely to
be hallucination.
On MRI, you were found to have 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. We do not think this stroke
was related to seeing red. It was likely a coincidence that we
found it while you were here.
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 (LDL 87) - goal LDL less than 70.
We are changing your medications as follows:
Continue aspirin 81 mg daily
Continue rosuvastatin 10 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10501909-DS-15 | 10,501,909 | 24,147,262 | DS | 15 | 2128-03-22 00:00:00 | 2128-03-22 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Myrbetriq / carvedilol / tele stickers / shrimp
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of
___ disease, right ACA/MCA stroke,
hypertension/orthostasis now presenting with weakness and
tremor.
History is taken from the patient and her daughter, who is at
the
bedside. The patient reports that she has felt increasingly weak
over the past few weeks. She reports that she has had decreased
appetite. She denies any changes in weight. She usually has
brisk
urine output but noticed that over the past few days prior to
admission she has not been urinating very much. She denies any
falls; uses a rollator to ambulate.
Beginning the day prior to admission, she developed an increase
in her tremulousness and shaking. She also notices that her
voice
seems more hoarse. She did not sleep very much on the evening
prior to admission due to the shaking. On the day of admission,
she reports that when she awoke she felt shaky and weak. She
reports that she always produces some phlegm when she first
wakes
in the morning. Denies any fevers, chills, sore throat, cough,
shortness of breath, or chest pain. No abdominal pain, dysuria,
diarrhea. She reports that she was walking down the stairs and
she felt nauseated and coughed up more phlegm. She felt like
weak
and felt like she might pass out.
She reports that she recently had thrust and used a nystatin
swish and swallow treatment. Other than that, no recent changes
in medications or their dosages, including her Sinemet. She
notes
that she has occasional double vision, which her Neurologist is
aware of. She denies any increased rigidity, freezing,
difficulty
turning. Per review of her neurology records, her donepezil was
increased 1 month ago from 5 to 10 mg. Of additional note, it is
thought that her symptoms of shortness of breath may in fact by
a
symptom of her Sinemet wearing off. They kept a diary of her
symptoms to attempt to correlate them with the medication
timing,
but it remains unclear whether these are causally related.
In the ED, initial vitals: 96.6 60 137/86 20 95% RA
Exam notable for: Generalized tremulousness, appears unwell,
tachypneic
Labs notable for; WBC 13.5, Hb 15.2, plt 461, Ca ___
trop<0.01,
proBNP 409
Imaging: CXR, EKG
Patient given: Carbidopa-Levodopa (___) 1 tabx2, Tylenol ___
mg, rosuvastatin 10 mg
On arrival to the floor, the patient reports that she feels very
shaky and her mouth feels very dry. She reports that in the
ambulance she had developed a brief, squeezing left-sided chest
pain that subsequently resolved and has not recurred. She is
unsure what is meant by the phrase shortness of breath, but
ultimately denies any difficulty breathing at present.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- R ACA/MCA ischemic stroke (___)
- ___ disease
- Thyroid cancer s/p thyroidectomy in the ___
- CAD s/p stent
- Labile blood pressures/orthostasis
- Urinary Incontinence
- Cervical spondylosis
- L4-L5 back problems, but no surgery
- Appendectomy
- Three C-sections
- Hysterectomy
- Cataract surgery
Social History:
___
Family History:
Family History of HTN, DM. No stroke history
Physical Exam:
ADMISSION EXAM:
VITALS: 98.4 130/82 67 18 93 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate; no
thrush; dry mucous membranes
CV: Heart regular, no murmur
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.
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 with mild hypomimia, moves all limbs, sensation to
light touch grossly intact throughout; large-amplitude tremors,
right>left; no cogwheel rigidity; mild bradykinesia; very mild
intention tremor but no dysmetria; gait deferred
PSYCH: Very pleasant, appropriate affect
DISCHARGE EXAM:
I evaluated when seated -
She appeared well, AOx3, pleasant
Clear lungs, CV: RRR
ABd: obese and soft
She had no cogwheel rigidity, only mild occasonial low amplitude
tremors.
Pertinent Results:
ADMISSION LABS:
___ 02:04PM BLOOD WBC-13.5* RBC-4.92 Hgb-15.2 Hct-47.9*
MCV-97 MCH-30.9 MCHC-31.7* RDW-14.2 RDWSD-51.2* Plt ___
___ 02:04PM BLOOD Neuts-83.8* Lymphs-7.8* Monos-6.2 Eos-1.2
Baso-0.5 Im ___ AbsNeut-11.32* AbsLymp-1.06* AbsMono-0.84*
AbsEos-0.16 AbsBaso-0.07
___ 02:04PM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-143
K-4.9 Cl-102 HCO3-24 AnGap-17
___ 02:04PM BLOOD Calcium-10.4* Phos-3.7 Mg-2.1
___ 02:04PM BLOOD CK(CPK)-42
___ 02:04PM BLOOD proBNP-409
___ 02:04PM BLOOD cTropnT-<0.01
___ 07:55PM BLOOD cTropnT-<0.01
___ 05:58AM BLOOD TSH-1.3
___ 05:58AM BLOOD Free T4-1.7
MICRO:
UCx (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING/STUDIES:
CXR (___):
IMPRESSION:
Comparison to ___. No relevant change is noted.
Moderate cardiomegaly. Mild elongation of the descending aorta.
No pleural effusions. No pulmonary edema. No pneumonia. No
pneumothorax.
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-8.8 RBC-4.84 Hgb-15.0 Hct-46.2*
MCV-96 MCH-31.0 MCHC-32.5 RDW-14.2 RDWSD-50.2* Plt ___
___ 06:15AM BLOOD Glucose-120* UreaN-19 Creat-0.7 Na-143
K-4.3 Cl-105 HCO3-26 AnGap-12
___ 07:55PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD Calcium-10.8* Phos-3.8 Mg-2.0
___ 05:58AM BLOOD TSH-1.3
___ 05:58AM BLOOD Free T4-1.7
Brief Hospital Course:
SUMMARY:
Ms. ___ is a ___ woman with history of ___
disease, right ACA/MCA stroke, hypertension/orthostasis now
presenting with weakness and tremor likely related to her
___ disease.
HOSPITAL COURSE BY PROBLEM:
# Tremulousness
# ___ disease: Patient presented with subacute sensation
of weakness and increased tremor. The fact that she has these
episodes of tremulousness and global weakness around the time
she is due for her carbidopa-levodopa, suggests that these
symptoms may be due to her PD. She was continued on her home
carbidopa-levodopa. Neurology was consulted. Her outpatient
neurologist, Dr. ___ her in the hospital and recommended
changing her morning levodopa-carbidopa to the controlled
release preparation (___) to be given at 7 AM. Her short
acting carbidopa-levodopa (___) to be given at 11 AM, 3PM and
7 ___. IT IS VERY IMPORTANT THAT THESE MEDICATIONS BE GIVEN AT
THE SCHEDULED TIMES TO MINIMIZE THE WEAR OFF EFFECT OF THESE
MEDICATIONS.
___ evaluated her and recommended discharge to rehab.
# Weakness
# Supine hypertension
# Orthostasis: Patient with history of labile blood pressures.
Patient's weakness was likely related to her PD as above. No
metabolic derangements or infection to explain weakness. No
recent medication changes except for increased dose of
Donepezil, which does not interact with carbidopa-levodopa. It
does, however, interact with beta blockers and she was
bradycardic on admission. Donezepil was decreased to 5mg daily
with improvement in her bradycardia. Her daughter does not want
to discontinue the donepezil all together because she had acute
worsening of her mental status after discontinuing this in the
past.
She has significant supine hypertension in the morning (with SBP
as high as 180). We recommended that the lisinopril be given at
night and midodrine to be given a half hour prior to activity,
but patient's daughter refused to allow for any changes in
medications (even with regards to timing) without consultation
with her cardiologist, Dr ___, who was contacted via
email, but out of the hospital. We ask that the rehab facility
perform orthostatic measurements at various times of the day and
that these measurements be taken to the visit with Dr ___.
___ performed orthostatics and reported the following at time of
discharge:
Supine 62 138/78 95%RA
Sit 65 110/80* 96%RA
Sit 130/70
Stand
Activity Bed>chair 61 120/70 96%RA
# Chest pain: Patient had a fleeting episode of chest discomfort
prior to admission. EKG without acute ischemic changes and
trop<0.01x2, chest pain did not recur in the hospital. Suspect
possibly musculoskeletal vs anxiety.
# Leukocytosis
# Thrombocytosis: All cell lines increased and suspect that this
was hemoconcentration. No fevers, no symptoms of infection. UA
bland, CXR without pneumonia.
# Hypernatremia: Mild, resolvd with receipt of IVF, encouraged
patient to drink free water. Consider intermittent checks of
sodium.
# CAD
# CVA
- Continued ASA, statin, atenolol
# Thyroid cancer s/p thyroidectomy:
TSH and FT4 were within normal limits.
- Continued levothyroxine
# GERD:
- Continued omeprazole
# Memory impairment:
- Decreased donepezil back to 5 mg daily
# Overactive bladder:
- Held oxybutynin ___, resumed on discharge given that it
is an "essential medication" per her daughter.
# Hypercalcemia: Intermittent, PTH checked and pending at the
time of discharge.
Please discuss any medication changes with her daughter.
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1.5 TAB PO Q7AM
3. Carbidopa-Levodopa (___) 1 TAB PO 1100, 1600, ___
4. Donepezil 5 mg PO QHS
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Rosuvastatin Calcium 10 mg PO QPM
9. Atenolol 25 mg PO DAILY
10. Ditropan XL (*NF*) 10 mg Other DAILY
11. Lisinopril 10 mg PO DAILY
12. Midodrine 2.5 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Calcium Carbonate 500 mg PO TID:PRN Indigestion
15. Vitamin B Complex 1 CAP PO DAILY
16. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Carbidopa-Levodopa CR (___) 1 TAB PO QAM
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Calcium Carbonate 500 mg PO TID:PRN Indigestion
6. Carbidopa-Levodopa (___) 1 TAB PO 1100, 1500, ___
7. Ditropan XL (*NF*) 10 mg Other DAILY
8. Docusate Sodium 100 mg PO BID
9. Donepezil 5 mg PO QHS
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Lisinopril 10 mg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Midodrine 2.5 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Rosuvastatin Calcium 10 mg PO QPM
16. Vitamin B Complex 1 CAP PO DAILY
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ disease with autonomic dysfunction (orthostatic
hypotension)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ were admitted to the hospital due to progressive weakness
and shaking episodes. ___ were seen by your neurologist, Dr.
___ recommended some adjustments of your ___
medications.
In particular, ___ were started on a long acting medication
(Carbidopa-levodopa CR) at 7 AM, and continued your short acting
mediations at 11 AM, 3 ___ and 7 ___. I have communicated to
your rehab that taking these medications on time is essential!
___ have some back pain, please apply heat or use a lidocaine
patch. Per your daughter, your back pain is long standing.
We recommend some changes in your dosing of midodrine and timing
of blood pressure medications, but ___ wish to discuss any
changes with Dr ___ please see her in followup.
___ wishes for your continued health.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10502365-DS-19 | 10,502,365 | 26,148,167 | DS | 19 | 2148-07-16 00:00:00 | 2148-07-17 21:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ciprofloxacin / Bactrim
Attending: ___.
Chief Complaint:
Right facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history of
breast mass, migraine headaches, tension headaches and occipital
neuralgia who is presenting with facial numbness and weakness.
She states that she was in her normal state of health until
___. That day, she states she felt nauseated, and
threw
up a few times. She also felt somewhat lightheaded (no spinning)
at times, and off balance. She had several falls - one where she
missed a step getting off the train and fell forward after
stumbling, another coming out ___ Donuts where she fell
forward again as if she "tripped over her own feet." She
stumbled
forward without falling two other times. Then on ___, she
woke
up in the morning with a headache which was slightly worse than
her typical headache (more throbbing, does not know if
unilateral). This headache resolved about half an hour after
taking Tylenol. She also noted, however, that the right side of
her upper lip felt numb as if there was novacaine. Her eye was a
little painful and watering, and she couldn't close it all the
way. She looked at herself in her phone camera and tried
puckering her lips and felt like the right side of her mouth was
weak. She said her vision was blurry and double at times but
just
out of the right eye. She is having some trouble pronouncing
words with the letter "F." She feels as though her tongue is
burned although it isn't.
Ms. ___ gets headaches about 3 days per week in the morning,
but they are usually less throbbing, throughout her whole ___,
and usually only occur when she forgets to take her
Nortriptyline
the night before.
She states that she has never had weakness before but previously
she has had intermittent numbness/tingling in both of her hands
and feet that come and go, about once or twice a year. This was
thought to be in association with Topamax but when she decreased
the dose of this she did not notice any difference. This started
around age ___.
She has urinary urgency and occasional incontinence, and is
scheduled to see urology for this as an outpatient.
Of note, she has recently undergone bilateral breast biopsy. She
states there is no set plan yet but she might be getting surgery
and/or ___ weeks of radiation.
Neurologyic ROS is as above and she also denies loss of vision,
dysphagia, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. No bowel
incontinence or retention.
On general review of systems, she denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Migraines/Tension headaches/occipital neuralgia
- Breast mass s/p biopsy (Pleomorphic lobular carcinoma in situ
(PLCIS)involving a fibroadenoma)
- C-section x2.
- Knee surgery x4 on the right knee.
- facial skin infection (staph)
Social History:
___
Family History:
- Positive for stroke (father at the age of ___), myocardial
infarction (father), diabetes (mother), and migraine (sister,
brother, daughter).
Physical Exam:
===============================
ADMISSION PHYSICAL EXAM
===============================
Vitals: 97.4 83 131/81 16 100% ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. No corneal injection. Right eye is watering, no
photophobia.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Right pupil 3-->2mm briskly reactive, left 3.5-->2 briskly
reactive. VFF to confrontation. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages, however did not tolerate
well on the right and a good view was not obtained. There is a
slight right ptosis.
III, IV, VI: Extraoccular movements are full, and there is no
nystagmus. Saccades are smooth. However, she cannot maintain
fixed gaze to the right. There is no double vision ellicited.
V: Facial sensation decreased to light touch on the right in all
distributions, ___ vs ___ on the left.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing decreased to finger rub on the right. Bone > air
conduction on left.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, full strength.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs: 3+ and symmetric throughout. 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 with slight difficulty. Some sway
with Romberg but does not fall.
===============================
DISCHARGE PHYSICAL EXAM
===============================
Afebrile and hemodynamically stable
General: Awake, cooperative, NAD
Pulmonary: CTA bilaterally
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No edema
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Normal and unchanged from admission exam.
-Cranial Nerves:
Right CN VI palsy. Decreased activation of right face with
smiling. Otherwise, normal and unchanged from admission exam.
-Motor: Normal and unchanged from admission exam.
-Sensory: Normal and unchanged from admission exam.
-DTRs: ___ from admission exam.
-Coordination: Normal and unchanged from admission exam.
-Gait: Normal and unchanged from admission exam.
Pertinent Results:
___ 07:21AM BLOOD TSH-2.2
___ 04:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 04:00PM CEREBROSPINAL FLUID (CSF) TotProt-32 Glucose-74
___ 3:48 pm CSF;SPINAL FLUID Source: LP TUBE 3.
MS PROFILE:
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
-----------
Multiple Sclerosis Profile
CSF Bands 0 bands
CSF Olig Bands 0 bands
<4
Interpretation
--------------
The oligoclonal band assay detected 3 or less IgG bands in the
CSF,
which are not present in the serum. This is a Negative result.
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
------------
Serum Bands 0 bands
IgG Index, CSF 0.46
<=0.85
IgG, CSF 3.9 mg/dL
<=8.1
Albumin, CSF 20.8 mg/dL
<=27.0
IgG/Albumin, CSF 0.19
<=0.21
Synthesis Rate, CSF 0.00 mg/24 h
<=12
IgG, S 1550 mg/dL
___
Albumin, S 3780 mg/dL
3200-4800
IgG/Albumin, S H 0.41
<=0.40
Test Result Reference
Range/Units
ANGIOTENSIN CONVERTING 1 <=15 U/L
ENZYME (ACE), CSF
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
=====================
IMAGING
=====================
CT Chest with contrast (___): 1. Sub 4 mm pulmonary nodule in
the lateral right upper lobe. If there is no history of
malignancy or smoking, no followup is required for this small
nodule.
2. No evidence of lymphadenopathy or acute cardiopulmonary
process.
3. Hypodense nodule in the left thyroid lobe. This could be
further evaluated by ultrasound, if clinically indicated.
MR ___ (___): 1. Asymmetric contrast enhancement of the distal
condyle ictal portion and first genu of the right facial nerve,
consistent with an inflammatory process such is Bell's palsy.
2. No evidence for demyelinating disease or other signal
abnormalities in the brain parenchyma.
NCHCT (___): No acute intracranial process.
Brief Hospital Course:
Ms. ___ is a ___ year old right-handed woman with a past
medical history of migraine headaches and family history of
multiple sclerosis who presented to the ___ ED on ___ with a
right facial droop, unsteadiness and diplopia. Neurologic exam
was remarkable for right sided facial weakness with right
abducens nerve palsy. NCHCT was unremarkable. She was admitted
to the neurology general wards service for further evaluation.
# NEUROLOGY
The initial differential for pt's presentation including
new-onset multiple sclerosis, neurosarcoidosis, aseptic
meningitis, and viral illness. She underwent a MRI of the brain
with and without contrast, chest CT and lumbar puncture for
further assessment. MRI showed asymmetric contrast enhancement
of the distal condyle ictal portion and first genu of the right
facial nerve with no evidence for demyelinating disease or other
signal abnormalities in the brain parenchyma, compatible with a
viral illness. Chest CT showed no hilar or mediastinal
lymphadenopathy concerning for sacoidosis. The lumbar puncture
was unremarkable with normal protein, glucose, and cell counts.
The MS profile was negative and the ACE level was normal in the
CSF. Cryptococcal antigen was negative and gram stain and
culture were negative.
Because imaging and CSF studies were negative, multiple
sclerosis, neurosarcoidosis and aseptic meningitis were
unlikely. Cranial nerve inflammation was attributed to a viral
illness. Pt clinically improved during hospital stay. She was
provided with an eye patch and gel to sleep at night to protect
her right eye. On day of discharge, right facial muscles had
minimal activation. Pt had a persistent right abducens nerve
palsy, however. She was started on a prednisone taper on day of
discharge to treat a possible viral infection. She will
follow-up closely with her outpatient neurologist, who she has
seen prior for migraine.
For pt's history of migraine, she was continued on her home
topamax and nortriptyline while in the hospital. On day of
discharge, she experienced a typical migraine that responded to
sumatriptan.
#HOSPITAL ISSUES
Pt was given heparin SQ for DVT prophylaxis while in the
hospital. She remained full code.
==========================
TRANSITIONS OF CARE
==========================
Ms. ___ presented with a peripheral right CN VII palsy and
right CN VI palsy. Work-up including chest CT and CXR (to assess
for sarcoidosis) was negative. LP was unremarkable. MRI showed
only inflammation of the right facial nerve. Pt was discharged
on a tapering course of prednisone for presumed viral-induced
cranial nerve inflammation. CSF fungal culture was pending at
time of discharge, please follow-up with these results. Serum
ACE level was also pending at time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 500 mg PO Q12H:PRN migraine
2. Nortriptyline 25 mg PO HS
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Sumatriptan Succinate 50 mg PO X1:PRN migraine
5. Topiramate (Topamax) 50 mg PO BID
Discharge Medications:
1. Artificial Tears ___ DROP LEFT EYE PRN dry eye
RX *white petrolatum-mineral oil [Lubricant Eye] 15 %-83 % 1
(One) drop in the right eye twice a day Refills:*1
2. Nortriptyline 25 mg PO HS
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Sumatriptan Succinate 50 mg PO X1:PRN migraine
5. Topiramate (Topamax) 50 mg PO BID
6. Naproxen 500 mg PO Q12H:PRN migraine
7. PredniSONE 10 mg PO DAILY Duration: 9 Days
Take 6 tabs daily for 4 days, then 5 tabs x1day, 4 tabs x1day, 3
tabs x1day, 2 tabs x1day, 1 tab x1day
Tapered dose - DOWN
RX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*66 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Right Bell's (Facial Nerve) palsy
- Right Abducens Nerve (Cranial Nerve VI) palsy
Secondary diagnosis:
- Likely viral infection of peripheral cranial nerves VI/VII
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at ___ for
your symptoms of facial weakness and double vision. We
evaluated you with studies including a lumbar puncture which was
unremarkable for any central nervous system infection, and an
MRI study which showed no acute abnormalities apart from
inflammation of a nerve which controls the muscles of the right
face. We believe your symptoms are due to a viral illness which
caused inflammation of the nerves and thus are causing the
facial weakness, and the double vision you are experiencing.
To treat the inflammation, we are discharging you on a course of
a steroid called prednisone to decrease the inflammation and
increase the speed at which your symptoms resolve. PLEASE NOTE,
if your symptoms of double vision worsen, or you experience
other symptoms different than those currently reported, you will
need to return to the emergency department for further
evaluation, promptly.
Followup Instructions:
___
|
10502580-DS-12 | 10,502,580 | 21,852,982 | DS | 12 | 2149-05-11 00:00:00 | 2149-05-11 16:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Numbness/Loss of function of arms/Loss of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a history of atypical
chest pain, HTN, Hepatitis B on Tenofovir, Pulmonary nodules,
and COPD presenting with several episodes of numbness and loss
of function of his arms as well as altered mental status. The
history is obtained from the patient as well as neurology notes,
as the patient's wife who witnessed most of the events, is no
longer at bedside.
Mr. ___ was in his previous state of health until ___. He
notes he was seated at his desk working when he noticed sudden
onset of bilateral arm weakness, stating he could not lift
either arm up off his desk. He had a similar episode ___ year ago
in his Left arm, which lasted approximately ___ minutes. This
most recent episode lasted ___ minutes as well, with no
identifiable precipitating factors or prodrome. He maintained
full function of the rest of his body. He denies a recurrence of
these symptoms over the weekend.
He had another episode this morning after returning home from
work, again while at the computer. He began having sensory
changes in his left arm again, at which point he called his
girlfriend. He does not remember what happened after this point
and the next thing he remembers is being on a gurney on the way
to the hospital. Per neuro notes: When his wife arrived he was
sitting with his right arm outstretched over the mouse in a
frozen position and had a mild shaking of his left hand. He had
a slight downward tilt to his head. He was not responsive to her
voice or to tactile stimulation and this lasted approximately 10
minutes. There was no repetitive shaking or eye fluttering. He
continued to hold this pose until he became responsive with EMS
on the scene. In the ED he had another episode of right arm
sensory changes and a period of unresponsiveness, which
responded to sternal rub.
He denies symptoms with cough, deglutition, defecation,
micturition. He endorses occasional palpitations with
lightheadedness though not around the time of his symptoms. Of
note the patient has been having small volume diarrhea x2 days
once a day and states he has been drinking a lot of gatorade. He
denies a history of immobility, long plane rides, pleuritic
chest pain.
Past Medical History:
Hepatitis B
HTN
Carpal tunnel syndrome
Pulmonary Nodules
Obesity
Colonic Polyp
OA
OSA not on CPAP
Social History:
___
Family History:
DM in mother. ___ a family history of arrhythmias, stroke,
seizure, migraine headaches.
Physical Exam:
ON ADMISSION:
Vitals: T:97.7 BP:126/72 P:72 R:20 O2:98% RA
General: Well appearing gentleman lying comfortably in NAD
HEENT: Head atraumatic, moist mucous membranes, sclera
anicteric, oropharynx without lesions or erythema
Neck: Supple with no lymphadenopathy and full ROM
CV: Regular rate and normal rhythm, ?___ SEM, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, crackles,
rhonchi
Abdomen: Normoactive BS, non-tender to palpation in all four
quadrants, no rebound or guarding
Ext: Warm and well perfused, no ___ edema
Neuro: CN II-XII intact, strength ___ in upper and lower
extremities bilaterally, relfexes 2+ bilaterally
ON DISCHARGE:
AVSS
Neurologic:
- Mental status: Alert & Oriented x3, fluent, linear, prompt,
appropriate. Able to name months of year in reverse normally.
- PERRL, EOMI without nystagmus or pain, face intact to touch,
face activates symmetrically and fully, auditition is equal,
palate elevates/tongue protrudes at the midline, shrug is ___.
- Motor:
Delt Bic Tric WF WE FF FE IO IP quad ham AT ___
Tone normal, no extra movements, no Babinski, no pronator drift
- Sensory:
Globally intact to light touch and temperature. Proprioception
and vibration sense are normal. Parietal testing, Romberg
deferred.
- Reflexes: 2+ globally
- Coordination: No dysmetria or intention tremor
- Gait: Formal testing deferred
Pertinent Results:
Admission labs:
___ 09:25PM cTropnT-<0.01
___ 09:25PM VIT B12-302
___ 09:25PM TSH-0.93
___ 03:15PM URINE HOURS-RANDOM
___ 03:15PM URINE GR HOLD-HOLD
___ 03:15PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:15PM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 03:15PM URINE MUCOUS-OCC
___ 10:10AM LACTATE-1.6
___ 10:00AM GLUCOSE-115* UREA N-20 CREAT-1.1 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
___ 10:00AM estGFR-Using this
___ 10:00AM ALT(SGPT)-54* AST(SGOT)-33 ALK PHOS-89 TOT
BILI-0.7
___ 10:00AM cTropnT-<0.01
___ 10:00AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-2.5*
MAGNESIUM-2.1
___ 10:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:00AM WBC-12.1* RBC-5.03 HGB-16.7 HCT-46.8 MCV-93
MCH-33.2* MCHC-35.7*# RDW-14.0
___ 10:00AM NEUTS-65.8 ___ MONOS-5.6 EOS-3.3
BASOS-1.1
___ 10:00AM PLT COUNT-220
.
REPORTS
CTA head/neck ___
NECT: There is no evidence of intracranial hemorrhage, edema,
shift of normal
midline structures, hydrocephalus, or acute large vascular
territorial
infarction. Minimal periventricular white-matter hypodensity is
a nonspecific
finding can be seen in the setting of chronic small vessel
ischemic disease.
Calcifications are noted along the bilateral carotid siphons.
The orbits are
unremarkable. Mucosal thickening is seen throughout scattered
anterior and
posterior ethmoidal air cells. There are also mucous retention
cysts within
both maxillary sinuses. Minimal mucosal thickening is seen
within the left
frontal sinus. The right frontal sinus is clear. The sphenoid
sinus is
clear. The mastoid air cells are well aerated. Note is made of
periodontal
disease involving several of the mandibular teeth (3:150-154).
CTA head: There is no large vessel occlusion, flow-limiting
stenosis, or
aneurysm greater than 2 mm involving the anterior or posterior
intracranial
arterial circulation. There is normal opacification of the
dural venous
sinuses.
CTA neck: Scattered calcifications are seen along the aortic
arch. Mild
calcifications are seen at the origin of the left subclavian
artery. Minimal
calcifications are seen at the origin of the right common
carotid artery.
There are scattered calcifications seen at both carotid
bifurcations. There
is no large vessel occlusion, flow-limiting stenosis, or
aneurysm larger than
2 mm.
Minimum diameter (Dmin) measurements for the cervical right
internal carotid
artery are 8.0 mm, proximally and 5.0 mm, distally. Dmin
measurements for the
left internal carotid artery are 7.0 mm, proximally and 5.0 mm,
distally.
The thyroid, parotid and submandibular glands are grossly
normal. There are
no pathologically enlarged cervical lymph nodes. The imaged
aspect of the
aerodigestive tract is within normal limits. There is mild
paraseptal
emphysema at both lung apices. There is also mild centrilobular
emphysema
seen throughout the visualized portions of both lungs. A 3 mm
pulmonary nodule
is seen within the right upper lobe (3:46, 400b:39). There is
dependent
subsegmental atelectasis within both lungs.
IMPRESSION:
1. No acute intracranial abnormality.
2. No large vessel occlusion, flow-limiting stenosis, or
aneurysm larger than 2 mm involving the intracranial anterior or
posterior circulation or cervical arterial vesssels.
3. 3 mm right upper lobe pulmonary nodule should be followed up
with
dedicated chest NECT within ___ year, given the underlying
emphysema.
4. Mandibular periodontal disease, as described above.
.
Discharge labs:
___ 07:15AM BLOOD WBC-9.4 RBC-4.90 Hgb-16.0 Hct-46.0 MCV-94
MCH-32.6* MCHC-34.7 RDW-13.3 Plt ___
___ 07:15AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-81 UreaN-21* Creat-1.1 Na-139
K-3.8 Cl-101 HCO3-27 AnGap-15
___ 04:50AM BLOOD ALT-60* AST-34 AlkPhos-84 TotBili-0.7
___ 04:50AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.3
___ 09:25PM BLOOD VitB12-302
___ 01:10PM BLOOD METHYLMALONIC ACID-PND
Brief Hospital Course:
___ h/o HTN, COPD, HBV p/w 2 episodes of altered mental status
with separate semiologies involving (1) weakness and
paresthesias of both arms and (2) an episode of unresponsiveness
with maintained tone. He was evaluated from a cardiac
perspective and for possible seizure or catatonia/cataplexy, all
of which were unrevealing. He was treated for cellulitis on the
left third digit (hand) with recommendations from hand surgery.
.
ACTIVE ISSUES
# Altered mental status: The patient presented with 2 episodes
of altered mental status at which time he was unresponsive and
without recollection of the event. Non-contrast head CT ruled
out acute bleed, CTA of the head and neck did not reveal
evidence of obstruction to suggest TIA. He was placed on
telemetry with no events overnight to suggest a cardiac etiology
and cardiac enzymes were negative. Urine toxicology was
negative, ruling out intoxication. He was transferred to the
neurology team who placed him on 24 hr EEG to evaluate for
seizures. His work-up was not consistent with seizure; EEG was
unreavealing. His condition was not obvious for catatonia or
cataplexy per psychiatry.
.
# Parasthesia: The patient presented with several episodes of
parasthesias and loss of function of both arms. Vitamin B12 and
TSH levels were obtained and were normal. Cervical radicolopathy
was on the differential though the patient denies neck pain. His
symptoms are likely tied to his loss of consciousness. 24 hr EEG
revealed ***
.
# Celluitis: The patient stated that he has had inflammation and
exudate over the PIP joint on the third digit of the left hand
for weeks-months. He denied constitutional symptoms, loss of
function, or recent spread. CRP and ESR were unremarkable. X-ray
did not show evidence of osteomyelitis. Hand surgery was
consulted. The patient received vancomycin while in house and
cephalexin at time of discharge.
.
# Leukocytosis: The patient presented with a mild leukocytosis
on admission without other symptoms to suggest infection and was
afebrile throughout the hospital stay. His WBC count downtrended
on the second hospital day. Urinalysis was negative in ED. This
continued to down-trend without obvious cause for elevation. It
had already trended down for several days prior to initiation of
antibiotics, so was not thought infectious.
.
INACTIVE ISSUES
# HTN: Given his history of altered mental status, there was
concern that a recent increase in his amlodipine dose may have
caused orthostasis. His amlodipine was held and orthostatics
performed. These were positive by heart rate criteria though the
patient remained asymptomatic. His amlodipine was restarted
prior to discharge.
.
# COPD: Continued Ipratropium PRN though the Combivent was not
on the hospital formulation as the patient administered it at
home. He did not have any episodes of shortness of breath
throughout his hospital stay.
.
# Hepatitis B: Continued Tenofovir
.
TRANSITIONAL ISSUES
# PULMONARY NODULE: 3 mm right upper lobe pulmonary nodule
should be followed up with dedicated chest NECT within ___ year,
given the underlying emphysema.
.
# B12: Patient had a borderline low B12; please follow up the
methylmalonic acid and replete B12 if MMA is high.
.
# Spells: Please follow for further developments which might aid
diagnosis.
.
# Cellulitis: Please follow for resolution on cephalexin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Ipratropium Bromide MDI 18 mcg IH QID PRN shortness of breath
2 puffs QID PRN
5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ranitidine 75 mg PO HS GERD
8. Albuterol-Ipratropium ___ mcg IH 2 INHALATIONS BY MOUTH 4
TIMES DAILY AS NEEDED shortness of breath
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Ipratropium Bromide MDI 18 mcg IH QID PRN shortness of breath
5. Lisinopril 40 mg PO DAILY
6. Ranitidine 75 mg PO HS GERD
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
8. Albuterol-Ipratropium ___ mcg IH 2 INHALATIONS BY MOUTH 4
TIMES DAILY AS NEEDED shortness of breath
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with episodes of numbness and loss of function
of your arms and intermittent periods of loss of consciousness.
We evaluated the possible causes for your symptoms, including
problems with your heart, the possibility of a stroke, or a
seizure. We determined that these symptoms were not due to your
heart or a stroke. We placed you on a monitor for 24 hours to
determine if you might have had seizures but none were found
Followup Instructions:
___
|
10502580-DS-16 | 10,502,580 | 20,540,677 | DS | 16 | 2154-12-23 00:00:00 | 2154-12-23 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by admitting MD:
Mr. ___ is a ___ M with a sig PMHx of COPD (FEV1 62%, not on
home O2), HTN, OSA, tobacco dependence, and possible seizure
disorder who presents with a productive cough and chest
tightness.
The patient was in his usual state of health until 2 weeks prior
to admission. He developed a productive cough with green-yellow
sputum,
with associated dyspnea and wheezing. He states he has had
several sick contacts at work, one of whom was diagnosed with
pneumonia. His symptoms progressed and the day prior to
admission, he developed fevers ___ F), chills, and a worsening
cough. He also had an associated pleuritic chest tightness. His
chest pain was not exertional and not positional. He denies any
orthopnea or PND. He took his home nebulizer treatments with
minimal improvement. He denied any recent hospitalizations.
Of note, the patient was recently seen at ___ ED for CAP in
___, where he was managed with PO levofloxacin and high dose
prednisone.
Past Medical History:
Hypertension
Carpal tunnel syndrome
Osteoarthritis of carpometacarpal joint of thumb
Tobacco abuse
COPD
Partial epilepsy
Social History:
___
Family History:
Brother Alive ___
Father ___
Mother ___ Arthritis
Pertinent Negatives
Neg HX Cancer - Colon, Cancer - Prostate
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.9 PO 128 / 68 91 17 95 RA
General: pleasant, sitting upright, no acute distress.
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: Clear to auscultation bilaterally, diffuse audible
wheezes
in all lung fields
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ DP pulses. no peripheral edema.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. gait not
assessed.
DISCHARGE PHYSICAL EXAM:
VS: 98.2PO 117 / 73 87 20 95 RA
GENERAL: well appearing, sitting up in bed, comfortable
HEENT: Sclerae anicteric, MMM
CV: RRR, nl S1/S2, no m/g/r
LUNGS: mild expiratory wheezing diffusely, no crackles, good air
exchange, no accessory muscle use
ABD: NABS, soft, nontender, nondistended
EXTR: no edema or cyanosis
NEURO: A/OX3, moves all extremities
SKIN: warm, dry, no rashes
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 10:45AM BLOOD WBC-15.2* RBC-4.72 Hgb-15.0 Hct-45.4
MCV-96 MCH-31.8 MCHC-33.0 RDW-14.0 RDWSD-49.4* Plt ___
___ 10:45AM BLOOD Neuts-74.5* Lymphs-14.3* Monos-7.6
Eos-2.6 Baso-0.5 Im ___ AbsNeut-11.34* AbsLymp-2.17
AbsMono-1.16* AbsEos-0.39 AbsBaso-0.08
___ 07:17AM BLOOD ___ PTT-26.1 ___
___ 10:45AM BLOOD Glucose-101* UreaN-26* Creat-1.1 Na-142
K-4.0 Cl-105 HCO3-25 AnGap-12
___ 07:17AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 07:18AM BLOOD WBC-15.3* RBC-4.69 Hgb-14.9 Hct-44.8
MCV-96 MCH-31.8 MCHC-33.3 RDW-14.0 RDWSD-49.0* Plt ___
___ 07:18AM BLOOD Plt ___
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ CULTURE No growth
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ X-RAY (PA & LAT)
Streaky and patchy bibasilar opacities may reflect atelectasis,
with early
infection not completely excluded in the correct clinical
setting.
Brief Hospital Course:
SUMMARY:
====================================
Mr. ___ is a ___ man with history of HTN, COPD on home O2,
and ?seizure disorder who presented with 2 weeks of productive
cough and progressive dyspnea. CXR was concerning for pneumonia
and he was started on antibiotics course for CAP was well as
steroid burst.
# Acute COPD Exacerbation
The patient presents with progressive dyspnea, wheezing, and a
productive cough X 2 weeks, acutely worsened in the days prior
to admission. He had several sick contacts and exacerbation was
felt to be precipitated by pneumonia. He remained stable and did
not require supplemental oxygen or intubation. He was treated
with prednisone 40mg QD x5 days (___). He was treated
symptomatically with Duonebs in addition to his home inhalers.
His home inhaler regimen was continued. An ambulatory o2 sat was
94-97% on RA on the day of discharge.
# Community Acquired Pneumonia
The patient was noted to have patchy bibasilar opacities on CXR,
concerning for atelectasis vs. pneumonia. He was afebrile but
did have mild leukocytosis and decision was made to treat for
CAP given relative severity of his respiratory status on
presentation. He was treated with IV CTX and azithromycin (start
date ___ and completed this prior to discharge (___)
# Hypertension
Continued home Lisinopril, HCTZ, and Amlodipine daily.
# GERD
Continued home Ranitidine daily.
#CAD
Continued home atorvastatin and ASA daily
TRANSITIONAL ISSUES:
====================================
[] Patient endorsed interest in smoking cessation, continue to
encourage and provide with supportive resources. He missed an
appointment to see a hypnotist to help with cessation and will
reschedule this.
MEDICATION CHANGES:
====================================
- Nicotine patch 21mg QD
CODE: Full
CONTACT: ___ ___
Time spent: 40 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Ranitidine 75 mg PO QHS
6. Aspirin 81 mg PO DAILY
7. Stiolto Respimat (tiotropium-olodaterol) 2.5-2.5
mcg/actuation inhalation DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine [Nicoderm CQ] 21 mg/24 hour Transdermal Daily Disp
#*30 Patch Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
9. Lisinopril 40 mg PO DAILY
10. Ranitidine 75 mg PO QHS
11. Stiolto Respimat (tiotropium-olodaterol) 2.5-2.5
mcg/actuation inhalation DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
#COPD exacerbation
#Community-acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had cough and difficulty breathing
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have an exacerbation of your COPD and
pneumonia
- You were treated with steroids and antibiotics
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10502959-DS-5 | 10,502,959 | 20,576,531 | DS | 5 | 2166-02-20 00:00:00 | 2166-02-23 21:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/no known PMH (doesn't see doctors) who is admitted for
worsening SOB, uncontrolled HTN and newly diagnosed heart
failure.
.
.
Patient has not been to see a doctor for many years and has no
significant known medical history. In the past ___ months she
has noticed worsening DOE and is down from being able to walk 21
to 8 steps w/o stopping. She also has Parox Noct Dysp X2. She
has not noticed any recent weight gain or leg swelling. She
denies orthopnea and sleeps with 1 pillow. For the past ___ days
she has been taking Advil+oral anti-congestants for nasal
congestion Q4H. This morning she had sudden worsening SOB while
going down stairs, and she drove herself to ED for evaluation.
On ROS in ED, she had c/o SOB and cough x ___ months, denied CP
or palpitations.
In the ED, initial vitals were 97.6 HR133 BP 189/115 RR19 97%RA.
Labs were notable for WBC 11.5 (76.2%PMNs), Cr 1.0, glucose 254,
BNP 260, TNT <0.01 x 1. EKG reportedly showed sinus tachy, no
st-t changes. CXR showed diffuse, bilateral opacities and
bilateral pleural effusions c/f pulmonary edema. Bedside echo
was performed and showed no effusion, no septal wall bowing, +
LV hypertrophy, tachycardic, no obvious wall abnormalities.
Patient was given ASA 325mg PO and SL Nitro 0.3mg x 1. She was
started on a Nitro gtt for persistent hypertension, and admitted
to ___ with concern for new HF diagnosis.
On review of systems, she reports prior history of increased
menstrual bleeding, she still gets regular period but with small
bleeds.
.
she denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
- Mennorrhagia: years ago required blood transfusion for anemia
___ to this
- Anemia
- s/p tonsillectomy in her ___.
MEDICATIONS:
Multivitamin + B complex
Recent Ibuprofen and nasal decongestant
Social History:
___
Family History:
Brother HTN, otherwise no family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Wt= 254lb ... T= 98.8...BP= 164/97 on nitro drip...HR=
130...RR= 24 (now 18 on my check)...O2 sat= 92RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate, no
respiratory distress, no speech dyspnea.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVD to angle of jaws
CARDIAC: Rapid RRR with gallop (S3? S4?) No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bi-basilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: +2 edema pre-tibial, no signs of DVT,
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAMINATION
VS: 98.6f 135/96 102 20 98% ra I/O 1320/1450 ___ ___
212 (AML)
GENERAL: NAD. Oriented x3. Mood, affect appropriate, no
respiratory distress, can speak in complete sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVD to angle of jaws
CARDIAC: RRR HR in 100s
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Mild bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: Mild pedal edema
Pertinent Results:
ADMISSION LABS
===============
___ 05:57PM LACTATE-1.9
___ 05:45PM cTropnT-<0.01
___ 09:40AM GLUCOSE-254* UREA N-9 CREAT-1.0 SODIUM-139
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
___ 09:40AM estGFR-Using this
___ 09:40AM ALT(SGPT)-75* AST(SGOT)-77* TOT BILI-0.8
___ 09:40AM LIPASE-18
___ 09:40AM proBNP-260*
___ 09:40AM cTropnT-<0.01
___ 09:40AM CALCIUM-9.6 PHOSPHATE-2.4* MAGNESIUM-1.8
CHOLEST-175
___ 09:40AM D-DIMER-2366*
___ 09:40AM %HbA1c-8.7* eAG-203*
___ 09:40AM TRIGLYCER-64 HDL CHOL-38 CHOL/HDL-4.6
LDL(CALC)-124
___ 09:40AM TSH-0.60
___ 09:40AM WBC-11.5* RBC-5.54* HGB-13.4 HCT-39.7 MCV-72*
MCH-24.2* MCHC-33.7 RDW-15.9*
___ 09:40AM NEUTS-76.2* ___ MONOS-3.3 EOS-0.9
BASOS-0.3
___ 09:40AM PLT COUNT-301
RELEVANT BLOODWORK
===================
___ 06:30AM BLOOD ALT-59* AST-33 AlkPhos-70 TotBili-0.8
___ 09:40AM BLOOD ALT-75* AST-77* TotBili-0.8
___ 09:40AM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD cTropnT-<0.01
___ 09:40AM BLOOD Triglyc-64 HDL-38 CHOL/HD-4.6 LDLcalc-124
___ 09:40AM BLOOD %HbA1c-8.7* eAG-203*
STUDIES
=======
CXR ___
IMPRESSION:
Findings most suggestive of moderate pulmonary edema. Small
bilateral pleural
effusions. Mild cardiomegaly.
CTA ___
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Cardiomegaly, small bilateral pleural effusions, and mild
pulmonary edema, consistent with decompensated congestive heart
failure.
3. Dilation of the main pulmonary artery is suggestive of
pulmonary
hypertension.
4. Large heterogeneous left thyroid nodule, which should be
further evaluated by ultrasound.
5. Pulmonary nodules in the right and left upper lobe which are
likely infectious or inflammatory, however, which should be
followed up upon resolution of acute symptoms with a formal
chest CT.
ECHO ___
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. There
is mild global left ventricular hypokinesis (LVEF = 45-50 %).
Overall left ventricular systolic function is mildly depressed.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (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. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and mild global hypokinesis. Elevated
estimated PCWP. Normal right ventricular cavity size and
systolic function. Mild mitral regurgitation. (At least) mild
pulmonary artery systolic hypertension.
Thyroid US ___
IMPRESSION:
1. Dominant left thyroid nodule. An ultrasound-guided FNA of
this nodule is
recommended.
2. Two small right thyroid nodules which can be reassessed on
the routine
follow up ultrasound.
ECG ___
Sinus rhythm and occasional ventricular ectopy. Slowing of the
rate as
compared with previous tracing of ___. Non-specific ST-T
wave flattening
persists without diagnostic interim change.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ w/no known PMH (doesn't see doctors)
who is admitted for worsening SOB found to have uncontrolled HTN
and newly diagnosed heart failure.
# Hypertensive urgency: Presented with HTN, systolic BPs in 190s
on presentation. Started on nitro gtt initially, transitioned to
ACEI and metoprolol with good response, SBP in 130s on
discharge.
# Worsening SOB/CHF: Tachycardia with worsening SOB initially
had a broad differential including infectious process, PE or HF.
No PE seen on CTA, no evidence of pneumonia on imaging. Most
likely cause given HTN, ___ edema and pulm edema on imaging is
acute exacerbation of CHF. HTN coupled with oral phenylephrine
agent use probably induced acute exacerbation. Diuresed using IV
lasix. Responded well to diuresis with improvement in symptoms
and exam, transitioned to oral lasix eventually. Given that
patient presented with hypertensive urgency, was started on ACEI
and beta blocker. TTE showed diastolic and systolic heart
failure. Risk factors for HF were controlled as described below.
# Tachycardia: Initially tachycardic to 140s, improved to 100s.
Likely secondary to decompensated heart failure +/- OTC meds
which potentially contain pseudophenylephrine which increases
both BP and HR. PE ruled out per CT, TSH WNL. As noted, HR
improved with HF treatment.
# DM: Hba1c checked to assess for risk factors for HF, found to
be 8.7. Patient maintained on HISS in house. Counseled re
diabetic diet, appropriate lifestyle modifications. Started on
metformin on discharge.
# Large heterogeneous left lobe of thyroid mass with internal
coarse calcifications, incidentally noted on CTA looking for PE.
TSH WNL. Thyroid ultrasound showed large left nodule, smaller
right nodules. Patient will undergo FNA for further workup as
outpatient.
# Mild transaminitis: Transaminases in ___ on admission,
improved. most likely liver congestion in the setting of heart
failure.
TRANSITIONAL ISSUES
===================
-6 mm RUL pulmonary nodule should be followed up in ___ year with
CT
-Thyroid nodule should be followed up with FNA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
6. Vitamin B Complex 1 CAP PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO DAILY
RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Systolic and diastolic heart failure, Hypertension,
Hyperlipidemia, Diabetes Mellitus, Thyroid nodule
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 ___ because you were having shortness
of breath. You were found to have a high blood pressure that
likely caused fluid to build up into your lungs making you short
of breath, that is, heart failure. We also found you had
diabetes and high cholesterol. An echo of your heart showed that
you had some changes from the high blood pressure, including
high pressures in the blood vessels in your lungs. We started
you on medications to help with all of these.
A CT scan of your chest did not show any blood clots in your
lungs but did show a nodule in your thyroid gland. An ultrasound
showed nodules, you will need further testing for these. The CT
scan also showed a nodule in your lung that should be followed
with a CT scan in one year.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10502984-DS-13 | 10,502,984 | 22,818,908 | DS | 13 | 2133-01-09 00:00:00 | 2133-01-08 20:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cats / metformin
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male 2 months s/p R TKA ___,
___ who fell directly onto his knee causing dehiscence of
his central incision, s/p R TKA I&D and closure ___, ___
and now s/p takeback presenting with right knee pain. He was
unable to fill his oxycodone prescription due to money concerns.
No fevers/ chills. No changes in medications. Patient has had
multiple recent falls. The falls are usually positionally
related, as in when he makes sudden movements etc. He develops
sharp pain in his knee which causes him to fall.
In the ED he was confused about timing of events and the order
of which things took place, and how recently he was operated on.
He has no localizing symptoms though he appears confused. He was
evaluated by ortho and his knee was healing well. His history
was changing in the ED. He was evaluated in the ED one week ago
and set up with 24 hour supervision, which failed due to the
patient eloping prior to services being established. He does
remember this, but was unaware that they were establishing 24H
care for him. He has been told he needs to have a neurologic
eval for cognitive eval and NPH eval.
He has no symptoms of fever, chills, nausea, vomiting, CP, SOB,
cough, abd pain, diarrhea, constipation, dysuria.
In the ED:
Initial vitals: 98.5 118 124/70 16 95%
Transfer vitals: 98.4 110 127/77 16 97% RA
Labs significant for leukocytosis (mild), thrombocytosis (500s),
anemia, + benzos on tox (prescribed clonazepam).
CT of c-spine shows DJD, CT head with continued signs of central
atrophy vs. NPH.
ROS: Pertinent positive and negatives per HPI, all others are
negative in detail.
Past Medical History:
OSA (Bipap)
HTN
DM2 (diet controlled A1C 6.1-6.3)
hypothyroid
GERD
BPH
s/p CCY
s/p BCC excised
dermatitis
keratosis
visual impairment
Hx of Campylobacter diarrhea
s/p L THA w/2x revisions
s/p nasal turbinate surgery
s/p Appy
s/p L meniscus repair
Social History:
___
Family History:
Father with ___
Physical Exam:
Admission Exam:
VS: HR 104 afebrile
Gen: NAD, pleasant
HEENT: anicteric, MMM
CV: tachycardic, regular rhythm, soft systolic murmur
Pulm: CTAB
GI: Soft, NT, ND, NABS
MSK: right knee with well healed incision, no erythema, no
effusion, no TTP except the superior lateral aspect of the scar
Psych: Mood/affect appropriate
Neuro: oriented, recounts history, understands the evaluation,
moving all extremities, mild cogwheeling in the upper
extremities
Discharge Exam:
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/NT/ND, BS present
NEURO: Alert, oriented, ___ strength in all 4 extremities
EXT: R knee mildly swollen, healed surgical incision (stable
exam from yesterday)
Pertinent Results:
Initial Labs:
___ 07:50AM BLOOD WBC-11.4* RBC-3.34* Hgb-9.2* Hct-28.1*
MCV-84 MCH-27.5 MCHC-32.7 RDW-14.6 Plt ___
___ 07:50AM BLOOD Neuts-66.9 ___ Monos-7.1 Eos-3.8
Baso-0.2
___ 07:50AM BLOOD Glucose-140* UreaN-16 Creat-1.1 Na-133
K-5.2* Cl-98 HCO3-23 AnGap-17
___ 07:37AM BLOOD Calcium-9.4 Phos-4.4# Mg-1.6
___ 09:00PM BLOOD VitB12-338 Folate-10.0
___ 09:00PM BLOOD %HbA1c-6.7* eAG-146*
___ 09:00PM BLOOD TSH-4.9*
___ 09:00PM BLOOD PEP-AWAITING F IgG-1297 IgA-323 IgM-72
IFE-PND
___ 07:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Most Recent Labs:
___ 07:50AM BLOOD WBC-9.0 RBC-3.18* Hgb-8.4* Hct-25.9*
MCV-81* MCH-26.3* MCHC-32.4 RDW-14.4 Plt ___
___ 07:50AM BLOOD Glucose-135* UreaN-20 Creat-1.1 Na-138
K-4.9 Cl-100 HCO3-28 AnGap-15
___ 10:08PM URINE Color-Straw Appear-Clear Sp ___
___ 10:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:50AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
R Knee Films (___) - IMPRESSION:
Study of ___, there is little change in the appearance of
the total knee arthroplasty, which appears well seated without
evidence of hardware-related complication. No evidence of
periprosthetic fracture.
CT CSpine - IMPRESSION:
1. No acute fracture or acute malalignment.
2. Multilevel degenerative changes as described above with
stable mild anterolisthesis of C4 on C5 with moderate right
neural foraminal narrowing at C4-5 and C6-7 ___s mild
canal narrowing at C5-6 and C6-7.
CT Head - IMPRESSION:
1. Persistent prominence of ventricles and sulci are unchanged
since previous examination and can be seen with central atrophy,
however correlation for signs of normal pressure hydrocephalus
is recommended.
2. No intracranial hemorrhage.
3. Mild mucosal thickening is noted on the right mastoid air
cells.
R Knee Films (___) - IMPRESSION:
Status post right total knee arthroplasty without evidence of
hardware-related complications.
CXR - IMPRESSION:
No evidence of acute cardiopulmonary process. Asymmetrical
opacity at right first costochondral junction is likely due to
asymmetrical degenerative changes, but additional shallow
oblique radiographs may be helpful to exclude a lung nodule.
Brief Hospital Course:
Mr. ___ is a ___ year old male 2 months s/p R TKA ___,
___ who fell directly onto his knee causing dehiscence of
his central incision, s/p R TKA I&D and closure ___, ___
and now s/p takeback presenting with right knee pain and mental
status changes.
Confusion: Very mild. Cleared on day 2 of admission. Likely
related to opiates given that he cleared while holding them.
Falls with knee pain: Seems mechanical given description. He
does have a shuffling gait and possible myelopathy. Neuro was
consulted for evaluation and felt this was likely related to
spinal DJD as well as neuropatht, recommended outpatient
follow-up. Neuro exam did reveal neuropathy, for which
outpatient follow-up was recommended. His pain regimen was
augmented to include tramadol and gabapentin. He received
toradol short term for acute pain. ___ recommended rehab.
Neurology will contact patient to arrange follow-up appointent.
GAD with Tachycardia: Continued clonazepam, fluoxetine,
mirtazapine and atenolol 50mg.
Hypertension: continued home lisinopril
Hyperlipidemia: Continued simvastatin
Hypothyroidism: Continued levothyroxine
TRANSITIONAL ISSUES:
- Patient would likely benefit from an OT evaluation.
- Lab work sent as work-up for neuropathy revealed a mildly
elevated TSH. T4 sent and pending at the time of discharge, will
need to be followed up.
- SPEP pending at discharge and needs to be followed up.
- CXR revealed "Asymmetrical opacity at right first
costochondral junction is likely due to asymmetrical
degenerative changes, but additional shallow oblique radiographs
may be helpful to exclude a lung nodule." Consider repeat CXR as
outpatient vs. comparison to prior examinations.
Medications on Admission:
1. Atenolol 50 mg PO QPM
2. ClonazePAM 1 mg PO BID
3. Duloxetine 60 mg PO QPM
4. Ketoconazole 2% 1 Appl TP QHS
5. Ketoconazole Shampoo 1 Appl TP ASDIR
6. Levothyroxine Sodium 137 mcg PO QPM
7. Lisinopril 20 mg PO QPM
8. Magnesium Oxide 400 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO QPM
11. Simvastatin 20 mg PO QPM
12. Docusate Sodium 100 mg PO BID
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
14. Senna 17.2 mg PO HS
15. Mirtazapine 15 mg PO QHS
16. Tamsulosin 0.4 mg PO DAILY
17. Aspirin 325 mg PO BID Duration: 3 Weeks
Discharge Medications:
1. Atenolol 50 mg PO QPM
2. ClonazePAM 1 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 60 mg PO QPM
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO QHS
10. Simvastatin 20 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Gabapentin 200 mg PO TID
13. TraMADOL (Ultram) 25 mg PO Q6H:PRN breakthrough pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*15 Tablet Refills:*0
14. Aspirin 325 mg PO DAILY
15. Ketoconazole 2% 1 Appl TP QHS
16. Ketoconazole Shampoo 1 Appl TP ASDIR
17. Magnesium Oxide 400 mg PO DAILY
18. bipap
use bipap as directed, nightly
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Arthropathy
Delirium from opiates
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for confusion and knee pain. You
confusion was likely related to your opiate medications which
improved with stopping them. ___ and neurology evaluated you.
Your symptoms were likely related to arthritis of your spine as
well as neuropathy. You will follow up with neurology as an
outpatient. Rehab was recommended.
Followup Instructions:
___
|
10502984-DS-16 | 10,502,984 | 28,996,226 | DS | 16 | 2136-10-03 00:00:00 | 2136-10-04 07:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cats / metformin / oxycodone / morphine
Attending: ___.
Chief Complaint:
Cough, Fever, Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of T2DM c/b neuropathy and nephropathy, stage
III CKD, HTN, dyslipidemia, OSA, hypothyroidism, and
depression/anxiety who presents with generalized weakness,
cough,
and fever.
Patient reports that two days ago, he developed fatigue,
generalized weakness, and productive cough with occasional
blood-tinged sputum. He presented to his PCP at ___ on ___,
where he was diagnosed with acute bronchitis (no abx
prescribed).
He denies associated SOB or recent sick contacts. He woke up
this
morning and fell onto his knees while getting out of bed. No
preceding CP, palpitations, or LH/dizziness. Denies head strike
or LOC. Downtime of ___ hours prior to EMS arriving because he
felt too weak to pull himself up.
In the ED, initial vitals were:
T100.6, HR 130, BP 142/78, RR 16, SpO2 95% on 2L NC
Exam notable for:
Gen: Comfortable, No Acute Distress
HEENT: NC/AT. EOMI. dry mucous membranes.
Neck: No swelling. Trachea is midline.
Cor: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Soft, nontender, nondistended.
Ext: No edema, cyanosis, or clubbing.
Skin: No rashes. No skin breakdown
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechia. No ecchymosis.
Relevant labs:
WBC 18.3, Hgb 12.2
Cr 1.1, Mg 1.3
LFT's unremarkable
VBG 7.43/38/68
Lactate 2.6 -> 2.0 prior to transfer
Trops negative
Flu negative
UA with negative nitrites and leuks, few bacteria
Relevant studies:
CXR with LLL consolidation c/f PNA.
NCHCT/CT C spine with no e/o acute fracture, no acute
intracranial disease.
EKG: HR 113, NSR, Q wave in III, ?aVF, and V1, not significantly
changed from prior ___ EKG)
Patient was given:
- 1L LR x2
- PO Tylenol 1g
- IV CTX 1g
- PO azithromycin 250mg
- PO levothyroxine 125mcg
- PO atenolol 50mg
- PO duloxetine 60mg
- PO lisinopril 20mg
- IV Mg 4g
Vitals on transfer:
T 97.9, HR 95, BP 121/68, SpO2 98% on 2L NC
On the floor, patient reports persistent cough without dyspnea.
Says that his legs feel at their baseline weakness. Denies back
pain, abdominal pain.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
T2DM, CKD stage III, HTN, hypothyroidism, OSA, MDD, anemia, BPH,
osteoarthritis, recurrent falls with h/o SDH, basal cell
carcinoma, seborrheic dermatitis
Social History:
___
Family History:
Non-contributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 1748)
Temp: 97.5 (Tm 97.5), BP: 119/69, HR: 86, RR: 20, O2 sat:
94%, O2 delivery: 2L NC
GENERAL: Sitting up in bed, alert and interactive, in NAD, no
increased WOB on 2L NC
HEENT: NCAT, clear oropharynx, MMM
CARDIAC: Distant heart sounds, S1, S2, RRR, no m/r/g
LUNGS: Decreased breath sounds with inspiratory crackles in the
bilateral bases
ABDOMEN: Soft, NTND
EXTREMITIES: No ___ edema, superficial abrasion on R knee, soft
compartments in all extremities
SKIN: Seborrheic dermatitis of face
NEUROLOGIC: AOx3, unsteady gait with small steps requiring
multiple assist, strength exam full to confrontation, intact
rectal tone
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 749)
Temp: 97.4 (Tm 98.5), BP: 95/59 (95-112/59-71), HR: 70
(70-91), RR: 16 (___), O2 sat: 93% (90-93), O2 delivery: Ra
GENERAL: Sitting up in chair eating breakfast. Alert and
conversant
HEENT: NCAT, clear oropharynx, MMM
CARDIAC: Normal S1, S2, RRR, no m/r/g
LUNGS: CTAB no wheezes, rales, or rhonchi.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: R ___ metatarsal edematous and erythematous, tender
to palpation.
SKIN: Seborrheic dermatitis of face
Pertinent Results:
ADMISSION LABS:
===============
___ 03:40AM BLOOD WBC-18.3* RBC-4.12* Hgb-12.2* Hct-38.1*
MCV-93 MCH-29.6 MCHC-32.0 RDW-13.7 RDWSD-46.5* Plt ___
___ 03:40AM BLOOD Neuts-83.3* Lymphs-7.5* Monos-8.1
Eos-0.2* Baso-0.2 Im ___ AbsNeut-15.28* AbsLymp-1.37
AbsMono-1.48* AbsEos-0.04 AbsBaso-0.04
___ 03:40AM BLOOD ___ PTT-27.1 ___
___ 03:40AM BLOOD Ret Aut-1.5 Abs Ret-0.06
___ 03:40AM BLOOD Glucose-163* UreaN-17 Creat-1.1 Na-137
K-4.4 Cl-99 HCO3-23 AnGap-15
___ 03:40AM BLOOD ALT-12 AST-13 AlkPhos-101 TotBili-0.8
___ 03:40AM BLOOD cTropnT-<0.01
___ 03:40AM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.0 Mg-1.3*
___ 11:42AM BLOOD calTIBC-282 VitB12-288 Folate-7
Ferritn-165 TRF-217
___ 11:50AM BLOOD %HbA1c-6.8* eAG-148*
___ 11:42AM BLOOD TSH-3.7
___ 04:00AM BLOOD ___ pO2-68* pCO2-38 pH-7.43
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 04:00AM BLOOD Lactate-2.6*
___ 06:55AM BLOOD Lactate-2.8*
___ 11:52AM BLOOD Lactate-2.0
___ 06:55AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:55AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:55AM URINE RBC-<1 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-2
___ 06:55AM URINE CastHy-1*
DISCHARGE LABS:
===============
___ 06:20AM BLOOD WBC-10.0 RBC-3.77* Hgb-11.1* Hct-36.1*
MCV-96 MCH-29.4 MCHC-30.7* RDW-13.5 RDWSD-47.9* Plt ___
___ 06:20AM BLOOD Glucose-123* UreaN-28* Creat-1.2 Na-138
K-4.8 Cl-100 HCO3-23 AnGap-15
___ 06:20AM BLOOD Calcium-9.4 Phos-5.2* Mg-1.9 UricAcd-7.0
MICROBIOLOGY:
=============
___ 04:10AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___: Urine legionella - negative
___: Urine strep pneumo - negative
IMAGING/STUDIES:
================
CXR ___:
IMPESSION:
Left lower lobe pneumonia. No pleural effusion.
CT Head ___:
IMPRESSION:
1. No acute intracranial abnormality on noncontrast CT head.
Specifically no acute large territory infarct or intracranial
hemorrhage.
2. Unchanged parenchymal atrophy. Probable sequelae of chronic
small vessel ischemic disease.
3. Mild anterior ethmoid paranasal sinus disease.
4. No evidence of acute displaced calvarial fracture.
CT C-Spine ___:
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Multilevel degenerative changes in the cervical spine,
similar to prior
Brief Hospital Course:
Providers: ___ with history of T2DM c/b neuropathy and
nephropathy, CKD stage III, HTN, HLD, OSA, and
depression/anxiety who presents after fall with fevers and acute
hypoxia ___ community-acquired LLL PNA.
ACUTE ISSUES:
=============
#Community-acquired LLL PNA
#Hypoxia
CXR on admission with LLL opacity concerning for viral or
bacterial PNA. No significant risk factors for MRSA or
Pseudomonas. Patient admitted for hypoxia which was felt to be
most likely secondary to his acute infection. Patient was placed
on Ceftriaxone and Azithromycin and subsequently transitioned to
cefpodoxime/azithromycin for total 5 day course (___) to
treat a likely CAP and his hypoxia resolved.
# Right first metatarsal edema and erythema
Patient developed pain and swelling in right first metatarsal
joint concerning for inflammatory process. He is being treated
empirically for gout flare with colchicine and naproxen. Less
likely infectious cause given improvement with anti-inflammatory
regimen and he has been afebrile without a leukocytosis. Patient
states that he has been told that he may have had gout in the
past but is unsure of where this occurred. He is being
discharged on colchicine 0.6mg daily which should be continued
until 48 hours after resolution of symptoms. He has not had a
joint aspiration for a formal diagnosis of gout, if he were to
develop another flare, this should be considered.
#Mechanical fall
#Gait disturbance
History of recurrent falls per ___ records felt to be likely
secondary to diabetic neuropathy and deconditioning. Given
clinical history, current fall seems precipitated by infection
superimposed on sensory ataxia. Felt to be less concerning for
ACS (EKG unchanged, trops negative)/arrhythmia or syncope.
Non-contrast head CT/CT C-spine atraumatic, and neurologic exam
intact on admission. Downtime of 4 hours prior to EMS arrival
made rhabdomyolysis less likely to be an issue especially with
Cr at baseline, no e/o compartment syndrome, CK normal.
Possibility exists that some of his home medications (benzo,
anti-HTN) may be contributing to falls though gait disturbance
and deconditioning likely played the major role. ___ evalauted
patient while he was admitted and felt that he would be best
served going to rehab when discharged from the hospital.
#HLD
Home atorvastatin 40mg QHS currently being held while being
treated with colchicine. Atorvastatin should be resumed when the
patient is no longer on colchicine.
#Risk of protein-calorie malnutrition
Nutrition consulted, patient started on daily MVI with minerals,
glucerna shakes TID
CHRONIC ISSUES:
===============
#Hypomagnesemia
continued home PO Mg 400mg qd
#Normocytic anemia
Hgb at baseline on admission. Likely ___ nutritional
deficiencies and anemia of
CKD.
#T2DM c/b neuropathy and CKD
A1c 6.8 on admission. Insulin sliding scale provided while in
house
#HTN
continued home lisinopril 20mg qd + atenolol 50mg qd
#Hypothyroidism
continued home levothyroxine 137mcg qd
#OSA
Reports using BiPAP at home in the past but home machine broken
presently. Provided CPAP while in house
#MDD/anxiety
continued home duloxetine 60mg qd, mirtazapine 15mg qHS + PO
clonazepam 1mg qHS
#GERD
continued home omeprazole 20mg qd
NEW MEDICATIONS: cefpodoxime, colchicine
CHANGED MEDICATIONS: Multivitamins to multivitamins with
minerals
TRANSITIONAL ISSUES
===================
Discharge Uric Acid: 7
[ ] Requires 1 dose of cefpodoxime 400 mg at ___ to
complete 5 day course ___ - ___.
[ ] Check chemistry panel on ___ to evaluate renal function.
Discharge Cr 1.2.
[ ] consider decreasing antihypertensives and/or sedating
medications as an outpatient if continuing to have recurrent
falls
[ ] ___ concern for gout, would pursue arthrocentesis for
diagnostic purposes if he develops another flare.
[ ] Discharged on colchicine 0.6mg daily for presumed gout
flare. This should be discontinued 48 hours after resolution of
symptoms.
[ ] Atorvastatin being held on discharge due to interaction with
colchicine. Can restart atorvastatin once colchicine
discontinued.
[ ] PCP ___ on rehab discharge
[ ] Consider repeat CXR in 6 weeks
[ ] Obtain uric acid level ___ weeks after resolution of gout
symptoms
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Magnesium Oxide 400 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. ClonazePAM 1 mg PO QHS
6. DULoxetine 60 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Lisinopril 20 mg PO DAILY
9. Atenolol 50 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 1 Dose
2. Colchicine 0.6 mg PO DAILY
Ongoing until 48 hours after symptoms (foot pain and swelling)
have subsided.
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. ClonazePAM 1 mg PO QHS
7. DULoxetine 60 mg PO DAILY
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. Mirtazapine 15 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until you are no longer taking
colchicine.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
==================
Community Acquired Pneumonia
Mechanical Fall
Gait Distrubance
SECONDARY DIAGNOSIS
===================
Anemia
Type 2 Diabetes
HTN
HLD
Hypothyroidism
OSA
Major Depressive Disorder
Anxiety
GERD
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. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were admitted to the hospital after your were unable to
get up from a fall at home and your oxygen level was found to be
low
What did you receive in the hospital?
- You were found to have a pneumonia and treated with
antibiotics
- A CT scan of your head was performed because you had a fall at
home. This scan did not show any injuries to your head or your
brain from your fall
- Our physical therapists evaluated you and felt that the best
plan for you after discharge would be for you to spend some time
in a rehab facility and get stronger before going home
- Our nutritionists saw you and helped us optimize your diet to
help you get the nutrition that you need
What should you do once you leave the hospital?
- Continue to take all your medications as prescribed
- Follow up with your scheduled appointments as below
- Work hard at rehab and get well soon!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10503003-DS-10 | 10,503,003 | 25,335,710 | DS | 10 | 2152-11-01 00:00:00 | 2152-11-01 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left hip fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with PMH Dementia is transferred from ___
___, with a left hip fracture around old
prosthesis. According to the report, she fell 2 days prior to
admission and was on the ground for a while before being
discovered. At ___, labs showed CK 1697 Cr 1.18 with WBC
11.3 HGB 10.9. She had plain films which showed left hip
fracture, CT head and C-spine were reportedly negative. She was
transferred for further management.
In the ED, initial VS: pain ___ 91 134/74 15 98% 2L Nasal
Cannula. Labs were remarkable for CK: 1487 Cr 0.9 WBC 8.4 HGB:
8.2 HCT 26.2, INR: 1.1 Lactate:1.7. U/A negative. Plain film of
the left hip confirmed fracture. Plain film of the left wrist
was unremarkable. She was given 4L IVNS and did not make urine
despite foley placement. Vitals on transfer Temp: 100.2 °F (37.9
°C) (Rectal), Pulse: 89, RR: 20, BP: 134/66, O2Sat: 95, O2Flow:
ra.
On arrival to the medical floor, vitals were T:98.6 P:92
BP:142/73 RR:16 SaO2: 94% on Room air. She denied pain and
thought she was in a movie theater year ___.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Dementia
s/p left hip arthroplasty
Social History:
___
Family History:
not relevant to chief complaint
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T:98.6 P:92 BP:142/73 RR:16 SaO2: 94% on Room air
GENERAL - ELderly female laying in bed eyes open, orienting to
voice, responding to questions slowly with occasional
inappropriate answers. Otherwise in NAD
HEENT - Left eye appearing cloudy, EOMI, sclerae anicteric, MMM,
OP clear
NECK - Supple, , JVP non-elevated, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ peripheral pulses Tender to palpation over
left hip, no obvious bony deformity.
SKIN - dry crusting throughout covered in moisturizing lotion,
with significant seborrheic dermatitis
NEURO - awake, Place: movie theater year: ___. CNs II-XII
grossly intact
.
DISCHARGE PHYSICAL EXAM:
VS 96.6 (98.8) 130/64 (108-143/60-73) 76 (72-80) 18 97RA
(96-98RA)
I/O 1000 PO + 100 IV / 625
GENERAL - Elderly female, comfortable, looks stated age. NAD.
HEENT - Left eye w/cataract, EOMI, sclerae anicteric, MMM, OP
clear
NECK - Supple, JVP non-elevated, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ peripheral pulses, no tenderness to
palpation over left hip, no obvious bony deformity. 1+ edema in
ankles.
SKIN - dry crusting throughout covered in moisturizing lotion
NEURO - awake, oriented to ___, ___ CNs II-XII
grossly intact
Pertinent Results:
ADMISSION LABS:
___ 12:10AM BLOOD WBC-8.4 RBC-2.69* Hgb-8.2* Hct-26.2*
MCV-98 MCH-30.6 MCHC-31.3 RDW-13.9 Plt ___
___ 12:10AM BLOOD Neuts-78.4* Lymphs-10.2* Monos-10.7
Eos-0.6 Baso-0.1
___ 12:10AM BLOOD ___ PTT-22.3* ___
___ 12:10AM BLOOD Glucose-124* UreaN-24* Creat-0.9 Na-143
K-4.5 Cl-108 HCO3-24 AnGap-16
___ 12:10AM BLOOD ALT-16 AST-49* CK(CPK)-1487* AlkPhos-52
TotBili-0.4
___ 12:10AM BLOOD CK-MB-8
___ 12:10AM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.9 Mg-1.9
___ 12:16AM BLOOD Lactate-1.7
.
RELEVANT LABS:
___ 09:15AM BLOOD CK-MB-9 cTropnT-0.01
___ 06:00PM BLOOD CK-MB-8 cTropnT-0.01
___ 09:15AM BLOOD CK(CPK)-1295*
___ 06:00PM BLOOD CK(CPK)-912*
___ 02:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:00AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 06:00AM BLOOD calTIBC-192* VitB12-94* Folate-14.0
Ferritn-60 TRF-148*
___ Intrinsic factor: PENDING
.
DISCHARGE LABS:
___ 05:16AM BLOOD WBC-4.7 RBC-2.96* Hgb-9.0* Hct-27.8*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.7 Plt ___
___ 05:16AM BLOOD ___ PTT-28.2 ___
___ 05:16AM BLOOD Glucose-87 UreaN-13 Creat-0.5 Na-141
K-3.4 Cl-107 HCO3-27 AnGap-10
___ 05:16AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0
.
MICROBIOLOGY:
___ blood cultures x2: no growth
___ urine culture: no growth
.
IMAGING:
___ X-RAY PELVIS (AP ONLY); FEMUR (AP & LAT) LEFT; KNEE
(AP, LAT & OBLIQUE) LEFT: Single view of the pelvis demonstrates
diffuse osteopenia. Right hip joint appears intact.
Moderate-to-severe degenerative joint changes of the right hip
joint are seen. Left hip joint prosthesis is noted. Compression
deformity of L3 vertebral body is present of uncertain
chronicity. Sacroiliac joints are partially obscured by
overlying bowel gas. Multiple small densities projecting over
pelvis likely represent phleboliths. Non-obstructive bowel gas
pattern is noted.
Three views of the left hip demonstrate a displaced comminuted
fracture of the proximal diaphysis of the femur. There is medial
and superior displacement of the medial fractured fragment. A
non-displaced transverse fracture involving the lateral aspect
of the femur is noted. The inferior aspect of the prosthetic
stem appears well seated within the femur. There is no
periprosthetic lucency to suggest hardware loosening in its
inferior aspect. Bony fragments projecting lateral to the hip
joint may represent heterotopic bone formation or fracture
fragments. No radiopaque foreign body is noted. Extensive
vascular calcifications are present.
Three views of the left knee demonstrate no evidence of acute
fracture or
dislocation. Diffuse osteopenia is present. Vascular
calcifications are
seen. There is no joint effusion.
IMPRESSION: A displaced fracture of the proximal left femur
around the
femoral prosthesis, as described above.
.
___ X-RAY LEFT WRIST (3 VIEWS): Three views of the left
wrist demonstrate no evidence of acute fracture or dislocation.
Diffuse osteopenia is noted. Degenerative changes of the
scaphotrapezial articulation are present with subchondral
sclerosis. No radiopaque foreign body is present.
IMPRESSION: No evidence of acute fracture or dislocation.
.
___ CXR (portable):
Portable supine view of the chest demonstrates normal lung
volumes without
pleural effusion, focal consolidation or pneumothorax. Biapical
opacities correspond to pleural thickening, best seen on limited
coronoal views of CT cervical spine dated ___. The
descending aorta is tortuous. Aortic arch calcifications are
noted. The ascending aorta appears prominent. Heart size is
normal. There is no pulmonary edema. No rib fracture is
identified.
IMPRESSION:
1. No rib fracture is identified. In the setting of high
clinical suspicion
for a rib fracture, dedicated rib series may be obtained.
2. Clear lungs.
.
___ X-RAY AP PELVIS and PA/LAT LEFT FEMUR: There is a left
hip hemiarthroplasty. There is a fracture of the proximal femur
about the left hip arthroplasty, with slight proximal migration
of the lesser tuberosity. The fracture line remains distinctly
visible and there is
surrounding soft tissue swelling.
The pelvic girdle is congruent. The sacrum is considerably
obscured by overlying bowel content, limiting direct assessment.
Visualized portion of the right hip is within normal limits
except for mild degenerative changes. There is severe diffuse
osteopenia.
IMPRESSION:
Fracture about the left proximal femur, unchanged compared with
radiographs obtained one day earlier. The fracture appears acute
and could be unstable. Clinical correlation is requested prior
to initiation of ___.
Brief Hospital Course:
A ___ year old female with ___ Dementia is brought to ___
___ after being found down with hip fracture and is
transferred to ___ for further management.
.
.
ACTIVE ISSUES:
# Hip fracture: Patient with periprosthetic fracture following a
fall. She had originally been planned for operative management
with orthopedics, but was determined to have a non-operative
fracture. Pain was well-controlled. Patient began to work with
___. Per Orthopedic team review, follow-up x-rays of pelvis and
femur (from ___ after starting work with ___ revealed a stable
fracture. She will have repeat films in 2 weeks, and follow up
with Orthopedics in two weeks. Placed on Lovenox for DVT
prophylaxis; this should be continued for a duration of 4 weeks.
She was also started on vitamin D supplementation, given her
osteopenia. ___ consider bisphosphanate therapy.
.
# Anemia: Acute on chronic normocytic anemia, most likely anemia
of acute blood loss. At OSH, was noted to have Hgb 10.9, but
this decreased to 8.2 at the time of arrival to ___. Patient
was transfused one unit PRBC, with appropriate increase in blood
counts. There were no signs of active bleeding, besides
ecchymosis over left leg, which was stable. She was
hemodynamically stable. Blood counts were stable thereafter. She
was noted to have vitamin B12 deficiency on labs. She was given
vitmain B12 1000 mcg IM x1, and started on daily oral
supplementation.
.
# Acute renal failure: By report, patient was down at home for a
prolonged period prior to being brought to the hospital.
Creatinine was up to 1.18 prior to transfer, with CK in the
1600's at ___, most likely as a combination of
prerenal azotemia from decreased PO intake and an element of
mild rhabdomyolsis. On arrival to ___, she received aggressive
hydration in the ED with 4L NS and 1u PRBCs, followed by 500 cc
bolus and gentle IVF on the floor while she was NPO. Creatinine
trended down to 0.8 and remained stable. The patient had good
UOP.
.
.
CHRONIC ISSUES:
# Social support: Patient has been living alone, but faculties,
including hearing and vision, have been declining. She has
minimal help from housekeepers twice weekly at home. Her niece,
HCP ___, expressed concern over the patient's safety in her
home situation. She desires further resources for patient care
after discharge.
.
.
TRANSITIONAL ISSUES:
# Patient will need evaluation for home resources, as well as
home physical therapy, after discharge from rehab.
# Patient noted to have diffuse osteopenia on x-rays. Would
consider bisphosphonate therapy to prevent future fractures.
# Patient noted to have vitamin B12 deficiency, and started on
supplementation as above. Labs were sent to check for pernicious
anemia, which were pending at the time of discharge. Results
will be communicated to PCP.
# CODE: Full (confirmed)
# CONTACT: ___ ___, ___
___
Medications on Admission:
Aspirin Dose uncertain
Calcium Dose uncertain
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. calcium Oral
3. Lovenox 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous
once a day for 4 weeks: Take through ___.
Disp:*1120 mg* Refills:*0*
4. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Left hip fracture
.
Secondary diagnoses:
Osteopenia
Vitamin B12 deficiency
Macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with a hip
fracture, which was treated conservatively, without any surgery.
Please note, the following changes have been made to your
medications:
- START Lovenox 40 mg subcutaneously daily for 4 weeks (through
___
- START vitamin D 1000 units by mouth daily
- START vitamin B12 250 mcg by mouth daily
Wishing you all the best!
Followup Instructions:
___
|
10503161-DS-14 | 10,503,161 | 29,481,843 | DS | 14 | 2169-11-08 00:00:00 | 2169-11-08 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
___ year old male with history of hypertension, hyperlipidemia
and stroke who presents with chest pain X 24 hours. According to
the patient he was exercising on a treadmill on ___ when he
developed chest pain, over his left shoulder, non radiating,
___ that did not radiate and did not improve after cessation of
exercise. The patient then walked about a mile and was generally
active throughout the rest of the day. He initially thought it
was due to a pulled muscle near his shoulder. He showered, went
out for dinner with his wife and friends, went to a movie and
occasionally forgot about the chest pain but it remained
present/constant. However, on ___, patient reported the pain
to his wife, who is a former ___, who had him report to ___
urgent care clinic. The patient walked into the ___ building of
his primary care physician right after closing complaining of
chest pain. The chest pain did not improve after he stopped
walking nor when he tried picking up his walking pace.
He denies associated symptoms of cough, diaphoresis, shortness
of breath, positional quality, radiation to jaw/arms or back,
nausea/vomiting, lightheadedness. He does have a sore throat but
no myalgias, abdominal pain, cough, diarrhea etc. Of note, the
patient has never had an exercise stress test or been diagnosed
with coronary artery disease. He has no prior hx of exertional
chest pain suggestive of angina. He was started on 4L nasal
cannula and transferred to ___.
In the ED, initial vitals were pain ___, T97.2, HR62, BP185/86,
RR18, 100% on 4L NC. EKG showed normal sinus rhythm with normal
axis and first degree AV block, with 1-2mm ST depressions in II,
III and aVF. The patient was given sublingual nitroglycerin
0.4mg X3 which decreased his chest pain to ___ and then 4mg IV
morphine X2 which decreased his chest pain to 0-1/10. Troponin
was negative X1. In discussions with ___ Cardiology, as the
patient did not feel his chest pain had definitively resolved,
decision was made to admit him for closer monitoring, rule out
MI. On transfer, VS were afebrile, HR64, BP135/73, RR15, 100% on
RA.
Currently, the patient is resting comfortably in bed. His second
set of Trop were normal as well.
REVIEW OF SYSTEMS:
Denies fever, chills, headache, vision changes, rhinorrhea,
congestion, cough, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, constipation, dysuria.
Past Medical History:
* CVA ___ presented with right hemiparesis, not paradoxical
per work-up. The patient has regained neurological function
* Shingles ___
* Hypertension
* Hyperlipidemia
* Onychomycosis
* Perioral dermatitis
Social History:
___
Family History:
Father had cancer, maternal grandfather died of a heart attack
in his ___, maternal grandmother had cancer, mother had
hypertension and multiple MIs (her first in her ___, paternal
grandmother had a stroke in her ___ and paternal uncle had
cancer.
Physical Exam:
VS - Tc 97.3 BP 142/90 HR 61 RR 18 100% on RA; NPO since
midnight
GENERAL - Well-appearing in NAD, comfortable, appropriate, still
with ___ chest pain
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, chest pain not
reproducible - located in left upper anterior chest laterally
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - No rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
LABS ON ADMISSION:
___ 06:27PM BLOOD WBC-5.0 RBC-4.68 Hgb-15.6 Hct-43.5 MCV-93
MCH-33.4* MCHC-35.9* RDW-12.1 Plt ___
___ 06:27PM BLOOD Neuts-70.6* ___ Monos-8.9 Eos-1.1
Baso-0.7
___ 06:27PM BLOOD ___ PTT-28.7 ___
___ 06:27PM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-129*
K-5.1 Cl-91* HCO3-29 AnGap-14
___ 06:27PM BLOOD CK(CPK)-194
___ 06:27PM BLOOD CK-MB-6 cTropnT-<0.01
___ 12:35AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:20AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:20AM BLOOD Calcium-8.5 Phos-2.9
LABS ON DC:
___ 07:00AM BLOOD WBC-6.4 RBC-4.72 Hgb-15.2 Hct-43.6 MCV-93
MCH-32.3* MCHC-34.9 RDW-12.3 Plt ___
___ 07:00AM BLOOD Glucose-77 UreaN-13 Creat-0.9 Na-132*
K-4.9 Cl-96 HCO3-29 AnGap-12
___ 07:00AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.3
EKG ___: Baseline artifact. Normal sinus rhythm with first
degree A-V block. Early R wave progression of uncertain
significance. Non-specific ST-T wave abnormalities. Compared to
tracing #1 no diagnostic change.
CXR: No acute cardiopulmonary process.
CATH ___:
1. Selective coronary angiography in this right dominant system
demonstrated no angiographically apparent flow limiting
stenoses. The LMCA was patent. The LAD had a 40% ostial
stenoses and a 40% stenosis
in the mid vessel. The LCx had a 40% stenosis in OM2. The RCA
was
patent.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with an LVEDP of 13 mmHg. There was mild
systemic
arterial systolic hypertension with an SBP of 137 mmHg.
3. There was no evidence of aortic valve gradient on left heart
pullback.
FINAL DIAGNOSIS:
1. No obstructive CAD.
2. Mild LV diastolic dysfunction.
Brief Hospital Course:
___ year old male with history of hypertension, hyperlipidemia
and stroke who presents with atypical chest pain X 24 hours,
unremarkable EKG and normal Troponins. Cardiac catheterization
no CAD.
# Chest pain: The patient presented with generally mild and
atypical chest pain. It's location was somewhat suspect for
shoulder/MSK etiology. He had an EKG unremarkable for ischemic
changes and normal troponins X 3. Cardiac catheterization showed
no CAD. He was already on aspirin 325 and plavix since his
stroke at home. We continued to monitor ___ on telemetry.We also
continued home atenolol and increased atorvastatin dose to
80mg.
# Hyponatremia: Unclear prior sodium levels. Possibly due to
mild hypovolemia in the setting of having poor PO intake. Also
possibly due to pain (SIADH) as he generally looks euvolemic on
exam. Urine lytes suggest patient may be inappropriately losing
NA, suggestive of SIADH.
# Hypertension: Stable although initially poorly controlled on
arrival to ___ likely secondary to pain. We continued home
atenolol.
# Hyperlipidemia: Stable, at goal per ___ lab values. We
continued home atorvastatin but at 80mg.
# h/o CVA: Currently without similar symptoms. We continued home
plavix
# FEN: IVFs / replete lytes prn / NPO
# PPX: Heparin SQ, bowel regimen
# ACCESS: PIV (18 gauge right AC)
# CODE: Full, confirmed with patient
# DISPO: discharge to home
___, PGY-1
___
TRANSITIONAL ISSUES: The patient was discharged home on new
medications. Appt was set up with his PCP for him to follow up
with.
Medications on Admission:
* Clopidogrel 75mg daily
* Atorvastatin 40mg daily (from ___)
* Atenolol 25mg daily
* Aspirin 81mg daily
* Multivitamin daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you at the ___. You came with
chest pain. After initial testing, a cardiac cause could not be
ruled out so you underwent a cardaic catheterization procedure.
The procedure showed that you had no coronary artery disease.
You were discharged home in a stable condition. Please follow up
with your PCP for continued workup. No new medications were
added.
Followup Instructions:
___
|
10503209-DS-18 | 10,503,209 | 20,515,236 | DS | 18 | 2154-03-23 00:00:00 | 2154-03-23 20:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status, type B aortic dissection
Major Surgical or Invasive Procedure:
Vertebral Bone Biopsy (___)
History of Present Illness:
Mr. ___ is a ___ male with no known past medical
history who presents as a transfer from ___ with
concern of a type B aortic dissection. Upon initial report
patient had presented to ___ with concern of confusion
and reportedly chest pain which was new. Of note while he has
no
known medical history the patient has not received medical care
for several years, possibly decades. A noncontrast head CT
there was unrevealing for any acute intracranial cranial
abnormalities. However he was noted to be hypertensive into the
200s and a CTA chest demonstrated a descending thoracic aortic
dissection with concern of penetrating ulcer involving and
intramural hematoma involving the aortic arch. He was started
on an esmolol drip for blood pressure control and transferred to
___ ED for vascular surgery evaluation. He currently denies
any current or prior chest or back pain.
Per his sister who is his next of kin the patient had been
increasingly confused and forgetful over the past month, and she
also noted to have some gait and coordination problems. She
confirmed that he was not experiencing any other symptoms such
as chest/back pain, abdominal pain, dyspnea. Of note this
history
was obtained several hours after patient presented to the ED due
to inadequate contact info paperwork from OSH and difficulty
obtaining sister's contact information.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 98.1 76 170/115 14 95 Room Air
GENERAL: Alert/pleasant, oriented to self only. Inconsistently
follows commands, however is re-directable.
CV: [x]RRR
PULM: no respiratory distress
ABD: [x]soft [x]Nontender [x]nondistended
EXTREMITIES: [x]no CCE []abnormal
PULSES: Upper and lower extremities palpable 2+ distally
bilateral symmetric
NEURO: ___ strength upper and lower extremities bilaterally.
CNII-XII intact, PERRLA, no focal sensory deficits.
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 1202): Temp: 97.9 (Tm 98.6),
BP: 101/64 (101-158/64-95), HR: 52 (52-79), RR: 18 (___), O2
sat: 100% (91-100), O2 delivery: Ra, Wt: 181.6 lb/82.37 kg
GENERAL: NAD, child-like affect. Aox1, unable to do DOWB even if
directed
HEENT: AT/NC, EOMI
NECK: nontender supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, +BS
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 08:57PM GLUCOSE-90 UREA N-21* CREAT-1.4* SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
___ 08:57PM estGFR-Using this
___ 08:57PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.0
___ 08:57PM WBC-11.8* RBC-4.35* HGB-13.2* HCT-39.7*
MCV-91 MCH-30.3 MCHC-33.2 RDW-13.1 RDWSD-44.1
___ 08:57PM NEUTS-81.3* LYMPHS-10.9* MONOS-6.5 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-9.59* AbsLymp-1.29 AbsMono-0.77
AbsEos-0.05 AbsBaso-0.05
___ 08:57PM PLT COUNT-275
DISCHARGE LABS:
===============
___ 05:15AM BLOOD WBC-10.4* RBC-4.28* Hgb-13.1* Hct-39.8*
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.4 RDWSD-45.6 Plt ___
___ 01:04PM BLOOD Glucose-93 UreaN-21* Creat-1.6* Na-139
K-4.9 Cl-102 HCO3-26 AnGap-11
___ 05:15AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0
MICROBIOLOGY:
===============
___ PLASMA REAGIN
TEST-FINAL NEGATIVE
___ CULTURE-FINAL NEGATIVE
___ CULTUREBlood Culture, Routine-FINAL
NEGATIVE
___ CULTURE-FINAL NEGATIVE
___ CULTUREBlood Culture, Routine
NEGATIVE
___ CULTUREBlood Culture, Routine
NEGATIVE
___ CULTURE-FINAL NEGATIVE
IMAGING:
=========
___ SCAN
1. Foci of increased radiotracer uptake in T7 and L2 as well as
the right eighth rib, consistent with osseous metastasis.
2. Irregular radiotracer uptake in the right sacroiliac joint is
indeterminate. Attention on follow-up is recommended.
___ TORSO
1. No significant interval change in intramural hematoma along
the lateral distal aortic arch extending into the proximal
descending aorta, with associated aneurysmal dilation measuring
up to 5.2 cm.
2. Unchanged penetrating aortic ulcers noted along the lateral
aortic arch and distal descending thoracic aorta.
3. Heterogeneous hyperenhancement of the prostate base extending
into the right seminal vesicle. Multiple top-normal sized
retroperitoneal and pelvic sidewall nodes. Sclerotic osseous
lesions in T7, L2, right eighth rib, and right proximal femur.
This constellation of findings raises suspicion for prostate
cancer with metastases. Correlation with PSA and urological
consult is recommended.
___ OPINION CT TORSO
Aneurysmal and tortuous thoracic aorta, with an intramural
hematoma and possible tiny ulcerated plaque within the distal
aortic arch and an ulcerated atherosclerotic plaque within the
midthoracic aorta. No evidence of pulmonary artery or coronary
artery involvement.
No evidence of thoracic aortic dissection.
___ SERIES COMPLETE
No evidence of internal carotid artery stenosis on either side.
___ Echo Report
The left atrial volume index is moderately increased. There is
no evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is moderate
symmetric left ventricular hypertrophy with a normal cavity
size. There is mild regional left ventricular systolic
dysfunction with basal inferior and basal to mid inferolateral
hypokinesis (see schematic) and preserved/ normal contractility
of the remaining segments. The visually estimated left
ventricular ejection fraction is 55%. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with moderately dilated
ascending aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is mild [1+]
aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD (LCx territory).
Trileaflet aortic valve with moderate dilation of the ascending
aorta. Aortic arch better visualized on the CTA chest.
___ BRAIN W/O CONTRAST
1. Severe small vessel ischemic changes in the bilateral
cerebral hemispheres and pons with evidence of multiple prior
lacunar infarcts and innumerable infratentorial and
supratentorial microhemorrhages.
2. No evidence of acute intracranial hemorrhage, recent
infarction or intracranial mass.
3. Prominence of the vertebrobasilar junction may reflect a
small segment of dolichoectasia versus short segment
fenestration.
4. Patulous appearance of the basilar tip without discrete
aneurysm formation.
5. Otherwise patent intracranial vasculature without evidence of
dissection, stenosis, occlusion or aneurysm formation.
Brief Hospital Course:
___ year old male with no known PMH who presented as a transfer
from an OSH with type b aortic dissection with intramural
hematoma. Patient admitted and managed medically with beta
blockade and blood pressure control. He was found to have
hyperenhancement of his prostate, lymphadenopathy, and sclerotic
bony changes on CT torso concerning for metastatic cancer s/p
CT-guided bone biopsy of the thoracic vertebral body lesion on
___ with pathology pending. Patient was also noted to have
dementia which was thought to be vascular in nature given severe
small vessel ischemic changes in the bilateral cerebral
hemispheres and pons with evidence of multiple prior lacunar
infarcts on brain MRI.
ACTIVE ISSUES:
============
# Intramural Hematoma:
# Aortic Ulcers:
# Type B Dissection:
Patient was transferred from ___ for concern for
confusion and new chest pain, where he was found to be
hypertensive to the 200's and had a CTA showing penetrating
aortic ulcer. He was started on an esmolol drip and transferred
to ___ ED for vascular surgery evaluation. At ___ he was
admitted to the vascular surgery CVICU, an arterial line was
placed for strict BP monitoring, he was started on an esmolol
drip for goal SBP <130 and nicardipine as needed. He was then
transitioned to nifedipine ER 120 mg PO daily and carvedilol 25
mg PO BID with good BP and HR control. He had repeat imaging on
___ that showed stable appearance of intramural hematoma
and ulcers. He is planned for follow-up with vascular surgery in
1 month with plan for repeat imaging at that time. He was also
started on aspirin 81 mg daily and atorvastatin 80 mg QHS given
his atherosclerotic disease.
# Altered Mental Status:
# Cognitive Impairment:
# Vascular Dementia:
# Prior strokes/Microhemorrhages:
Patient initially transferred with new AMS. A neurology consult
was placed for concern of worsening cognitive decline/confusion
with unclear etiology. On ___, he had an MRI which showed
severe small vessel ischemic changes in the bilateral cerebral
hemispheres and pons with evidence of multiple prior lacunar
infarcts and innumerable infratentorial and supratentorial
microhemorrhages. Bilateral carotid ultrasounds were normal. The
neurology team recommended empiric thiamine/folate, and felt
that his mental status changes and imaging findings were
consistent with accelerated atherosclerosis and vascular
dementia. They recommended checking a RPR which was negative.
Per neurology team, his mental status would take several days to
recover, and he did indeed become more conversive and oriented
beginning ___, but his cognitive impairment was still
apparent. Patient was started on aspirin and atorvastatin with
plan is for follow-up with vascular neurology in ___ months from
the time of discharge.
# Metastatic Cancer of Unknown Primary:
# RP and Pelvic Lymph Nodes:
On repeat CTA Torso to evaluate for progression in his
dissection were incidental findings concerning for metastatic
cancer, possibly prostate. Report noted heterogeneous
hyperenhancement of the prostate base extending into the right
seminal vesicle with multiple top-normal sized retroperitoneal
and pelvic sidewall nodes, and sclerotic osseous lesions in T7,
L2, right eighth rib, and right proximal femur. PSA was 5.2.
Heme-One was consulted and recommended continued inpatient stay
for further oncological workup including tissue biopsy. He
underwent a bone scan for biopsy planning and on ___, he
underwent successful CT-guided bone biopsy of a thoracic
sclerotic vertebral body lesion and biopsy is pending. Plan is
for outpatient hematology-oncology follow-up pending final
pathology results.
# ___:
His admission creatinine was 1.4 which was unclear whether that
was his baseline ___ given no prior medical records. Patient
was given boluses of IVF without improvement in his renal
function. His creatinine was 1.3-1.6 during his hospitalization
and we believe this is his baseline. Patient should have
outpatient follow-up with nephrology.
# Cardiac Wall Motion Abnormality:
# CAD:
As part of his work-up for his prior strokes, the patient was
noted to have mild regional systolic dysfunction c/w CAD (Lcx
territory) on TTE. Patient was started on medical therapy with
ASA, atorvastatin, and beta blocker with plan for outpatient
follow-up with cardiology for further work-up and management.
TRANSITIONAL ISSUES:
====================
[ ] Please follow-up pending pathology studies from ___ bone
lesion biopsy
[ ] Patient requires follow-up with heme-one for further
evaluation and management of his metastatic cancer of unknown
primary (biopsy results pending). Patient is set-up for
follow-up with hematology-oncology at ___, but family prefers
hematology-oncology closer to ___, ___, which they will
try to arrange.
[ ] The patient needs f/u with vascular surgery within 1 month
of discharge with repeat CT torso which they will arrange.
[ ] The patient needs follow-up with vascular neurology within
___ months as follow-up for his vascular disease and associated
vascular dementia.
[ ] The patient was started on nifedipine 120 mg PO daily and
carvedilol 25 mg BID for heart rate and BP control given his
type B dissection. His goal BP <130/80, resting HR<70. Please
uptitrate as needed.
[ ] The patient was noted to have mild regional systolic
dysfunction c/w CAD (Lcx territory) on TTE. Please ensure
appropriate follow-up with cardiology for further evaluation and
medical management. The patient was started on atorvastatin 80
mg QHS and aspirin 81 mg daily.
[ ] Ensure outpatient follow-up with nephrology for his newly
discovered CKD.
# CODE STATUS: Full Code
# CONTACT (HCP): ___ (Sister) - ___
Time spent coordinating discharge > 30 minutes
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
2. Atorvastatin 80 mg PO QPM
3. CARVedilol 25 mg PO BID
4. NIFEdipine (Extended Release) 120 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type B Aortic Dissection
Intramural Hematoma
Vascular Dementia
Metastatic Cancer of Unknown Primary
Acute Kidney Injury
Chronic Kidney Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you had chest pain and a CAT scan of your torso showed
an abnormality in your aorta (main blood vessel of the heart)
known as a dissection, or separation of the layers of the wall
of the blood vessel.
The type of dissection that you had does not require surgery.
You were started on medications to lower your heart rate and
blood pressure, and you had no evidence that this abnormality
was getting worse.
The CT scan also showed that you have a new mass in your
prostate and a few masses in your spine concerning for cancer.
You underwent a biopsy of the lesions in your spine and we are
awaiting the results. You were seen by the cancer doctors, and
will follow-up with them in the outpatient clinic once the
result of your biopsy returns.
Please continue to take all your medications as prescribed keep
your follow-up appointments listed below.
Wishing you a speedy recovery,
Your ___ care team.
Followup Instructions:
___
|
10503209-DS-19 | 10,503,209 | 29,869,159 | DS | 19 | 2154-03-31 00:00:00 | 2154-03-31 14:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o Type B aortic dissection, recently diagnosed
metastatic prostate cancer, CAD, CKD, who presented from OSH
with
syncope.
He was recently admitted at ___ ___ for
evaluation of newly diagnosed type B aortic dissection. He was
initially treated with esmolol gtt with transition to nifedipine
ER 120 mg PO daily and carvedilol 25 mg PO BID. He was also
found
to have vascular dementia, as well as imaging findings
concerning
for metastatic cancer later found to be prostatic adenoca on
bone
bx.
The AM of presentation, the patient was reportedly found slumped
over at his nursing home ___,
unresponsive. CPR was initiated by a visitor, continued for 10
minutes. Per OSH report, when EMS arrived patient had decreased
respirations and was unresponsive and he was bagged until he was
more awake, appropriate, and had normal respirations on his own.
Alt report: When EMS arrived the patient was in NSR and alert.
He was taken to ___ where his workup was notable for a
negative troponin but a CTA chest showed aortic arch intramural
hematoma with new extension contrast into the hematoma that is
worse from previous. NCHCT without acute process. CXR without
consolidation or pneumothorax or effusion. He was transferred to
___ for continuity of care. Upon arrival the patient is a poor
historian but endorses pain in his back. He denies chest pain or
shortness of breath.
Past Medical History:
type b aortic dissection, with Intramural Hematoma
vascular dementia
Metastatic Cancer of Unknown Primary, likely prostate
CKD
CAD
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: reviewed in metavision
GEN: WD man in bed in NAD wearing posey belt
EYES: PERRL
HENNT: supple neck, dry MM
CV: RRR, no m/r/g
RESP: CTAB anteriorly
GI: soft, obese, mildly TTP suprapubic
MSK: no pitting ___
SKIN: warm, no rashes noted, no ecchymosis/trauma on chest
NEURO: AAOX1 (not to time or place), difficult to understand
sometimes garbled speech, moving all extremities with purpose
DISCHARGE PHYSICAL EXAM:
========================
VSS
GEN: Appears much older than stated age, in bed in NAD,
sleeping, arouses easily to voice
EYES: Pupils equal and reactive to light. No facial droop.
HENNT: supple neck, moist mucus membranes, no JVP appreciated
CV: RRR, no m/r/g
RESP: Normal breathing effort. Clear to auscultation bilaterally
anteriorly
GI: Abdomen is soft, non-tender, and non-distended.
EXTREMITIES: Very thin legs, no edema
SKIN: Warm, no rashes noted, no ecchymosis/trauma on chest
NEURO: AAOX1, difficult to understand sometimes garbled speech,
moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
==============
___ 05:23PM BLOOD WBC-13.0* RBC-4.17* Hgb-12.7* Hct-38.8*
MCV-93 MCH-30.5 MCHC-32.7 RDW-13.4 RDWSD-45.5 Plt ___
___ 05:23PM BLOOD Neuts-88.1* Lymphs-5.4* Monos-4.6*
Eos-0.9* Baso-0.5 Im ___ AbsNeut-11.44* AbsLymp-0.70*
AbsMono-0.60 AbsEos-0.12 AbsBaso-0.07
___ 05:23PM BLOOD Glucose-113* UreaN-26* Creat-1.8* Na-138
K-5.4 Cl-102 HCO3-21* AnGap-15
___ 03:25AM BLOOD ALT-14 AST-9 AlkPhos-89 TotBili-0.4
___ 05:23PM BLOOD cTropnT-<0.01
___ 05:23PM BLOOD Calcium-9.8 Phos-5.5* Mg-1.9
___ 10:53PM BLOOD ___ pO2-31* pCO2-51* pH-7.35
calTCO2-29 Base XS-0
___ 06:19PM BLOOD Lactate-0.9
PERTINENT LABS:
=============
___ 07:00AM BLOOD cTropnT-0.03*
___ 04:50PM BLOOD cTropnT-0.02*
DISCHARGE LABS:
==============
___ 05:43AM BLOOD WBC-9.1 RBC-3.97* Hgb-12.0* Hct-36.5*
MCV-92 MCH-30.2 MCHC-32.9 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:43AM BLOOD Glucose-91 UreaN-22* Creat-1.8* Na-144
K-4.0 Cl-106 HCO3-26 AnGap-12
___ 05:43AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0
MICROBIOLOGY:
============
___ AND ___ blood cultures no growth to date
IMAGING:
=======
___ CT chest second opinion:
IMPRESSION:
1. Mild enlargement of penetrating ulcer along the lateral
aspect of the
aortic arch.
2. Stable intramural hematoma and additional penetrating
ulcers.
3. Hypodense renal lesions which may reflect cysts but for
which ultrasound
should be performed.
4. Enlarged retroperitoneal lymph nodes and sclerotic osseous
lesions
concerning for metastatic disease likely prostate.
___ TTE:
IMPRESSION: Low-normal left ventricular systolic function. Mild
aortic and tricuspid
regurgitation. Normal pulmonary pressure.
___ renal ultrasound:
There is no hydronephrosis, stones, or masses bilaterally.
Multiple simple right renal cysts measuring up to 2.3 cm are
noted. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. There is trace
nonspecific fluid adjacent to the right inferior pole. Right
kidney: 10.4 cm Left kidney: 12.2 cm
Brief Hospital Course:
ASSESSMENT/PLAN:
================
___ is a ___ year-old man with history of Type B aortic
dissection, recently diagnosed metastatic prostate cancer at
last admission (___), CAD, CKD, who presented to
OSH with episodes of unresponsiveness, transferred for further
management given history of a type B aortic dissection. Briefly
stayed in the MICU for management of hypertension but quickly
transitioned back to the floor. On the floor, cardiac,
neurologic, medication work up was unremarkable for cause of
unresponsiveness. Patient discharged in stable condition.
TRANSITIONAL ISSUES:
==================
-To Do's:
[] He will need a repeat CT chest with contrast to follow his
known type b aortic dissection in 6 months
[] patient has an aortic dissection - per previous discharge
paper work (based on recommendations from vascular medicine),
goal BP <130/80 and resting HR <70. HR and BP near goal upon
discharge. Uptitrate carvedilol and nifedipine as indicated.
[] Should have creatinine checked in one week. If uptrending
significantly from 1.6-1.8, would consider referral to
nephrology. On discharge, Cr was stable at 1.8.
-Referrals:
[] Follow up with hem-onc (GU oncology for metastatic prostate
cancer) on ___
[] Patient will need follow up with cognitive neurology within 1
month as follow up for his vascular disease and associated
vascular dementia
[] The patient was noted to have mild regional systolic
dysfunction c/w CAD (Lcx territory) on TTE. Please ensure
appropriate follow-up with cardiology for further evaluation and
medical management. The patient was started on atorvastatin 80mg
QHS and aspirin 81 mg daily on his last admission. Cardiology
should also weigh in on medication management of aortic
dissection.
[] Will need to establish care with vascular surgery on
outpatient basis for aortic dissection
-Updates:
[] Patient had difficulty swallowing pills. Crushed all pills
while in-house.
[] On CT second read: mild enlargement of penetrating ulcer
along lateral aspect of the aortic arch. Stable intramural
hematoma and additional penetrating ulcers. Vascular surgery
evaluated imaging and did not recommend surgical management.
Recommended conservative management with BP control as noted
above.
ACUTE ISSUES:
=============
# Encephalopathy vs syncope vs ?arrest
# Cognitive Impairment
# Vascular Dementia
# Prior strokes/Microhemorrhages
Patient was initially brought in by ambulance to ___
___ by EMS, when he was found slumped over at his nursing
home reportedly without VS. He was given CPR by a bystander for
approximately 10 minutes. When EMS arrived, he had normal
breathing, EKG with NSR. Unclear if this was a true cardiac
arrest. Initial workup at ___ notable for negative
troponins, non-contrast head CT without intracranial process,
and CXR without pneumonia or pneumothorax. He was transferred to
___ for further evaluation of his known type b aortic
dissection.
Per review of imaging by vascular, there was no worsening of
known aortic dissection that could have been contributing to his
presentation. Cardiac work up: EKG without evidence of ischemia
and negative troponins, unremarkable TTE and no events on
telemetry for over 48 hours. Neurologic work up: negative NCHCT,
no seizure history of evidence or such in the hospital, and
return to baseline per corroboration from HCP. No infectious
symptoms.
Of note, during last admission, patient had prior workup for
altered mental status. MRI showed severe small vessel ischemic
changes in the bilateral cerebral hemispheres and pons with
evidence of multiple prior lacunar infarcts and innumerable
infratentorial and supratentorial microhemorrhages. Neurology
had been consulted on last admission and felt that his mental
status changes and imaging findings were consistent with
accelerated atherosclerosis and vascular dementia. While
in-patient on this admission, SBP ranged from 110s-160s without
any change in his mental status. Given laboratory work-up
without evidence of severe organ damage and unclear if truly
lost pulse as CPR was delivered by bystander, it was unlikely
patient had a cardiac arrest at his nursing home. Patient was at
baseline throughout hospitalization, and mental status change
may have been secondary to fluctuations in his underlying
vascular dementia. Other alternative explanations could be a
vasovagal event or traumatic fall leading to LOC.
# Type B aortic dissection
Patient with a known type B aortic dissection that on OSH
imaging was initially concerning for worsening (extension of
contrast into intramural hematoma), but on review by vascular
surgery at ___, it appeared to be stable compared to recent
admission. Vascular surgery did not recommend surgery and
recommended conservative management with BP control. While
in-patient, patient was transitioned from nifedipine 120mg ER to
nifedpine 40mg TID, as patient was chewing his medications.
# ___ on CKD
On admission, his creatinine was 1.8-1.9. He has baseline CKD
with creatinine ranging from 1.3-1.6 during the last admission.
Received 1L LR on admission without improvement in creatinine.
FeNa was 1.8% which was consistent with intrinsic renal disease.
Renal ultrasound was negative for hydronephrosis. Additionally,
the patient also received contrast for his chest CT, which may
have transiently induced Cr elevation. Cr fluctuated between
1.6-1.8. Likely has CKD from longstanding hypertension. Will
defer to outpatient basis for work up of CKD for other
etiologies if clinically indicated. On day of discharge, Cr 1.8,
which is likely within his new baseline Cr plus possibly mild
prerenal. FENa on day of discharge 0.2%, suggestive of prerenal
etiology from likely poor PO intake. Recommend continued
encourage of PO intake on outpatient basis and short term follow
up with repeat BMP.
CHRONIC ISSUES:
==============
# Metastatic prostate cancer:
He was recently diagnosed with metastatic prostate cancer.
Initially c/f metastatic cancer was incidentally noted on
imaging for aortic dissection, including sclerotic lesion in T5
and abnormal signal in the prostate and underwent bone biopsy
during last admission. Bone biopsy consistent with metastatic
prostate adenocarcinoma. The metastasis is NKX3.1 positive. Will
need outpatient GU oncology follow up.
# CAD
TTE on last admission concerning for mild regional systolic
dysfunction c/w CAD (Lcx territory) on TTE. No cath at that
time. Started aspirin 81mg daily and atorvastatin 80mg at that
admission which was continued during this admission. TEE this
admission revealing mild regional left ventricular systolic
dysfunction with basal inferior hypokinesis.
>30 min spent on d/c activities on the day of discharge
(___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. CARVedilol 25 mg PO BID
4. NIFEdipine (Extended Release) 120 mg PO BID
Discharge Medications:
1. NIFEdipine (Immediate Release) 40 mg PO Q8H Aortic
dissection
Capsule may be opened and administered in patent's food.
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Altered mental status
SECONDARY DIAGNOSIS
===================
Acute kidney injury
Aortic dissection
Discharge Condition:
Mental Status: Confused - always. Alert to self. Cognitively
impaired.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
================================================
MEDICINE Discharge Worksheet
================================================
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
You passed out in your nursing home and had to receive CPR. You
were admitted to evaluate you.
What was done for me while I was in the hospital?
You had a full cardiac evaluation that did not reveal an
underlying cardiac disease to explain your loss of
consciousness. Your known aortic dissection was unchanged from
your prior admission. You had a CT scan of your head at the
outside hospital, which did not show any bleeding, stroke, or
metastasis. You had an ultrasound of your kidney which did not
show significant disease. We are unclear as to why exactly you
were found on the ground, but we have ruled out the major
serious reasons. You could have been found down on the ground
due to dehydration or something called vasovagal syncope where
if you move too fast, your heart rate and blood pressure cannot
keep up and you lose consciousness.
What should I do when I leave the hospital?
Please note any new medications in your discharge worksheet.
Please call us if you start feeling more confused or if you lose
consciousness again.
-Your appointments are as below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10503322-DS-13 | 10,503,322 | 20,658,334 | DS | 13 | 2172-05-04 00:00:00 | 2172-05-04 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / methotrexate / methotrexate / Remicade / Plaquenil
/ leflunomide / Voltaren / Actemra / ibuprofen / naproxen
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with history of COPD, RA, ILD and hypothyroidism
initially presented to ___ with fever and shortness of breath,
found to have moderate to high risk PEs.
Recent admission to ___ on ___ for fever and
shortness
of breath. On presentation to the ED she was hypoxemic to low
___
on RA. She was found to have an influenza B infection and
treated
with prednisone 40mg x5 days, Oseltamivir x5d and CTX/Azithro.
She was discharged on 2L of O2 which was a new home O2
requirement.
Of note she recently fractured her R humorous on ___
after she tripped at home and was subsequently in a sling since
then with minimal movement.
Patient reports she had been doing well since discharge the end
of ___ on her new home oxygen however continued to have
some
shortness of breath and required her new home oxygen requirement
increased from ___ liters. Last night she was finally able to
take off her sling and was excited to sleep in her bed, however
on her way to bed she began to have severe palpitations and
reports "I knew something was wrong." She did not have chest
pain but had worsening shortness of breath as well. Her husband
who is a retired path___ took her vitals and noted that her
O2 Sats were in the ___ despite supplemental oxygen, and her HR
was 160s.
She then represented to ___ with worsening shortness of
breath, fever and non productive cough. A CTA was notable for
bilateral pulmonary emboli and a troponin was 0.19. She was
initiated on heparin gtt and transferred to ___.
In the ED,
- Initial Vitals: T 97.4, HR 88, BP 126/74, RR 20 O2 Sat 94% on
3L NC
- Exam:
No acute distress, breathing comfortably, speaking in full
sentences
RRR, no appreciable murmur
Diminished breath sounds due to body habitus, no crackles or
wheezing
Obese, abdomen soft and nontender
Skin warm and dry, no peripheral edema
- Labs: Trop .17, BNP 523,
- Consults:
MASCOT:
-Admit to MICU for monitoring
-Continue heparin GTT, please ensure she has therapeutic PTTs
-Please obtain formal TTE in AM
-If she develops worsening hemodynamics or escalating O2
requirement please let us know and we will consider advanced
therapeutic options
- Interventions: Continued heparin gtt
On arrival to the MICU without chest pain, SOB improving. No
syncope at home.
Past Medical History:
RA on Rituxan, previously on MTX
COPD
ILD previously on MMF
Hypothyroidism
Fibromyalgia
RLS
S/p recent humeral fracture ___
Social History:
___
Family History:
No known family history of VTE. Mother had CABG and CVA, father
had valvular heart disease
Physical Exam:
ADMISSION PHSYICAL EXAM:
=======================
VS: Afebrile HR 94 BP 148/74 RR 24 O2 sat 93% on 4L
GEN: Well appearing in NAD, in good spirits
EYES: PERRLA, sclera anicteric
HENNT: NC/AT EOMI
CV: Tachycardic, no m/r/g appreciated
RESP: CTAB bilaterally
GI: non tender, non distended
MSK: no lower extremity edema or swelling, ecchymosis over RUE
SKIN: warm, dry, intact
NEURO: CN ___ grossly intact, moving extremities with purpose
PSYCH: AOx3, appropriate affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 2323)
Temp: 98.2 (Tm 102.5), BP: 110/60 (92-131/50-82), HR: 64
(64-77), RR: 18, O2 sat: 91% (91-95), O2 delivery: 1L
GENERAL: Resting in bed playing games on her phone in NAD,
pleasantly conversational
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no JVP
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: mild bibasilar rales (L>R), no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Trace peripheral edema bilaterally, tender to touch
(given her fibromyalgia)
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Ecchymosis on right wrist and right arm
Pertinent Results:
ADMISSION LABS:
___ 12:03AM BLOOD WBC-8.4 RBC-3.93 Hgb-12.0 Hct-36.8 MCV-94
MCH-30.5 MCHC-32.6 RDW-13.8 RDWSD-47.5* Plt ___
___ 05:31AM BLOOD ___ PTT-150* ___
___ 04:21AM BLOOD Glucose-105* UreaN-15 Creat-0.8 Na-139
K-4.4 Cl-106 HCO3-22 AnGap-11
___ 04:21AM BLOOD CK(CPK)-80
___ 12:03AM BLOOD ALT-13 AST-35 LD(LDH)-690* AlkPhos-67
TotBili-0.4
___ 04:21AM BLOOD CK-MB-5 cTropnT-0.17* proBNP-523*
___ 12:03AM BLOOD Albumin-3.2* Calcium-8.6 Phos-4.3 Mg-2.1
IMAGING:
OSH CT:
1. There is worsening of mild centrilobular emphysema.
2. There is central filling defect in the left pulmonary artery
extending into left upper lobe and left lower lobe branches of
the left pulmonary artery and there is also central filling
defect n the right pulmonary artery which extends into right
upper
lobe, right lower lobe and right middle lobe branches of the
pulmonary arteries consistent with bilateral acute pulmonary
embolism with no saddle embolus.
3. There is some straightening of the interventricular septum
suspicious for possible right ventricular strain.
4. There may be punctate nonobstructive left nephrolithiasis.
___ CXR: No significant interval change. No evidence of
pneumonia.
___ CXR PA & Lateral: No acute cardiopulmonary process.
___ CT Chest:
IMPRESSION:
1. New ground-glass opacities and a peripheral which shaped
consolidation in
the right middle lobe suggesting evolving pulmonary infarct
given recent
extensive pulmonary emboli seen on the prior exam.
Superinfection cannot be
excluded, however.
2. Numerous pulmonary nodules as described measuring up to 9 mm
in the right
middle lobe. Recommend follow-up per ___ criteria.
3. Mild apical predominant centrilobular emphysema.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules
bigger than 8mm, a CT follow-up in 3 to 6 months is recommended
in a low-risk
patient, with an optional CT follow-up in 18 to 24 months. In a
high-risk
patient, both a CT follow-up in 3 to 6 months and in 18 to 24
months is
recommended.
MICROBIOLOGY:
=============
___ Blood Culture: No growth
___ Urine Culture: No growth
___ MRSA Screen: No MRSA isolated
DISCHARGE LABS:
==============
___ 06:10AM BLOOD WBC-7.5 RBC-3.37* Hgb-10.2* Hct-31.5*
MCV-94 MCH-30.3 MCHC-32.4 RDW-13.3 RDWSD-45.7 Plt ___
___ 06:10AM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-138
K-4.7 Cl-101 HCO3-21* AnGap-16
___ 06:10AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
___ 06:10AM BLOOD Cortsol-15.8
___ 07:13AM BLOOD IgG-609* IgA-292 IgM-35*
Brief Hospital Course:
___ yo F with history of COPD, RA, ILD and hypothyroidism
initially presented to BID-P with fever and shortness of breath,
found to have moderate to high risk PEs, transferred to MICU for
MASCOT consultation, started on heparin gtt and then
transitioned to apixaban. Pt remained stable and was transferred
to the floor on ___, where she remained stable.
ACUTE ISSUES
===========
#Intermediate High-Risk PE
#Sinus tachycardia
Patient presenting with several days of fever and shortness of
breath, found to have acute submassive PEs with radiographic
evidence/EKG evidence of right heart strain and with elevated
troponin and BNP. Likely provoked in setting of recent
immobilization and RA. DVT in right tibial vein on LENIs.
Initiated on heparin gtt in ICU, ultimately transitioned to
Apixaban as follows Apixaban 10mg BID x 7 days, followed by 5mg
BID x 6 months, and 2.5mg BID indefinitely. Also APLS serologies
pending on DC.
# Fever
# Leukocytosis
# Hospital acquired pneumonia
No localizing symptoms other than pulmonary with no evidence on
NA on CT. Pancultured ___ with no growth. She
continued to have recurring fevers up to 101 while hospitalized,
presumed secondary to her clot burden. She did have a recent
hospitalization for influenza so there was concern about
development of Staph pneumonia, though no findings on CXR.
Leukocytosis downtrended and however continued to have fevers.
Levofloxacin was started for a ___espite antibiotics
pt had recurrent fevers so infectious disease was consulted,
they agreed with a short course of levofloxacin for possible
HAP.
#Hypoxemic respiratory failure
#COPD
#?ILD
Presented with SOB but without wheezing to suggest COPD
exacerbation. Recently treated with 5d course of steroids.
Suspect hypoxemia is in setting of PE as above, continued home
Breo and Incruse Ellipta.
#Normocytic anemia
Pt had a downtrending Hgb. Retic index is low. No evidence of GI
source. CBC has been stable. LDH was downtrending and
haptoglobin high. Recommend follow up CBC within 1 wk after
discharge. Hbg on DC 10.2.
CHRONIC ISSUES
=============
# hypothyroidism: Continued home levothyroxine
# RLS: Continued home pramipexole
# RA: On rituximab, non given during admission
TRANSITIONAL ISSUES:
==================
[] New Meds:
Apixaban 10mg BID x 7 days, followed by 5mg BID x 6months,
and 2.5mg BID indefinitely
[] Stopped/Held Meds:
[] Changed Meds:
[] Post-Discharge Follow-up Labs Needed:
- CBC within 1 wk for anemia (Hbg on DC 10.2)
[] Pending labs:
- Awaiting anti-cardiolipin and beta2 microglobulin Ab
(given increased risk for APLS in RA)
[ ] Ensure patient has up to date age-appropriate cancer
screening
[] Incidental Findings:
- Numerous pulmonary nodules measuring up to 9 mm in the
right middle lobe Recommend follow-up per ___ guidelines
(a CT follow-up in 3 to 6 months is recommended in a low-risk
patient, with an optional CT follow-up in 18 to 24 months. In a
high-risk patient, both a CT follow-up in 3 to 6 months and in
18 to 24 months is recommended)
___ is clinically stable for discharge today. On
the day of discharge, greater than 30 minutes were spent on the
planning, coordination, and communication of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 2 mg PO QHS
2. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
3. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
4. Pramipexole 0.25 mg PO QHS
5. Levothyroxine Sodium 137 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*90 Tablet Refills:*0
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*62 Tablet Refills:*2
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
4. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
5. ClonazePAM 2 mg PO QHS
6. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Pramipexole 0.25 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Pulmonary embolism c/b recurrent fevers
SECONDARY DIAGNOSIS:
===================
Fever
Hypoxemic Respiratory Failure
COPD
ILD ___ MTX use
Normocytic anemia
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a blood clot in your lungs.
- You had fevers and we suspect that this was due to your blood
clot.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We treated you with with medication for the blood clot in your
lung
- We treated your fevers with a short course of antibiotics
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
- Seek medical attention if you have new or concerning symptoms
or you develop SOB, blood in your sputum, palpitations.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10503509-DS-22 | 10,503,509 | 29,188,359 | DS | 22 | 2149-09-02 00:00:00 | 2149-09-04 06:09:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with new dx of gastric CA, not on chemo p/w syncopal
episode. Pt began having abdominal pain in ___ of this year. ___
by GI: EGD and EUS on ___, showed an ulcerated 7 cm mass in
the fundus. Biopsy returned as moderately-differentiated
squamous cell carcinoma. No evident mets on CT torso. Today,
while walking with daughter, pt became unresponsive for a few
seconds as noted by his daughter. He was about to fall but did
not due to a combination of his daughter supporting him and him
suddenly "coming to." He denies any sxs preceding the episode
and reports that he was wide awake and conscious immediately
after the episode which his daughter confirms. He denies CP,
dyspnea, cough, HPs, LH/dizziness, HA. Pt does report scant
BRBPR on outside of stool, last time last week. Pt has had dark,
hard stools daily.
.
In ED: 96.9 106 106/66 18 100% ra. chem panel notable only for
gluc 195. CBC wbc 10.5, hct 25.3 (down 34.7 on ___, plt 355.
u/a negative. CXR: "Nodular opacity projecting over the left
lower lung may represent a nipple shadow." Pt given zofran, NS,
transfusion of one unit PRBCs
.
ROS: as above; otherwise, complete ROS negative
Past Medical History:
DM II, insulin dependent
Hypertension
Gastric CA
Social History:
___
Family History:
Father has hx of DM. Mother had pancreatic cancer and mother's
sister had an unknown type of bowel malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
t 98 bp 116/62 hr95 rr16 sat 100%ra
NAD
eomi, perrl
neck supple
no ___
chest clear
rrr
abd benign
ext w/wp, no edema
neuro: cn ___ intact
strength/sensation wnl
DTRs wnl
gait normal
Skin: no rash
DISCHARGE PHYSICAL EXAM:
======================
Vitals: T: 98.8 BP: 114/65 (94-114/55-65) HR: 80s-90s RR: 18 02
sat: 100 %RA
GENERAL: no acute distress, minimally interactive
CARDIAC: RRR, no m/r/g
LUNG: CTAB w/o adventitious sounds
ABDOMEN: NABS, minimal tender in epigastrium, otherwise
nontender
EXTREMITIES: warm and well perfused, no edema
PULSES: intact bilaterally
NEURO: no focal deficits
SKIN: no rash observed
Pertinent Results:
PERTINENT LABS:
=====================
___ 01:00PM BLOOD WBC-10.5 RBC-3.71*# Hgb-7.8* Hct-25.3*#
MCV-68* MCH-21.1* MCHC-30.9* RDW-21.2* Plt ___
___ 03:52AM BLOOD Neuts-70.1* ___ Monos-7.1 Eos-1.4
Baso-0.2
___ 09:30PM BLOOD WBC-10.8 RBC-3.96* Hgb-8.9* Hct-27.6*
MCV-70* MCH-22.4* MCHC-32.2 RDW-21.6* Plt ___
___ 03:52AM BLOOD WBC-8.4 RBC-4.05* Hgb-9.0* Hct-28.6*
MCV-71* MCH-22.3* MCHC-31.6 RDW-21.2* Plt ___
___ 11:00AM BLOOD WBC-12.6* RBC-4.22* Hgb-9.5* Hct-30.5*
MCV-72* MCH-22.5* MCHC-31.2 RDW-21.2* Plt ___
___ 06:00PM BLOOD WBC-13.2* RBC-4.14* Hgb-9.3* Hct-29.6*
MCV-72* MCH-22.6* MCHC-31.6 RDW-21.2* Plt ___
___ 09:05AM BLOOD WBC-10.8 RBC-4.53* Hgb-10.2* Hct-32.7*
MCV-72* MCH-22.6* MCHC-31.3 RDW-21.5* Plt ___
___ 03:52AM BLOOD ___ PTT-28.0 ___
___ 01:00PM BLOOD Glucose-195* UreaN-20 Creat-0.7 Na-135
K-4.3 Cl-99 HCO3-27 AnGap-13
___ 03:52AM BLOOD Glucose-126* UreaN-15 Creat-0.7 Na-139
K-4.0 Cl-106 HCO3-24 AnGap-13
___ 09:05AM BLOOD Glucose-156* UreaN-9 Creat-0.7 Na-139
K-4.4 Cl-101 HCO3-29 AnGap-13
___ 01:00PM BLOOD ALT-8 AST-13 AlkPhos-61 TotBili-0.2
___ 09:05AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
___ 01:00PM BLOOD Albumin-3.3*
MICROBIOLOGY:
====================
___ 04:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:10PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
___ urine culture - no growth
ECG:
=====================
Sinus tachycardia. Non-specific ST-T wave changes. No previous
tracing
available for comparison.
IntervalsAxes
___
___
IMAGING:
=====================
FINDINGS: PA and lateral views of the chest were provided
demonstrating left
chest wall Port-A-Cath with tip residing in the low SVC. No
focal
consolidation, effusion or pneumothorax is seen. A subtle
nodular opacity
projects over the left lower lung between ribs 8 and 9
posteriorly which could
represent a nipple shadow, though a true pulmonary nodule cannot
be excluded.
Consider repeat study with nipple markers. Otherwise, the lungs
are clear.
Cardiomediastinal silhouette is normal. No pneumothorax or
effusion. Bony
structures are intact.
IMPRESSION: Nodular opacity projecting over the left lower lung
may represent
a nipple shadow. Recommend repeat radiograph with nipple
markers.
Brief Hospital Course:
___ yo M with DM and new diagnosis of gastric cancer presenting
after pre-syncopal episode.
# Pre-syncope: Due to acute blood loss anemia. No symptoms
consistent with cardiac, vasovagal, or neurologic source. No
events on telemetry. Orthostatics negative after transfusion and
normal saline.
# Acute blood loss anemia: Evidence of slow upper GI bleed from
known gastric tumor based on acute hematocrit drop between ___
and day of presentation. Received total 2 units of pRBC and 1 L
NS. Stable hematocrit after transfusion with appropriate bump.
GI and ___ were aware, but did not recommend intervention given
stability. Had one brown stool while inpatient. Diet was
advanced to clears in the evening day after admission given
stable Hct. He was initially on a pantoprazole drip that was
transitioned to IV BID then oral BID. After one day of
monitoring, he was hemodynamically stable with no evidence of
further bleed and was therefore discharged home with plans for
neoadjuvant chemotherapy as below.
# Gastric cancer: New diagnosis as of ___. PET scan prior to
this admission revealed local disease only. He was started on
his pre-chemotherapy dexamethasone the day of discharge, and was
to start neoadjuvant chemotherapy starting ___ ___
___. He was offered symptomatic management while inpatient,
which he did not require.
# Social support: Patient required assistance with getting to
chemotherapy and medical appointments. He was provided a CRS for
rides by social work.
# IDDM: Continued on home NPH 10 U BID and insulin sliding
scale.
TRANSITIONAL ISSUES:
- continue oral pantoprazole 40 mg twice a day
- initiation of neoadjuvant chemotherapy with Dr. ___ ___
- CRS provided for rides to oncology/chemo visits
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NPH 10 Units Breakfast
NPH 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Ferrous Sulfate 325 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Ondansetron 8 mg PO Q8H:PRN n/v
5. Prochlorperazine 10 mg PO Q6H:PRN n/v
6. Omeprazole 20 mg PO BID
7. Lorazepam 0.5-1 mg PO Q4H:PRN n/v
8. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Prochlorperazine 10 mg PO Q6H:PRN n/v
3. Ferrous Sulfate 325 mg PO DAILY
4. LOPERamide 2 mg PO QID:PRN diarrhea
5. Lorazepam 0.5-1 mg PO Q4H:PRN n/v
6. Omeprazole 20 mg PO BID
7. Ondansetron 8 mg PO Q8H:PRN n/v
8. Dexamethasone 8 mg PO BID
RX *dexamethasone 4 mg 2 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
9. NPH 10 Units Breakfast
NPH 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
11. Lancets,Thin (lancets) 23 gauge miscellaneous four times a
day Duration: 30 Days
RX *lancets [Lancets,Thin] 23 gauge use for blood sugar testing
four times a day Disp #*120 Each Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pre-syncope from blood loss
acute blood loss anemia from slow upper GI bleed due to gastric
tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented with dizziness after losing a lot of blood. You
were losing blood from your tumor in your stomach. While here at
___ you received 2 units of blood, with improvement in your
symptoms and blood count. As you were stable after that, you
were discharged to follow-up with your oncologist for
chemotherapy.
We wish you the best.
Your ___ team.
Followup Instructions:
___
|
10503509-DS-23 | 10,503,509 | 27,856,794 | DS | 23 | 2149-09-13 00:00:00 | 2149-09-13 22:57:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
___ embolization of L gastric artery
History of Present Illness:
___ yo M with a h/o gastric CA p/w weakness. Pt admitted
___ after a syncopal episode thought to be ___ severe
anemia. Admitting Hb 7.8. Pt received a total of 2 units PRBCs
with d/c hb at 10.2. GI and ___ aware but no intervention was
made given clinical improvement. Pt reports feeling well at the
time of discharge. However, over the past ___ days he has felt
generally weak with dizziness, epigastric pain ___ and nausea,
no vomiting. He denies BRBPR but has been having dark stools. Pt
seen in ___ clinic today for neulasta which he did receive.
However, given his sxs and elevated BS to 369, he was
transferred to the ED.
.
In the ED: 97.8 ___ 16 100% ra. Labs notable for a Na 125,
Cl 90, gluc 354, AG10. Hb 6 (down from 10.2 on ___. u/a with no
e/o infection, though 1000 gluc, 40 ket. The patient was given 2
units PRBCs and 1 L NS.
.
ROS: as above; o/w complete ROS negative
Past Medical History:
DM II, insulin dependent
Hypertension
Gastric CA
Social History:
___
Family History:
Father has hx of DM. Mother had pancreatic cancer and mother's
sister had an unknown type of bowel malignancy
Physical Exam:
Admission Physical Exam
t___ 96/55 95 18 98%ra
NAD
eomi, perrl, conjunctiva pale
neck supple
no ___
chest clear
rrr
abd: mild epigastric ttp, no r/g
ext w/wp
neuro: non-focal
no rash
DISCHARGE PHYSICAL EXAM
VS: 98.8, 86, 115/64, 18, 98% on RA
GENERAL: no apparent distress, lying in bed
HEENT: nonicteric conjunctiva, MMM, OP clear
NECK: supple, no lymphadenopathy
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
Resp: CTA bil, good resp effort, no use of accessory muscles,
breathing comfortbaly
GI: nondistended, +BS, mildly tender over epigastric and
bilaterall upper quadrants. No rebound or guarding.
EXT: moving all extremities well, no cyanosis, clubbing. 2+
edema
equal and bilateral, no obvious deformities
NEURO: grossly equal strength and sensation bilateral upper and
lower extremities
Pertinent Results:
ADMISSION LABS
___ 10:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 10:45PM URINE RBC-3* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:08PM LACTATE-1.5
___ 09:41PM ___ PTT-25.9 ___
___ 08:40PM GLUCOSE-354* UREA N-17 CREAT-0.7 SODIUM-125*
POTASSIUM-4.2 CHLORIDE-90* TOTAL CO2-25 ANION GAP-14
___ 08:40PM LIPASE-15
___ 08:40PM NEUTS-62 BANDS-4 ___ MONOS-2 EOS-0
BASOS-0 ___ METAS-1* MYELOS-0
DISCHARGE LABS
___ 06:00AM BLOOD WBC-9.9# RBC-3.43* Hgb-8.7* Hct-26.5*
MCV-77* MCH-25.4* MCHC-32.8 RDW-23.3* Plt ___
___ 06:00AM BLOOD Glucose-180* UreaN-5* Creat-0.6 Na-133
K-3.7 Cl-99 HCO3-26 AnGap-12
___ 06:00AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.7
PERTINENT STUDIES
___ ___
FINDINGS:
1. Normal anatomy of the celiac axis within the splenic, left
gastric, and common hepatic artery arising from it.
2. Left gastric arteriogram showing significant neovascular
tumor blood supply arising from the left gastric artery.
3. Post Gel-Foam embolizationleft gastric arteriogram showing no
significant blood supply to the area.
4. Common hepatic arteriogram showing the origin of the
gastroduodenal artery.
5. Gastroduodenal arteriogram showing only minor blood supply to
the region of the tumor via the right gastroepiploic artery.
IMPRESSION:
Gelfoam embolization of the left gastric artery to stasis.
Brief Hospital Course:
___ yo M with a h/o squamous cell gastric cancer p/w weakness to
his ___ clinic and was found to be severely anemic.
ACTIVE ISSUES
# GI bleeding: Pt had acute GIB with presenting hematocrit of 18
from baseline of 34. EGD was performed, which showed bleeding
at gastric cancer, with friable tissue, that is not amenable to
intervention. Hemostasis was achieved through ___ embolizatin of
L gastric artery. He received a total of 3 units pRBC. He was
observed in the hospital for 48 hours, with demonstrated
stability.
The operative note was attached below:
PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and
alternatives to the
procedure, written informed consent was obtained from the
patient. The patient
was then brought to the angiography suite and positioned supine
on the exam
table. A pre-procedure time-out was performed per ___
protocol. Both groins
were prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common
femoral artery was
punctured using a 19 gauge needle. A ___ wire was advanced
easily into the
aorta. The needle was exchanged for a 5 ___ sheath which was
attached to a
continuous heparinized saline side arm flush.
A C2 Cobra catheter was advanced over ___ wire into the
aorta. The wire
was removed, and the celiac artery was selectively cannulated
and a small
contrast injection was made to confirm position. A celiac
arteriogram was
performed.
Next, the C2 catheter was used to advance the wire into the
ascending aorta. T
he C2 catheter was then exchanged for ___ catheter which
was formed in
the aortic arch. The ___ catheter was used to cannulate
the left gastric
artery, and a digitally subtracted left gastric arteriogram was
performed.
A pre loaded double angled glidewire and Renegade ___ catheter
was used to
access a slightly more distal portion of the left gastric
artery. Gel-Foam
slurry was used to perform embolization of the left gastric
artery to stasis.
The microcatheter was then withdrawn, and a repeat digitally
subtracted
arteriogram of the left gastric artery was performed through the
___
catheter.
Next, the ___ catheter was exchanged for theCobra catheter
which was
used to select the common hepatic artery to assess the origin of
the
gastroduodenal artery. Using the wire, the gastroduodenal artery
was selected
and the catheter was advanced into the gastroduodenal artery. A
digitally
subtracted gastroduodenal arteriogram was performed.
The catheter was then removed over the wire, and the sheath was
removed.
Manual pressure was held until hemostasis was achieved. Sterile
dressings were
applied. The patient tolerated the procedure well.
# Gastric cancer: Pt has squamous cell gastric cancer, currently
on C1D1 ___ (last dose ___. No change
to his oncology care was made during this admission. Pt showed
anorexia throughout this hospitalization, for which we started
Megestrol Acetate 400 mg daily.
CHRONIC ISSUES
# DM: Pt has type II diabetes. He was given ISS during this
hospitalization.
TRANSITIONAL ISSUES
PENDING LABS: blood culture
MEDICATION CHANGES:
- STARTED Megestrol 400 mg daily
FOLLOWUP PLAN:
- pt will be followed in the ___ clinic on ___ and ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Prochlorperazine 10 mg PO Q6H:PRN n/v
3. Ferrous Sulfate 325 mg PO DAILY
4. LOPERamide 2 mg PO QID:PRN diarrhea
5. Lorazepam 0.5-1 mg PO Q4H:PRN n/v
6. Pantoprazole 40 mg PO Q12H
7. Ondansetron 8 mg PO Q8H:PRN n/v
8. NPH 10 Units Breakfast
NPH 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. LOPERamide 2 mg PO QID:PRN diarrhea
3. Lorazepam 0.5-1 mg PO Q4H:PRN n/v
4. Ondansetron 8 mg PO Q8H:PRN n/v
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. Pantoprazole 40 mg PO Q12H
7. Prochlorperazine 10 mg PO Q6H:PRN n/v
8. Megestrol Acetate 400 mg PO DAILY
Please do not stop this medication without discussing with your
doctors.
RX *megestrol [Megace] 400 mg/10 mL (40 mg/mL) 10 ml
suspension(s) by mouth daily Refills:*0
9. NPH 10 Units Breakfast
NPH 10 Units Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric cancer
GI bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital for GI bleeding. This is caused by the
malignancy in the stomach. The bleeding has been controlled by
an embolization procedure performed by interventional radiology.
You have been observed for 48 hours after the procedure, and
deemed safe to return home.
Followup Instructions:
___
|
10503804-DS-13 | 10,503,804 | 23,590,107 | DS | 13 | 2165-02-03 00:00:00 | 2165-02-12 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ abd pain, nausea, transfer
Major Surgical or Invasive Procedure:
___ ERCP
History of Present Illness:
Mr. ___ is a ___ PMHx obesity and recent symptomatic
cholelithiasis and biliary colic who presents as a transfer from
___ for complaint of a gallbladder attack with RUQ
abdominal pain.
He has been previously evaluated by Surgery (Dr. ___ for
these symptoms and was planned for an elective cholecystectomy
this week (on ___. He was seen on ___ ___
___ US at that time showed cholelithiasis without evidence of
cholecystitis and no intrahepatic ductal dilatation; his CHD at
the time measured 4mm in size.
Today, he presented to ___ with abdominal pain, nausea,
and multiple episodes of NBNB emesis. There he was also
reportedly hypertensive and tachycardic but afebrile. Given
concern for possible need for ERCP evaluation, he was
transferred to ___.
In the ___, initial VS afebrile, 92, 226/132, 14, 98% on RA.
Labs showed wnl Chem7, ALT 65, AST 97, AP 168, Tbili 1.1, WBC
12.6 with 87.7% PMNs; Hgb wnl. Lactate 2.9. UA negative for
UTI. ___ US showed gallbladder contracted around multiple
stones without any gallbladder wall edema, positive sonographic
___ sign. His CBD was dilated to 8.5 mm. The patient
received multiple doses of dilaudid and Zofran was placed on
Zosyn for empiric coverage of cholangitis. He was taken to ___
where an 8mm CBD stone was found with post-obstructive dilation
of the CHD upto 10 mm. Balloon sweeps revealed pus, sludge and
stone fragments following sphincterotomy and a plastic stent was
place within the CBD. Post-ERCP, the patient's VS were
reportedly wnl with resolution of his HTN.
Upon arrival to the floor, the patient reports that his
abdominal pain, n/v are both entirely resolved. He otherwise
feels well and has no current medical complaints.
Past Medical History:
HTN
HLD
T2DM
prior gallstones
hayfever
rhinitis
osteoarthritis
obesity
PSH: ENT procedure
Social History:
___
Family History:
Mother deceased, + bladder cancer.
Father deceased, + thyroid cancer.
Physical Exam:
Vitals:98.7, 132/68, 81, 16, 99% on RA
General: pleasant, overweight middle-aged male lying flat in bed
in NAD
HEENT: MMM, NCAT, EOMI, anicteric sclera
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, NTND, no RUQ abdominal TTP, no
rebound/guarding, + bowel sounds
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Discharge Physical Exam:
Vitals: T 97.9 Bp 140/70 P 66 r 18 97% O2 FSG 126
General: No acute distress, reclined in bed. Conversational,
speaking in clear and fluent speech, with full sentences.
Mentating appropriately.
HEENT: No scleral icterus or injection. No rhinorrhea. NCAT,
MMM.
Lungs: Clear to auscultation bilaterally, no adventitious
sounds. Symmetric.
CV: Regular rate, normal S1 and S2 present. No murmurs, rubs, or
gallops. No peripheral edema. Operative occlusive dressings in
place, with no shadowing or strikethrough. JP in right upper
quadrant with serosanguine output removed. No erythema, edema,
or ecchymosis at insertion site. No purulence. Dry sterile
dressing placed over site.
Abdomen: soft, obese. Minimal appropriate tenderness
periincisionally. Nondistended, no rebound or guarding. Bowel
sounds present.
Ext: Warm. well perfused. No cyanosis or edema. Left thumb and
forefinger tingling and dullness, improved from ___.
Pertinent Results:
ADMISSION LABS
===============
___ 02:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-150 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:00PM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:00PM URINE MUCOUS-RARE
___ 11:27AM GLUCOSE-214* UREA N-15 CREAT-0.9 SODIUM-135
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-17* ANION GAP-27*
___ 11:27AM ALT(SGPT)-65* AST(SGOT)-97* ALK PHOS-168* TOT
BILI-1.1
___ 11:27AM LIPASE-17
___ 11:27AM ALBUMIN-4.8
___ 11:27AM WBC-12.6*# RBC-5.20 HGB-14.6 HCT-44.9 MCV-86
MCH-28.1 MCHC-32.5 RDW-12.9 RDWSD-40.3
___ 11:27AM NEUTS-87.7* LYMPHS-6.7* MONOS-4.7* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-11.07* AbsLymp-0.85* AbsMono-0.59
AbsEos-0.01* AbsBaso-0.03
___ 11:27AM PLT COUNT-369
___ 11:27AM ___ PTT-38.3* ___
___ 11:26AM LACTATE-2.9*
MICROBIOLOGY
=============
___ UCx pending
___ BCx x 2 pending
IMAGING
========
LIVER OR GALLBLADDER US - ___ 12:16 ___ - IMPRESSION:
1. Multiple gallstones without evidence of acute cholecystitis.
2. Dilation of the common bile duct to 8.5 mm suggestive of
possible choledocholithiasis.
3. Gallbladder adenomyomatosis.
4. 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.
ERCP ___
IMPRESSION:
The scout film was normal.
Normal major papilla.
Cannulation of the biliary duct was successful and deep after
performing a small precut.
Contrast medium was injected resulting in complete
opacification.
A single 8 mm stone that was causing partial obstruction was
seen at the middle third of the common bile duct.
There was post-obstructive dilation of the CHD up to 10 mm.
An extension of the sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire.
Mild oozing was noted post sphincterotomy, epinephrine was
injected with excellent homeostasis.
After performing the sphincterotomy moderate amount of pus was
noted coming out from the common bile duct.
Balloon sweeps reveled pus, sludge and stone fragments.
Due to the presence of pus and the stone size a decision to
proceed with biliary plastic stent placement was made
A ___ FR*8 cm biliary plastic stent was placed within the common
biliary duct.
Post stent placement there was good bile and contrast drainage
both fluoroscopically and endoscopically
Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Mr. ___ is a ___ PMHx obesity and recent symptomatic
cholelithiasis and biliary colic who presents with
choledocholithiasis/cholangitis prior to scheduled laparoscopic
cholecystectomy. He had an US that showed multiple gallstones
and a contracted gallbladder without intrahepatic ductal
dilatation, CBD 4mm. He was transferred from ___ with
abdominal pain, nausea, multiple nonbloody nonbilious emesis
events, hypertension, tachycardia, and leukocytosis WBC 12.6
with left shift. Another RUQ ultrasound showed CBD 8.5mm and no
evidence of cholecystitis, steatosis vs steatohepatitis,
gallbladderadenomyomatosis, likely consistentwith
choledocholithiasis and cholangitis. He was taken to ERCP, put
on IV antibiotics, given IV hydration. On ___ (day of
admission), he had the ERCP which found sludge, purulent
material, and stone fragments with an 8mm obstructing stone in
the middle third of the common bile duct. He has a sphinterotomy
and a biliary plastic stent ___ in the common bile duct.
After this procedure, he had been feeling much improved, without
abdominal pain and passing flatus. His white blood cell count
normalized. His lipase was 77, and AST increased to 417 (65,
ALT 507 (97). They trended downward by the time of discharge,
and T bili decreased from max of 1.9 on ___ to 0.5 on
discharge ___. On ___, he was taken to the operating room
with Dr. ___ laparoscopic cholecystectomy, where he
was found to have evidence of severe chronic cholecystitis and
multiple gallstones. A drain was placed that was removed the
morning of post operative day one after having acceptable
serosanguinous output. He tolerated the procedure well, and was
able to ambulate, tolerate a regular diet, urinate, and control
his pain on a PO regimen. He had minor mild thumb paresthesia
with intact motor and sensory function, which was improving upon
discharge and attributed to a hospital band on his wrist that
was removed prior to surgery. He was discharged home with
instructions to remove his operative dressings the next day,
with 5 total days of Augmentin. He is to follow up in a four
weeks with ERCP in order to have the stent re-evaluated and
removed.
He was in agreement with this plan and all his questions had
been answered to his satisfaction.
# Cholangitis, Choledocholithiasis: Patient with prior
evaluation for likely biliary colic, now representing with RUQ
abdominal pain, leukocytosis, transaminitis and obstructing
choledocholithiasis with associated pus and post-obstructive
dilation of his CHD consistent with cholangitis. S/p ERCP with
sphincterotomy and stenting of his CBD. Cholecystectomy on
___ (___). LFTs initially increased but trended down
prior to discharge, leukocytes/pain/lactate resolved shortly
after ERCP. No BCx drawn at OSH, BCx here pending. Received
Zosyn (___), transitioned to CTX/flagyl (___) and
discharged with Augmentin. Should complete abx course.
# Hypertensive urgency: BP elevated on admit ___ pain, resolved
with resolution of pain. Continued home lisinopril 20 mg daily.
# HLD: held home gemfibrozil given transaminitis and ASA given
ERCP.
# T2DM. Reportedly previously poorly controlled on metformin,
but HbA1c now improved from 9.7 to 7.8 recently in ___ with
lifestyle modifications. Metformin was held and he required
minimal to no coverage on SSI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gemfibrozil 600 mg PO BID
2. Lisinopril 20 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Aspirin 650 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Take regularly for a few days. Do not exceed 3000mg in 24 hours.
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 (One) tablet(s)
by mouth every twelve (12) hours Disp #*18 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Take while taking oxycodone
RX *docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a
day Disp #*30 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Take for pain uncontrolled by Tylenol
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4) to
six (6) hours Disp #*20 Tablet Refills:*0
5. Aspirin 650 mg PO DAILY
You may start taking this again tomorrow ___.
6. Gemfibrozil 600 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
cholodocholithiasis, status post ERCP with stent placement and
laparoscopic cholecystectomy
hepatic steatosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after coming to the Emergency
Room with abdominal pain, nausea, and vomiting with high blood
pressure and high white blood cell count (usually a sign of
infection). You had an ultrasound and an ERCP (endoscopic
retrograde cholangiopancreatography), which found sludge, pus,
and stone fragments and placed a biliary stent in your common
bile duct and a small cut, sphincterotomy, to make the opening
in your sphincter larger. Your white blood count went down, and
your pain and nausea resolved.
You were then taken to the operating room and had your
gallbladder removed laparoscopically (Laparoscopic
cholecystectomy). You tolerated this procedure well **. Your are
tolerating a regular diet, are walking, urinating, and your pain
is controlled with pain medication by mouth. You are now being
discharged home to continue your recovery with the following
instructions.
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. Please
get pleanty or rest and continue to walk several times a day.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the clear sticky tape
(tegaderm) and gauzes over your incisions. Under these dressing
you have small bandage strips called steri-strips. Do not remove
the steri-strips- they will fall off on their own in 1 to 2
weeks. If any are still on in 2 weeks and the edges are peeling,
you may carefully pull them off.
o Your incisions may be slightly red around the stitches (under
your skin). 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.
- The site of your drain that was removed can be covered with a
dry sterile gauze that you change at least twice a day or if it
becomes dirty. It will close by itself. Keep it clean and dry.
If you have any redness, swelling, drainage other than minimal
watery fluid, or increased pain.
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.
- You may have more fatty or loose stools with fatty meals
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 oxycodone to
take by mouth. It is important to take this medicine as
directed. Do not take it more frequently than prescribed. Do not
take more medicine at one time than prescribed. You should use
Tylenol for mild pain, and you should take this regularly for
the first few days. Do not take more than 3000mg in 24 hours.
You may take the Oxycodone for pain uncontrolled by Tylenol that
is moderate or severe.
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. Do not operate heavy machinery or
drive while taking pain medications.
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 or return to the Emergency Department:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- vomiting and nausea, inability to keep down fluids, food, or
your medications.
- dehydrated (dry mouth, rapid heart beat, feeling dizzy or
faint especially while standing)
- pain that is getting worse over time, or going to your chest
or back
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
- burning or blood in your urine or the inability to urinate
- shaking chills, fever
- any change or new symptoms that concern you
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently. You may
restart your normal amount of aspirin tomorrow ___.
-Continue to control your blood sugar well. With your lifestyle
changes, you have already shown improvements!
- Continue taking the prescribed antibiotics as written, until
all of your pills are gone. Do not stop them early.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
You had some minimal tingling in your left hand that has been
significantly improved. If this continues or worsens (your hand
becomes cold, painful, pale, or blue) call the office or return
to the emergency room.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care! We hope you have a
quick return to your usual life and activities.
Followup Instructions:
___
|
10503869-DS-20 | 10,503,869 | 21,272,663 | DS | 20 | 2189-12-31 00:00:00 | 2190-01-04 16:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Beta-Blockers (Beta-Adrenergic Blocking Agts) /
Lasix
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo F with a history of HTN, s/p aortic dissection
repair and graft placement (___), LBBB and recurrent UTIs
who presented to her PCP today for altered mental status.
.
At her PCP office the daughter in law reported an acute onset
confusional state since ___. The patient was picked up
by her family from her ___ home and was noted to have word
finding difficulty, excessive fatigue, and gait/postural
instability. The daughter in law was concerned this was another
urinary tract infection. The patient was worried per PCP ___
"something changed in my head this past ___. The PCP
referred the patient to the ED.
.
In the ED, initial vital signs were 97.4 64 142/70 18 97% RA.
Initial labs were significant for a Cr 1.1 (baseline 0.9), wbc
8.7, hct 41.7 and platelets 236. A UA showed large leuks,
moderate bacteria and 5 epis. She was 400mg cipro IV in the ED.
A CT head demonstrated no acute intracranial process. A chest
xray showed no evidence of pneumonia. Vitals on transfer were:
97.4 65 131/61 98%RA
.
Vitals on the floor:97.4 136/75 60 18 98% on RA. On the floor,
patient is alert and oriented, and states that she was in her
summer home in ___ and had some trouble with the
transformer in her home that was emitting a high pitched noise
all day ___ and ___ that made her very upset,
dispirited, and feel like "her brain was exploding". She spoke
with her daughter and son in law who told her to come back to
___ and she took a bus. She reports she slept most of
___ and was slow thinking and was having difficulty
finding her words. Her daughter took her to her MD's office
where she reports having difficulty with calculations and
orientation. She did not have any urinary complaints, but has
moderate urinary incontinence for which she wears a pad.
Past Medical History:
PAST MEDICAL HISTORY
1. Hypertension.
2. History of thoracic aortic dissection status post repair and
known outpouching at anastomosis b/w graft and native aorta.
3. Mild hypertrophic cardiomyopathy.
4. H/o bladder cancer vs polyp on by treated with BCG and
mitomycin per Dr. ___
5. Hemorrhoids
PAST OB GYN HISTORY
SVD x 5
She denies having Chlamydia, Gonorrhea, Syphilis, Genital
Herpes,
Trichomonas, Human Papilloma Virus (HPV) or HIV
She admits to using vaginal estrogen cream.
She denies post-menopausal bleeding.
Social History:
___
Family History:
Father died at ___ from MI; Mother: CVA in old age
Physical Exam:
Admission Physical Exam:
Vitals- 97.4 136/75 60 18 98% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
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, diaper in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal,
concentration intact able to do 93-7, states date, floor,
building, year, good recall
Discharge Physical Exam
Vitals- 97.8 130/76 66 18 98% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
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, diaper in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal,
concentration intact able to do 93-7, states date, floor,
building, year, good recall
Pertinent Results:
___ 03:00PM BLOOD WBC-8.7 RBC-4.88 Hgb-13.7 Hct-41.7 MCV-86
MCH-28.2 MCHC-32.9 RDW-13.8 Plt ___
___ 03:00PM BLOOD Neuts-68.9 ___ Monos-4.3 Eos-2.6
Baso-0.6
___ 07:05AM BLOOD UreaN-15 Creat-1.0 Na-137 K-4.6 Cl-102
HCO3-25 AnGap-15
___ 03:00PM BLOOD Glucose-97 UreaN-18 Creat-1.1 Na-136
K-5.0 Cl-99 HCO3-28 AnGap-14
___ 03:00PM URINE RBC-3* WBC-139* Bacteri-MOD Yeast-NONE
Epi-5 TransE-1
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
Urine Culture:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
FECAL
CONTAMINATION.
Blood cultures negative.
CT Head: ___ IMPRESSION:
1. No acute intracranial process including no evidence of acute
large
territorial infarction.
2. Mild small vessel disease
CXR ___:
IMPRESSION: No acute cardiothoracic process.
Brief Hospital Course:
This is a ___ yo F with a history of HTN, s/p aortic dissection
repair and graft placement (___), LBBB and recurrent UTIs
who presented to her PCP today for altered mental status found
to have a UTI.
.
Altered Mental Status: Resolved. CT head negative for
hemorrhage, and rapid neurological improvement with lack of
focal deficit argued against ischemic event. UTI in the setting
of UA with large ___ and 139 WBC, mod bacteria. Other infections
are less likely, CXR clear, no cough, shortness of breath, or
increased O2 requirement. Patient was given cipro IV in the ED
with rapid improvement of symptoms and mental status. Back to
baseline within hours. Urine culture showed mixed bacteria/flora
consistent with fecal contamination. Switched to Bactrim PO.
Stable and safe for discharge home with family to finish week
long course of PO Bactrim. Of note, spoke with PCP in ___ who notes that this is typical presentation for her UTIs and
who recommended longer treatment duration.
.
UTI: UA positive, urine culture showed mixed bacteria/flora
consistent with fecal contamination. Switched to Bactrim PO.
Stable and safe for discharge home with family to finish week
long course of PO Bactrim. Per report, she gets around 4 UTIs
per year, often with acute delirium.
.
Inactive issues:
.
Hypertension:
-continued home meds losartan, amlodipine, atenolol
.
GERD:
-continued home omeprazole
.
CAD/chol/Aortic dissection s/p repair:
-continued home ASA, simvastatin
.
.
Transitional issues:
-follow up with PCP
-___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 10 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Estrace *NF* (estradiol) 0.01 % (0.1 mg/g) Vaginal twice
weekly dryness
5. Omeprazole 20 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Estrace *NF* (estradiol) 0.01 % (0.1 mg/g) Vaginal twice
weekly dryness
5. Losartan Potassium 100 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Simvastatin 20 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
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 confused and
were found to have a urinary tract infection. You were given
antibiotics and fluids, and you improved significantly. Your
confusion resolved very quickly, and we gave you oral
antibiotics to finish taking at home.
Please START Bactrim 1 tab DS twice a day for 5 more days,
ending on ___. Please finish taking all of the
medication.
Please continue taking your home medications as prescribed.
Followup Instructions:
___
|
10503925-DS-10 | 10,503,925 | 25,634,730 | DS | 10 | 2143-08-07 00:00:00 | 2143-08-09 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
___ - capsule endoscopy
History of Present Illness:
Mr. ___ is a ___ yo M w/ PMHx of recently diagnosed anemia
who was admitted for work-up of GI bleed after blood had been
found in his colon on colonoscopy ___. His story begins in
___ when he went to ___ with leg swelling and shortness
of breath. He was found to be anemic. His H&H in ___ was
9.6/29.8. Previously in ___, his H&H was 14.9/44.8. The
culprit of his anemia was believed to be secondary to high dose
NSAID use. He had been taking ibuprofen or aleve two times a day
since he tore his rotator cuff. He underwent rotator cuff
surgery and he was given celecoxib afterwards as well. After
discharge from ___, he went to his PCP who recommended
stopping NSAIDs and starting omeprazole. He also states he has
been taking iron for approx 3 weeks. In ___, H&H ranged from
9.2-9.6. Iron studies revealed a low iron (17) and high TIBC
with appropriate reticulocyte count c/w iron deficiency anemia.
He had a colonoscopy in ___ but it was recommended that he
undergo a repeat colonoscopy and EGD to better evaluate his iron
deficiency anemia. His prep was uneventful until his second
bottle of magnesium hydroxide when he started passing red liquid
per rectum. Since his GI prep was cherry colored, he thought
this was secondary to the prep. His only other symptoms is
shortness of breath. He denies any melena or hematochezia. He
denies any abdominal pain or change to his bowel movements.
In the ED, initial VS were 97.7 60 123/83 18 100% RA. There were
small spots of blood noted on stool. CTA revealed no active
source of bleeding and pulmonary emboli. Transfer VS were 97.3
68 131/88 14 99%RA.
On arrival to the floor, patient reports that he is feeling
fine.
Past Medical History:
iron deficiency anemia
Social History:
___
Family History:
- no family history of colon cancer or GI disease
Physical Exam:
admission:
---------
VS - 97.9 139/65 66 18 100%RA
General: NAD, A+Ox3
HEENT: anicteric sclera, mild pallor, EOMI, PERRL
Neck: supple, non-elevated JVP
CV: RRR, no m/r/g, nl s1&s2
Lungs: CTAB, no wheeze/rales/rhonchi
Abdomen: soft, NT/ND, no hsm, +BS
GU: no foley, otherwise deferred
Ext: WWP, no pitting edema, +2 pulses distally
Neuro: CN II-XII intact
Skin: no rash
discharge:
---------
VS: 98.2 110/64 83 18 100%RA
General: NAD, A+Ox3
HEENT: anicteric sclera, mild pallor, EOMI, PERRL
Neck: supple, non-elevated JVP
CV: RRR, no m/r/g, nl s1&s2
Lungs: CTAB, no wheeze/rales/rhonchi
Abdomen: soft, NT/ND, no hsm, +BS
GU: no foley, otherwise deferred
Ext: WWP, no pitting edema, +2 pulses distally
Neuro: CN II-XII intact
Skin: no rash
Pertinent Results:
admission:
---------
___ 02:50PM BLOOD WBC-4.7 RBC-3.67* Hgb-9.9* Hct-31.8*
MCV-87 MCH-26.9* MCHC-31.0 RDW-13.9 Plt ___
___ 02:50PM BLOOD Neuts-45.3* Lymphs-45.6* Monos-7.1
Eos-1.4 Baso-0.7
___ 03:08PM BLOOD ___ PTT-27.3 ___
___ 02:50PM BLOOD Glucose-90 UreaN-11 Creat-1.0 Na-140
K-4.3 Cl-107 HCO3-27 AnGap-10
___ 07:00AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.2
discharge:
--------
___ 08:15AM BLOOD WBC-3.6* RBC-3.90* Hgb-10.2* Hct-34.2*
MCV-88 MCH-26.2* MCHC-29.9* RDW-14.2 Plt ___
imaging:
-------
___ CT Ab/P
1. No CT evidence for small bowel mass. Given that proximal
loops of small
bowel are collapsed, correlation with capsule endoscopy results
is recommended
as CT is insensitive for small, small bowel lesions.
2. Filling defects persist within subsegmental vascular
branches of the
bilateral lower lobes, likely due to pulmonary emboli.
Dedicated chest CT
examination could be performed for more complete assessment of
extent of
thrombus.
___ Ab XR
1. Capsule projecting over the right mid lateral abdomen,
likely within the
ascending colon. No evidence of bowel obstruction.
___ ballon endoscopy:
1. Erythema in stomach
2. Delayed gastric emptying
3. Lymphangiectasia in small bowel
4. ___ small ileal angioectasias (nonbleeding)
___ CT Ab/P
1. Small bilateral segmental pulmonary emboli in the lower
lobes. No evidence of right heart strain.
2. No active extravasation of contrast within the small bowel
and colon to suggest active bleeding.
3. Left renal cyst.
4. Small hydrocele.
___ colonoscopy:
Grade 1 internal hemorrhoids
Fresh blood was noted throughout the colon and into the terminal
ileum. No active source of bleeding was identified. Highly
suspicious though for a small bowel lesion.
Otherwise normal colonoscopy to cecum and 15cm into terminal
ileum
___ EGD:
Normal esophagus.
Normal stomach.
Normal duodenum.
Brief Hospital Course:
___ yo M w/ hx of iron deficiency anemia orginally attributed to
chronic NSAID use admitted after colonoscopy showed fresh blood
in the colon into the terminal ileum suspicious for small bowel
lesion.
# Gastrointestinal bleeding, NOS- CTA was unsuccesful at
localization of source of bright red blood. He then underwent
capsule endoscopy which revealed gastritis, delayed gastric
emptying and ileal angioectasias which may have been the source
of his bleeding. Since the capsule ran out of battery before
traversing his entire intestine, he underwent CT abdomen which
was unrevealing for any source of bleeding. His H&H was trended
and was stable and he had no episodes of hematochezia or melena
during his hospitalization. He was started on a PPI twice daily.
# H. pylori infection - Started on triple therapy with a PPI,
clarithromycin, and amoxicilin.
# Pulmonary embolism - Likely source of pts SOB and unilateral
leg swelling that prompted presentation to ___. Unprovoked
in the absence of risk factors including recent immobilization,
long travel with prolonged periods of being sedentary. PE was
noted incidentally on CTA done to evaluate bleeding source. He
was started on a heparin drip and then transitioned to lovenox.
His H/H remained stable while on anticoagulation. He was also
started on coumadin. He will follow up with his PCP who will
manage his anti-coagulation.
# Iron deficiency anemia - Likely from GIB, continued on iron
pills.
TRANSITIONAL ISSUES:
* f/u INR as outpatient
* f/u CBC as outpatient to ensure resolution of iron deficiency
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Amoxicillin 1000 mg PO Q12H Duration: 10 Days
RX *amoxicillin 500 mg 2 capsule(s) by mouth twice a day Disp
#*40 Capsule Refills:*0
2. Clarithromycin 500 mg PO Q12H Duration: 10 Days
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
3. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 90 mg SC q12hr Disp #*30 Syringe
Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
5. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
6. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. acute blood loss anemia
2. acute gastrointestinal bleed
3. bilateral pulmonary emboli
4. iron deficiency anemia
5. H pylori infection
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 during your
outpatient colonoscopy and EGD, you were found to have blood in
your intestines. Out of concern for an acute bleed from your
gastrointestinal tract, you were brought to the hospital for
further evaluation. We had the GI team see you who recommended
capsule endoscopy - this entailed swallowing a camera to get a
look at your intestines. This revealed AVMs (arteriovenous
malformations - or abnormal connections between your arteries
and veins) in your intestines. AVMs are common sources of
bleeding.
Also, while you were here, you underwent a CT scan in an attempt
to localize the source of your bleeding. This CT scan found
bilateral blood clots in your lungs. These blood clots are
called pulmonary emboli. They are likely contributing to your
shortness of breath. We started to anticoagulate you (meaning we
thinned your blood) as a treatment to prevent more clots from
forming and to dissolve the ones that are present. You will do
shots of lovenox while taking coumadin until your INR is in the
appropriate range. Your goal INR will be between ___.
You were also started on antibiotics for a stomach infection
called H. pylori. You will take these for a total of 10-days.
It is extremely important to follow up with your Primary Care
Doctor ___ see below for upcoming appointments).
Followup Instructions:
___
|
10504238-DS-11 | 10,504,238 | 20,636,625 | DS | 11 | 2141-02-22 00:00:00 | 2141-02-22 22:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin / tramadol / ptu / Humira
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
History of Present Illness:
___ with PMH rheumatologic autoimmune disease of unclear
etiology, possible rheumatoid arthritis and cholecystectomy
performed for gallstone pancreatitis over ___ years ago, with
chronic epigastric abdominal pain associated with eating since
___, followed by GI at ___ and ___, p/w worsening
epigastric abdominal pain similar to chronic pain but more
severe x 3 days and seeing white spots in ___ stool yesterday.
Stool was slightly loose, saw some mucus and reports thought
also stool had coffee-ground appearance at one portion.
pt states that the pain in the epigastric region radiates to the
back, is the same as waht she has been having for the past few
months but worse. Comes on , gets worse and then dissapates.
Has some nausea. no vomiting. is afraid to eat she reports.
States that she lost 40lbs since ___. she was reading the
internet and is worried about possible parasite. ___ MD thinks
that she needs an ERCP.
She reports occ low grade temps, occ sweats at night.
Since ___ was taken off all rheum meds other than plaquenil
until ___ stomach problems "get sorted out". she denies any
nsaids at this time. rec by ERCP team here to take reglan 5 tid,
she reports doing so but is not sure if it helps at all.
10 systems reviewd and are negative except where stated above
Past Medical History:
unclear rheumatologic condition
possible RA
CCY due to gallstone pancreatitis
possible delayed gastric empyting
Social History:
___
Family History:
Coronary artery disease and diabetes
Physical Exam:
Afeb, VSS
Cons: NAD, lying in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs,soft, vol guarding epigastric region, tender to very
light touch, ? distractable?
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: flattened affect
Discharge exam:
normal VS
benign abdomen
appropriate affect, pleasant, anxious at times
Pertinent Results:
___ 11:02PM GLUCOSE-84 UREA N-16 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-29 ANION GAP-13
___ 11:02PM ALT(SGPT)-12 AST(SGOT)-19 ALK PHOS-52 TOT
BILI-0.3
___ 11:02PM LIPASE-123*
___ 11:02PM ALBUMIN-4.7 CALCIUM-9.8 PHOSPHATE-3.9
MAGNESIUM-2.2
___ 11:02PM WBC-11.4* RBC-4.52 HGB-14.1 HCT-44.1 MCV-98
MCH-31.2 MCHC-32.0 RDW-12.6
___ 11:02PM NEUTS-48.7* LYMPHS-44.3* MONOS-5.0 EOS-1.1
BASOS-0.9
___ 11:02PM PLT COUNT-238
Liver Ultrasound:
IMPRESSION:
Diffuse intra and extrahepatic biliary duct dilation with CBD
measuring up to 1.2 cm, and smooth but abrupt tapering of the
CBD at the ampulla without definite obstructing mass or stone.
Mild prominence of the pancreatic duct. The findings may
represent sphincter of Oddi dysfunction or ampullary stenosis,
and further evaluation with ERCP is recommended.
ABD XRAY
IMPRESSION: Full of stool in the transverse and descending
colon. Unusual configuration to bowel gas in the rectum.
RIB XRAY:
IMPRESSION:
The lungs are clear without infiltrate or effusion. The cardiac
and
mediastinal silhouettes are normal. No rib fractures identified.
There is no pneumothorax.
Discharge labs:
___ Ct
___
UreaNCreatNaKClHCO3AnGap
___
ALTASTAlkPhosTotBili (all trending towards normal):
___
HBsAg HBsAb HBcAb
NEGATIVEPOSITIVE1NEGATIVE
HCV Ab negative
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative)
CT abdomen ___:
1. No evidence of bowel perforation, pneumoperitoneum, or
pneumoretroperitoneum. No CT evidence of pancreatitis.
2. 2.8 x 1.6 cm benign-appearing ovoid lesion interposed between
spleen and
greater curvature of stomach. Nonemergent US or MRI is
recommended for
further evaluation
Abdominal ultrasound ___:
Ultrasound again demonstrating a 2.4 cm structure intimately
associated with the spleen possibly subcapsular in location.
This did not demonstrate any evidence of vascularity and has
heterogeneous internal components raising the possibility of a
hematoma.
However, this remains speculative and definitive
characterization with MRI is recommended to assess for
enhancement characteristics and evidence of blood product.
MR abdomen ___ (prelim report):
1. Splenic lesion is likely a subcapsular proteinaceous cyst or
chronic subcapsular hematoma. No suspicious features. This could
be correlated with prior imaging to determine chronicity.
2. Slight interval decrease in common bile duct dilation after
sphincterotomy with stable mild intrahepatic bile duct dilation.
Brief Hospital Course:
___ yo F with h/o chronic pain, gastroparesis p/w abd pain.
# Abd pain: RUQ ultrasound showed ductal dilation, so ERCP was
consulted given rising LFTs. ERCP as noted above, underwent
sphincterotomy for ampullary stenosis, with improvement in LFTs.
Initially managed with IVF and IV pain medications, and was
tolerating a regular diet with PRN PO pain meds prior to
discharge. Constipation also likely a contributor to symptoms,
and patient was counseled to use laxatives to help improve GI
motility at home, and will only use morphine if needed. Morphine
use should decrease significantly over coming days as mild
post-procedure discomfort continues to improve. Also given
Zofran PRN nausea.
# Splenic structure- as noted on above imaging. No follow up
needed as long as PCP is able to compare to prior imaging.
# transaminitis: likely due to ampullary stenosis/Sphincter of
Oddi dysfunction. Hepatitis serologies were negative.
Hydroxychloroquine rarely associated with LFT abnormalities, so
continued.
# ? Gastroparesis- equivocal results with recent gastric
emptying study. Continued Reglan for time being, can likely be
discontinued in the coming weeks.
# h/o gastritis- continued PPI
# Anxiety/psychosocial stress- received lorazepam as needed
full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 200 mg PO BID
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Adderall (dextroamphetamine-amphetamine) 5 mg oral q8hprn
adhd
4. Levothyroxine Sodium 200 mcg PO DAILY
5. Metoclopramide 5 mg PO QIDACHS
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg PO BID
2. Levothyroxine Sodium 200 mcg PO DAILY
3. Lorazepam 0.5 mg PO Q8H:PRN anxiety
4. Metoclopramide 5 mg PO QIDACHS
5. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth three times a day Disp
#*12 Tablet Refills:*0
6. Adderall (dextroamphetamine-amphetamine) 5 mg oral q8hprn
adhd
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain
Only take when needed.
Do not drive when taking this medication.
RX *morphine 15 mg 1 tablet(s) by mouth three times a day Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ampullary stenosis
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain. You had an xray of the
abdomen that showed constipation.
Your liver function tests were mildly elevated, and you
underwent an ERCP that showed a narrowing at the end of the bile
duct. You underwent a procedure to open this narrowing (see the
drawing that I gave you). After this, your liver tests
improved. This narrowing, along with constipation, are the
likely cause of your abdominal pain.
You also underwent imaging tests to evaluate part of your
spleen, and all tests were reassuring, and the findings are
benign.
Please see below for your follow up appointments and
medications.
Followup Instructions:
___
|
10504238-DS-12 | 10,504,238 | 26,957,518 | DS | 12 | 2141-09-12 00:00:00 | 2141-09-12 22:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin / tramadol / ptu / Humira
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
This is a ___ with PMH rheumatologic autoimmune disease of
unclear etiology (?RA), cholecystectomy
performed for gallstone pancreatitis over ___ years ago, biliary
ampullary stenosis s/p sphincterotomy, with chronic epigastric
abdominal pain associated with eating since ___, followed
by GI at ___ and ___, who p/w worsening LUQ abdominal
pain and N/V.
The pt was in her USOH until 1 week PTA when she developed LUQ
abdominal pain, fairly constant, but much worse with eating. She
has been vomiting intermittently, nonbloody. She was seen at
___, reportedly had a neg cardiac w/u, discharged. She
felt better but then 3 days PTA symptoms worsened again. She
tried ibuprofen over the weekend but this made her symptoms even
worse. She says this is different then the pain that brought her
in ___, found to have transaminitis and biliary ampullary
stenosis s/p sphincterotomy, which was more right-sided.
She also carries a diagnosis of possible gastroparesis of
unclear etiology, though gastric emptying study here was
previously equivocal. Recent history notable for attempted
downtitration of reglan (5 BID to daily) 2 months ago by her
outpt GI, which led to worse abdominal pain and nausea, now back
to 5 BID. Around this time she also went from a BID PPI to
daily. She had one loose BM but otherwise wnl and no blood seen.
She does note that ___ yr ago she an EGD at ___ which
showed gastritis and ulcers, previously H. pylori neg. Of note
ERCP ___ did not show any stomach abnormality. She denies any
wt loss.
In the ED, initial vitals: 99.5 78 134/76 18 100%
Labs wnl. Abd CT showed stable mild biliary dilation
She received:
IV Ondansetron 4 mg
IVF 2L NS
IV Morphine Sulfate 15 mg
IV Ondansetron 4 mg
IV Ketorolac 30 mg
IVF 1000 mL NS
Vitals prior to transfer: 98.7 60 126/74 15 99% RA
Currently, the pt's symptoms are unchanged.
ROS: As above. Otherwise neg.
Past Medical History:
-Unclear rheumatologic condition, possibly RA (previously on
Humira), not currently on any therapy, follows at ___
-___ due to gallstone pancreatitis
-Possible delayed gastric empyting
-Chronic abdominal pain
-Biliary ampullary stenosis s/p sphincterotomy
-Mood disorder
Social History:
___
Family History:
Coronary artery disease and diabetes, dad with stomach ulcers
Physical Exam:
DISCHARGE:
Vitals- 98.7 144/72 62 16 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, mild ttp diffusely, worst in the LUQ, ND, 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:
ADMISSION LABS:
___ 12:10PM PLT COUNT-257
___ 12:10PM NEUTS-61.1 ___ MONOS-5.3 EOS-1.0
BASOS-0.5
___ 12:10PM WBC-7.6 RBC-4.63 HGB-14.8 HCT-44.1 MCV-95
MCH-32.0 MCHC-33.6 RDW-13.0
___ 12:10PM ALBUMIN-4.7
___ 12:10PM LIPASE-31
___ 12:10PM ALT(SGPT)-16 AST(SGOT)-22 ALK PHOS-66 TOT
BILI-0.4
___ 12:10PM estGFR-Using this
___ 12:10PM GLUCOSE-91 UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
___ 12:15PM URINE UHOLD-HOLD
___ 12:15PM URINE UCG-NEGATIVE
___ 12:15PM URINE HOURS-RANDOM
___ 12:15PM URINE HOURS-RANDOM
___ 12:34PM LACTATE-1.0
___ 12:34PM ___ COMMENTS-GREEN TOP
___ 04:39PM URINE MUCOUS-MOD
___ 04:39PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-29
___ 04:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:39PM URINE COLOR-Yellow APPEAR-Hazy SP ___
DISCHARGE LABS:
___ 05:14AM BLOOD WBC-6.3 RBC-4.06* Hgb-13.4 Hct-38.8
MCV-96 MCH-33.1* MCHC-34.6 RDW-12.7 Plt ___
___ 05:14AM BLOOD Glucose-81 UreaN-5* Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-27 AnGap-12
___ 05:14AM BLOOD Glucose-81 UreaN-5* Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-27 AnGap-12
___ 05:30AM BLOOD ALT-13 AST-15 LD(LDH)-143 AlkPhos-49
TotBili-0.3
___ 05:14AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0
MICRO:
___ 12:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 10:57 pm
SEROLOGY/BLOOD TAKEN FROM ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
EQUIVOCAL BY EIA.
(Reference Range-Neg
IMAGING:
CT abd/pelvis ___:
IMPRESSION:
1. No acute intraabdominal process.
2. Status post cholecystectomy with mild intrahepatic and
common bile duct
dilation, unchanged.
EGD ___:
Impression:Irregular z-line appreciated at distal esophagus
concerning for ___ esophagus. (biopsy)
Mild erythema with small scattered gastric erosions seen in the
stomach body and antrum. (biopsy)
Duodenal mucosa appeared grossly normal. (biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
This is a ___ with PMH rheumatologic autoimmune disease of
unclear etiology (?RA), cholecystectomy performed for gallstone
pancreatitis over ___ years ago, biliary ampullary stenosis s/p
sphincterotomy, with chronic epigastric abdominal pain
associated with eating since ___, who p/w worsening LUQ
abdominal pain and N/V.
# Abdominal pain/vomiting: Symptoms predominantly prandial, c/w
gastritis. DDx included PUD. Question of gastroparesis and seems
to have tolerated poorly reglan downtitration, though her
gastric emptying study was previously equivocal. CT abd/pelvis
was non-acute. EGD revealed gastritis and possibly ___ and
biopsies were taken. She was given BID pantoprazole and
sucralfate. Home Reglan was continued. H. pylori serology was
equivocal. Her diet was advanced.
# Narcotics: Pt requested narcotics for abdominal pain during
her admission. Per review of recent outpatient ___
narcotics prescribing she had multiple prescribers ___. It was
explained to her that these medications can slow down gut
motility and potentially make her gastroparetic abdominal pain
worse.
# Mood disorder: Continued home lamictal, wellbutrin, ativan
prn. Instructed to not take Adderall at the same time as
pantoprazole.
# Hypothyroidism: Continued home levothyroxine
Transitional issues:
- Started on BID pantoprazole and sucralfate
- Followup esophageal and stomach biopsies
- Suggest sending H. pylori stool antigen as outpatient
- If symptoms refractory, may benefit from outpatient SmartPill
motility study
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Lorazepam 0.5 mg PO Q12H:PRN anxiety
3. Metoclopramide 5 mg PO BID
4. Adderall (dextroamphetamine-amphetamine) 10 mg oral daily prn
adhd
5. Pantoprazole 40 mg PO Q24H
6. LaMOTrigine 100 mg PO DAILY
7. BuPROPion (Sustained Release) 300 mg PO QAM
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. LaMOTrigine 100 mg PO DAILY
3. Levothyroxine Sodium 200 mcg PO DAILY
4. Lorazepam 0.5 mg PO Q12H:PRN anxiety
5. Metoclopramide 5 mg PO BID
6. Sucralfate 1 gm PO TID
Separate from levothyroxine by at least 4 hours
RX *sucralfate 1 gram 1 g by mouth three times a day Disp #*60
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
8. Adderall (dextroamphetamine-amphetamine) 10 mg ORAL DAILY PRN
adhd
Do not take at the same time as pantoprazole
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. LaMOTrigine 100 mg PO DAILY
3. Levothyroxine Sodium 200 mcg PO DAILY
4. Lorazepam 0.5 mg PO Q12H:PRN anxiety
5. Metoclopramide 5 mg PO BID
6. Sucralfate 1 gm PO TID
Separate from levothyroxine by at least 4 hours
RX *sucralfate 1 gram 1 g by mouth three times a day Disp #*60
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
8. Adderall (dextroamphetamine-amphetamine) 10 mg ORAL DAILY PRN
adhd
Do not take at the same time as pantoprazole
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Gastritis
Possible ___ Esophagus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___. You were admitted
with abdominal pain and found to have gastritis, or inflammation
in the stomach. We have provided you with medication to help
soothe the stomach and have taken biopsies. Please followup with
your gastroenterologist, where more tests may need to be done
(including H. pylori stool antigen). Please avoid ibuprofen and
alcohol as they can make gastritis worse.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10504238-DS-13 | 10,504,238 | 26,834,122 | DS | 13 | 2144-01-29 00:00:00 | 2144-01-30 13:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin / tramadol / ptu / Humira
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with CVID (?) and biliary stones
s/p CCY and sphincterotomy who presents with 2 days of
epigastric and RUQ pain with nausea and vomiting.
Reports that her CVID was diagnosed ___ years ago after she was
noted to be getting sick frequently. Three days ago, she
developed a few episodes of non-bloody emesis without other
symptoms. Yesterday, she was at a cookout and had some food.
Soon after, she developed severe abdominal pain that worsened
throughout the day. This morning, she presented to the ED for
this pain. She describes it as "someone punching me in the
abdomen" and says it radiates to her back and LUQ. Had 2
episodes of emesis yesterday. She has had this type of pain in
the past related to gallstones and before her sphincterotomy.
She says the pain worsens with respiration and movement, but
denies an association with food. No fevers, diarrhea,
constipation.
In the ED, initial vital signs were: T 97.9, HR 73, BP 131/52,
RR 16, O2 99% RA
- Exam notable for: Moderate epigastric tenderness, RUQ pain
- Labs were notable for WBC 7.0, Hgb 14.2, Cr 0.8, Lipase 44,
LFTs wnl, UA negative
- Studies performed include CT A/P with contrast that showed no
acute abnormalities, and RUQUS which showed stable CBD dilation
and pneumobilia from sphincterotomy
- Patient was given: Dilaudid IV,, Toradol, IVF 2L
- Vitals on transfer: 98.0, 60, ___, 18, 97% RA
Upon arrival to the floor, the patient endorses worsening
abdominal pain. She says the pain radiates to her back. She is
asking how we are going to treat her pain.
Review of Systems:
Per HPI
Past Medical History:
-Unclear rheumatologic condition, possibly RA (previously on
Humira), not currently on any therapy, follows at ___
-___ due to gallstone pancreatitis
-Possible delayed gastric empyting
-Chronic abdominal pain
-Biliary ampullary stenosis s/p sphincterotomy
-Mood disorder
Social History:
___
Family History:
Coronary artery disease and diabetes
Physical Exam:
Admission exam:
===============
Vitals: 98.0, 60, ___, 18, 97% RA
GENERAL: AOx3, NAD
HEENT: MMM, no JVD
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Mildly distended, soft, no guarding or rigidity,
moderately tender to palpation in the epigastric and LUQ
regions, negative murphys sign
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: No facial rashes
NEUROLOGIC: CN2-12 intact.
Discharge exam:
===============
Vitals: 97.9, 90-110/50-70, 60-80, 18, 93% RA
GENERAL: AOx3, NAD
HEENT: MMM, no JVD
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Mild inspiratory and expiratory wheezing diffusely
ABDOMEN: Mildly distended, soft, no guarding or rigidity,
moderately tender to palpation in the epigastric and LUQ
regions, negative murphys sign, quiet BS
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: No facial rashes
NEUROLOGIC: CN2-12 intact.
Pertinent Results:
Admission labs:
===============
___ 11:45AM BLOOD WBC-7.0 RBC-4.32 Hgb-14.2 Hct-40.9 MCV-95
MCH-32.9* MCHC-34.7 RDW-12.6 RDWSD-44.2 Plt ___
___ 11:45AM BLOOD Neuts-63.0 ___ Monos-5.8 Eos-0.7*
Baso-0.6 Im ___ AbsNeut-4.42 AbsLymp-2.08 AbsMono-0.41
AbsEos-0.05 AbsBaso-0.04
___ 11:45AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-24 AnGap-16
___ 11:45AM BLOOD ALT-10 AST-19 AlkPhos-67 TotBili-0.5
___ 11:45AM BLOOD Albumin-4.5
___ 07:30AM BLOOD IgG-1001 IgA-128 IgM-109
Imaging:
========
CT Abdomen/Pelvis with contrast ___:
No acute findings in the abdomen or pelvis.
RUQUS ___:
1. Stable dilation of the common bile duct measuring up to 11
mm, a normal finding after cholecystectomy.
2. Pneumobilia, a normal finding status post sphincterotomy.
Microbiology:
=============
___ 12:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 7:30 am Blood (CMV AB) ADDED QIMMUN,EBV,CMV ___.
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
26 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Preliminary):
___ 7:30 am Blood (EBV) ADDED QIMMUN,EBV,CMV ___.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ 7:30 am SEROLOGY/BLOOD ADDED QIMMUN,EBV,CMV ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
Discharge labs:
===============
___ 07:30AM BLOOD WBC-5.3 RBC-3.90 Hgb-12.5 Hct-37.6 MCV-96
MCH-32.1* MCHC-33.2 RDW-12.8 RDWSD-45.4 Plt ___
___ 07:40AM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-141
K-3.8 Cl-103 HCO3-22 AnGap-20
___ 07:30AM BLOOD ALT-8 AST-14 AlkPhos-54 TotBili-0.5
___ 07:40AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ y/o female with CVID (?) and biliary stones
s/p CCY and sphincterotomy who presents with 2 days of
epigastric and RUQ pain with nausea and vomiting
# Nausea/vomiting
# Abdominal Pain
# Constipation: Presented with two days of symptoms, and CT scan
showing no infection but significant stool burden. Ig levels are
normal, so CVID is less likely to be an underlying cause. Most
likely cause is constipation given CT A/P stool burden and
history of no bowel movements recently. Her constipation may be
exacerbated by opioid use. She was started on an aggressive
bowel regimen (senna, Colace, bisacodyl, miralax, lactulose,
methylnaltrexone, and a tap water enema) and eventually had four
bowel movements, with improvement of her pain. She was started
on senna, Colace, miralax, and latulose on discharge. She was
counseled on the importance of having daily bowel movements,
especially when taking opioids.
# CVID: Outside records demonstrate history of CVID with Ig
infusions. Ig levels here are within normal limits.
# Chronic pain: Endorses history of chronic pain related to
cervical spine problems c/b left sided radiculopathy. Per recent
neurosurgery evaluation, she has C3-C4, C4-C5, C5-C6 disc
protrusions that is not operable. She also reports being in a
MVA recently which has worsened her pain. Takes oxycodone PRN as
an outpatient, which we continued but did not increase.
# Asthma: Continued home albuterol
# Hx of thyroidectomy: Continued home synthroid
# Depression: Continued home wellbutrin and lamictal
Transitional Issues:
- STARTED senna, Colace, miralax, and lactulose on discharge to
maintain normal bowel movement frequency. Please ensure daily
bowel movements.
- Consider starting methylnaltrexone PO as an outpatient for
opioid induced constipation
- STARTED triple therapy for h.pylori blood test positive --
continue Clarithromycin 500 mg q12h, Amoxicillin 1g q12h, and
Pantoprazole 40 mg BID x14 days (Day 1 = ___, Last day =
___
#Code: FC (presumed)
#Contact: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. LamoTRIgine 200 mg PO BID
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
6. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Amoxicillin 1000 mg PO Q12H Duration: 14 Days
RX *amoxicillin 500 mg 2 capsule(s) by mouth every twelve (12)
hours Disp #*56 Capsule Refills:*0
2. Clarithromycin 500 mg PO Q12H Duration: 14 Days
RX *clarithromycin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Lactulose 30 mL PO DAILY:PRN constipation
RX *lactulose 20 gram/30 mL 1 by mouth daily Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY Constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
7. Senna 8.6 mg PO BID Constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Tablet Refills:*0
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
9. BuPROPion XL (Once Daily) 300 mg PO DAILY
10. LamoTRIgine 200 mg PO BID
11. Levothyroxine Sodium 200 mcg PO DAILY
12. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
13. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Nausea, vomiting
- Abdominal pain
- Common variable immune deficiency
Secondary diagnoses:
- Asthma
- Depression
- Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for abdominal pain, nausea, and vomiting. A CT
scan of your abdomen showed significant constipation, and all of
your lab values were normal. We obtained outside hospital
records to learn more about your medical history. You were given
several medications to assist in having a bowel movement. After
you had some bowel movements, you felt better. You should
continue to take medicine at home (senna, Colace, miralax) to
make sure you have a bowel movement atleast once per day. If you
go more than one day without a bowel movement, please take
lactulose. If you go more than two days without a bowel
movement, please call your primary care physician.
Your blood test was positive for h pylori. You were started on
antibiotics (Amoxicillin and Clarithromycin) as well as
Pantoprazole to treat the h pylori infection. You should
continue to take these three medicines until ___.
You should see your outpatient physicians in ___.
It was a pleasure to take care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10504424-DS-11 | 10,504,424 | 28,594,235 | DS | 11 | 2124-06-21 00:00:00 | 2124-06-22 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness, altered mental status
Major Surgical or Invasive Procedure:
R.IJ HD Catheter Replacement - ___
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of HTN, HLD, CAD s/p
CABG, ESRD on HD, COPD (unknown if on home O2) who presents with
altered mental status and left-sided weakness.
The patient was found in bed this morning with new lethargy,
altered mental status, and left-sided weakness. Per his
daughter,
he also vomited one time. He was sent to ___,
where
initial vitals were notable for BP ___ and O2 sat in the
___,
improved with 2L NC. He was oriented to person and place and
noted that he felt terrible but could not elaborate further.
Labs
showed WBC 21, H/H ___, BUN/Cr 38/5.6, VBG 7.35/___, lactate
2.3, TSH 6.1, fT4 1.2. CXR was concerning for LLL atelectasis
and
___ was without acute intracranial process, demonstrated old
infarcts of the right thalamus and left cerebellar hemisphere
appear to be new since the prior study. He was given vancomycin
and ceftazidime and transferred to ___ for neurology stroke
evaluation.
In the ED, initial VS were: Temp 96.0F BP 116/87 HR 87 RR 22
94%
on RA (->97% on 4L NC)
Exam notable for: Fatigued, chronically ill appearing,
diminished BS at the bases. Breathing comfortably. RRR.
ECG: HR 79. NSR. Normal axis. Prolonged QTc. ST depressions in
V4-V6, TWI I, II, aVF, V4-V6.
Labs showed: BUN 40, Cr 5.7, BG 168, AG 23, WBC 21.5, ALT 43,
AST
42, Tbili 0.4, serum/urine tox negative.
Imaging showed:
- CT head: chronic right occipital, left cerebellar, and right
thalamic infarcts are noted
- CTA head/neck: Severe stenosis of the origin of the left
vertebral artery, which is totally occluded through most of the
V1 segment with reconstitution of flow at the level of the V2
segment. There are severe atherosclerotic narrowing of the right
internal carotid artery at the level of the bifurcation, however
remains patent. Right vertebral artery remains patent through
the
remainder its course with areas of severe stenosis.
Consults:
- Neurology: Symptoms likely ___ recrudescence of prior right
parietal and occipital strokes iso infection. Stroke cannot be
ruled out but he is out of the window for tPA and no large
vessel
cut off to consider thrombectomy. If symptoms do not improve
with
infection, consider MRI
Patient received:
___ 17:25 IV Azithromycin 500 mg ___
Stopped (1h ___
___ 20:16 IVF LR 500 mL ___ Stopped
___ 21:17 IVF LR ( 500 mL ordered)
Transfer VS were: Temp 97.6F BP 131/65 HR 80 RR 16 100% on RA
On arrival to the floor, patient reports feeling terrible but
cannot elaborate further. He denies headache, fever, chills,
chest pain, shortness of breath, cough, abdominal pain, nausea,
vomiting, diarrhea, constipation, dysuria, hematuria, or new
rashes. Further questioning limited by altered mental status.
Speaking with his daughter, she reports that he is
bed/wheelchair
bound at baseline and can move his left arm but does not use it
often. She is not aware of any recent illness and believes he
had
been feeling well. She does note that he has had intermittent
hospitalizations since his HD line was placed not too long ago
and there was a scabies outbreak in the Nursing Facility 1.5
weeks ago.
Past Medical History:
Congestive heart failure (unknown EF)
CAD s/p CABG
CVA w/ left-sided weakness
Hypertension
ESRD on HD
Hypothyroidism
Vascular dementia
Social History:
___
Family History:
Unable to obtain due to mental status
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
HEENT: AT/NC, anicteric sclera, Dry MM. Oropharynx evaluation
limited but clear.
NECK: supple, no lymphadenopathy.
CV: RRR with normal S1 and S2. Distance heart sounds. No
murmurs,
rubs or gallops appreciated.
PULM: Normal respiratory effort. Decreased breath sounds
throughout, no wheezes, rales or rhonchi appreciated over
anterior chest.
GI: soft, non-tender, non-distended. No masses. Normoactive BS.
No guarding or rebound tenderness.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
PULSES: 2+ radial pulses bilaterally
NEURO: Somnolent, kept eyes closed. Oriented x2 (unable to do
year). Able to do days of the week backwards. Vision present in
the right visual fields, none in the left (reported baseline).
Unable to move eyes to the left. Slight left sided facial droop.
CN VII-XII intact. ___ strength in RUE. LUE lay motionless. 3+/5
strength over BLE.
DERM: Warm, dry. No rashes or skin breakdown appreciated.
LINES: Right tunneled HD line with minimal surrounding erythema.
No drainage or TTP.
Pertinent Results:
ADMISSION LABS
===============
___ 02:45PM BLOOD WBC-21.5* RBC-5.48 Hgb-15.6 Hct-48.2
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.3 RDWSD-48.5* Plt ___
___ 02:45PM BLOOD Neuts-76.2* Lymphs-11.9* Monos-8.1
Eos-0.3* Baso-0.7 Im ___ AbsNeut-16.38* AbsLymp-2.57
AbsMono-1.74* AbsEos-0.06 AbsBaso-0.16*
___ 02:45PM BLOOD ___ PTT-24.1* ___
___ 02:45PM BLOOD Glucose-168* UreaN-40* Creat-5.7*# Na-136
K-4.7 Cl-89* HCO3-24 AnGap-23*
___ 02:45PM BLOOD ALT-43* AST-42* CK(CPK)-258 AlkPhos-164*
TotBili-0.4
___ 02:45PM BLOOD CK-MB-3
___ 11:06PM BLOOD proBNP-3278*
___ 02:45PM BLOOD Albumin-4.3 Calcium-9.8 Phos-4.9* Mg-1.8
___ 02:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:02PM BLOOD ___ pO2-28* pCO2-56* pH-7.32*
calTCO2-30 Base XS-0
___ 03:02PM BLOOD Glucose-186* Lactate-3.7* Na-136 K-4.3
Cl-91*
___ 08:25PM BLOOD Lactate-3.5*
___ 11:28PM BLOOD Lactate-3.3*
PERTINENT LABS
==============
___ 10:30AM BLOOD WBC-33.5* RBC-4.73 Hgb-13.5* Hct-40.9
MCV-87 MCH-28.5 MCHC-33.0 RDW-15.9* RDWSD-49.5* Plt ___
___ 05:45AM BLOOD Neuts-83.1* Lymphs-5.2* Monos-9.6
Eos-0.7* Baso-0.4 Im ___ AbsNeut-21.89* AbsLymp-1.37
AbsMono-2.53* AbsEos-0.18 AbsBaso-0.11*
DISCHARGE LABS
==============
MICROBIOLOGY
=============
___ 2:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS SPECIES. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS SPECIES
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 80 R
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
**FINAL REPORT ___
C. difficile PCR (Final ___:
Reported to and read back by ___ @ 0629 ON
___/ - ___.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
POSITIVE. (Reference Range-Negative).
PERFORMED BY EIA.
This result indicates a high likelihood of C. difficile
infection
(CDI).
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
STUDIES
=======
CXR (___)
IMPRESSION:
Moderate size left pleural effusion with associated left
basilar atelectasis.
Underlying pneumonia is difficult to exclude.
CT-HEAD/CTA (___)
IMPRESSION:
1. Multifocal severe atherosclerotic disease affecting the neck
and circle of
___ arterial vasculature. Notably, there is severe
(approximately 80%)
proximal right ICA narrowing. There are areas of severe
stenosis of the
bilateral vertebral arteries, with an area of non opacification
of the
proximal left vertebral artery. There are multifocal areas of
moderate to
severe luminal narrowing affecting the circle ___
vasculature, as detailed
above, however nonetheless with patent distal intracranial
run-off.
2. Right parieto-occipital and left cerebellar encephalomalacia
likely
represent sequelae of remote/chronic infarction.
3. Moderate to severe changes of chronic white matter
microangiopathy.
4. No evidence of an acute intracranial abnormality by
unenhanced head CT.
5. Due to significant motion degradation and suboptimal
automated selection of
AIF and VOF regions of interest, CT perfusion result are
non-diagnostic.
6. Moderate to severe cervical spondylosis. Sequelae of chronic
sinusitis in
the completely opacified sphenoid sinus. Other incidental
findings, as above.
CT CHEST (___)
IMPRESSION:
1. There is no consolidation within the lung parenchyma to
suggest
infection/pneumonia.
2. The distal tip of the atrial limb of the dialysis catheter
ends in the
proximal coronary sinus.
TTE (___)
Poor image quality. The left atrium is moderately dilated. There
is normal left ventricular wall thicknesswith a normal cavity
size. There is suboptimal image quality to assess regional left
ventricular function.Overall left ventricular systolic function
is moderately depressed. The visually estimated left ventricular
ejection fraction is (?) 35%. There is no resting left
ventricular outflow tract gradient. Moderately dilated right
ventricular cavity 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. The
aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets are mildly thickened. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is a small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
IMPRESSION: Poor image quality. No gross 2D echocardiographic
evidence for endocarditis. If clinically suggested, the absence
of a discrete vegetation on echocardiography does not exclude
the diagnosis of endocarditis.
Brief Hospital Course:
==================
SUMMARY STATEMENT
==================
Mr. ___ is a ___ y/o male with a history of HTN, HLD, CAD s/p
CABG, ESRD on HD, COPD (unknown if on home O2) who presented
with altered mental status, weakness, and hypotension concerning
for sepsis, found to be secondary to a pseudomonas UTI. His
hospital course was complicated by C.diff.
=====================
TRANSITIONAL ISSUES
=====================
[] To finish course of PO vancomycin 125mg QID ___
[] Isosorbide mononitrate held on discharge as normotensive-
please monitor BP and resume if needed
[] Consider Holter monitoring for AFib, had isolated episode
believed to be from HD catheter near coronary sinus. He does
have a history of ischemic stroke but unknown if cardioembolic.
Discharge weight 95.1 kg (209.66 lb)
Discharge Diuretic Home furosemide
Discharge Cr 3.8
NEW MEDICATIONS
14 day course of oral vancomycin
MEDICATIONS WE CHANGED
None
MEDICATIONS WE STOPPED
Isosorbide mononitrate held- your nursing facility will decide
whether to resume this
===========================
HOSPITAL COURSE
===========================
ACUTE ISSUES:
=============
#Sepsis
#Toxic metabolic encephalopathy
#Pseudomonas UTI
Patient initially presented with hypotension and significant
leukocytosis to 24 concerning for sepsis of unknown origin.
Chest x-ray was concerning for left sided pleural effusion
however CT chest revealed no consolidation or associated
parapneumonic effusion. Urine culture grew Pseudomonas that was
sensitive to levofloxacin patient was transitioned from
broad-spectrum antibiotics to oral levofloxacin after
stabilization, completed a 7 day course on ___. All blood
cultures no growth to date.
#C.diff Infection
Pt developed worsening leukocytosis (nadir of 35.8),
tachycardia, and loose bowel movements while completing his
antibiotic course for pseudomonas UTI and was found to have
C.diff. He was started on PO vancomycin with clinical
improvement and will finish his 14 day course on ___.
#Malpositioned CVC
CT chest incidentally revealed a malpositioned central venous
catheter tip in the coronary sinus. ___ was consulted and the
patient had his line repositioned ___ prior to receiving
dialysis. He continued to have dialysis while inpatient without
any difficulty.
#Atrial fibrillation
Patient had an episode of atrial fibrillation with heart rates
in the 120s. Despite his significant risk factors including
previous CVA (CHADS2VASC 6), anticoagulation was deferred as
patient's dialysis catheter may have been a provoking factor for
arrhythmia. He had no further episodes while inpatient.
- Consider Holter as an outpatient to capture any further
episodes of atrial fibrillation now that dialysis catheter is
correctly placed
#Left-sided weakness
#Hx of Right-sided CVA
Patients initial presentation concerning for worsening
left-sided weakness, thought to be secondary to recrudescence of
deficits from iso a known prior right CVA. A Code stroke (and
neurology consult) was called on arrival CT head re-demonstrates
prior infarcts (thalamic,occipital, cerebellar) and CTA with
diffuse disease including vertebral and PCA, but no acute clot.
Code stroke, neurology: most likely recrudescence in the setting
of UTI. Overall his weakness improved to baseline. He was noted
to have upper extremity tremor this admission which was new but
thought to be an essential tremor. He showed no other signs of
focal neurologic deficit.
#Troponemia
#CAD s/p CABG
Initial presentation significant for troponin .08x2 likely in
setting of ESRD, pt was asymptomatic at this time. We continued
his home ASA 81, pravastatin, Metoprolol.
CHRONIC ISSUES:
===============
#HFrEF
EF 35% on repeat TTE here. On Lasix at home, however make
minimal urine. Appeared euvolemic during this admission. HF
regimen initially held in the setting of hypotension but
restarted.
- Preload: Lasix 80mg daily
- Afterload: Restart imdur 60mg at discharge
- NHBK: Home metoprolol fractionated to 12.5 mg Q6 while
inpatient, restart home dose on discharge
#DMT2
On linagliptin and insulin at home.
- Held home linagliptin while inpatient, to restart at discharge
- Continued home glargine 15U, with limited SSI required for
correction
#Hypertension
Initially presented to ___ w/ hypotension ___, imrpvoed
to low 100s here. Initially held home antihypertensives.
Restarted Lasix by discharge. Isosorbide was held, can be
resumed if needed.
#COPD
No wheezing on exam. Breathing comfortably. Initial VBG with
respiratory acidosis, though appears chronic given pH and HCO3.
While inpatient on Advair (formulary equivalent for Spiriva),
will be restarted on home Spiriva on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
4. Furosemide 80 mg PO DAILY
5. Gabapentin 600 mg PO DAILY
6. guaiFENesin 100 mg/5 mL oral q4h prn
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Omeprazole 20 mg PO DAILY
11. Calcium Acetate 667 mg PO TID W/MEALS
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
13. linaGLIPtin 5 mg oral daily
14. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Sepsis due to Pseudomonas Urinary tract infection
Toxic metabolic encephalopathy
===================
SECONDARY DIAGNOSIS
===================
C.difficile
Prior ischemic stroke
End stage renal disease on dialysis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___ ,
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were confused, weak, and your blood pressure was low.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were found to have a urinary tract infection which was
treated with antibiotics.
- You also developed diarrhea from an infection which also
required antibiotics.
- Your HD catheter was placed incorrectly so we repositioned it.
- You received dialysis while in the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Continue to take Vancomycin four times a day until ___.
- Take all of your medications as before.
We wish you all the best!
- Your ___ Care Team
Discharge weight: 95.1 kg (209.66 lb)
Discharge Diuretic: Home dose of furosemide
NEW MEDICATIONS
Vancomycin 125 mg QID PO, 14 day course (last day ___
MEDICATIONS WE CHANGED
None
MEDICATIONS WE STOPPED
Isosorbide mononitrate
Followup Instructions:
___
|
10504711-DS-13 | 10,504,711 | 21,340,106 | DS | 13 | 2169-09-26 00:00:00 | 2169-09-27 06:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH HTN, CKD III, presenting with shaking chills and fevers
x 2 days. Patient reprots started having fevers ___ as high
as 102.2 with associated chills and abdominal pain. Patient also
endorses no BM for past 2 days. He did vomit on ___ but has
not vomited since. No cough, sore throat, sick contacts. No
recent travel.
In the ED initial vitals were: 103.1 68 125/52 16 95% r
- Labs were significant for WBC 21, positive UA, creatinine 1.8,
and potassium 3.2.
- Patient was given IC cefriaxone
Vitals prior to transfer were: 98.7 83 138/58 20 94% RA
On the floor, patient reports he has been spiking intermittent
fevers but overall he has improved since coming to the Emergency
Room.
Review of Systems:
(+) per HPI
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Chronic Kidney Disease- baseline creatinine around 1.4
-Hypertension
-BPH
-Hyperlipidemia
-Hx CVA ___
-Pre DM- A1c 6.4 ___
Social History:
___
Family History:
Mother ___ ___ HYPERTENSION STROKE
Father ___ ___ SOFT TISSUE SARCOMA
Physical Exam:
ADMISSION EXAM:
Vitals - T:99.4 BP:130/56 HR:76 RR:16 02 sat:96RA
GENERAL: NAD
HEENT: AT/NC, EO, minimally ___ speaking
MI, PERRL, anicteric sclera, pink conjunctiva, patent nares,
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
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VITALS: 98.7 98.1 112/41 64 16 92% on RA
I/O: 860/700
GENERAL: NAD
HEENT: AT/NC, EOMI, minimally ___ speaking, PERRL, pink
conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended but soft, +BS, nontender in all quadrants, no
CVA tenderness, no rebound/guarding
EXTREMITIES: moving all extremities well, no c/c/e
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:
___ 10:09PM WBC-21.0*# RBC-3.65* HGB-12.5* HCT-38.1*
MCV-104* MCH-34.4* MCHC-33.0 RDW-13.7
___ 10:09PM GLUCOSE-144* UREA N-38* CREAT-1.8* SODIUM-134
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-25 ANION GAP-16
___ 10:09PM NEUTS-85.3* LYMPHS-7.4* MONOS-6.8 EOS-0.1
BASOS-0.2
___ 10:09PM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-2.5*
MAGNESIUM-2.0
___ 10:09PM LIPASE-27
___ 10:09PM ALT(SGPT)-36 AST(SGOT)-34 ALK PHOS-62 TOT
BILI-0.6
___ 10:22PM LACTATE-1.6
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-13.6* RBC-3.80* Hgb-13.3* Hct-39.4*
MCV-104* MCH-34.9* MCHC-33.7 RDW-14.7 Plt ___
___ 07:05AM BLOOD Glucose-103* UreaN-32* Creat-1.4* Na-137
K-3.8 Cl-101 HCO3-23 AnGap-17
___ 07:05AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.3
MICROBIOLOGY:
___ 01:30AM URINE RBC-4* WBC->182* BACTERIA-MOD YEAST-NONE
EPI-0
___ 01:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
___ Blood Cx: Pending
IMAGING:
___ CXR:
IMPRESSION:
No acute cardiopulmonary process.
___: CT/AP Final Read:
IMPRESSION:
1. No CT findings to explain patient's abdominal pain.
2. Moderate BPH.
3. Diverticulosis without evidence of diverticulitis.
Brief Hospital Course:
ID: Mr. ___ is an ___ yo M w/ PMH of HTN and BPH who presents
with fevers, chills, and urinary urgency found to have UTI with
___ urine culture growth of >100K E.coli.
ACTIVE ISSUES:
#Complicated UTI: Patient presents with abdominal pain, nausea,
fevers, and positive UA >182 WBCs, meeting SIRS criteria (fever,
leukocytosis), consistent with UTI. Preliminary urine culture
showed growth of >100K of E.coli, sensitivities pending.
Preliminary blood culture showed no growth by day of discharge.
He was treated for a complicated UTI (male gender), with IV
Ceftriaxone, and he subsequently defervesced with downtrending
leukocytosis (21.0 on admission -> 13.6 on day of d/c). The
etiology of his UTI was believed to be secondary to urinary
retention from BPH. He was discharged to complete a total 7 day
course of antibiotice with PO Cefpodoxime (___).
___/ CKD: Patient was noted to have elevated Cr 1.8, baseline
Cr of ~1.4. Pt's Cr improved to baseline with IVF suggesting
pre-renal etiology. His home chlorathalidone and losartan was
held in the context of his elevation in Cr.
CHRONIC ISSUES:
#Hypertension: He was continued on his home nifedipine and
carvedilol. His home chlorthalidone and losartan were held given
his ___ as above. Patient's BP at discharge ranged SBP 100-120,
and he was advised to check BP daily after discharge, and
restart his home chlorthalidone and losartan if SBP >140.
#Hyperlipidemia: He was continued on his home atorvastatin.
#History of CVA: He was continued on his home ASA.
#Pre-DM: He was maintained on a low carb diet.
TRANSITIONAL ISSUES:
[ ] New antibiotic cefpoxodime 100mg PO BID until ___
[ ] Pt's home chlorthalidone and losartan were held at
discharge, with plans for follow up with PCP ___
[ ] Pt advised to check blood pressure daily and restart home
chlorathalidone and losartan if SBP >140.
[ ] F/u pending ___ Urine Culture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. B-100 Complex (B complex vitamins;<br>vit B complex ___ combo
no.2) 100 mg oral Daily
2. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit oral
Daily
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. NIFEdipine CR 30 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Carvedilol 12.5 mg PO BID
8. Chlorthalidone 25 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Losartan Potassium 50 mg PO BID
11. Potassium Chloride 10 mEq PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. NIFEdipine CR 30 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. B-100 Complex (B complex vitamins;<br>vit B complex ___ combo
no.2) 100 mg oral Daily
7. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit oral
Daily
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Potassium Chloride 10 mEq PO DAILY
10. Cefpodoxime Proxetil 100 mg PO Q12H Complicated UTI
Duration: 4 Days
Take ___ pill twice a day until all pills are gone.
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Complicated Urinary Tract Infection
Secondary:
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for
treatment of a urinary tract infection. You were treated with IV
antibiotics and transitioned to the oral antibiotic cefpodoxime.
You were discharged to complete a total 7 day course of
antibiotics for your urinary tract infection (___), which
is an additional 4 days after discharge. Of note, your
hypertension medications chlorathalidone and losartan were held
at discharge because your blood pressure was low-normal. Please
check your blood pressure daily after discharge, and if your BP
is >140, please restart your losartan and chlorthalidone. You
will follow-up with your primary care physician's office on
___.
Followup Instructions:
___
|
10504997-DS-10 | 10,504,997 | 24,418,220 | DS | 10 | 2184-11-10 00:00:00 | 2184-11-10 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus Vaccines and Toxoid / codeine / Ultram / amoxicillin /
doxycycline / ibuprofen
Attending: ___.
Chief Complaint:
AMS and hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with PMH of AS s/p biprothetic valve ___, bipolar disorder,
possible etoh abuse, enterococal endocarditis diagnosed
(___) on daptomycin, prior embolic stroke who presents to
___ with AMS and hypoxia.
She developed hypoxia ___ and presented to ___. She was
given zosyn and additionally found to have an SMA aneurysm on
CT. She was transferred to ___ for higher level of care for
her hypoxic symptoms and for vascular evaluation.
Her cardiac history is notable for severe AS, s/p bioprosthetic
valve ___ ___. Course recently complicated by large PVE
diagnosed ___ ___ with aortic root dilatation. TEE at the time
and reportedly showed mild-moderate AI. Per her outpatient
cardiologist, she was evaluated at ___ by cardiac surgery who
deferred surgery ___ the setting sepsis. She grew enterococcus
sensitive to vanc, amp. Was started on ampicillin + Ceftriaxone
but developed hypoxic respiratory failure with nonspecific
infiltrates of unclear etiology. It was thought that this was
ARDS vs hypersensitivity pneumonitis. She was transitioned to
Vancomycin + Meropenem but developed hearing loss which was
thought to be vancomycin ototoxicity. She was then switched to
daptomycin to complete a 6 week course (completion ___.
She was also started on prednisone taper.
She was recently admitted to the hospital from ___,
through ___, where she was diagnosed with a prosthetic
aortic valve enterococcal endocarditis, presenting with
generalized malaise, nonspecific pain and a minimally
symptomatic left cerebellar embolic CVA radiographically.
She then had a repeat TTE 2 weeks ago which showed improvement
___ size of her vegetation and mild AI per outpatient
cardiologist.
Per her son, she has been on nasal cannula for the last 2 days
at her SNF between ___ NC. Last night, he noticed the oxygen
was not flowing through her nasal cannula. At that time, she
became acutely confused. She was then transferred to ___
___ the ED vitals were T 99.0, HR 100, BP 130/81, RR 16, O2 95%
Mask her exam was notable for: tachycardia, tachypnia, rhonchi
bilaterally
labs notable for: WBC 17, BNP 21000, Trop 0.___HEST ___. Enlarged ascending aorta, measuring up to 4.3 cm.
2. Nonspecific diffuse ground-glass opacity throughout the
lungs. Differential includes, but is not limited to pulmonary
edema, multifocal pneumonia and pulmonary hemorrhage.
3. Moderate right pleural effusion with Ho___ units greater
than expected for simple fluid. Small nonhemorrhagic pleural
effusion.
4. Cardiomegaly.
CT Head ___: No acute intracranial abnormality.
Patient received: IV furosemide 20 mg
Consults: Vascular surgery felt SMA aneurysm was non-emergent
She was initially admitted to the FICU for decompensated heart
failure. She was given 20mg IV Lasix placed on Bipap. EKG showed
RBBB with inferior st depressions. She was then transferred to
CCU for further management.
On arrival to CCU patient is alert and oriented, breathing
comfortably on high flow NC. Denies subjective sob, chest pain,
or palpitations. ___ addition she denies any fever, chills,
night sweats, abdominal pain, back pain, N/V, diarrhea,
constipation, or dysuria. She denies any painful joints,
headache, eye pain, or changes ___ vision.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
Bipolar
HTN
AS s/p TAVR
Enteroccocal TVE
Hypothyroidism
OSA on CPAP at night (but has been off it for a few months while
awaiting replacement parts)
Anemia of chronic disease
Hypothyroid
Acute pneumonitis of uncertain etiology
Social History:
___
Family History:
bipolar ___ daughter
Physical ___:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed ___ Metavision
GENERAL: appears stated age, very animated ___ speech, speaking
___ full sentences, oriented to being ___ ICU, date, day of the
week, and name, high flow NC on
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP elevated to jaw, neck supple
LUNGS: diffuse crackles throughout entire lung fields
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, moderately distended, bowel sounds
present, no rebound tenderness or guarding
EXT: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
edema, no TTP of vertebral processes, no stigmata of
endocarditis on exam (splinter hemorrhages, ___ nodes)
SKIN: chronic venous stasis changes to ___ calves
NEURO: A&Ox3
ACCESS: PICC
DISCHARGE PHYSICAL EXAM:
VITALS: T 97.7 BP 139/71 HR 85 RR 18 O2 94% on CPAP
GENERAL: Rouses to light voice. Sitting up ___ bed, ___ no acute
distress. Upon waking says, "That was the best night's sleep of
my life."
HEENT: Sclerae anicteric
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2,
mid-systolic ejection murmur best auscultated at the RUSB. No
gallops/rubs.
LUNGS: Crackles from bases to ___ of the way up, stable from
prior.
ABDOMEN: Abdomen is soft, nontender to palpation throughout,
non-distended, no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEURO: Moves all four extremities purposefully.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:15AM BLOOD WBC-17.1* RBC-2.37* Hgb-7.7* Hct-24.5*
MCV-103* MCH-32.5* MCHC-31.4* RDW-15.2 RDWSD-57.3* Plt ___
___ 01:15AM BLOOD Neuts-79.7* Lymphs-13.2* Monos-5.6
Eos-0.5* Baso-0.2 Im ___ AbsNeut-13.60* AbsLymp-2.26
AbsMono-0.96* AbsEos-0.09 AbsBaso-0.03
___ 01:15AM BLOOD ___ PTT-26.6 ___
___ 01:15AM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-139
K-4.3 Cl-99 HCO3-26 AnGap-14
___ 01:15AM BLOOD ALT-281* AST-595* LD(LDH)-882* AlkPhos-83
TotBili-0.9
___ 01:15AM BLOOD CK-MB-5 ___
___ 01:15AM BLOOD Albumin-2.9* Calcium-7.7* Phos-4.5 Mg-1.6
___ 05:54AM BLOOD ___ pO2-42* pCO2-49* pH-7.40
calTCO2-31* Base XS-3
MICROBIOLOGY LABS:
==================
___ Blood cultures x2 - pending
___ 5:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:45 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 8:00 am SPUTUM Site: EXPECTORATED
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 AND CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Preliminary):
PROTEUS MIRABILIS. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 4:41 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
___ 9:20 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
RELEVANT IMAGING:
=================
___ ECHO
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. There is no
valve rocking, obvious dehiscence or paravalvular abscess. The
prosthetic aortic valve leaflets are thickened. The transaortic
gradient is higher than expected for this type of prosthesis. A
paravalvular jet of mild aortic regurgitation is seen. There is
a probable vegetation on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Mild (1+) mitral regurgitation is seen. No masses
or vegetations are seen on the tricuspid valve, but cannot be
fully excluded due to suboptimal image quality. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Probable prosthetic aortic valve endocarditis. Mild
paravalvular regurgitation. Symmetric LVH with normal
biventricular systolic function.
___ CT CHEST w/o CONTRAST
Final Report
EXAMINATION: CT chest without contrast
INDICATION: History: ___ with AMS and hypoxia// head bleed,
chest etiology
for hypoxia
TECHNIQUE: Contiguous axial images were obtained through the
chest without
intravenous contrast. Coronal and sagittal reformats were
obtained.
COMPARISON: Same-day chest radiograph
FINDINGS:
HEART AND VASCULATURE: The ascending aorta is enlarged,
measuring up to 4.3 cm (___). The patient is status post
aortic valve replacement. There is mild cardiomegaly.
Otherwise, the heart, pericardium, and great vessels are within
normal limits based on an unenhanced scan. No pericardial
effusion is seen. A partially visualized right PICC catheter
terminates ___ the mid SVC.
AXILLA, HILA, AND MEDIASTINUM: There are multiple enlarged
mediastinal lymph nodes, measuring up to 1.3 cm (for example,
___. No axillary
lymphadenopathy. No mediastinal mass or hematoma.
PLEURAL SPACES: There is a moderate right pleural effusion with
Hounsfield
units greater than expected for simple fluid. There is a small
nonhemorrhagic pleural effusion. No pneumothorax.
LUNGS/AIRWAYS: There is nonspecific diffuse ground-glass opacity
throughout the lungs. The airways are patent to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture. Midline sternotomy wires are intact.
IMPRESSION:
1. Enlarged ascending aorta, measuring up to 4.3 cm.
2. Nonspecific diffuse ground-glass opacity throughout the
lungs.
Differential includes, but is not limited to pulmonary edema,
multifocal
pneumonia and pulmonary hemorrhage.
3. Moderate right pleural effusion with Hounsfield units greater
than expected for simple fluid. Small nonhemorrhagic pleural
effusion.
4. Cardiomegaly.
___ CT head w/o contrast
Final Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with AMS and hypoxia// head bleed,
chest etiology for hypoxia
TECHNIQUE: Contiguous axial images from skullbase to vertex
were obtained
without intravenous contrast. Coronal and sagittal reformations
and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy
(Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territory infarction,
hemorrhage, edema, or mass effect. The ventricles and sulci are
prominent, consistent with involutional changes. There is
extensive periventricular and subcortical white matter
hypodensity, which is nonspecific, but likely represents chronic
microvascular ischemic changes.
No osseous abnormalities seen. Minimal mucosal thickening ___
some anterior ethmoidal air cells. Otherwise, the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
Status post bilateral lens replacements.
IMPRESSION:
No acute intracranial abnormality.
___ CXR
Final Report
EXAMINATION: CHEST (SINGLE VIEW) ___ O.R.
INDICATION: History: ___ with AMS and hypoxia// head bleed,
chest etiology
for hypoxia
TECHNIQUE: Single supine AP chest radiograph
COMPARISON: CT chest ___ chest radiograph ___
FINDINGS:
A right PICC terminates ___ the lower SVC. The patient is status
post aortic valve replacement. Heart size and mediastinal and
hilar contours are stable. There is diffuse lung disease, as
seen on prior CT, concerning for pulmonary edema, pulmonary
hemorrhage or multifocal pneumonia, ___ the proper clinical
setting. No pleural effusion or pneumothorax is seen. There are
no acute osseous abnormalities.
IMPRESSION:
There is diffuse lung disease, as seen on prior CT, concerning
for pulmonary edema, pulmonary hemorrhage or multifocal
pneumonia ___ the proper clinical setting.
ADDENDUM Please note: There is complete opacification of the
left mastoid air cells, which is of indeterminate chronicity ___
may be secondary to chronic mastoiditis. Recommend clinical
correlation.
___ CXR
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxic respiratory
failure// interval
changes
IMPRESSION:
___ comparison with the study of ___, the patient has
taken a better inspiration. Again there are diffuse bilateral
pulmonary opacifications, which would be consistent with some
combination of pulmonary edema or hemorrhage or multifocal
pneumonia ___ the appropriate clinical settings. Retrocardiac
opacification is consistent with volume loss ___ the left lower
lobe.
DISCHARGE LABS:
===============
___ 06:28AM BLOOD WBC-8.8 RBC-2.51* Hgb-8.1* Hct-25.7*
MCV-102* MCH-32.3* MCHC-31.5* RDW-14.9 RDWSD-56.7* Plt ___
___ 06:28AM BLOOD Glucose-82 UreaN-8 Creat-0.7 Na-142 K-4.2
Cl-103 HCO3-28 AnGap-11
___ 05:35AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-PND
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
___ with PMH of biprothetic valve endocarditis on daptomycin,
prior embolic stroke who presented with AMS and hypoxia.
Multiple prior noted reactions to antibiotics (concern for
Munchausens) (worsening pulm inf w/ unasyn, vanco stopped for
ototoxicity). After arrival, diuresed for pulmonary edema with
improvement. Started on ceftriaxone and flagyl for asp PNA, and
getting Amp/CTX for endocarditis. Improved hypoxemia, and
patient was able to be transitioned to 4L nasal cannula.
=================
ACTIVE ISSUES
=================
# Hypoxemic respiratory failure:
# Decompensated heart failure
# Congestive hepatopathy
Presented with resp distress likely due to acute onset heart
failure, with residual hypoxia possibly due to pneumonia versus
resolving ARDS from arrival. CT Chest w/ diffuse GGOs, septal
thickening and B/L pleural effusion concerning for acute heart
failure exacerbation (given elevated BNP) vs infection (given
WBC 17 iso known endocarditis). Pt had previously been on a
short course of steroids prior to arrival, but it was less than
2 weeks x 20mg daily equivalent of prednisone (less concerning
for PJP pneumonia ___ this setting). She was diuresed to
euvolemia; a right heart cath on ___ demonstrated Pt relatively
dry. Treated for possible aspiration pneumonia with
CTX/metronidazole; also temporarily started on a course of
ciprofloxacin for scant Proteus growth ___ sputum (this was
stopped early due to prolonged QTc at almost 600). Pt had a
follow-up respiratory culture without Proteus, notable only for
commensal flora. By discharge, she was working well with rehab
and weaned down to ___ O2 by nasal cannula. Pulmonary was
consulted and they thought there may be some component of ARDS
contributing to her persistent hypoxia. They anticipated that it
would take a long time for her to wean off oxygen completely.
#Prosthetic aortic valve enterococcus endocarditis
#Leukocytosis:
To 17 on admission w/ PMN predominance, I/S/O enterococcal
endocarditis, with possible valvular dysunction and new
pulmonary nodules that could represent microabcesses. She was
initially on dapto, though this would not treat pulm infection.
TTE showed probable prosthetic aortic valve endocarditis with
mild paravalvular regurgitation. She was given one dose of
vancomycin ___ FICU but this was discontinued d/t ototoxicity
allergy documented at ___. ID consult recommended
restarting ampicillin + ceftriaxone for her endocarditis. She
was started back on ampicillin 2g q6h and ceftraixone 2 g q12h
for 6 weeks (end date ___ to cover both her endocarditis
and possible pneumonia. Flagyl was also added to assist ___ her
aspiration coverage; this was discontinued due to low suspicion
for aspiration after Pt presented to the floor. A TEE on
___ demonstrated no aortic valve vegetation. She will
continue on her Abx until ___.
#Anemia: patient presented with hbg 7.7. She was transfused
1uPRBCs prior to CCU admission. Repeat Hgb 8.8->8.1. LFTs were
elevated but haptoglobin and tbili wnl. She had no evidence of
acute bleed, no melena, but does have potential nidus of bleed
from possible septic emboli. She does have history of anemia of
chronic disease at prior admission. Hbg stable throughout this
admission.
#Eosinophilia: Of unclear etiology. Previously attributed to
possible hypersensitivity pneumonitis, but it improved despite
not being managed with further steroids. Allergy was contacted
as well and felt that there may have been a concern for
hypersensitivity pneumonitis as a possible adverse reaction to
ampicillin and recommended try to desensitize patient to
ampicillin or use another therapy; given that her eosinophilia
trended downward despite continued ampicillin, hypersensitivity
pneumonitis less likely. The patient had no rash which would
likely occur with a hypersensitivity pneumonitis.
# NSTEMI: likely demand ___ setting of new onset heart failure.
peaked on admission at 0.26. On differential is missed MI,
although hospitalization and ___ ___ no troponemia
and thought to be atypical chest pain. Trop down trending
currently 0.17 and asymptomatic. Continued home ASA 81mg, but
deferred heparin gtt for now given bleeding risk of potential
septic emboli. A subsequent troponin on ___ was < 0.01.
# SMA aneurysm: Transferred to ___ for evaluation of same.
Vascular surgery consulted ___ ED and said non-emergent, deferred
management at this time. No need for anticoagulation at this
time. Recommended a CTA of the abdomen to re-evaluate this
aneurysm ___ 1 month's time. Patient is asymptomatic.
=================
CHRONIC ISSUES
=================
# H/O bipolar disorder with
# Passive SI:
Initially held all benzodiazepines and stimulants ___ the setting
of respiratory distress. She was restarted on alprazolam 0.5 mg
nightly as she became tachycardic, was not sleeping, and there
was concern for benzo withdrawal. Seen by Psychiatry while
___ SI were felt to be passive and without clear specific
plan, not requiring sitter or ___. Pt had improved mood
at discharge.
- Continued home citalopram at 20mg BID.
- Held home Ritalin, LORazepam 0.5 mg PO ___ insomnia.
- Decreased ALPRAZolam 0.5 mg PO TID:PRN anxiety.
#Hypothyroidism - Continued home levothyroxine.
#Family: son and patient do not want communication with
daughter.
#History of OSA:
Pt had not been on her sleep apnea machine x 1 month due to
needing some replacement parts. Restarted Pt's CPAP on the
night of ___, to good improvement of her sleep.
- Continue CPAP at settings described below
#Home medications:
- Continued Miconazole Powder 2%, Omeprazole 20 mg PO DAILY,
Milk of Magnesia 30 mL PO Q6H:PRN constipation, Calcium
Carbonate 600 mg PO BID, Bisacodyl 10 mg PR ___
constipation, Fleet Enema (Mineral Oil) ___AILY:PRN
Constipation, Polyethylene Glycol 17 g PO DAILY:PRN
constipation, Cyanocobalamin 1000 mcg PO DAILY, Vitamin D 1000
UNIT PO DAILY, Vitamin E 1000 UNIT PO DAILY, Senna 8.6 mg PO
BID:PRN constipation, Lactulose 15 mL PO PRN constipation,
Docusate Sodium 100 mg PO BID:PRN constipation
TRANISITIONAL ISSUES:
=====================
# Communication: HCP: ___ and HCP ___
# Code: DNR/DNI
[ ] MEDICATION CHANGES:
- Added: Ampicillin 2g IV q6h (end date ___, benzonatate
100mg PO TID:PRN cough, ceftriaxone 1g q12h (end date ___,
ramelteon 8mg PO ___ insomnia.
- Discontinued: Ritalin, lorazepam
- Changed: Alprazolam (0.5mg TID:PRN anxiety -> 0.5mg ___
add a one-time 0.5mg daily:PRN agitation)
[ ] PSYCHIATRY MEDICATION RECOMMENDATIONS:
- Pt's son has concerns about the number of sedating and
stimulating meds Pt initially came ___ on (two different
benzodiazepines and amphetamine-dextroamphetamine).
- Per psych evaluation ___: Recommended not to discharge Pt
with prescriptions for lorazepam, diazepam, zolpidem, or
amphetamine-dextroamphetamine.
- If Pt requires additional anxiolysis after her discharge, she
can receive additional spot dose of 0.5 alprazolam daily:PRN
anxiety.
[ ] HEART FAILURE WITH PRESERVED EJECTION FRACTION EXACERBATION:
- Discharge weight: 64.9kg (bed weight)
- Discharge creatinine: 0.8
- Discharge diuretic: 20mg PO furosemide daily
[ ] FOLLOW-UP IMAGING:
- Repeat CTA abdomen 1 month after initial imaging (___) to
follow stability of Pt's SMA aneurysm.
- Repeat CT chest 8 weeks after discharge (___) to follow
improvement of her pneumonia and GGO's
[ ] HARD-OF-HEARING:
- Consider audiology referral given that Pt is hard of hearing
and does not have any hearing aids.
[ ] CPAP SETTINGS:
- Patient will bring her own mask and other supplies.
- Mode: Autoset
- Autoset range: ___
- O2 flow rate: 4 L/min
- Mask type: Full, size small
- Humidifier setting: Off
Ms. ___ is clinically stable for discharge ___. The total
time spent on discharge planning, counseling and coordination of
care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Amphetamine-Dextroamphetamine 10 mg PO BID
3. Citalopram 20 mg PO BID
4. bisoprolol fumarate 5 mg oral EVERY OTHER DAY
5. Omeprazole 20 mg PO DAILY
6. Daptomycin 500 mg IV Q24H
7. melatonin 3 mg oral QPM:PRN
8. LORazepam 0.5 mg PO ___ insomnia
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Calcium Carbonate 600 mg PO BID
11. Bisacodyl 10 mg PR ___ constipation
12. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Cyanocobalamin 1000 mcg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Vitamin E 1000 UNIT PO DAILY
17. Senna 8.6 mg PO BID:PRN constipation
18. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
19. Levalbuterol Neb 0.63 mg NEB Q4HR
20. Ipratropium Bromide Neb 1 NEB IH TID
21. Zolpidem Tartrate 5 mg PO ___ insomnia
22. Aspirin 81 mg PO DAILY
23. PredniSONE 10 mg PO DAILY
24. Lactulose 15 mL PO PRN constipation
25. Docusate Sodium 100 mg PO BID:PRN constipation
26. Ibuprofen 800 mg PO TID:PRN Pain - Mild
27. Furosemide 20 mg PO DAILY
28. Potassium Chloride 10 mEq PO DAILY
29. ALPRAZolam 0.5 mg PO TID:PRN anxiety
30. Miconazole Powder 2% 1 Appl TP Frequency is Unknown
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB NEB Q4H:PRN shortness of
breath
2. Ampicillin 2 g IV Q6H
End date through ___.
3. Benzonatate 100 mg PO TID:PRN cough
4. CefTRIAXone 1 gm IV Q12H
End date ___
5. Ramelteon 8 mg PO ___ insomnia
6. ALPRAZolam 0.5 mg PO ___
RX *alprazolam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
7. Miconazole Powder 2% 1 Appl TP ___
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
9. Aspirin 81 mg PO DAILY
10. Bisacodyl 10 mg PR ___ constipation
11. Calcium Carbonate 600 mg PO BID
12. Citalopram 20 mg PO BID
13. Cyanocobalamin 1000 mcg PO DAILY
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. Furosemide 20 mg PO DAILY
16. Ipratropium Bromide Neb 1 NEB IH TID
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
19. Omeprazole 20 mg PO DAILY
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Senna 8.6 mg PO BID:PRN constipation
22. Vitamin D 1000 UNIT PO DAILY
23. Vitamin E 1000 UNIT PO DAILY
24. HELD- Amphetamine-Dextroamphetamine 10 mg PO BID This
medication was held. Do not restart
Amphetamine-Dextroamphetamine until you discuss resuming with
your primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Aortic valve Endocarditis
Acute on Chronic heart failure with preserved ejection fraction
Hospital associated pneumonia with hypoxemic respiratory failure
SECONDARY DIAGNOSIS
===================
History of bipolar disorder
Chronic anemia, stable
Non-ST elevation MI, resolved
Superior mesenteric artery aneurysm
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 ___,
WHY YOU CAME TO THE HOSPITAL:
You came to the hospital with confusion and shortness of breath.
WHAT HAPPENED WHILE YOU WERE ___ THE HOSPITAL:
- You received medication to get rid of the water on your lungs
- You were treated with antibiotics for a lung infection
- You were treated with antibiotics for an infection on one of
your heart valves; these will continue until ___.
- You initially required a lot of oxygen support and used a
BiPap machine, but your breathing improved and you were able to
breathe comfortably with nasal cannula oxygen by the time you
left the hospital.
- You had a special study called a TEE to look at the valves of
your heart; this study did not show any bacterial growths on the
valves.
WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL:
- You need to continue taking your antibiotics until ___.
You will keep your PICC line for this.
- Please continue to work hard at rehab to get stronger.
It was a pleasure taking care of you!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10505267-DS-10 | 10,505,267 | 22,908,264 | DS | 10 | 2163-01-09 00:00:00 | 2163-01-12 14:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motor vehicle trauma
Major Surgical or Invasive Procedure:
Patient had a ___ feeding tube and tracheostomy placed at the
bed side on ___.
History of Present Illness:
This is a ___ year old female with history of polysubstance abuse
that was a restrained passenger in a motor vehicle accident
traveling at ___ MPH. The patient was taken to ___ and was found
to have intracranial hemorrhage. The patient was intubated and
medflighted to ___ for further evaluation. The patient
was found to have a right humerus fracture.
Past Medical History:
IDVU, ETOH abuse, fibromyalgia
Social History:
___
Family History:
unknonwn
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
HEENT: pupils 2mm, limited responsiveness
C collar in place, intubated
Chest: bilateral breath sounds, no chest wall crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, no rigidity
GU/Flank: no spine crepitus, deformity or stepoff
Extr/Back: + distal pulses, R upper arm deformity
Skin: multiple abrasions
Neuro: intubated and sedated
___: No petechiae
Physical examination upon discharge: ___:
vital signs: t=98.2, hr=89, bp=124/86, rr=16, 100% room air
___: Resting comfortalby, NAD
CV: ns1, s2, -s3, -s4, Grade ___ systolic murmur, ___ ICS, LSB,
no radiation to carotids
LUNGS: clear, diminshed
ABOMEN: soft, flat, ___ tube left side abdomen with
DSD
EXT: no pedal edema bil., no calf tenderness bil.
Muscle st. upper ext., left arm +2/+5, right arm +4/+5, lower
ext. right +4/+5 bil., brace left shoulder
NEURO: alert and oriented x 3, speech soft, clear, no tremors
Pertinent Results:
TRAUMA #3 (PORT CHEST ONLY) Study Date of ___ 10:36 AM
Opacification of bilateral lung bases likely atelectasis and
possibly a
component of aspiration. Endotracheal tube appears in
appropriate position.
CTA HEAD W&W/O C & RECONS Study Date of ___ 11:25 AM
IMPRESSION:
1. Parenchymal hemorrhage of the left frontal lobe and left
splenium of the corpus callosum concerning for diffuse axonal
injury.
2. Bilateral subarachnoid hemorrhages and right anterior
temporal lobe
parenchymal hemorrhage is similar in appearance to outside
hospital CT head.
3. Although likely secondary to differences in technique, the
sulci of the bifrontal vertices are less well defined and may
represent developing cerebral edema. Attention on followup is
recommended.
4. There is a 2 mm left paraclinoid outpouching, likely
representing an
infundibulum. However, a small aneurysm is not entirely
excluded. The
remainder the intracranial circulation is unremarkable.
5. The cervical vessels are unremarkable without evidence of
dissection or occlusion.
6. The thyroid gland is heterogeneous. Correlation with
laboratory values and evaluation with ultrasound if indicated,
is recommended.
7. Diffusely enlarged cervical lymph nodes described above.
This may be
reactive in nature. Clinical correlation is recommended.
8. Biapical atelectasis with multiple nodules and ground-glass
opacities which may be inflammatory in nature. Clinical
correlation is recommended.
CT C-SPINE W/O CONTRAST Study Date of ___ 12:09 ___
FINDINGS:
There is no acute cervical spine fracture or traumatic
malalignment. The
cervical vasculature is patent without signs of vascular injury
or dissection. The visualized lung apices are partially
visualized, however appear clear. The thyroid gland is
unremarkable. Orogastric and endotracheal tubes are in place,
the distal tips of these tubes are not seen in this examination.
IMPRESSION:
No evidence of acute fracture or traumatic cervical spine
malalignment.
HUMERUS (AP & LAT) RIGHT Study Date of ___ 4:04 ___
IMPRESSION:
No previous images. The overlying splint or cast is seen about a
comminuted fracture of the distal humerus. As visualized, the
shoulder and elbow joints are within normal limits. However, if
there is pain referable to these areas, specific views would be
recommended.
CT HEAD W/O CONTRAST Study Date of ___ 5:03 AM
FINDINGS:
Foci of hemorrhage within the left frontal (series 2, image 14),
and splenium of the corpus callosum (series 602b, 50), are
concerning for diffuse axonal injury. There is new
intraventricular blood layering within the occipital horn of the
left lateral ventricle. Overall ventricular size and
configuration is unchanged. Subarachnoid hemorrhage within the
left parietal and right temporal lobe again noted. A region of
intraparenchymal hemorrhage within the right temporal lobe has
mildly increased in size from prior measuring approximately 17
mm (series 2, image 9) (AP). Small subgaleal hematoma along the
right parietal bone. No significant shift of midline structures.
The basal cisterns are patent.
No fracture seen. There is aersolized secretions in the
bilateral maxillary sinuses and nasopharynx as well as fluid
within the ethmoid air cells and sphenoid sinus, likely
secondary to intubation.
IMPRESSION:
New intraventricular hemorrhage within the occipital horn of the
left lateral ventricle, and mild increase in small right
temporal intraparenchymal hemorrhage. Otherwise, no significant
interval change in multicompartmental hemorrhage including foci
of hemorrhage within the left frontal lobe and left splenium of
the corpus callosum, concerning for diffuse axonal injury.
MR HEAD W/O CONTRAST Study Date of ___ 12:01 AM
FINDINGS:
There is a small parenchymal hemorrhage in the cortex and
subcortical white matter medial right temporal lobe with mild
surrounding edema, similar to the prior CTs. Right anterior
midbrain is mildly deformed, and ambient cisterns are effaced,
unchanged compared to the most recent CT from the morning of
___.
There are 3 smaller foci of hemorrhage in the left splenium,
posterior body, and genu of the corpus callosum, as well as
numerous punctate foci of hemorrhage in the deep and subcortical
white matter of bilateral frontal lobes, with low signal on
gradient echo images and high signal on the diffusion tracer
sequence, consistent with diffuse axonal injury. The lesions in
the left corpus callosum, and 1 of the lesions in the left
frontal white matter, were visible on the prior CT scans.
FLAIR images demonstrate scattered foci of high signal in right
frontal and temporal sulci, corresponding to mild subarachnoid
hemorrhage seen on the prior CTs.
There is a small amount of blood in the occipital horn of the
left lateral ventricle, unchanged compared to the most recent CT
from the morning of ___. Ventricular size is stable and
normal.
There is no shift of midline structures. Cerebellar tonsils are
normally
positioned.
Major arterial flow voids appear grossly preserved.
There are secretions and mucosal thickening in bilateral
maxillary sinuses. A left anterior ethmoid air cell is
completely opacified. There is mild mucosal thickening in other
bilateral ethmoid air cells and in the left frontal sinus. There
is mild mucosal thickening in the sphenoid sinuses with trace
fluid in the right sphenoid sinus. There is fluid layering in
bilateral mastoid air cells. These findings are likely related
to prolonged supine positioning in the inpatient setting.
IMPRESSION:
1. Stable parenchymal hemorrhage in the medial right temporal
lobe with mild surrounding edema. Stable associated mild mass
effect on the right anterior midbrain.
2. Hemorrhagic diffuse axonal injury involving the left corpus
callosum and bilateral frontal subcortical and deep white
matter.
3. Mild right frontal/ temporal subarachnoid hemorrhage, not
significantly changed.
4. Stable small
HUMERUS (AP & LAT) RIGHT Study Date of ___ 2:20 ___
FINDINGS:
Again seen is a comminuted fracture of the distal diaphysis of
the right
humerus, with 2 large butterfly fragments. On today's exam,
there is slight overriding, lateral apex angulation, and slight
anterior displacement of 1 of the butterfly fragments. The
fractures appear slightly more dispersed and angulated than on
the prior exam. No gross callus formation is identified.
IMPRESSION:
Comminuted fracture distal right humeral diaphysis, alignment as
described.
___ 05:01AM BLOOD WBC-12.0* RBC-3.70* Hgb-11.6* Hct-34.0*
MCV-92 MCH-31.4 MCHC-34.2 RDW-14.3 Plt ___
___ 04:09AM BLOOD WBC-15.1* RBC-3.69* Hgb-11.7* Hct-33.6*
MCV-91 MCH-31.7 MCHC-34.8 RDW-14.4 Plt ___
___ 05:01AM BLOOD Plt ___
___ 05:28AM BLOOD ___ PTT-30.3 ___
___ 05:05AM BLOOD Glucose-97 UreaN-21* Creat-0.5 Na-141
K-4.2 Cl-101 HCO3-31 AnGap-13
___ 04:09AM BLOOD Glucose-117* UreaN-19 Creat-0.5 Na-140
K-4.0 Cl-99 HCO3-30 AnGap-15
___ 05:28AM BLOOD Glucose-97 UreaN-18 Creat-0.5 Na-141
K-4.3 Cl-101 HCO3-29 AnGap-15
___ 10:44AM BLOOD Lipase-40
___ 05:25AM BLOOD Albumin-3.9
___ 05:05AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.1
___ 05:25AM BLOOD Phenyto-9.8*
___ 10:53AM BLOOD freeCa-0.93*
Brief Hospital Course:
The patient is a ___ year old female, restrained passenger,
involved in a MVC. Upon EMS arrival, the patient was reported
to have a GCS of 3; she was intubated/boarded/collared at the
scene. The patient was initially transferred to ___
___ where her reported identified injuries included closed
head injury (intraparenchymal hemorrhages) and right humerus
fracture. She was hemodynamically stable throughout, with
crystalloid resusictation. The patient was transferred to ___
ED. Upon arrival to ___, the patient remained HD stable,
+small amount intraperitoneal fluid on FAST examination. The
patient remained intubated and was transferred to the trauma
intensive care unit for further monitoring. She was evaluated by
both the Orthopedic service and Neurology.
Upon admission to the intensive care unit, her ct scan imaging
was reviewd by the Neurologist. Head cat scan imaging showed
showed new intraventricular hemorrhage within the occipital horn
of the left lateral ventricle. Besides this finding, she was
also noted to have an increase in the small right temporal IPH.
The patient was placed on q2 hour neurological assessment and
loaded with dilantin. The patient continued to have minimal
response to noxious stimuli and because of this, underwent an
MRI which showed hemorrhagic diffuse axonal injury. The patient
underwent a series of EEG monitoring to evaluate for seizure
activity. Although artifact was identified, no seizure activity
was reported. The patient had a left PICC line placed for
access. While intubated in the intensive care unit, the patient
was reported to have increased pulmonary secretions. A culture
was sent and was reported to be growing stap aureus coag + and
H. Flu. The patient was started on a course of levofloxacin.
To evaluate her right humerus fracture, the Orthopedic service
was contacted. On review of the imaging, the patient was
reported to have a right closed segmental extra-articular distal
humerus fracture. No surgical intervention was indicated at
this time, and the patient was placed in ___ brace.
Because of the patient's neurological status, and her inability
to eat, the patient underwent placement of a trach and ___ on
___. The patient was started on tube feedings to help maintain
her nutritional status. Throughout her hospital course, she
remained on tube feedings via the ___. She was weaned off the
ventilator and transitioned to a trach mask. She was reported
to be more awake during her hospital stay as she began to track
individuals in the room and following simple commands. Her
respiratory status remained stable and she was transferred to
the surgical floor on ___.
During her care on the surgical floor, she required minimal
suctioning and maintained a satisfactory oxygen saturation. Her
trach tube was downsized on ___ and the trach tube was
buttoned. At this time, the patient began to verbalize simple
words. On ___, the trach tube was removed and the trach site
covered with a DSD. The patient became more vocal and
teary-eyed during conversation. Her oxygen saturation remained
stable.
To prepare her for discharge, physical and occupational therapy
were consulted to assess the patient's needs. The social worker
provided support to her family and family meetings were held to
address her families concerns. The screeing process for
discharge to a ___ facility was initiated. Prior to
discharge, the patient's vital signs were stable and she was
afebrile. She remained on her tube feeding at goal via the ___.
Her trach site was covered with a DSD. She had reported
urinary frequency and urgency. A urine specimen was sent and
showed no bacteria, urine culuture reported a contamination.
The patient was discharged dilatin per recommedations of
Neurosurgery. Her last dilantin level on ___ was 11.2.
The patient was discharged to a rehabiliation center on HD # 31
in stable condition with appointments in the Orthopedc,
Neurosurgery, and the acute care clinic.
Medications on Admission:
unknown
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN thick secretions
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Acetaminophen ___ mg PO Q6H:PRN fever/pain
4. Docusate Sodium (Liquid) 100 mg NG/OG BID
5. FoLIC Acid 1 mg PO DAILY
6. Heparin 5000 UNIT SC TID
7. Multivitamins 1 TAB PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Famotidine 20 mg PO BID
10. Phenytoin (Suspension) 125 mg PO Q8H
weekly dilantin levels (goal ___
11. Lorazepam 0.5 mg PO Q8H:PRN agitation
wean ativan to off as patient tolerates
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
scatteed bilat SAH
+ comm right humerus fracture
Left frontal lobe IPH
Anterior right temporal IPH
IPH Splenum of corpus collosum
Diffuse axonal injury
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound with lift to chair
Discharge Instructions:
Dear ___,
___ sustained diffuse brain injury after your motor vehicle
accident. ___ also have a broken long bone (humerus) of the
right arm. Both these injuries were treated without surgery.
However ___ requried a surgery to place a tracheostomy in your
neck to help ___ breath and a gastric feeding tube into your
stomack to help ___ ge thte calories ___ need. Both the neck and
stomach tubes were necessary because ___ are unable to protect
your airway and to eat as ___ did prior to your accident. ___
are being discharged to a rehabilitation faciliy that will
continue to help ___ as ___ progress and heal after your brain
injury. We are here to help and hope we can be of service. We
will see ___ in clinic and have arranged for ___ to follow up
with the neurosurgeons and orthopedic surgeons in clinic.
We wish ___ all the best!
Your ___ Care Team
Followup Instructions:
___
|
10505380-DS-18 | 10,505,380 | 26,290,407 | DS | 18 | 2124-06-08 00:00:00 | 2124-06-09 10:25:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal ___
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy and lysis of adhesions
History of Present Illness:
Mrs. ___ is a ___ year old female s/p ex ___, LOA, ___, open
appendectomy ___ and cholecystectomy ___ with multiple small
bowel obstructions over
the past ___ years presents with a six hour history of lower
abdominal ___ associated with nausea and non bilious, non
bloody emesis. She has not experienced any fevers, chills,
shortness of breath, cough, chest ___, dysuria. Her last BM
was four days ago and the last time she passed flatus was >24
hrs ago. Currently in the ED, her ___ has improved as she has
passed gas but continues to have discomfort.
Past Medical History:
Past Medical History:
HTN
Hyperlipidemia
EtOH, Cocaine abuse
Migraines with visual aura
Gout
Anemia
Leukopenia
Menicus tear
Recurrent SBO
Past Surgical History:
exlap/LOA ___
appendectomy ___
lap chole ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
Temp 99.3 HR 109 BP 131/75 RR 16 92% RA
General: awake, alert, oriented x 3
HEENT: NCAT, EOMI, anicteric
Heart: sinus tachycardia, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Chest: non-tender, no deformities
Back: no vertebral tenderness, no CVAT
Abdomen: Soft, mildly distended, minimally tender RLQ, no
rebound
or guarding. Incisions well healed, no hernias or masses.
Pelvis: normal rectal tone, soft stool in vault, no gross or
occult blood
Extremities: WWP, no CCE, no tenderness
On discharge:
VS: T98, 56, 135/59, 14, 95% on room air.
Abdomen is soft, non-tender. Mid-line incision CDI,
well-approximated. Surgical staples removed.
Pertinent Results:
___ 08:35AM BLOOD WBC-8.4# RBC-3.14* Hgb-9.9* Hct-29.6*
MCV-94 MCH-31.3 MCHC-33.3 RDW-13.9 Plt ___
___ 07:40AM BLOOD WBC-5.4 RBC-3.76* Hgb-11.8* Hct-35.2*
MCV-94 MCH-31.4 MCHC-33.6 RDW-14.0 Plt ___
___ 07:40AM BLOOD Neuts-76.5* ___ Monos-3.6 Eos-0.2
Baso-0.3
___ 08:35AM BLOOD Glucose-96 UreaN-17 Creat-1.0 Na-137
K-3.7 Cl-104 HCO3-25 AnGap-12
___ 07:40AM BLOOD Glucose-112* UreaN-20 Creat-1.2* Na-140
K-4.0 Cl-100 HCO3-26 AnGap-18
___ 07:40AM BLOOD ALT-20 AST-40 AlkPhos-127* TotBili-0.3
___ 08:35AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8
IMAGING:
___ KUB
Focally dilated loop of bowel in the left upper quadrant, may be
focal ileus. However, in the appropriate clinical setting an
early or partial small bowel obstruction cannot be excluded.
___ CT abdomen and pelvis with contrast
Focal dilation of the proximal jejunum with transition point in
the proximal jejunum in the left abdomen. Contrast courses
distal to this, suggesting this is either an early or partial
small bowel obstruction. Equivocal associated minimal wall
thickening. Underlying lesion can not be entirely excluded. No
free air or free fluid.
___ KUB
There are several dilated small bowel loops in the upper
abdomen, unclear if represents ileus or beginning of obstruction
in the patient after recent surgery. Evaluation with
cross-sectional imaging if clinically warranted is recommended.
Brief Hospital Course:
Mrs. ___ was admitted to the Acute Care Surgery service on
___ for management of her small bowel obstruction. CT of her
abdomen and pelvis revealed focal dilation of the proximal
jejunum with transition point in the proximal jejunum in the
left abdomen. Although initially passing stool and flatus, she
was having severe abdominal ___. She was managed
conservatively, keeping her NPO and administering IV fluids.
She was given narcotic and non-narcotic analgesics as needed.
While NPO, her electrolytes were checked daily and repleted as
necessary. As her bowel function seemed to return, she was
advanced to a regular diet but it was poorly tolerated. After
much discussion and based on the patient's history of frequent
obstructions, she was taken to the Operating Suite on ___
where she underwent an exploratory laparotomy and lysis of
adhesions. Please see the operative report for further details.
During the post-operative period, Mrs. ___ was kept NPO and
given IV fluids. Her ___ was managed with a Dilaudid PCA. Due
to her history of narcotic use, she required high doses of
Dilaudid in addition to non-narcotic analgesics, such as
acetaminophen and ketorolac. Although her bowel function was
slow to return, she was started on clear liquids on POD 4. She
had intermittent nausea, but overall, tolerated clears well.
Once it was confirmed that she could tolerate clear liquids, she
was also started on her home anti-hypertensive medications.
During this time, she had some flatus but no bowel movements.
She was, therefore, started on a bowel regimen. Her Dilaudid
PCA was then transitioned to oral narcotics. Because she was
requiring such high levels of Dilaudid via PCA, a less strong
narcotic, such as oxycodone, in addition to acetaminophen and
ibuprofen, was ineffective. She often refused non-narcotic
analgesics stating that "they don't work".
On POD 7, the patient's diet was advanced to a regular diet.
Overall, she tolerated it well. She still complained of
intermittent ___ at times, but it was much improved from prior
painful episodes. She had no nausea or vomiting. All
medications were administered orally.
As Mrs. ___ clinical status improved, she was discharged
home on POD 9. As she is under a ___ contract with ___
___'s ___ Management service, calls were made to her PCP
and the ___ clinic. The patient stated that she spoke to
___ from ___ service about getting a month supply of Nucenta
as her current prescription ran out and she had no extra
medication. Attempts were made to reach the ___ clinic but no
contact was made. Therefore, Mrs. ___ was given a one month
supply of Nucenta (1 tab q 6 hours, 120 tabs/month) and a
two-week supply of Dilaudid. Although it would have been ideal
to provide the patient with oxycodone, her ___ was fairly
well-managed with Dilaudid. Any current de-escalation of ___
medication would likely lead to untreated ___ (multiple
attempts such as this were made during her inpatient stay).
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and in no acute distress. She was
scheduled for follow-up in the ___ clinic. She was also
instructed to contact ___ ___ Management clinic
for follow-up.
Medications on Admission:
Nucynta 100 Q6h, Allopuriniol 300', colchicine 0.6', Atenolol
50', Lisinopril 20', Omeprazole 20', oxycodone 5PRN, Verapamil
ER 240', trazodone 50'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN ___
2. Amitriptyline 100 mg PO HS
3. Atenolol 50 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipatin
5. Docusate Sodium 100 mg PO BID
6. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN ___
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*45 Tablet Refills:*0
7. Lisinopril 20 mg PO DAILY
8. Nucynta *NF* (tapentadol) 100 mg Oral q 6 hours
RX *tapentadol [Nucynta] 100 mg 1 tablet(s) by mouth every six
(6) hours Disp #*56 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
10. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Partial bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal ___ on ___. A CT
of the abdomen showed that you likely had a partial small bowel
obstruction. You were admitted overnight for observation. You
were kept NPO and given IV fluids. Soon after admission, you
were passing gas and having bowel movements. You're tolerating
a regular diet and are now being discharged home.
Followup Instructions:
___
|
10505380-DS-20 | 10,505,380 | 22,635,786 | DS | 20 | 2126-09-21 00:00:00 | 2126-09-21 17:48:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Hypokalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o SBO, leukopenia, remote ETOH in remission had
routine outpatient labs (needed prior to her getting an MRI of
the abdomen for evaluation of SBOs) demonstrating hypokalemia 4
days ago. They attempted to contact patient but her phone was
not accepting messages. C/o weakness 3 weeks. Having regular BMs
now, had loose stools 2 days ago- non-bloody with vomiting x1
lasting only one day. No fevers, dysuria. Poor PO intake due to
low appetite. No CP. + DOE which is new for her x 1 week. +
cough when she eats a slushy or ice cream but not after solid
food. + 11 lbs since ___. No appetitie. + early satiety. +
chronic stomach pain triggered by eating which began after she
started having recurrent bowel obstructions.Last colonoscopy
Last took abx approx 6 weeks ago for dental infection. No
foreign travel. No strange foodsl.
In ER: (Triage Vitals:
___ /143/86 /18 100% RA )
Meds Given: IV magnesium 2g IV, potassium40 meq
Fluids given:
Radiology Studies: CXR/KUB
consults called: none
.
PAIN SCALE: + ___ pain in abdomen
REVIEW OF SYSTEMS:
CONSTITUTIONAL: + As per HPI
HEENT: [X] All normal
RESPIRATORY: [+] Per HPI but negative edema, PND
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [+] fatigued
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
Hypertension
Ocular hypertension
Leukopenia
Depressive disorder
Transaminase or LDH elevation
Menopause
INSOMNIA
HEADACHE - MIGRAINE, UNSPEC
GOUT, UNSPEC
Alcohol dependence in remission
Hx SBO
Lateral meniscal tear
Chronic pancreatitis
S/P appendectomy
Chronic pain
Osteoporosis
Intractable pain
Pain medication agreement
DJD (degenerative joint disease) of knee
GERD (gastroesophageal reflux disease)
Shoulder impingement syndrome
S/P TKR (total knee replacement)
Depression
Past Surgical History:
exlap/LOA ___
appendectomy ___
lap chole ___
biopsy lung; ligate fallopian tubes, abd; biopsy lung; partial
removal radial head/neck ___ knee scope,med&lat menisectomy
___ RT); knee scope,shave articular cart ___ RT); knee
scope,med or lat meniscec (6 55 45 LT); appendectomy ___
and arthroplasty - knee (Right, ___.
Social History:
___
Family History:
Sister with diabetes, sister with ?TB and sarcoidosis who died
at ___
Physical Exam:
ADMISSION EXAM
Vitals: T 97.7 P 85 BP 138/101 RR 16 SaO2 100% on RA
GEN: NAD, comfortable appearing
HEENT: ncat anicteric MMM
NECK:
CV: s1s2 rr + ___ SEM at LUSB
RESP: b/l ae no w/c/r
ABD: +bs, soft, NT, ND, no guarding or rebound
back:
EXTR:no c/c/e 2+pulses
+ b/l tronchanteric bursae tenderness with palpation
R knee with small effusion, mild increase warmth with tenderness
to palpation.
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
DISCHARGE EXAM
Orthostatics negative, vss
GEN: No acute distress, comfortable appearing, alert, oriented
HEENT: NCAT, anicteric sclera, dry MM
CV: Normal S1, S2, no murmurs
RESP: Good air entry, no rales or wheezes
ABD: Normal bowel sounds, soft, non-tender, non-distended, no
rebound/guarding;
EXTR: No edema. Intact pulses.
DERM: No rash.
NEURO: Face symmetric, speech fluent, non-focal, gait is stable,
narrow-based
PSYCH: Calm, cooperative
Pertinent Results:
ADMISSION LABS:
___ 12:54PM GLUCOSE-100 UREA N-15 CREAT-1.4* SODIUM-141
POTASSIUM-2.8* CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
___ 12:54PM estGFR-Using this
___ 12:54PM ALT(SGPT)-29 AST(SGOT)-36 CK(CPK)-100 ALK
PHOS-85 TOT BILI-0.3
___ 12:54PM LIPASE-9
___ 12:54PM cTropnT-<0.01
___ 12:54PM CK-MB-1
___ 12:54PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.1
MAGNESIUM-1.5*
___ 12:54PM WBC-3.7*# RBC-3.40* HGB-10.5* HCT-31.2*
MCV-92 MCH-30.9 MCHC-33.7 RDW-13.2 RDWSD-43.9
___ 12:54PM NEUTS-29.1* LYMPHS-58.0* MONOS-11.3 EOS-0.8*
BASOS-0.5 IM ___ AbsNeut-1.08* AbsLymp-2.15 AbsMono-0.42
AbsEos-0.03* AbsBaso-0.02
___ 12:54PM PLT COUNT-177
___ 12:54PM ___ PTT-31.0 ___
ECG: SR at 89, PR = 200, QTC = 460, TWI V2.
IMAGING:
Chest x-ray: No acute process
KUB: Non-obstructed bowel gas pattern. Mild to moderate colonic
fecal loading
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-3.5* RBC-3.30* Hgb-10.3* Hct-31.4*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.5 RDWSD-46.9* Plt ___
___ 06:30AM BLOOD Glucose-108* UreaN-19 Creat-1.2* Na-138
K-4.0 Cl-104 HCO3-23 AnGap-15
___ 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.3
___ 04:00AM BLOOD calTIBC-304 VitB12-332 Ferritn-43 TRF-234
___ 04:00AM BLOOD TSH-4.4*
Brief Hospital Course:
___ year old female with HTN, OA, b/l hip bursitis, depression
who was referred in for hypokalemia and hypomagnesemia on
pre-MRI labs. Reports several month history of anorexia, weight
loss, weakness.
# HYPOKALEMIA, HYPOMAGNESEMIA, DEHYDRATION, WEAKNESS, ACUTE
KIDNEY INJURY:
# GASTROENTERITIS:
Likely due to poor PO intake, chlorthalidone, and resolved
self-limited episode of gastroenteritis several days prior to
admission. Gave IV fluids and electrolyte repletions.
Discontinued chlorthalidone - she is on a combination
atenolol/chlorthalidone as an outpatient, so this may need to be
changed to a different antihypertensive as an outpatient.
Orthostatic vital signs were negative. Electrolytes within
normal limits, and patient was tolerating a PO diet without
problem upon discharge.
# ANOREXIA, WEIGHT LOSS, CONSTIPATION: Patient has a history of
recurrent SBOs. Reports early satiety and weight loss for
several months. She is undergoing outpatient workup including
MRCP and colonoscopy. KUB demonstrates significant fecal
loading but no obstruction or ileus. She continues to be able
to tolerate PO and can complete the rest of her workup as an
outpatient
CHRONIC / STABLE ISSUES
# KNEE PAIN/BILATERAL HIP BURSITIS: continue oxycodone prn
# HTN: continue atenolol and verapamil, hold chlorthalidone as
above
.
# DEPRESSION AND INSOMONIA: continue bupropion and trazodone
prn
.
# CHRONIC PANCREATITIS: continue creon
.
# HYPOTHYROIDISM: Continue levothyroxine 75 mcg tablet
.
# CHRONIC PAIN: amitriptyline 50 mg tablet TAKE 1 TABLET AT
BEDTIME
.
# GERD: omeprazole 40 mg Oral capsule,delayed ___ 1
tab po bid, ___ before breakfast and supper
[x]Pt is medically stable for discharge.
[]Time spent coordinating discharge: > 30 minutes.
TRANSITIONAL ISSUES
- Evaluate blood pressure regimen; consider changing atenolol to
a different agent as it may cause decreased energy, weakness,
and is no longer favored in hypertension; if restarting
chlorthalidone, please monitor electrolytes closely
- Outpatient MRCP and colonoscopy as previously planned with PCP
to evaluate failure to thrive
Medications on Admission:
* oxyCODONE 5 mg tablet TAKE 1 TABLET EVERY FOUR TO SIX HOURS no
more than 6 tablets a day
*atenolol-chlorthalidone 50-25 mg tablet Take 1 tablet by mouth
daily
*verapamil 240 mg capsule,ext rel. pellets 24 hr SR 24 Hr Take
1 tablet daily
*buPROPion (WELLBUTRIN XL) 300 mg tablet extended release 24 hr
XL 24 Hr Take 1 tablet by mouth daily ; do not stop without
consulting clinician
*butalbital-acetaminophen-caffeine 50-325-40 mg tablet Take 1
tablet by mouth every 6 hours as needed
*traZODone 100 mg tablet Take 1 tablet by mouth at bedtime PRN
*pancrelipase, Lip-Prot-Amyl, (CREON) 6,000-19,000 -30,000
unit capsule,delayed ___ take 2 capsules before and
after each meal
* levothyroxine 75 mcg tablet Take 1 tablet by mouth daily
*amitriptyline 50 mg tablet TAKE 1 TABLET AT BEDTIME
* polyethylene glycol (MIRALAX) 17 gram/dose Oral Powder use two
to three capfuls po per day as needed for constipation
omeprazole 40 mg Oral capsule,delayed ___ 1 tab po
bid, ___ before breakf and supper
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN pain
2. Amitriptyline 50 mg PO QHS
3. Creon 12 2 CAP PO QIDWMHS
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Omeprazole 40 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. TraZODone 100 mg PO QHS:PRN insomnia
9. Verapamil SR 240 mg PO Q24H
10. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
11. Docusate Sodium 100 mg PO BID
12. Senna 8.6 mg PO BID:PRN constipation
13. Lactulose 15 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL 15 ml by mouth daily Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypokalemia
Dehydration
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hospitalized for low potassium levels, weakness, and
decreased appetite. Your low potassium levels were most likely
caused by a combination of your recent gastroenteritis as well
as one of your medications, chlorthalidone. We stopped your
chlorthalidone and gave you potassium supplements. Please
follow up with your PCP to ensure good blood pressure control.
You were also found to be quite constipated. We gave you an
enema with good response.
It is important that you see your PCP and obtain the MRCP and
colonoscopy as previously planned.
Followup Instructions:
___
|
10505380-DS-22 | 10,505,380 | 27,664,427 | DS | 22 | 2127-10-10 00:00:00 | 2127-10-10 16:54:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with h/o SBO, chronic pancreatitis,
cholecystectomy, appendectomy and chronic abdominal pain who
presents with 12 hours of worsening abdominal pain, nausea and
vomiting. Her PMH is notable for multiple similar presentations
over the past year with nausea/abdominal pain/constipation of
undetermined etiology. She says she has suffered from this
chronic abdominal pain since her SBOs in ___ and ___ (both of
which required ex lap, ___. She was hospitalized at the ___
___ for her most recent abdominal pain exacerbation,
which resolved with conservative management and was correlated
with findings of possible small bowel enteritis on CT abdomen.
Since this prior admission, the patient has apparently suffered
from abdominal pain with increased frequency: constant, ___
lower abdominal pain occurring nearly every day provoked by
eating more than a few bites of food, relieved only with
oxycodone and assuming the fetal position. She endorses losing
13 pounds during this 2-month period (165 to 152 pounds) from
reduced PO intake. Yesterday morning, she awoke with worse
(___) abdominal pain, with nausea and 2 episodes of non-bloody
vomiting. She gave herself a Fleets enema because her last BM
had been 2 days ago and she worried that constipation was
causing the pain. This caused her to have a normal BM but
without any pain relief. She therefore presented to the ED that
evening (___) for ongoing abdominal pain and nausea, but
without any F/C, diarrhea, melena/hematochezia, CP/SOB. She
doesn't drink on a regular basis but did have a few beers and
some wine this week when family visitors were in town.
In the ED, initial vitals were: 98.2 73 113/66 18 100% RA
(Range in ED: BP 99-135/50-70s, remained afebrile 97.7-98.2)
Exam not recorded.
Labs notable for WBC 5.7, H/H ___, Cr 2.0 (Baseline 1.0);
Initial K 3.2, BUN 28. Lactate 1.7.
U/A showed small Leuk Esterase, few bacteria, 7 WBC; neg for
ketones.
T bili ALT 32, AST 44, AP 133. Tbili wnl.
Repeat labs CBC improved to 1.3, K4.0 after 2L NS.
Imaging notable for:
KUB ___:
No evidence of obstruction.
CT A/P ___:
On this p.o. contrast only CT examination, no focal dilated
loops of small bowel are noted. No other intra-abdominal
pathology identified to explain abdominal pain.
Patient was given:
___ 00:04 IV Morphine Sulfate 4 mg
___ 00:04 IV Ondansetron 4 mg
___ 00:04 IVF NS
___ 00:42 IVF NS 1 mL
___ 00:46 IV Morphine Sulfate 4 mg
___ 02:05 PO OxyCODONE (Immediate Release) 5 mg
___ 02:06 IVF NS
___ 02:06 PO Potassium Chloride 40 mEq
___ 02:58 IVF NS 1 mL
___ 03:46 IV Morphine Sulfate 4 mg
___ 06:14 PO/NG Levothyroxine Sodium 12.5 mcg
___ 08:37 IV Morphine Sulfate 4 mg
___ 11:58 IV Morphine Sulfate 4 mg
___ 13:29 PO DiphenhydrAMINE 25 mg
___ 14:25 PO/NG Creon 12 1 CAP
___ 15:13 IVF NS
Decision was made to admit for ___ and further workup/management
of abdominal pain.
Of note, patient is s/p recent admission for similar complaint
("band-like lower abd pain, nausea, constipation, dry cough")
___ at that time c/w mild focal enteritis on CT A/P, no ssx
of SBO. Felt at that time likely exacerbation of chronic
abdominal pain likely ___ mild gastroenteritis.
On the floor, the patient uncomfortable. She is in the fetal
position and endorses ___ abdominal pain, requesting "pain
pills". Denies nausea, F/C, CP/SOB. Kept down toast, soup, apple
sauce earlier today, last BM yesterday morning, has passed gas
since then. Making urine normally, denies any dysuria.
Review of systems:
(+) Per HPI: abd pain, nausea/vomiting, also chronic dry cough
and night sweats.
(-) Denies fever, chills, headache, sinus tenderness, rhinorrhea
or congestion. Denies chest pain or tightness, palpitations,
SOB. Denies diarrhea or change in bladder habits. No dysuria.
Denies arthralgias or myalgias.
Past Medical History:
Hypertension
Ocular hypertension
Leukopenia
Depressive disorder
Transaminase or LDH elevation
Menopause
INSOMNIA
HEADACHE - MIGRAINE, UNSPEC
GOUT, UNSPEC
Alcohol dependence in remission
SBO requiring ex lap LOA ___
Lateral meniscal tear
Chronic pancreatitis
S/P appendectomy
Chronic pain
Osteoporosis
Intractable pain
Pain medication agreement
DJD (degenerative joint disease) of knee
GERD (gastroesophageal reflux disease)
Shoulder impingement syndrome
S/P TKR (total knee replacement)
Depression
Social History:
___
Family History:
Sister with diabetes, sister with ?TB and sarcoidosis who died
at ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=============================
VS: 98.4 139/74 79 18 98%RA
Gen: tired, uncomfortable-appearing AA woman lying in the fetal
position, in mild distress
HEENT: NC/AT, sclerae anicteric, MMM, no LAD
CV: RRR, nl S1/S2, II/VI systolic murmur heard best at the R
upper sternal border.
Pulm: CTAB without crackles or wheezes.
Abd: soft, obese, nondistended. Diffusely tender to palpation,
without rebound or guarding. No palpable masses or organomegaly.
No CVAT.
GU: no foley.
Ext: WWP, positive DPs b/l, no edema.
Skin: without jaundice or notable rashes.
Neuro: A&Ox3, conversing appropriately, moves all extremities
spontaneously.
Psych: mood depressed/frustrated, affect congruent with mood.
PHYSICAL EXAM ON DISCHARGE:
==============================
Physical exam:
VS: 98.0, 135/79, 79, 95%RA
Gen: middle-aged AA woman sleeping comfortably
HEENT: NC/AT, sclerae anicteric, MMM, no LAD
CV: RRR, nl S1/S2, II/VI systolic murmur heard best at the R
upper sternal border.
Pulm: CTAB without crackles or wheezes.
Abd: soft, obese, nondistended. Diffusely tender to palpation,
without rebound or guarding. No palpable masses or organomegaly.
No CVAT.
GU: no foley.
Ext: WWP, positive DPs b/l, no edema.
Skin: without jaundice or notable rashes.
Neuro: A&Ox3, conversing appropriately, moves all extremities
spontaneously.
Psych: affect euthymic.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 11:30PM BLOOD WBC-5.1 RBC-3.49* Hgb-10.7* Hct-32.7*
MCV-94 MCH-30.7 MCHC-32.7 RDW-13.4 RDWSD-45.9 Plt ___
___ 11:30PM BLOOD Glucose-112* UreaN-28* Creat-2.0* Na-135
K-3.2* Cl-97 HCO3-21* AnGap-20
___ 11:30PM BLOOD Albumin-4.0
LABS ON DISCHARGE:
=======================
___ 05:45AM BLOOD WBC-3.6* RBC-3.08* Hgb-9.4* Hct-29.0*
MCV-94 MCH-30.5 MCHC-32.4 RDW-13.4 RDWSD-46.3 Plt ___
___ 05:45AM BLOOD Glucose-102* UreaN-18 Creat-1.3* Na-140
K-4.1 Cl-106 HCO3-23 AnGap-15
___ 05:45AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.5*
___ 11:48PM BLOOD Lactate-1.7
IMAGING:
CT ABD/PELVIS ___
===========
EXAMINATION: CT of the abdomen and pelvis
INDICATION: ___ with hx of SBO here with recurrent abdominal
pain.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were acquired without intravenous contrast. Non-contrast scan
has several limitations in detecting vascular and parenchymal
organ abnormalities, including tumor detection.Oral contrast was
administered. Coronal and sagittal reformations were performed
and reviewed on PACS.
DOSE: Total DLP (Body) = 706 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Mild basal atelectasis noted. The imaged portion
of the heart is unremarkable.
ABDOMEN:
HEPATOBILIARY: The unenhanced appearance of the liver is normal.
Gallbladder surgically absent.
PANCREAS: Atrophic.
SPLEEN: Normal in size.
ADRENALS: Normal bilaterally.
URINARY: No kidney stone or hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber and wall thickness throughout.
The colon and rectum are within normal limits. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis. Uterus and adnexal
structures appear normal.
LYMPH NODES: There is no lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
No findings to account for pain.
Brief Hospital Course:
Ms. ___ is a ___ w/ Hx of HTN, GERD and SBO x 2 requiring
surgical lysis x 2, chronic pancreatitis, s/p cholecystectomy,
s/p appendectomy who presents with diffuse abdominal pain,
nausea, and vomiting and found to have ___ with negative CT
abdomen now admitted for further work up.
# Abdominal pain:
The patient presented with acute on chronic abdominal pain in
the context of her known prior surgical history. Evaluation
included CT scan that did not show evidence of bowel obstruction
or diverticulitis, or pancreatitis. LFT's and lipase were within
normal limits. The patient was noted to have planned endoscopy
on ___ by outpatient GI provider. Her abdominal pain and
nausea improved upon admission and patient was tolerating
regular diet and PO intake prior to discharge. Her symptoms were
thought to possibly be due to dyspepsia for which outpatient
work up is pending with plan for endoscopy on ___ with
outpatient GI provider. We also encouraged the patient to
discuss with her outpatient primary care provider other
underlying factors contributing to her chronic abdominal pain
including psychosocial factors and the role if any for ongoing
oxycodone as there was not a clear indication.
# ___ on CKD (baseline Cr 1.3):
The patient was noted to have acute kidney injury on
presentation with Cr of 2.0 that improved with IV hydration to
baseline of about 1.3 prior to discharge.
#Anemia:
Acute on chronic, Hgb has been 9s-10s over the past year and
remained stable while in the hospital.
CHRONIC ISSUES:
==========================
#Depression: continued bupropion
#Migraines:
-continued amitriptyline
-fioricet continued PRN
#Chronic pancreatitis: Presentation, imaging, and labs not
consistent with acute pancreatitis. Continued creon with meals.
# Chronic bursitis pain on oxycodone prescribed by PCP. ___
checked and patient receives prescriptions every 28 days
prescribed by PCP. Has outpatient pain management contract.
Continued oxycodone per outpatient regimen with bowel regimen
while in the hospital. Would like patient to have ongoing
discussions with PCP regarding potential weaning and
discontinuation of oxycodone with consideration of other pain
management regimens.
#HTN:
Lisinopril and HCTZ initially held in setting ___ and
restarted prior to discharge. Continued verapamil and atenolol.
#GERD: continued omeprazole 40 mg PO BID.
#Hypothyroidism: continued levothyroxine.
#Constipation: continued Miralax
#Insomnia: continued 100 mg trazodone QHS prn.
TRANSITIONAL ISSUES:
=======================
-consider tapering and discontinuing oxycodone on an outpatient
basis
-patient to continue follow up with GI for planned outpatient
endoscopy on ___
-follow up chemistry to ensure stable renal function on ___
when patient sees PCP
___ on ___:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 40 mg PO BID
4. Verapamil SR 240 mg PO Q24H
5. Atenolol 100 mg PO QAM
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
7. Amitriptyline 100 mg PO QHS
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. Creon 12 2 CAP PO TID W/MEALS
10. Cyclobenzaprine ___ mg PO HS:PRN spasm
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. TraZODone 100 mg PO QHS:PRN insomnia
15. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
2. Amitriptyline 100 mg PO QHS
3. Atenolol 100 mg PO QAM
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. Creon 12 2 CAP PO TID W/MEALS
6. Cyclobenzaprine ___ mg PO HS:PRN spasm
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QPM
10. Lisinopril 10 mg PO DAILY
11. Omeprazole 40 mg PO BID
12. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. TraZODone 100 mg PO QHS:PRN insomnia
15. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with abdominal pain. We evaluated with
a scan of your abdomen that showed no acute process or surgical
emergency. Your lab work also showed some kidney injury from
dehydration that improved with hydration. Your pain improved and
you were eating and drinking normal before discharge.
We recommend that you continue to follow up with your primary
care physician when you leave the hospital as well as your
Gastroenterologist who you have an appointment with tomorrow.
It was a pleasure being involved in your care.
Your ___ Team
Followup Instructions:
___
|
10505380-DS-24 | 10,505,380 | 22,740,406 | DS | 24 | 2127-11-24 00:00:00 | 2127-11-29 12:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, well known to the Acute Care Surgery service, with
extensive PSH and recurrent SBO (most recently admitted
___ with pSBO managed non operatively) returns to the ED
with c/o increasing abdominal discomfort and nausea for 24h. She
has been unable to eat or drink since the previous day. Last BM
was three days ago but she is currently passing flatus. No
fevers or
chills.
Past Medical History:
Past Medical History:
Recurrent SBOs, hypertension, hyperlipidemia, chronic
pancreatitis, EtOH and cocaine use, depression, GERD,
constipation, leg spasms, DJD, chronic pain, hypothyroidism
Past Surgical History:
Exploratory laparotomy ___ ___, open appendectomy
___ ___, laparoscopic cholecystectomy (___),
exploratory laparotomy/lysis of adhesions ___ ___
Social History:
___
Family History:
Sister with diabetes, sister with ?TB and sarcoidosis who died
at ___
Physical Exam:
Admission Physical Exam:
Vitals: 98.2 72 121/69 16 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, midly distended, midly tender to palpation in the
lower quadrants
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: VSS afebrile
GEN: A&O x3 calm in NAD
CV: HRR
PULM: LS ctab
ABD: soft, NT/ND
EXT: No edema
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
1. There is mild dilation of small bowel loops in the right
upper and mid
abdomen, similar to ___. Transition point within the
right lower
quadrant abdomen is re- demonstrated. Findings are consistent
with low-grade small bowel obstruction with the transition point
likely in the right abdomen. Correlate to serial radiographs of
the abdomen to ensure resolution. Consider further workup with
small bowel series to assess for fixed loop and to exclude a
possible stricture. Alternatively an MRI enterography study
could be performed for further workup.
2. Diffusely thickened stomach wall may reflect gastritis.
Upper GI study or endoscopy is recommended for further
evaluation.
RECOMMENDATION(S): Upper GI or endoscopy to evaluate potential
gastritis.
___: KUB:
No radiographic evidence of obstruction.
LABS:
___ 03:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:18AM LACTATE-2.0
___ 10:38AM GLUCOSE-112* UREA N-22* CREAT-1.5* SODIUM-134
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-19
___ 10:38AM ALT(SGPT)-29 AST(SGOT)-36 ALK PHOS-113* TOT
BILI-0.3
___ 10:38AM LIPASE-7
___ 10:38AM ALBUMIN-3.8
___ 10:38AM WBC-4.7 RBC-3.45* HGB-10.6* HCT-32.8* MCV-95
MCH-30.7 MCHC-32.3 RDW-14.2 RDWSD-49.1*
___ 10:38AM NEUTS-63.0 ___ MONOS-7.4 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-2.97 AbsLymp-1.35 AbsMono-0.35
AbsEos-0.03* AbsBaso-0.01
___ 10:38AM PLT SMR-NORMAL PLT COUNT-169
___ 10:38AM ___ PTT-21.7* ___
Brief Hospital Course:
Ms. ___ is a ___ w/ an extensive PSH and recurrent SBO (most
recently admitted ___ with pSBO managed non operatively)
who returned to the ED on ___ with increasing abdominal
discomfort and nausea for 24 hours. CT abdomen/pelvis revealed
a low-grade small bowel obstruction with the transition point
likely in the right abdomen. The patient continued to pass
flatus so no nasogastric tube was inserted. The patient was made
NPO, started on IVF and admitted to the Acute Care Surgical
service for further conservative management.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with one time doses of IV morphine
and acetaminophen. She was transitioned to oral medications
once tolerating a diet.
The patient remained stable from a cardiovascular and pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. Diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible.
Chronic pain was consulted and made some changes to the
patient's regimen due to complaints of poorly controlled chronic
hip pain. The patient has follow-up scheduled in the Pain
clinic.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 100 mg PO QHS
2. Atenolol 50 mg PO BID
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Creon 12 2 CAP PO TID W/MEALS
5. Cyclobenzaprine 10 mg PO DAILY muscle spasm- home med
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. TraZODone 100 mg PO QHS:PRN insomnia.
11. Verapamil SR 240 mg PO Q24H
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Ointment 1 Appl TP BID:PRN hip pain
RX *lidocaine 5 % apply to both hips twice a day Refills:*1
4. Lidocaine 5% Patch 2 PTCH TD QPM hip pain
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Pregabalin 25 mg PO BID
RX *pregabalin [Lyrica] 25 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Atenolol 50 mg PO DAILY
9. Creon 12 1 CAP PO TID W/MEALS
10. Amitriptyline 100 mg PO QHS
11. BuPROPion XL (Once Daily) 300 mg PO DAILY
12. Cyclobenzaprine 20 mg PO QHS muscle spasm- home med
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. Levothyroxine Sodium 75 mcg PO DAILY
15. Lisinopril 10 mg PO DAILY
16. Omeprazole 40 mg PO BID
17. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
18. TraZODone 100 mg PO QHS:PRN insomnia.
19. Verapamil SR 240 mg PO Q24H
20.Outpatient Physical Therapy
Dx: Gait instability
Px: Good
Duration: 13 (thirteen) months
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
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 to the hospital with a
partial small bowel obstruction. This obstruction was managed
conservatively with bowel rest and intravenous fluids. Your
diet was gradually advanced and you are now tolerating a regular
diet. You were seen by the Chronic Pain Service for
recommendations for an oral pain regimen. You have a follow-up
appointment scheduled in the Chronic Pain outpatient clinic and
it is recommended that you start attending Physical Therapy
sessions.
You are now ready to be discharged home to continue your
recovery. Please follow the discharge instructions below to
ensure a safe recovery while at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10505380-DS-27 | 10,505,380 | 25,902,050 | DS | 27 | 2129-02-01 00:00:00 | 2129-02-01 12:25:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, known to ACS service, with multiple past surgeries and
recurrent SBO, now returning with abdominal pain. Patient
reports developing abdominal pain three days ago. Abdominal pain
came on gradually and is now sharp, continuous, and
non-radiating. She has also had one episode of emesis daily
since the pain started. Last BM, formed, was two days ago. Last
passed flatus yesterday.
Endorses abdominal distention. She has not eaten today. Symptoms
are similar to the prior time she had a SBO. She was last
admitted this past ___ for similar symptoms and was managed
conservatively. Denies fevers, chills, chest pain, shortness of
breath, dysuria, or hematuria. Does report that over the last
few months, she has lost about 30 lbs for unknown reason,
because she
does not recall having had any changes in her diet or bowel
habits other than the acute episodes. Takes her medications
regularly.
Past Medical History:
Past Medical History:
Recurrent SBOs, hypertension, hyperlipidemia, chronic
pancreatitis, EtOH and cocaine use, depression, GERD,
constipation, leg spasms, DJD, chronic pain, hypothyroidism
Past Surgical History:
Exploratory laparotomy ___ ___, open appendectomy
___ ___, laparoscopic cholecystectomy (___),
exploratory laparotomy/lysis of adhesions ___ ___
Social History: ___
Family History:
Sister with diabetes, sister with ?TB and sarcoidosis who died
at ___
Physical Exam:
Admission Physical Exam:
Vitals: 98.5 | 98 | 105/70 | 16 | 98% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Regular borderline tachycardia, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender all four quadrants, primarily
LUQ, voluntary guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Neuro: non-focal
Discharge Physical Exam:
VS:98.4 104 / 71 110 18 100 Ra
GEN:nad
CV:rrr
PULM:nonlabored breathing on room air
ABD:soft, mildly tender, nondistended
EXT:wwp
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
1. A dilated loop of proximal in the anterior mid abdomen is
similar in
appearance to ___, with gradual transition back to
normal caliber. Either this is a resolving obstruction or a
partial small bowel obstruction. Jejunum traversing posterior
to the transverse colon raises some concern for an internal
hernia.
2. Slight interval increase in displacement of a right inferior
pubic ramus fracture, which also demonstrates early healing.
Left parasymphyseal superior pubic ramus fracture demonstrates
early healing and is in unchanged alignment.
LABS:
___ 04:50PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-LG*
___ 04:50PM URINE RBC-3* WBC-23* BACTERIA-FEW* YEAST-NONE
EPI-13 TRANS EPI-1
___ 04:50PM URINE MUCOUS-RARE*
___ 03:14PM LACTATE-1.0
___ 03:05PM GLUCOSE-69* UREA N-18 CREAT-0.8 SODIUM-135
POTASSIUM-5.2 CHLORIDE-95* TOTAL CO2-23 ANION GAP-17
___ 03:05PM ALT(SGPT)-14 AST(SGOT)-36 ALK PHOS-205* TOT
BILI-0.3
___ 03:05PM LIPASE-10
___ 03:05PM ALBUMIN-3.3* CALCIUM-9.7 PHOSPHATE-4.0
MAGNESIUM-1.5*
___ 03:05PM WBC-4.1 RBC-3.46* HGB-10.9* HCT-31.0* MCV-90
MCH-31.5 MCHC-35.2 RDW-14.3 RDWSD-46.4*
___ 03:05PM NEUTS-57.9 ___ MONOS-10.5 EOS-0.7*
BASOS-0.5 IM ___ AbsNeut-2.38 AbsLymp-1.24 AbsMono-0.43
AbsEos-0.03* AbsBaso-0.02
___ 03:05PM PLT COUNT-330
___ 03:05PM ___ PTT-33.3 ___
Brief Hospital Course:
Ms. ___ is a ___ y/o F with multiple past surgeries and
recurrent SBO, now returning with abdominal pain. CT
abdomen/pelvis demonstrated a resolving obstruction versus
partial small bowel obstruction. The patient's clinical exam
was stable and she was admitted to the Acute Care Surgery
service. No NGT was required. The patient was made NPO with IVF
for hydration while awaiting for return of bowel function. The
patient received a mineral oil enema and ducolax suppository
resulting in a loose bowel movement on HD2. The patient's diet
was advanced to clear liquids and then later a regular diet
which she tolerated. On HD3, the patient passed flatus.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV morphine and then
transitioned to her home dose of oxycodone once tolerating a
diet. The patient remained stable from a cardiovascular and
pulmonary standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
Diet was advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
amitriptyline 50' HS, atenolol 50' (pt states not taking),
levothyroxine 50', lisinopril 20' (patient states not taking),
omeprazole 40'', oxycodone 5' PRN pain, verapamil ER 240'
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 8.6 mg PO BID
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
4. Amitriptyline 100 mg PO QHS
5. BuPROPion 150 mg PO BID
6. Creon 12 1 CAP PO TID W/MEALS
7. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Omeprazole 40 mg PO BID
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
11. Verapamil 120 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a
small bowel obstruction. You were restricted from eating to
promote bowel rest and received intravenous fluid for hydration.
You received bowel medication and you had return of bowel
function. Your diet was advanced and you are now tolerating a
regular diet. You are now ready to be discharged home to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10505380-DS-31 | 10,505,380 | 28,499,141 | DS | 31 | 2129-05-22 00:00:00 | 2129-05-22 12:31:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparotomy- Lysis of Adhesions
History of Present Illness:
___ well-known to ___ service for h/o multiple SBOs, recently
discharged for partial SBO managed conservatively now presenting
with one day history of abdominal pain and emesis. Notably, she
does report a bowel movement yesterday and states she had flatus
this morning. However, her abdominal pain brought her to the
ED. CT of the abdomen in the ED revealed dilated loops of fluid
filled small bowel with a transition point in the pelvis, with
radiology concerned for an internal hernia. She had a normal
WBC and normal lactate. She adamantly refused a nasogastric
tube.
Of note, the patient is known to ACS service for her history of
multiple SBOs, in two occasions requiring operative management
___ and ___. She was admitted 3 times in ___, 3 times in
___ and 2 times in ___ for recurrent SBOs, all of them
resolving with conservative management. She has chronic
abdominal pain and 50lb weight loss over the last 6 months.
Workup included normal TSH while on thyroid replacement therapy,
negative HIV, negative hepatitis C antibody, normal inflammatory
markers.
She states she eats what she thinks is a lot, denies food fear,
and says she has the resources to get food when she is hungry.
Past Medical History:
- Recurrent SBOs secondary to multiple prior abdominal
surgeries:
Exploratory laparotomy ___ ___, open appendectomy
___ ___, laparoscopic cholecystectomy (___),
exploratory laparotomy/lysis of adhesions ___ ___
- hypertension
- hyperlipidemia
- chronic pancreatitis
- EtOH and cocaine use
- depression
- GERD,
- Hypothyroidism
Social History:
___
Family History:
Sister with diabetes, sister with ?TB and sarcoidosis who died
at ___. No family members with malignancy, however she does note
that she "does not have longevity in my family"
Physical Exam:
General: NAD
CV: RRR
Pulm: No respiratory Distress
Abd: Soft, nontender, non distended- abdominal incision with
staples healing well
Pertinent Results:
IMAGING:
CT ABDOMEN & PELVIS ___:
FINDINGS:
Lung Bases: The imaged lung bases are clear. The superior most
portion of the left hemidiaphragm is excluded. The imaged
portion of the heart is
unremarkable. No pleural or pericardial effusion is seen.
Abdomen: The liver enhances normally without focal concerning
lesions seen.
There is mild biliary ductal dilation which is unchanged likely
reflecting
prior cholecystectomy. Main portal vein is patent. The spleen
is within
normal limits of size. Adrenals appear normal bilaterally. The
pancreas is markedly atrophic. The kidneys enhance symmetrically
and demonstrate prompt excretion of contrast. No worrisome
renal lesion or hydronephrosis. The abdominal aorta is normal
in course and caliber with mild atherosclerotic calcifications.
The stomach is unremarkable. The duodenum is slightly fluid
distended.
Pelvis: Fluid-filled mildly dilated loops of small bowel noted
with bowel
loops measuring up to 3.3 cm. There is a gradual transition
point in the
pelvis, seen best on series 602 image 42 and 43. Distally,
there is
decompression of small bowel loops leading to the ileocecal
junction. The
configuration of small-bowel at the level of transition point is
most
suggestive of an internal hernia. Small volume free fluid
noted. No evidence of perforation. The appendix is not
definitively visualized though there are no secondary signs of
appendicitis. Moderate fecal load of the colon noted. The
uterus is unremarkable. No adnexal mass. Urinary bladder is
mostly decompressed. No pelvic sidewall or inguinal adenopathy.
Bones: Subacute appearance of a right acetabular and right
inferior pubic
ramus fracture. Irregularity at the pubic symphysis may reflect
insufficiency fractures, which were first seen in ___.
IMPRESSION:
1. Small-bowel obstruction with transition point in the pelvis,
likely due to an internal hernia. Small volume free fluid.
2. Subacute pelvic fractures as described.
Brief Hospital Course:
The patient presented to pre-op/Emergency Department on ___
. Upon arrival to ED the patient had abdominal pain and emesis.
The patient was seen to have a SBO on CT and was initially
treated conservatively, made NPO and patient refused NG tube.
After several days of continued abdominal pain and a KUB
consistent with SBO, surgical options were discussed with the
patient and given her history of SBOs, the patient consented to
surgical laparotomy with lysis of adhesions on ___. There
were no adverse events in the operating room; please see the
operative note for details. Pt was extubated, taken to the PACU
until stable, then transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout most of the
hospitalization; There were several nights where the patient
became delirious and was combatant. Geriatric Psychology was
consulted. Patient was put on 1-to-1 and treated per ___
recommendations. Pain was initially managed with IV dilaudid and
tylenol and then transitioned to oral oxycodone once tolerating
a diet. Due to the patients chronic pain history the CPS was
consulted for treatment of pt pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___, the NGT
was removed, therefore, the diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 50 mg PO QHS
2. Atenolol 50 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Creon 12 4 CAP PO TID W/MEALS
5. Lisinopril 20 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
8. Verapamil SR 240 mg PO Q24H
9. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
10. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amitriptyline 50 mg PO QHS
3. Atenolol 50 mg PO DAILY
4. Creon 12 4 CAP PO TID W/MEALS
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*10 Tablet
Refills:*0
11. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital with a
partial small bowel obstruction. This obstruction was managed
with bowel rest and intravenous fluids, but your pain continued.
You had a surgical procedure called lysis of adhesions where we
removed scar tissue from previous surgeries around your bowels
to try to prevent another bowel obstruction from occurring. Your
diet was gradually advanced and you are now tolerating a regular
diet.
You are now ready to be discharged home to continue your
recovery. Please follow the discharge instructions below to
ensure a safe recovery while at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
10505380-DS-32 | 10,505,380 | 27,529,490 | DS | 32 | 2129-06-10 00:00:00 | 2129-06-10 15:24:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubate with mechanical intubation, extubated ___
History of Present Illness:
___ is a ___ year-old woman w/ PMH of recent SBO, HTN,
HLD, chronic pancreatitis, depression, GERD, chronic pain
syndrome, hypothyroidism, and migraines, history of etoh and
cocaine abuse presenting to ___ ED with new onset seizure.
Briefly, patient was recently discharged from ___ after
treatment for SBO and presented ___ after a mechanical fall
with headstrike at home. Per chart review, she tripped on the
first stair at roughly 11 ___ on ___, causing her to fall
forward and strike her head on the right side. She went to ___
ED where she complained of headache, but otherwise denied vision
changes, dizziness, focal weakness or numbness. She reportedly
is a poor historian, but her husband reportedly corroborated the
story. Her exam on ___ per ED documentation was notable for
slurred speech, which per husband is baseline, hematoma right
forehead, normal cranial nerve exam, intact strength and
sensation in all 4. She underwent CT head which showed a right
subgaleal hematoma and she was subsequently discharged home.
On ___ the patient represented to ___ ED after her husband
saw her having a tonic clonic seizure that lasted about 1
minute. EMS was called and found her to be postictal. On arrival
to ___ ED patient was reportedly alert and oriented x3,
somnolent but following commands PERRL, EOMI, moving all
extremities to command. Neurology was consulted for further
evaluation of seizure. On initial exam by neuro, patient not
answering any questions, not following commands, intermittently
eyes rolled up, moving all 4's spontaneously. STAT EEG ordered,
and complete infectious/metabolic work up including tox screen.
Shortly after patient noted to have left eye deviation and some
whole body "twitching" per ED, she was given Ativan 2mg x2 and
keppra loaded 20mg/kg. Due to decreased mental status, the
patient was intubated for airway protection in the ED. She was
stated on propofol gtt and per neurology EEG was then consistent
with burst suppression. LP was completed in ED which was bland.
She was admitted to the neuro ICU for further management.
Past Medical History:
- Recurrent SBOs secondary to multiple prior abdominal
surgeries:
Exploratory laparotomy ___ ___, open appendectomy
___ ___, laparoscopic cholecystectomy (___),
exploratory laparotomy/lysis of adhesions ___ ___
- hypertension
- hyperlipidemia
- chronic pancreatitis
- EtOH and cocaine use
- depression
- GERD,
- Hypothyroidism
Social History:
___
Family History:
Sister with diabetes, sister with ?TB and sarcoidosis who died
at ___. No family members with malignancy, however she does note
that she "does not have longevity in my family"
Physical Exam:
ADMISSION EXAM:
===============
Vitals: ___ , BP163/100, RR 18 RA 99%
General: laying in stretcher
HEENT: mmm
CV: RRR, S1S2, no murmurs
Pulm: CTAB
Abd: s/nt/nd
Ext: no c/c/e
Neuro:
-MS: Somnolent, not answering question. No verbal output,
intermittently regards examiner, intermittently eyes rolling up
-CN:PERRL ___ sluggish, intact lateral gaze, face symmetric,
-Sensory/Motor: Moves all 4 spont but not to command. Withdraws
briskly in all 4's and grimaces to nox in all 4's.
DISCHARGE EXAM:
===============
Physical Exam:
24 HR Data (last updated ___ @ 1216)
Temp: 98.8 (Tm 98.8), BP: 134/76 (104-136/68-87), HR: 104
(89-110), RR: 18 (___), O2 sat: 100% (96-100), O2 delivery: Ra
General: Cachetic woman lying comfortably in bed, NAD.
HEENT: NC/AT, b/l proptosis
Pulmonary: breathing comfortably on room air
Cardiac: warm, well-perfused
Abdomen: soft, NT/ND
Extremities: wwp, no C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-MS: awake, alert. Oriented to self, date, ___. Aware that she
had two seizures. Able to convey a coherent history. Language is
fluent. No paraphasic errors. Normal prosody. Follows commands.
-CN: PERRL 5-3mm, b/l, brisk. EOMI, no nystagmus. Intact and
equal sensation in V1, V2, V3. No facial droop. No dysarthria.
Tongue midline, symmetric palate elevation.
-Motor: No pronator drift. No asterixis or tremor.
-Sensory: deferred
-Reflexes: deferred
-Coordination: Intact FNF.
-Gait: deferred.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-18
GLUCOSE-67
___ 10:50PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 POLYS-4
___ ___ 08:12PM LACTATE-2.6*
___ 06:26PM URINE HOURS-RANDOM
___ 06:26PM URINE UHOLD-HOLD
___ 06:26PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 06:26PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG*
___ 06:26PM URINE RBC-<1 WBC-36* BACTERIA-FEW* YEAST-NONE
EPI-11 TRANS EPI-1
___ 04:15PM GLUCOSE-88 CREAT-1.0 SODIUM-135 POTASSIUM-4.8
CHLORIDE-100 TOTAL CO2-19* ANION GAP-16
___ 04:15PM estGFR-Using this
___ 04:15PM ALT(SGPT)-18 AST(SGOT)-34 ALK PHOS-112* TOT
BILI-0.4
___ 04:15PM LIPASE-11
___ 04:15PM ALBUMIN-2.7* CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-1.7
___ 04:15PM ASA-NEG ACETMNPHN-NEG tricyclic-POS*
___ 04:15PM WBC-5.0 RBC-2.82* HGB-8.6* HCT-25.5* MCV-90
MCH-30.5 MCHC-33.7 RDW-18.8* RDWSD-61.1*
___ 04:15PM NEUTS-49.7 ___ MONOS-9.7 EOS-7.0
BASOS-0.8 IM ___ AbsNeut-2.50 AbsLymp-1.64 AbsMono-0.49
AbsEos-0.35 AbsBaso-0.04
___ 04:15PM ___ PTT-31.8 ___
___ 04:15PM PLT COUNT-281
___ 03:35AM URINE HOURS-RANDOM
___ 03:35AM URINE UHOLD-HOLD
___ 03:35AM URINE COLOR-Yellow APPEAR-Clear SP ___
___:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD*
___ 03:35AM URINE RBC-1 WBC-6* BACTERIA-FEW* YEAST-NONE
EPI-6
DISCHARGE LABS:
===============
___ 04:15AM BLOOD WBC-4.1 RBC-3.14* Hgb-9.8* Hct-27.7*
MCV-88 MCH-31.2 MCHC-35.4 RDW-17.8* RDWSD-56.4* Plt ___
___ 04:15AM BLOOD Glucose-74 UreaN-8 Creat-0.9 Na-141 K-4.0
Cl-104 HCO3-24 AnGap-13
___ 04:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.8
IMAGING:
========
CXR ___:
No acute intrathoracic process. No acute fractures identified.
CT C-Spine ___:
No fracture or subluxation.
CT Head without contrast ___:
1. No evidence for an acute intracranial abnormality.
2. Right frontal/anterior parietal subgaleal hematoma without
evidence for an underlying fracture.
CT Head without contrast ___:
1. No interval change from the previous examination with no
acute intracranial abnormality.
2. Similar right frontal/anterior parietal subgaleal hematoma.
MRI Head with/without contrast ___:
1. No evidence of acute hemorrhage or infarction. No structural
abnormality identified. No suspicious FLAIR signal abnormality.
2. Global mild volume loss, unchanged from prior.
3. Additional findings described above.
EEG:
====
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of: Generalized background slowing suggestive of a
mild-moderate
encephalopathy, non specific in etiology. This later improved to
a mild
encephalopathy
Brief Hospital Course:
___ year-old woman w/ PMH of SBO, HTN, HLD, chronic pancreatitis,
Depression, GERD, chronic pain syndrome, hypothyroidism, and
migraines, history of etoh and cocaine abuse presenting with
seizure.
Briefly, patient was recently discharged from ___ after
treatment for SBO and presented to ___ after a fall, CT showed
subgaleal hematoma but no intracranial hemorrhage and pt was
sent home.
One day after, she presented to ___ ED after her husband saw
her having a tonic clonic seizure that lasted about 1 minute.
EMS was called and found her to be postictal. In ED, patient had
another seizure and given Ativan and Keppra loaded. Patient was
intubated for airway protection on ___. No suspicious FLAIR
signal abnormality. And cvEEG was without any evidence of
seizure. The patient arrived to the Neuro ICU intubated for
airway protection but was soon extubated on ___ given
ability to follow commands. She was started on LevETIRAcetam
1000 mg PO Q12H and then transferred out of the ICU for further
monitoring. Patient quickly transferred to the floor after she
was stable on Keppra 1000 mg BID.
Unclear reason for new onset seizures. Patient has been losing
weight and PCP thought it was due to chronic pancreatitis. CT
torso done to look for malignancy but no findings.
Nutrition evaluated patient and found her to have severe protein
calorie malnutrition. Patient was started on Ensure Enlive
3x/day and megestrol 400 mg daily for appetite stimulation.
Patient also anemic with hemoglobin down to 7.0, down from
baseline of ___. Pt received 1 U PRBC for symptomatic anemia.
Transitional Issues:
[ ] buproprion held due to seizures
[ ] atenolol, Lisinopril, verapamil held as pt BP at goal.
Please restart meds as appropriate.
[ ] f/u with PCP (Dr. ___ - appt made for ___ at 11:50
am.
[ ] further workup for unintentional weightloss
[ ] anemia needs to be followed and worked up
[ ] severe protein calorie malnutrition needs to be addressed
[ ] ___ PCP ___ need to refer to ___ neurologist to
work-up new onset seizures
Medications on Admission:
Medications: Per recent DC summary
1. Acetaminophen 1000 mg PO Q8H
2. Amitriptyline 50 mg PO QHS
3. Atenolol 50 mg PO DAILY
4. Creon 12 4 CAP PO TID W/MEALS
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*10 Tablet
Refills:*0
11. Verapamil SR 240 mg PO Q24H
Discharge Medications:
1. Creon 12 4 CAP PO TID W/MEALS
2. FoLIC Acid 1 mg PO DAILY
3. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Megestrol Acetate 400 mg PO DAILY
RX *megestrol 400 mg/10 mL (10 mL) 10 ml by mouth once a day
Disp #*300 Milliliter Refills:*1
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO BID
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
9. Thiamine 100 mg PO DAILY
10. TraZODone 25 mg PO QHS:PRN Insomnia
11.Rolling walker
Please dispense 1 rolling walker.
Discharge Disposition:
Home With Service
Facility:
___ -
Discharge Diagnosis:
New onset seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were transferred from another hospital because you had two
witnessed generalized seizures. You were admitted to the
intensive care unit. An anti-seizure medication (Keppra
(levitiracetam) 1000 mg twice a day) was started to prevent more
seizures.
Because of your weight-loss, nutrition was consulted and found
you to be malnourished. You were started on Ensure Enlive three
times a day as a supplement and on Megestrol as an appetite
stimulant.
You have a history of anemia but your blood levels became lower
(hemoglobin 7.0) and you were symptomatic. You received 1 unit
of blood with improvement.
Physical therapy evaluated you and recommended staying in a
rehabilitation center until you get stronger. However, you
declined and decided to go home with home physical therapy.
Please follow up with your primary medical doctor at ___ who
___ refer you for neurology follow-up. See your primary medical
doctor to see if you need to restart any blood pressure
medication that were held.
We helped make an appointment for you with your primary doctor,
___, on ___ at 11:50 am.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
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