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10505380-DS-33 | 10,505,380 | 22,455,716 | DS | 33 | 2129-08-28 00:00:00 | 2129-08-29 12:09:00 |
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:
Ms. ___ is a ___ with hx multiple prior SBOs s/p recent lysis
of adhesions, cholecystectomy, appendectomy, chronic
pancreatitis, GERD, chronic pain syndrome, and recent admission
for seizures who presents with acute on chronic abdominal pain.
Patient reports that her pain has been ongoing since surgery in
___, but has been getting progressively worse. Endorses ___
diffuse abdominal pain, worse with movement and eating/drinking,
better with pain medication. Feels like "lumps" in her stomach
that are very painful. She takes oxycodone q6hrs at home but
pain
breaks through between doses and she has been taking advil 400mg
BID to try and help. Last BM yesterday - has been having regular
bowel movements recently. Passing flatus. Endorses nausea, but
no
vomiting or diarrhea. No fevers or chills. No dysuria but
endorses urinary frequency.
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 PHYSICAL EXAM:
========================
Vital Signs: 98.2, 155/93, 111, 18, 98% Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, wearing
dentures, EOMI, PERRL, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Visible well-healed surgical scar at midline. Scar
tissue causing distortion of overlying soft tissue. Soft,
distended, tender to light palpation of bilateral RUQ, RLQ, and
LLQ. No guarding or rebound. +BS.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all 4 extremities with purpose
DISHCARGE PHYSICAL EXAM:
========================
Vital Signs:
24 HR Data (last updated ___ @ 1128)
Temp: 98.2 (Tm 98.4), BP: 166/81 (153-166/80-96), HR: 101
(82-110), RR: 18, O2 sat: 100% (98-100), O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, wearing
dentures, EOMI, PERRL, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Visible well-healed surgical scar at midline. Scar
tissue causing distortion of overlying soft tissue. Soft,
distended, tender to light palpation of bilateral RUQ, RLQ, and
LLQ. No guarding or rebound. +BS.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all 4 extremities with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:32AM BLOOD WBC-5.6 RBC-2.60* Hgb-7.8* Hct-24.3*
MCV-94 MCH-30.0 MCHC-32.1 RDW-14.5 RDWSD-49.3* Plt ___
___ 01:32AM BLOOD Neuts-39.3 ___ Monos-11.7 Eos-1.8
Baso-0.5 Im ___ AbsNeut-2.18 AbsLymp-2.57 AbsMono-0.65
AbsEos-0.10 AbsBaso-0.03
___ 12:50AM BLOOD Glucose-91 UreaN-34* Creat-1.5* Na-140
K-4.5 Cl-107 HCO3-22 AnGap-11
___ 01:32AM BLOOD ALT-19 AST-25 AlkPhos-98 TotBili-<0.2
___ 01:32AM BLOOD cTropnT-<0.01 proBNP-159
___ 12:50AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
___ 07:35AM BLOOD calTIBC-419 Ferritn-19 TRF-322
___ 01:33AM BLOOD Lactate-2.5*
DISCHARGE LABS:
================
___ 07:37AM BLOOD WBC-5.4 RBC-2.63* Hgb-7.9* Hct-24.8*
MCV-94 MCH-30.0 MCHC-31.9* RDW-14.6 RDWSD-50.0* Plt ___
___ 07:37AM BLOOD Glucose-97 UreaN-20 Creat-1.4* Na-142
K-4.3 Cl-108 HCO3-20* AnGap-14
___ 07:37AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
STUDIES:
========
CHEST (PORTABLE AP) ___
No acute process in the chest.
CT ABD & PELVIS WITH CO ___. No evidence of small-bowel obstruction or free
intraperitoneal air.
2. No acute findings and no significant change from prior exam
re-demonstrating a moderate to large amount of fecal material in
the colon.
Brief Hospital Course:
Brief Hospital Course:
___ with hx multiple prior SBOs s/p recent lysis of adhesions,
cholecystectomy, appendectomy, chronic pancreatitis, GERD,
chronic pain syndrome, and recent admission for seizures,
admitted with acute on chronic abdominal pain found to have ___.
ACTIVE ISSUES:
==============
# ACUTE ON CHRONIC ABDOMINAL PAIN
# CHRONIC PANCREATITIS
Patient has a long history of multiple prior SBOs, however her
presenting acute on chronic pain was unlikely due to SBO since
she was having bowel movement and passing gas. She had no fevers
or significant leukocytosis to suggest infectious etiology of
pain. LFTs and lipase WNL, patient is s/o cholecystectomy and
appendectomy. There was no evidence of potential complications
of chronic pancreatitis including pseudocyst or pancreatic
ascites. Most likely due to constipation given substantial fecal
material identified on CT. We Continued her home Creon, home
Megestrol Acetate, home DICYCLOMine, and treated with an
aggressive bowel regimen.
# ___ on potential CKD
Cr 1.7 on arrival to ED from baseline of 0.8-0.9. Pre-renal was
the most likely etiology in setting of poor PO intake. We
treated with IV fluids. Her creatinine remained elevated and
upon review of her records, it appears that her kidney function
has been declining over the previous months. Her urine was spun
and was not consistent with ATN. She should see a nephrologist
to evaluate potential CKD.
# Iron deficiency anemia
Hemoglobin noted to be between 7.5 and 9 with increased
RDW and iron studies showing low ferritin consistent with iron
deficiency anemia. She would benefit from a non-urgent
outpatient
EGD/colonoscopy to evaluate for GI sources of bleeding. She
received IV iron X3 on this admission.
# UTI
Reporting dysuria in ED, and UA looks suspicious for UTI. No
fevers, chills, nausea, or flank pain. No leukocytosis.
She was started on ceftriaxone in the ED which was continued and
she completed a ___HRONIC ISSUES:
===============
# MIGRAINES: Continued home amitriptyline
# SEIZURE DISORDER: continued LevETIRAcetam 1000 mg PO Q12H
# HTN: held home HCTZ in the setting of new ___
# DEPRESSION: Dose reduced TraZODone 75 mg PO QHS:PRN Insomnia
to 25mg QHS given multiple sedating meds
# HYPOTHYROIDISM: Continued home Levothyroxine Sodium 75 mcg PO
DAILY
# GERD: Continued home Omeprazole 40 mg PO BID
# H/O LEG SPASMS: continued home Cyclobenzaprine 10 mg PO HS:PRN
leg muscle spasms
Transitional Issues:
=====================
[] Recommend outpatient non-urgent EGD ___ for work up of
anemia of iron deficiency.
[] Would recommend outpatient iron supplementation.
[] Will need repeat BMP in 7 days to follow up Cr from ___ vs
CKD that was stabilized on discharge.
[] Recommend outpatient nephrology workup of potential CKD.
[] PPIs have been associated with CKD.
[] We held her hydrochlorothiazide given her ___, if Cr. at
baseline on discharge would consider resuming HCTZ.
[] We dose reduced her trazodone to 75mg PO trazodone to 25mg
due to somnolence -- may need adjusting in the outpatient
setting.
Discharge Cr 1.4
Discharge hgb: 7.9
Discharge Code status: Full
Discharge Contact/HCP: ___ (husband) ___
Greater than 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 4 CAP PO TID W/MEALS
2. LevETIRAcetam 1000 mg PO Q12H
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Megestrol Acetate 400 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO BID
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
8. TraZODone 75 mg PO QHS:PRN Insomnia
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Amitriptyline 50 mg PO QHS
11. Cyclobenzaprine 10 mg PO HS:PRN leg muscle spasms
12. DICYCLOMine 20 mg PO TID before meals
Discharge Medications:
1. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN abd pain
RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400
mg-400 mg-40 mg/5 mL 15 ml by mouth three times a ___ Refills:*0
2. Amitriptyline 50 mg PO QHS
3. Creon 12 4 CAP PO TID W/MEALS
4. Cyclobenzaprine 10 mg PO HS:PRN leg muscle spasms
5. DICYCLOMine 20 mg PO TID before meals
6. LevETIRAcetam 1000 mg PO Q12H
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Megestrol Acetate 400 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO BID
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
12. TraZODone 75 mg PO QHS:PRN Insomnia
13. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you are told
to do so by your physician.
Discharge Disposition:
Home
Discharge Diagnosis:
# Abdominal pain
# Urinary Tract infection
# Iron deficiency anemia
# Acute renal failure
#Migraines
#Seizures
#HTN
#Depression
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 on this hospital admission
at ___.
Why was I admitted to the hospital?
===================================
- You were admitted to the hospital for abdominal pain.
- You also had a urinary tract infection and got IV antibiotics
for three days.
What happened while I was in the hospital?
==========================================
- We continued your home medications for your chronic
pancreatitis.
- We gave you medications to help your constipation.
- We gave you IV fluids for your kidneys.
- We gave you IV iron for your anemia.
What do I need to do when I leave the hospital?
===============================================
- You should take all of your home medications as prescribed.
- You should see your doctor within one week of leaving the
hospital.
- You should have an endoscopy and colonoscopy to evaluate for
bleeding in your gastrointestinal tract.
- You should see a kidney specialist.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10506015-DS-20 | 10,506,015 | 23,961,391 | DS | 20 | 2178-05-11 00:00:00 | 2178-05-13 09:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Thrombin / Nortriptyline / vancomycin
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old gentleman with end-stage renal disease secondary to
IgA nephropathy, status post kidney transplant from high risk
donor in ___ c/b nephrolithiasis s/p several procedures,
most recently combination retrograde ureteroscopy and antegrade
ureteroscopy on ___ with NU stent in place then removed on
___ presenting to the ED with generalized malaise, fevers.
He reported chills and fever to 104 earlier today along with
mild cough but no shortness of breath. He denied sore throat,
dysuria, leg swelling, rash, diarrhea. He had one episode of
non-bloody bilious emesis yesterday and then again today. He was
seen in at the ___ clinic yesterday for the fever and
urine cultures were collected. He was sent home to return to ED
if he worsened.
In the ED, he was found to be hypotensive to SBP of ___, tachy
to 110s with a T max of 100.2. He was given stress dose
steroids, 2L IVF, started on vanco then switched to linezolid
given rash (see allergies) + Zosyn and admitted to the ICU for
concern for sepsis of unclear origin.
In ED initial VS:
100.2 HR 117, 77/38 20 97% RA
Patient was given:
___ 13:12 IVF NS
___ 13:29 IV Piperacillin-Tazobactam
___ 13:29 IV Hydrocortisone Na Succ. 100 mg
___ 13:29 IV Ondansetron 4 mg
___ 13:30 IVF NS 1 mL
___ 14:31 IV Piperacillin-Tazobactam 4.5 g
___ 14:35 IV Vancomycin
___ 15:40 IV Vancomycin 750 mg
___ 15:45 IVF NS
___ 17:20 IVF NS 1 mL
___ 17:34 IVF NS ( 1000 mL ordered)
Labs notable for:
132 99 22 134
3.6 19 1.9
14.7 12.0 160
38.1
___: 15.1 PTT: 29.4 INR: 1.4
LFTs wnl
Lactate:2.4
Trop-T: <0.01
UA w/ Lrg leuks, RBC 3, WBC 32 Bact Few
FluAPCR: Negative
FluBPCR: Negative
Imaging notable for:
Renal US:
Mild hydronephrosis of the right lower quadrant transplant
kidney. Normal resistive indices. No perinephric abnormality.
CXR: neg for acute cardiopulmonary process
Consults: renal transplant
On arrival to the MICU, he reports developing fever and chills
after returning from a weekend trip to ___ on ___ at 1am. He
reports possibly a mild cough which has resolved. Denies
dyspnea, rhinorrhea, or sore throat. He denies abdominal or
flank pain, dysuria or hematuria. He also denies diarrhea,
hematochezia/melena or mucoid stool. He feels tired, but back to
his baseline state of health.
REVIEW OF SYSTEMS: see HPI
Past Medical History:
IgA nephropathy
ESRD on HD - HD initiated in ___, transplanted in ___
MSSA bacteremia - ___ - TTE negative, but suboptimal
quality. TEE not pursued. Treated with 14 days of cefazolin.
HTN
Obesity
Lt brachiocephalic AV fistula ___
superficialization of AV fistula ___
-obesity
- hypothyroidism
- peripheral neuropathy
Social History:
___
Family History:
Father had ESRD s/p kidney transplant (not IgA nephropathy).
Mother is healthy.
Physical Exam:
ADMISSION EXAM:
==============
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, well healed surgical scar in RLQ
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: grossly intact
ACCESS: PIVs, avoid left arm
DISCHARGE EXAM
================
VITALS: Tm 99.3 Tc 99.0 113/74 82 18 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, well healed surgical scar in RLQ
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS
=================
___ 11:37PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 08:46PM LACTATE-1.4
___ 08:29PM GLUCOSE-190* UREA N-20 CREAT-1.7* SODIUM-137
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-16* ANION GAP-20
___ 08:29PM CALCIUM-9.4 PHOSPHATE-2.9 MAGNESIUM-1.7
___ 08:29PM CMV VL-NOT DETECT
___ 08:29PM WBC-10.6* RBC-4.39* HGB-11.1* HCT-35.5*
MCV-81* MCH-25.3* MCHC-31.3* RDW-14.4 RDWSD-42.0
___ 08:29PM PLT COUNT-147*
___ 03:20PM URINE HOURS-RANDOM
___ 03:20PM URINE UHOLD-HOLD
___ 03:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 03:20PM URINE RBC-3* WBC-32* BACTERIA-FEW YEAST-NONE
EPI-0
___ 03:20PM URINE HYALINE-1*
___ 03:20PM URINE MUCOUS-RARE
___ 03:12PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 01:36PM ___ PO2-40* PCO2-28* PH-7.49* TOTAL
CO2-22 BASE XS-0
___ 01:25PM tacroFK-7.4
___ 01:16PM LACTATE-2.4*
___ 01:00PM GLUCOSE-134* UREA N-22* CREAT-1.9*
SODIUM-132* POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-19* ANION GAP-18
___ 01:00PM estGFR-Using this
___ 01:00PM ALT(SGPT)-14 AST(SGOT)-12 ALK PHOS-99 TOT
BILI-0.7
___ 01:00PM LIPASE-26
___ 01:00PM cTropnT-<0.01
___ 01:00PM ALBUMIN-4.0 CALCIUM-10.2 PHOSPHATE-1.5*
MAGNESIUM-1.6
___ 01:00PM WBC-14.7*# RBC-4.78 HGB-12.0* HCT-38.1*
MCV-80* MCH-25.1* MCHC-31.5* RDW-14.3 RDWSD-41.3
___ 01:00PM NEUTS-85.2* LYMPHS-3.5* MONOS-10.9 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-12.49*# AbsLymp-0.51*
AbsMono-1.60* AbsEos-0.00* AbsBaso-0.02
___ 01:00PM PLT COUNT-160
___ 01:00PM ___ PTT-29.4 ___
IMAGING:
=========
Renal US ___:
Mild hydronephrosis of the right lower quadrant transplant
kidney. Normal resistive indices. No perinephric abnormality.
CXR ___: neg for acute cardiopulmonary process
MICROBIOLOGY
================
___ urine cultures grew Group B strep.
___ 3:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 1:26 pm BLOOD CULTURE
Blood Culture, Routine (Pending): NO GROWTH TO DATE
___ 11:37 pm Rapid Respiratory Viral Screen & Culture
Source: Nasal swab.
Respiratory Viral Culture (Preliminary):
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..
DISCHARGE LABS
=================
___ 04:58AM BLOOD WBC-6.8 RBC-4.30* Hgb-10.8* Hct-34.9*
MCV-81* MCH-25.1* MCHC-30.9* RDW-14.5 RDWSD-42.8 Plt ___
___ 04:58AM BLOOD ___ PTT-29.2 ___
___ 04:58AM BLOOD Plt ___
___ 04:58AM BLOOD Glucose-116* UreaN-17 Creat-1.4* Na-138
K-3.8 Cl-105 HCO3-23 AnGap-14
___ 04:58AM BLOOD ALT-12 AST-8 AlkPhos-81 TotBili-<0.2
___ 04:58AM BLOOD Albumin-3.5 Calcium-9.9 Phos-3.1 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with end-stage renal
disease secondary to IgA nephropathy, status post kidney
transplant from high risk donor in ___ c/b
nephrolithiasis s/p with multiple procedures most recently on
___ with NU stent placed then removed on ___ who
presented to the ED with fever, hypotension and tachycardia. The
patient was initially managed with IVF resuscitation, IV
antibiotics and admitted to the ICU given borderline
hypotension. His BP improved with IV fluid resuscitation and he
remained afebrile, and on HD #2 was transferred to the floor. He
continued to be afebrile and stable and outpatient urine culture
was notable for beta-hemolytic streptococcus at 50-100k CFU.
Thus his antibiotics were narrowed to augmentin to complete a
14d course (end date ___.
#SEPSIS SECONDARY TO GROUP B STREP UTI: Patient presented with
low-grade fever, hyotension to ___ systolic, elevated lactate.
UA was positive for concern for UTI given pyuria. Patient denied
flank pain or dysuria to suggest a recurrence of his
nephrolithiasis and his renal US was reassuring. He reported
mild cough but CXR was unremarkable and he has no additional
respiratory symptoms. He received 3L IVF and stress dose
steroids in the ED and he was afebrile, normotensive and
normocardic, with a downtrending lactate on arrival to the ICU.
Antibiotics were narrowed from linezolid and Zosyn to
ceftriaxone based on culture data from ___ indicating Group B
strep on prelim results. Blood and urine cultures from ___
were collected did not show any growth. Patient was transferred
to the floor where he remained stable and afebrile. He was
discharged to complete a 14-day course of treatment with
Augmentin (D1 = ___.
#ESRD SECONDARY TO IGA NEPHROPATHY, ___: Patient is s/p kidney
transplant in ___ with baseline creatinine of 1.1-1.5 range. He
then developed complications including nephrolithiasis requiring
several procedures and his Cr peaked at 2.7 several months ago,
and downtrended to 1.8 just prior to admission. Creatinine on
admission was 1.9 and improved with fluids to 1.6 by discharge
to the floor. His ___ and diuretic were held, to be restarted
prior to discharge. Patient was continued on his home tacrolimus
1mg BID dose (goal trough ___ and home prednisone 5mg QD. MMF
was decrased on admission to 500mg BID then increased to his
previous dose of 750mg BID at discharge.
===============
Chronic Issues:
#HTN: His home ___ and lasix were held during admission in the
setting of infection and mild ___. These meds were held at
discharge until outpatient nephrology follow up.
Transitional issues:
========================
-Pt will continue augmentin to complete a full 14d course for
complicated UTI in a transplant patient
-Patient's MMF was continued at his home dose of 750mg BID upon
discharge
-Patient's home valsartan and furosemide were held given ___ and
sepsis, these should be resumed at nephrology visit on ___
# Communication: HCP: ___, father/HCP, ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 750 mg PO BID
2. PredniSONE 5 mg PO DAILY
3. Pregabalin 75 mg PO BID
4. Tacrolimus 1 mg PO Q12H
5. Vitamin D ___ UNIT PO DAILY
6. Cinacalcet 30 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*22 Tablet Refills:*0
2. Cinacalcet 30 mg PO DAILY
3. Mycophenolate Mofetil 750 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Pregabalin 75 mg PO BID
6. Tacrolimus 1 mg PO Q12H
7. Vitamin D ___ UNIT PO DAILY
8. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until your visit with your nephrologist
9. HELD- Valsartan 80 mg PO DAILY This medication was held. Do
not restart Valsartan until your visit with your nephrologist
Discharge Disposition:
Home
Discharge Diagnosis:
Fevers
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___-
You were admitted to the hospital for fevers at home. Initially,
you were found to have a low blood pressure, and were given
fluids through your IV, IV antibiotics, and monitored in the
intensive care unit. You were stabilized will continue to take
an oral antibiotics until ___.
Please take all your medications as prescribed and attend all
follow-up appointments-
-Your ___ Care Team
Followup Instructions:
___
|
10506015-DS-9 | 10,506,015 | 25,008,660 | DS | 9 | 2173-03-08 00:00:00 | 2173-03-10 13:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Tunnel Hemodialysis line pulled on ___
Tunnel Hemodialysis line placement on ___
History of Present Illness:
___ y/o male with ESRD from IgA nephropathy, on ___
dialysis, came to the ED today for fevers to 103 this morning,
with accompanying nausea and vomiting that occurred in the
morning hours, associated with fevers and chills. Emesis was
clear and contained food contents; denies hematemesis.
Throughout the morning, he had ___ episodes of emesis. He had
some epigastric discomfort after vomiting, but no other
significant abdominal pain. In addition, he had several episodes
of watery, non-bloody diarrhea. He does make some urine but
denies dysuria, hematuria, polyuria, or incomplete voiding.
His HD catheter was placed several months ago, and functioned
fine on ___ during his last HD session. He has had no pain
at the catheter site. He denies manipulating the catheter at
all, between HD sessions. Of note, patient had history of MSSA
bacteremia associated with HD line in ___.
In the ED, initial VS: 103.0 131 145/56 20 100%. Exam notable
for soft, nontender abdomen; there were no signs of infection or
inflammation around the HD catheter site. Labs were notable for
normal WBC count with 90% PMNs and no bandemia. CXR showed no
infiltrate. Blood cultures were collected and pt was
subseuqently given 1 gram vancomycin, 1L normal saline and 650
mg acetaminophen. Transplant surgery was consulted but felt
there was not acute surgical issue. Prior to transfer, VS were:
100.1,116,18,109/51,100% RA.
Currently, he feels well, and denies longer nausea, abdominal
pain, or diarrhea. He has not felt febrile since the ED. Denies
headache, arthralgias, rash, visual changes, sore throat, cough,
dyspnea, palpitations, or chest pain.
Past Medical History:
- IgA nephropathy, status post biopsy of kidney at ___ and
___. Started hemodialysis 2 weeks prior to
this admission.
- Hypertension.
- Obesity
Social History:
___
Family History:
Father with end-stage renal disease of unclear etiology (?
hypertensive) s/p kidney transplant in ___ at ___. His father
was on dialysis prior to transplantation.
Mother has no active health issues. He has three sisters, who
are all in
good health. No history of malignancy in the family or family
history of IgA nephropathy.
Physical Exam:
Admission exam:
VS - Temp 100.2F, BP 123/78, HR 110, R 18, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MM dry, OP clear
NECK - Supple, no JVD or LAD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG. R chest HD
catheter site without surrounding erythema, fluctuance,
purulence, or drainage.
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no CVA
tenderness
EXTREMITIES - warm well perfused, no c/c/e, symmetric 2+
peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, muscle strength ___ throughout, sensation
grossly intact throughout, cerebellar exam intact, gait
assessment deferred
Discharge exam:
VS: Afebrile, VSS
New tunnel catheter without erythema, bleeding or drainage
rest of exam unchanged from admission
Pertinent Results:
Admission labs:
___ 07:43PM BLOOD WBC-8.6 RBC-3.84*# Hgb-11.9*# Hct-35.0*#
MCV-91 MCH-31.1# MCHC-34.1 RDW-17.1* Plt ___
___ 07:43PM BLOOD Neuts-90.2* Lymphs-5.9* Monos-3.2 Eos-0.1
Baso-0.5
___ 07:45PM BLOOD Glucose-98 UreaN-68* Creat-13.9*# Na-136
K-4.6 Cl-98 HCO3-20* AnGap-23*
___ 07:45PM BLOOD ALT-34 AST-17 AlkPhos-58 TotBili-0.4
___ 07:45PM BLOOD Lipase-26
___ 07:45PM BLOOD Albumin-3.8 Calcium-9.4 Phos-2.6* Mg-2.3
___ 07:19PM BLOOD Lactate-1.9
Vanc levels (dialysis dosed):
___ 12:17PM BLOOD Vanco-22.9*
___ 06:41AM BLOOD Vanco-19.7
___ 07:00AM BLOOD Vanco-26.9*
Discharge labs:
___ 07:50AM BLOOD WBC-6.0 RBC-3.43* Hgb-10.7* Hct-31.3*
MCV-91 MCH-31.3 MCHC-34.2 RDW-16.5* Plt ___
___ 07:50AM BLOOD Glucose-89 UreaN-57* Creat-15.0*# Na-138
K-3.8 Cl-93* HCO3-27 AnGap-22*
___ 10:42AM BLOOD Calcium-9.6 Phos-6.4* Mg-2.7*
Microbiology:
___ 7:40 pm BLOOD CULTURE
3 of 4 bottle positive for
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 6:08 pm CATHETER TIP-IV
Source: HD tunnel line.
*FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. <15 colonies.
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood cultures from ___ and ___ with no growth at time of
discharge on ___
Imaging:
ECG ___:
Sinus tachycardia. Compared to the previous tracing of ___
the rate has increased. Otherwise, no diagnostic interim change.
CXR ___:
FINDINGS: Frontal and lateral views of the chest were obtained.
A large-bore dual-lumen right-sided central venous catheter is
seen, distal tip is not well seen, but likely terminating in the
mid-to-distal SVC. Lungs are clear without focal consolidation.
No pleural effusion or pneumothorax is seen. Cardiac and
mediastinal silhouettes are stable and unremarkable.
IMPRESSION: No acute cardiopulmonary process.
ECHO (TTE) ___:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF=55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. No mitral regurgitation is seen. No masses
or vegetations are seen on the tricuspid valve, but cannot be
fully excluded due to suboptimal image quality. The pulmonary
artery systolic pressure could not be determined. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Normal global biventricular function. Aortic valve
and mitral valve well seen without apparent vegetations.
Tricuspid valve and pulmonic valve imaging suboptimal, but no
large vegetation or pathologic regurgitant flow identified. If
clinically indicated, a TEE may better assess for valvular
vegetations given suboptimal image quality.
___ HD tunnel line placement ___:
IMPRESSION:
Placement of a 15.5 ___, 19 cm tip-to-cuff tunneled
hemodialysis line via the right internal jugular vein with tip
in the right atrium. The line is ready for use.
Brief Hospital Course:
___ y/o M with ESRD ___ IgA nephropathy, admitted for fever,
nausea, vomiting, diarrhea, found to have MSSA bacteremia,
likely related to tunneled HD line. He was treated with
antibiotics. HD line was removed and replaced by ___ once
afebrile with negative surveillance cultures.
# MSSA Bacteremia: Patient with high fevers to 103. Although he
presented with N/V/D and no signs of skin/soft tissue infection
at HD line site, given his history of prior episodes of MSSA
bacteremia, he was started on Vancomycin in the ED. Blood
cultures drawn from the ED on ___ showed 3 of 4 bottles with GPC
after <24 hours. He was continued on Vancomycin until
sensitivities showed MSSA. At that point, antibiotics were
changed to Nafcillin for bactericidal activity. At the time of
discharge, antibiotics switched to cefazolin to be administered
after HD sessions for ease as outpatient. TTE showed no
valvular vegetation or regurgitation to suggest endocarditis.
Patient reluctant to undergo TEE again. In consultation with
patient's outpatient nephrologist, Dr. ___ was felt that
given transient bacteremia that was rapidly cleared after
initiation of antibiotics, and no history of endocarditis,
patient can safely go home with a 14-day course of cefazolin
with repeat blood cultures. Patient's HD line was removed after
HD session on ___. HD line tip also grew MSSA. Patient
defervesced on ___ AM. Surveillance blood cultures from ___
had no growth by the day of discharge.
# Nausea/vomiting/diarrhea: Patient had <24 hours of N/V/D on
the day of presentation. Symptoms resolved by the time he
reached the ED. Abdominal exam was benign. Although this could
have been a viral gastroenteritis, it is more likely a reaction
to his bacteremia. Patient given 1L NS in the ED, then placed
on fluid restriction as he missed one HD session in the
hospital. He was given BRAT diet for one meal, then advanced to
regular, low-phos, low-Na, low-K diet. Diet resume to regular
once he resumed HD.
# ESRD: Home HD schedule ___. Patient received HD on ___
prior to positive cultures were known. HD line was removed
after HD session on ___. He missed ___ HD session. HD line
replaced on ___ morning, and he received HD on ___.
Plan to resume outpatient schedule on ___. Patient continues
to resist the idea of permanent fistula. Left arm veins
preserved (no IVs or blood draws) during this hospitalization.
Plan to follow up with nephrology and transplant surgery.
# Hypertension: Patient not on anti-hypertensives as outpatient.
Blood pressure normal throughout hospitalization.
# Tachycardia: Sinus tachycardia to 110-120s on presentation
secondary to fever and relative volume depletion. HR decreased
to 80-90s after fevers resolved.
# Anemia: Likely ___ CKD. Patient receives Epo with HD. Hct of
35 on admission is above baseline, likely hemoconcentrated. Hct
dropped to 31.4 the next morning after fluids. Hct otherwise
stable during this hospitalization and did not require
transfusions.
# Patient was full code throughout this hospitalization
# Transitional issues:
- Code status: full code
- Re-initiate outpatient HD on ___
- Cefazolin administered at outpatient HD ___ at least 14
days, pending repeat blood cultures
- Follow up final results of blood cultures from ___
- Follow up with PCP- Dr. ___ on ___
- Follow up with ___ in ___ to discuss fistula or
other permanent access
Medications on Admission:
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - 1
Capsule(s) by mouth daily
POLYETHYLENE GLYCOL 3350 - 17 gram Powder in Packet - 17g by
mouth once a day as needed for constipation please only take if
constipated for several days
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 3 Tablet(s) by
mouth three times a day with meals
DOCUSATE SODIUM [COLACE] - 50 mg Capsule - one Capsule(s) by
mouth daily
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Colace 50 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation: stop for diarrhea.
4. Miralax 17 gram Powder in Packet Sig: One (1) PO as needed
for constipated for several days.
5. clotrimazole 1 % Cream Sig: One (1) application Topical twice
a day as needed for rash.
6. cefazolin 1 gram Recon Soln Sig: ___ gram Intravenous
___ for 14 days: 2 g on ___,
2 g on ___,
3 g on ___,
all at dialysis.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Methicillin-sensitive Staphylococcus aureus bacteremia, line
associated
SECONDARY:
IgA Nephropathy
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 participating in your care at ___
___. You were admitted for fevers, chills,
nausea, vomiting, and diarrhea. We found that you had a
bloodstream bacterial infection, likely related to your
hemodialysis line. We pulled your hemodialysis line and treated
you with antibiotics. We replaced the hemodialysis line and
resumed dialysis. You will need antibiotics for at least 14
days.
You will need to set up a dermatology appointment for your skin
changes that has not been responsive to medicated cream.
We made the following changes to your medications:
STARTED cefazolin IV, 2 g on ___, 2 g on ___, and 3 g
on ___. This will be given on your days of dialysis.
Followup Instructions:
___
|
10506111-DS-11 | 10,506,111 | 22,715,601 | DS | 11 | 2153-01-11 00:00:00 | 2153-01-14 16:23:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / tenofovir
Attending: ___.
Chief Complaint:
Left facial droop, left arm heaviness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old RH man with a history of well
controlled HIV on HAART ___ CD4 949, VL ND), obesity, OSA (off
CPAP), HTN, HLD, smoking, occ MJ and cocaine use, p/w suttering
L
facial droop and L arm heaviness, and found to have multiple R
sided subacute strokes on an outpatient MRI who was sent into
the
ED for further work up and evaluation.
The patient was in his usual state of health until ___ weeks
ago,
when he was having dinner with the friend when he noted sudden
onset "numbness" in his L face. He had no sensory decrement, but
his face felt "like novicaine." His friend noted that his face
looked droppy at the time like he might have Bells Palsy. The
patietn also said he was speaking with a lisp at that time. The
patient finished his dinner and went home, and within 30 minutes
this had completely resolved. There were no associated symptoms
in his arms or legs, no headache or visual changes. The patient
was well again until this past ___ (1 week ago) when he had
the same symptoms again while he was at work, again, this
resolved spontaneously within an hour. The facial droop returned
again on ___ night when the patient was at a comedy show,
and he noted that the funny feeling in his face and the lisp
seemed to be present on and of throughout the evening. He also
noted a general feeling of being not quite himself that evening.
On ___ morning, the patient continued to have the on and off
facial sensation, and also noted that his L arm felt heavy. He
thought he might have pinched a nerve because had some L sided
neck spasm on the at day and when he massaged those muscles his
arm felt better. On ___ he went to work and was having more
difficulty doing things with his L arm, for example he was
having
difficulty picking up a paper clip, and he dropped his phone
several times out of his left hand. Throughout this week both
the
facial symptoms and the arm symptoms have been occuring on and
off.
He went to see his doctor on ___ who felt he may have a Bells
palsy, but ordered an MRI brain to rule out stroke. He was
started on a steroid burst to treat presumed Bells Palsy. MRI
was
done on ___, and showed multiple R sided
temporo-parietal-occipital subacute strokes in a ?watershed type
distribution. The patient was instructed to go to the ED based
on
this finding.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech,
although he has been speaking with a "lisp".
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation
Past Medical History:
- HIV on HAART ___ CD4 949, VL ND)
- Fanconis
- obesity
- OSA on CPAP (recently CPAP machine broke and he has not been
able to get it fixed)
- smoking
- HTN
- HLD
Social History:
___
Family History:
Father - heart valve problem, no history of strokes
Physical Exam:
Physical Examination:
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival injection or scleral icterus, MMM
Neck: Supple, FROM
Pulmonary: Non-labored
Abdomen: Obese, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert. Attention to examiner easily attained and
maintained. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences and intact verbal
comprehension. Content of speech demonstrates mild dysarthria
and no paraphasias. Normal prosody.
- Cranial Nerves -
I. Not tested
II. Equal and reactive pupils (3mm to 2mm) and post surgical.
III, IV, VI. Smooth and full extraocular movements without
diplopia or nystagmus.
V. Facial sensation intact.
VII. L UMN facial droop.
VIII. Hearing was intact to finger rub bilaterally.
IX, X. Symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. Mild L arm pronation without
drift. No tremor or asterixis.
Delt Bic Tri ECR FExt Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch, temperature, and proprioception
throughout. Mildly decreased vibration sense in the toes.
- DTRs -
Bic Tri ___ Quad Gastroc
L 1 1 1 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Decreased
RAM on the L hand.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing. Stable without sway.
Pertinent Results:
___ 07:25PM ___ PTT-60.0* ___
___ 01:20PM PTT-54.8*
___ 05:40AM GLUCOSE-87 UREA N-16 CREAT-1.0 SODIUM-143
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
___ 05:40AM CK(CPK)-136
___ 05:40AM CK-MB-3 cTropnT-<0.01
___ 05:40AM CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-2.1
CHOLEST-173
___ 05:40AM %HbA1c-5.9 eAG-123
___ 05:40AM TRIGLYCER-176* HDL CHOL-45 CHOL/HDL-3.8
LDL(CALC)-93
___ 05:40AM TSH-2.3
___ 05:40AM WBC-12.8* RBC-4.68 HGB-15.0 HCT-43.6 MCV-93
MCH-32.0 MCHC-34.3 RDW-13.4
___ 05:40AM PLT COUNT-264
___ 05:40AM ___ PTT-33.6 ___
___ 04:57AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:57AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:57AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:30PM GLUCOSE-110* UREA N-18 CREAT-1.0 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
___ 10:30PM ALT(SGPT)-25 AST(SGOT)-20 ALK PHOS-75 TOT
BILI-0.3
___ 10:30PM cTropnT-<0.01
___ 10:30PM ALBUMIN-4.6 CALCIUM-9.0 PHOSPHATE-3.4
MAGNESIUM-2.0
___ 10:30PM WBC-12.6* RBC-4.99 HGB-16.1 HCT-46.7 MCV-94
MCH-32.4* MCHC-34.5 RDW-13.4
___ 10:30PM NEUTS-79.3* LYMPHS-15.9* MONOS-4.2 EOS-0.1
BASOS-0.5
___ 10:30PM PLT COUNT-267
MRI:
IMPRESSION:
1. Multiple punctate and round foci of slow diffusion with
associated FLAIR hyperintensity and one punctate focus of
apparent enhancement within the right hemisphere (predominantly
in the right parietal lobe). No significant mass effect. The
findings are most consistent with multiple embolic infarcts,
although the distribution of some of these foci is also
consistent with watershed distribution.
2. No other evidence of abnormal enhancement. There is no
midline shift. The or hydrocephalus.
3. Near complete opacification of right maxillary sinus, as seen
previously in ___, with a markedly hypointense central signal
on GRE. Findings again raise concern for fungal colonization/
inspissated secretions within an obstructed right maxillary
sinus.
CT/A Head and Neck:
IMPRESSION:
Noncontrast head CT demonstrates subtle hypodensities within the
right
cerebral hemisphere in the watershed territory corresponding to
the foci of slow diffusion on recent MRI. There is no
hemorrhage.
Head CTA demonstrates extensive soft and calcified plaque
involving the right MCA with focal high-grade stenosis of the M1
segment. There is no aneurysm.
Unremarkable Neck CTA without evidence of significant stenosis.
There is near complete opacification of the right maxillary
sinus with
associated or thickening. There is also widening of the
accessory ostium. On MRI there inspissated secretions within
the area. This could be secondary to fungal infection. Clinical
correlation recommended.
Brief Hospital Course:
Mr ___ was admitted to the Stroke Service at ___
___ after presenting with an intermittent L facial
droop and L arm heaviness and being found to have multiple
R-sided subacute strokes on an outpatient MRI. CTA was notable
for extensive soft and calcified plaque involving the right MCA
with focal high-grade stenosis of the M1 segment that was felt
to be the etiology of his infarcts. He was started on heparin
and then transitioned to Lovenox and Coumadin prior to
discharge. He will have a TTE as an outpatient. He was also
started on a nicotine patch. He was stable throughout his
admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 60 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Labetalol 300 mg PO BID
6. Lisinopril 30 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
8. abacavir-lamivudine 600-300 mg oral daily
9. Efavirenz 600 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Efavirenz 600 mg PO DAILY
3. Labetalol 300 mg PO BID
4. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
5. Potassium Chloride 20 mEq PO DAILY
6. Lisinopril 30 mg PO DAILY
7. Amlodipine 10 mg PO DAILY
8. abacavir-lamivudine 600-300 mg oral daily
9. Enoxaparin Sodium 100 mg SC TWICE DAILY
Start: ___, First Dose: Next Routine Administration Time
please take this medication through injections until told to
stop by your physician.
RX *enoxaparin 100 mg/mL 1 syringe inj twice per day Disp #*30
Syringe Refills:*0
10. Nicotine Patch 21 mg TD DAILY
RX *nicotine [Nicoderm CQ] 21 mg/24 hour 1 patch Disp #*30 Patch
Refills:*3
11. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
cerebral embolism with infarction
intracranial right MCA stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ because of
strokes found on an MRI you had done as an outpatient.
You were found to have a narrowed vessel in your brain that is
the likely cause of these strokes. Because you are at high risk
for further strokes, we started you on a medication to thin your
blood called Coumadin (aka warfarin). You should continue taking
this medication once your leave the hospital. This medication
takes several days to take effect. During that time you will
need to take another blood thinner in addition to the Coumadin
called Lovenox. You will need to inject Lovenox twice per day.
It is VERY important that you follow up with the ___ clinic
once you leave the hospital.
You should be contacted by the ___ clinic on ___.
If you do not hear from them on ___, please call ___
for further instruction. They will draw your blood and monitor
the level of coumadin until it reaches the correct range. They
will instruct you on further changes to your coumadin or
lovenox. Please do not stop these medications or change the dose
without consulting a physician as they could lead to excessive
bleeding or further strokes. This medication might be stopped in
several months by Dr. ___.
You will have an ultrasound of your heart (echocardiogram), that
is scheduled as an outpatient. You should call ___ on
___ to schedule this appointment.
You will follow up with Dr. ___ in clinic, the date/time is
listed below. You will also have other follow up appointments
with cardiology and infectious disease.
It is important that to minimize further strokes, that you stop
smoking cigarettes and/or using stimulant drugs such as cocaine.
Followup Instructions:
___
|
10506600-DS-16 | 10,506,600 | 27,217,281 | DS | 16 | 2184-09-24 00:00:00 | 2184-09-24 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Hyoscyamine
Attending: ___.
Chief Complaint:
fall, left sided weakness, left facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with history of afib (not on
coumadin due to fall risk and difficulty with INR f/u
previously)
and recent occipital stroke who was brought into the hospital
for
slurred speech and facial weakness.
In ___, she presented with "worsened gait imbalance,"
"dizziness" and found to have L homonymous hemianopsia. She was
also found to have mild quadriparesis.
Per DC summary, "Her CT/CTA head and neck CT ___ showed a
large infarct in the right occipital region. ASA 325 was
continued. She was started on Atorvastatin for LDL of 82. After
review of her prior records and discussion with her PCP (high
falls risk, reluctance to do regular INR checks in the past when
on warfarin) a decision was made not to start her on
anticoagulation for her atrial fibrillation. She will follow
up with Stroke Neurology as outpatient." She was discharged to
rehab. She has been back in assisted living since ___ and has
been stable.
Her daughter reports that she last saw the patient about 10 days
ago at a family barbeque, but has been in touch with her and
there was nothing new that was concerning. The daughter received
a call this morning from the nurse saying that the patient fell
in the bathroom and was seen by EMS, but not taken to ED the
first time. Later on, she came to see her mother and noticed
that
her face seemed asymmetric with drool/food coming out of her
mouth and speech was slow/slurred so she was brought to ED.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. +Walks with a walker at baseline.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough. 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:
- Dementia.
- Bowel and bladder incontinence.
- Atrial fibrillation on aspirin.
- Hypertension.
- Hyperlipidemia.
- Tricuspid regurgitation.
- Gait instability/Falls.
- R occipital embolic stroke ___
- Recurrent urinary tract infections.
- Osteoarthritis.
- anxiety
Social History:
___
Family History:
Positive for diabetes and hypertension in
the patient's mother. Her daughter has a kidney transplant
Physical Exam:
ADMISSION EXAM:
Vitals: 97.7 93 184/91 --> 167/86 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: irregularly irregular, mild systolic murmur
Abdomen: soft, nontender, nondistended
Extremities: no edema, warm to touch
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, awake. Does not believe there is much
different with her. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Speech is mild dysarthria, more gutteral than labial/lingual.
Able to follow both midline and appendicular commands. There was
no evidence of left-right confusion as the patient was able to
accurately follow the instruction to touch left ear with right
hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. L hemianopsia (old).
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: L NLF, slightly decreased activation of L. Air escapes with
cheek puffing.
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. Exam limited by effort and patient with diffuse
weakness (4 to 4+ throughout), but possible asymmetry in L
tricep
> R tricep.
-Sensory: No deficits to light touch or vibratory sense.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 0
L 2+ 2+ 2+ 2+ 0
Brisk withdrawal with plantar stimulation bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: deferred (no walker available).
DISCHARGE EXAM
Pertinent Results:
___ 09:20AM BLOOD WBC-9.6 RBC-4.75 Hgb-14.8 Hct-45.9 MCV-97
MCH-31.2 MCHC-32.3 RDW-12.6 Plt ___
___ 04:30AM BLOOD ___ PTT-24.9* ___
___ 04:30AM BLOOD Glucose-95 UreaN-20 Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-23 AnGap-16
___ 05:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:30AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
___ 09:20AM BLOOD %HbA1c-5.9 eAG-123
___ 10:50AM BLOOD TSH-2.7
___ CT HEAD w/o CONTRAST
1. 3.1 x 2.6 cm hypodensity in the right frontal lobe consistent
with subacute infarction, new from the prior exam on ___. No evidence of acute intracranial hemorrhage. MRI is more
sensitive for detection of acute infarction.
2. Chronic bilateral occipital lobe infarcts.
___ CT HEAD w/o CONTRAST
The infarcted areas in the right frontal lobe and bilateral
occipital lobe are stable since ___.
___ CXR
No acute cardiopulmonary abnormality.
___ TTE
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild aortic
regurgitation. Borderline pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ woman with history of Afib (not on coumadin due to fall risk
and difficulty with INR f/u previously) and recent occipital
stroke (___) who was brought into the hospital for slurred
speech and L facial weakness. Pt was evaluated by Speech and
swallow and cleared for a modified consistency diet. ___ shows
(sub)acute R frontal infarct in addition to chronic bilateral
occipital lobe infarcts. A repeat head CT on the day following
admission unchanged (subacte R frontal lobe infarct). Pt was
continued on her home full dose aspirin and rivaroxaban was
added as her stroke was felt to be embolic in etiology (based on
primarily cortical location).
Her blood pressure was allowed to autoregulate during
hospitalization (home lisinopril held, verapamil given at half
dose). All home BP meds were restarted at full dose upon
discharge. Telemetry monitoring was initiated during
hospitalization which showed that the patient was predominately
in Afib. TTE was performed which showed mild symmetric LVH w
preserved EF function. Mild AR.
Pt was also found to have a new leukocytosis on admission that
persisted for 48hrs. Pt was without symptoms. There was some
concern for UTI initially and ceftriaxone was started on
admission (___). Ucx grew skin flora and leukocytosis resolved
- ceftriaxone was discontinued on the day of discharge. CXR was
unconcerning
Pt also had mild ___ on admission which quickly resolved with
IVF.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
39) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? () Yes - (x) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - (rivaroxaban), () No [if no,
reason not discharge on anticoagulation: high fall risk;
previously noted troubles maintaining therapeutic range INR;
discharged on full ASA + rivaroxaban] - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Verapamil SR 240 mg PO Q24H
4. Acetaminophen 325 mg PO Q6H:PRN pain
5. Aspirin 325 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Milk of Magnesia 30 mL PO Q12H:PRN constipation
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Milk of Magnesia 30 mL PO Q12H:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Verapamil SR 240 mg PO Q24H
8. Lisinopril 10 mg PO DAILY
9. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary: acute ischemic infarct
Secondary: atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition in which a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- atrial fibrillation
We are changing your medications as follows:
- adding a new anticoagulant, rivaroxaban
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10506842-DS-23 | 10,506,842 | 28,694,998 | DS | 23 | 2132-09-19 00:00:00 | 2132-09-20 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with RCC metastatic to bone and recent
admission for hypercalcemia who presents from rehab with
confusion and hypercalcemia.
Per rehab notes, he was noted to be increasingly confused and
paranoid over the last two days. Calcium was checked and was
12.2. He was started on IVF and sent to the ED. In the ED,
initial vitals were 97.7 88 111/68 16 95%RA. EKG showed normal
sinus rhythm with prolonged PR. CT head showed no acute
process. CXR showed mild bibasilar atelectasis. Labs notable
for Ca ___ (free calcium 1.70).
Notably, he was recently admitted ___ to ___ with altered
mental status and hypercalcemia. Underwent MR head which showed
no evidence of intracranial metastasis, infarct or hemorrhage
but did show chronic microvascular ischemic disease. He was
treated with IV fluids, lasix, and pamidronate and his calcium
improved. His altered mental status improved with treatment of
his hypercalcemia and he was reportedly oriented x 3 at the time
of discharge. Also continues on Augmentin for UTI diagnosed on
last admission.
Review of Systems:
(+) Per HPI
(-) Unreliable historian currrently but denies fever, chills,
headache, chest pain or tightness, palpitations, lower extremity
edema. Denies cough, shortness of breath, or wheezes. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria. All other
systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
- presented with right flank pain and hematuria and was admitted
to the hospital with concern for AAA (given his hx of this). MRI
on ___ revealed a 7cm mass of the right kidney with
extension
into the renal sinus and tumor thrombus extending to the
infrahepatic IVC. There was retroperitoneal lymphadenopathy
with
the largest node at the iliac bifurcation measuring 1.7 cm.
Noncontrast (bc of allergy) chest CT on ___ was negative.
- ___: Dr. ___ right radical nephrectomy, regional
lymph node dissection, and removal of tumor thrombus from the
vena cava (with Dr. ___. Pathology revealed 7.2 cm clear
cell renal cell carcinoma with focal sarcomatoid growth (5%),
___ grade ___, as well as an abutting papillary renal cell
carcinoma, 0.7 cm, ___ grade ___. The clear cell renal cell
carcinoma extended into the renal vein as well as the
pelvicalyceal system. The renal vein margin was positive (tumor
adherent to the wall of the renal vein). Lymphovascular invasion
was present. 4 lymph nodes were negative. Pathologic stage at
diagnosis was stage III (pT3b, pN0, cM0).
- ___: Exploratory laparotomy and removal of retained
sponge
- ___: MRI abdomen with numerous new liver lesions.
- ___: CT chest with numerous new pulmonary lesions.
- ___: ultrasound-guided liver biopsy confirmed metastatic
RCC
- ___: started Sutent 37.5 mg daily (4 weeks on, 2 weeks
off)
- ___: CT chest with near resolution of pulmonary nodules
and
increased size of mediastinal lymph nodes. MRI abdomen with
interval decrease in multiple liver lesions, with increasing
areas of necrosis.
- ___: CT chest stable. MRI abdomen fairly stable except for
new left portal vein thrombus with contrast enhancement
consistent with tumor thrombus. Warfarin initiated.
- ___: Sutent increased to 50 mg.
- ___: Restaging MRI of the abdomen stable and showed
persistent partially occlusive portal vein thrombosis without
apparent tumor involvement and CT of the chest was without
evidence of malignancy.
- continued to have stable disease as seen on ~q3month repeat
imaging
- ___ MRI L-spine done bc pt complaining of back pain and
bilat leg pain and it showed a heterogenous lesion in L1 which
may represent atypical hemangioma, however metastatic focus
cannot be completely excluded. also, there were multilevel
degenerative changes incl left > right neural foramen narrowing
at L3-L4 with possible contact of the left L3 nerve root.
- ___ noted to have significant pain in L hip, Xray showed
lytic and destructive lesion involving the left superior pubic
ramus, inferior pubic ramus and medial acetabulum likely
reflecting metastasis.
- ___, pt started XRT to left hip lesion. he completed 3
treatments. was unable to receive the last 2 bc of uncontrolled
ain.
- ___ resumed Sutent which had been hold since
hospitalization
- ___ CT showing stable metastases
- ___ advised to put Sutent on hold, given ulcer/infection on
leg
OTHER PAST MEDICAL HISTORY:
Hypertension
Diabetes
Left Adrenal adenoma
Abdominal aortic aneurysm
Left common iliac artery aneurysm
Coronary artery disease - last stress test ___.
Active Smoker
Social History:
___
Family History:
Per OMR, history of "genetic syndrome of kidney cancer" in a
cousin -states whole family had kidney cancer. This was tested
many years ago, and per pt's report he was found not to have
this mutation. Has 5 brothers, 1 sister. 1 Brother died of
leukemia, pt was a bone marrow donor.
Physical Exam:
ADMISSION:
Vitals: 98.1 118/64 86 18 96%RA
GENERAL: Awake and alert but unable to engage in conversation,
oriented x 0
HEENT: NCAT, pupils small but reactive and equal, EOM appear
intact, anicteric sclera, MM very dry
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: Apperas to be moving all extremities, no cyanosis,
clubbing or edema, no obvious deformities
SKIN: Pressure ulcers noted on left lateral calf, also on left
flank
DISCHARGE:
Vitals: afebrile 97.4 132/74 HR 67 100% on RA
GENERAL: unchanged; still confused about situation, NAD
HEENT: clear oropharynx
CARDIAC: NR, RR, no murmur
LUNG: few ronchi throughout
ABDOMEN: NT, ND, soft
EXTREMITIES: no edema
SKIN: 3 Pressure ~3cm nonpurulent ulcers noted on dorsal aspect
of left calf, 2cm ulcer on right
NEURO: alert, oriented aside from to situation; moving all
extremities
Pertinent Results:
___ 07:24PM WBC-4.7 RBC-2.82* HGB-7.2* HCT-23.8* MCV-85
MCH-25.7* MCHC-30.4* RDW-16.7*
___ 07:24PM NEUTS-75* BANDS-0 LYMPHS-15* MONOS-9 EOS-1
BASOS-0 ___ MYELOS-0
___ 07:24PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
___ 07:24PM PLT SMR-NORMAL PLT COUNT-347
___ 07:24PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:24PM ALBUMIN-3.2* CALCIUM-12.6* PHOSPHATE-2.6*
MAGNESIUM-2.4
___ 07:24PM ALT(SGPT)-10 AST(SGOT)-12 LD(LDH)-115 ALK
PHOS-78 TOT BILI-0.4
___ 07:24PM GLUCOSE-97 UREA N-33* CREAT-1.1 SODIUM-134
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-14
___ 07:57PM LACTATE-1.3
___ 07:57PM ___ PO2-45* PCO2-38 PH-7.40 TOTAL CO2-24
BASE XS-0
EKG: Normal sinus rhythm with q waves in III, avF, V1-V2, ___
degree AV delay, ST elevation in V1-V3 c/w prior, mild ST
elevation inIII appears new
IMAGING:
CT Torso without Contrast ___: IMPRESSION:
1. Status post right nephrectomy without evidence of local
recurrence.
2. Extensive pulmonary nodules, presumably metastases.
3. Stable left adrenal mass, likely a metastatic lesion.
4. Progression of left pelvic bony metastasis with destruction
of the
acetabulum, left femoral head protrusio, and with mass effect on
the bladder, rectum and left ureter.
5. Cholelithiasis.
6. Left perinephric inflammation may reflect urinary stasis;
correlate with UA.
7. Stable L3 lytic lesion, likely metastatic.
CXR ___: Mild bibasilar atelectasis.
CT head ___: No acute process.
Brief Hospital Course:
___ year old male with RCC metastatic to bone and recent
admission for hypercalcemia who presents from rehab with
confusion and hypercalcemia due to worsening metastatic disease.
# Hypercalcemia: Due to his malignancy with metastatic disease
to bones, now can be seen on latest imaging of torso. PTH
appropriately suppressed. Altered mental status and being very
dry on admission is likely due to hypercalcemia. Last admission
pamidronate 60mg IV x1 given on ___. Endocrine consulted on
admission. TSH/T4 & cortisol normal and checked since possible
pituitary met per Endocrine. Administered Pamidronate 90mg IV x1
___. Vit D deficient, but will hold Vit D since ___ worsen
HyperCa++. Vit D 1,25: elevated: Endocrine would like to hold
off on steroids at this time. MIVF was given intermittent IV
lasix 40mg daily. Given Pamidronate 90mg IV x1 on ___.
-Please check Calcium twice weekly; hold weekly Pamidronate if
Ca<10
-Next Pamidronate dose is ___
-If serum calcium is no longer responding to Pamidronate 90mg IV
weekly, please d/c Pamidronate which was discussed with his
Proxy
-Give 1L NS over 4 hours, once daily
# Toxic Metabolic encephalopathy: Oriented only to self and
sometimes place. Most likely due to hypercalcemia given history
and lab findings. No signs of infection as afebrile and CXR
clear. Labs otherwise unremarkable. No signs of seizure. Head
CT w/o acute process, recent MRI w/o mets. U/A neg. Treat
hypercalcemia as above.
# Metastatic RCC: With bone mets, now with disease progression.
Previously on Sutent which is on hold due to pressure ulcers on
legs. Patient cared for by Dr. ___ Dr. ___ with
___ at ___. CT torso ___ showed diffuse progression of
disease with new pulmonary metastases and further growth of
large left hip mass. Touched base with Dr. ___
Fellow. Pt's ___ primary team decided with pt and brother on
___ to not pursure further chemo. Palliative care consulted.
# Anemia: Normocytic anemia, guaiac negative on prior admission.
Stable since recent discharge, but baseline of ~30. No evidence
of hemolysis. Recent ferritin 1000+ and B12 of 178. Retic count
inappropriately low at 2.2%. Transfused 1 unit RBCs on ___.
Transfused 1 unit on ___. Continued oral B12.
# Diabetes mellitus: No recent HgbA1c on record. Held Glipizide,
and given Humalog on SS.
# Atrial Fibrillation: CHADS2 score of 2 if has not had CVA or
TIA. Continued Metoprolol at home dosing. On ___
discontinued coumadin due to poor prognosis and risk of bleed.
# Recent Troponinemia: Troponin level checked on admission due
to 1mm STE seen on lead III of admission EKG. CKMB was negative.
Troponin was trending down on day of admission which could have
meant prior demand ischemia in setting of hematocrit of 22.
Deferred cardiac cath at this time given downtrending trop and
poor overall prognosis.
# CAD: Continued home Metoprolol, Lisinopril, ASA 81mg daily.
Started Atorva 80mg daily.
# Hypertension, benign: Stable. Continued home Lisinopril.
# Lower Ext Ulcers: Reportedly pressure ulcers according to
prior notes. Wound care consult recs.
# Recent UTI: Resolved - was On course of Augmentin for Proteus
UTI. last day = ___.
-DVT ppx with Hep sc
-CODE: DNR/DNI: discussed with HCP on ___
EMERGENCY CONTACT: HCP is brother ___ ___ cell
___
### TRANSITIONAL ISSUES ###
-Please check Calcium twice weekly; hold weekly Pamidronate if
Ca<10
-Next Pamidronate dose is ___
-If serum calcium is no longer responding to Pamidronate 90mg IV
weekly, please d/c Pamidronate which was discussed with his
Proxy
-Give 1L NS over 4 hours, once daily
-Please consider increasing opiate regimen as pain increases
with worsening metastatic cancer
-DNR/DNI: would like to avoid any further rehospitalization
given poor prognosis and lack of further treatment options
-Please initiate Hospice care once condition deteriorates and
discuss with family; this has been discussed with Brother
(proxy) in some detail
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
Hold for loose stools
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
Hold for HR<55, SBP<100
7. Omeprazole 20 mg PO DAILY
8. Oxycodone SR (OxyconTIN) 20 mg PO BID
At 8am, 4pm. Hold for sedation, RR<12
9. Senna 2 TAB PO BID
Hold for loose stools
10. Warfarin 6.5 mg PO DAILY16
11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last day ___
12. GlipiZIDE XL 2.5 mg PO DAILY
13. Oxycodone SR (OxyconTIN) 30 mg PO HS
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
8. Atorvastatin 80 mg PO DAILY
9. Heparin 5000 UNIT SC TID
10. Neutra-Phos 2 PKT PO TID
11. Ondansetron 8 mg IV Q8H:PRN Nausea
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*100 Tablet Refills:*0
13. Furosemide 40 mg PO DAILY
14. GlipiZIDE XL 2.5 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 2 TAB PO BID
17. Pamidronate 90 mg IV 1X/WEEK (TH) Duration: 1 Doses
please give 1st dose ___
18. Acetaminophen 1000 mg PO Q8H
19. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 12
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypercalcemia
Metastatic Renal Cell Carcinoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with calcium that was high. This
likely caused you to be confused as well. We have given you
medicine and IV fluids to get your calcium back towards normal
range. We have also done a CT scan which showed that your tumor
has progressed. We had you met with our palliative care team who
have spoken to you alongside your primary oncology team, and per
discussion, you will no longer be getting treatment for your
cancer. We are transferring you to a facility where your
calcium, as well as other tests will be monitored.
Followup Instructions:
___
|
10506944-DS-12 | 10,506,944 | 21,261,205 | DS | 12 | 2154-09-30 00:00:00 | 2154-09-30 18:15:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Seconal Sodium / Erythromycin Base / Doxycycline /
Latex / Adhesive Tape / Peanut / Tomato / raw fruit
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo with h/o male with a history HTN, HLD, CAD (sp DES to RCA
in ___, has known diffuse LAD 60%, OM1 70% from ___ cath) who
presents with chest pain that started yesterday.
Pt states that CP started at rest after breakfast. Upper chest
in a band-like distribution, radiating to jaw. Concomitant with
mild SOB. Pain is differenr from prior MI, but it is difficult
for her to compare the pain to her prior shingles episode which
occured on her mid to right chest. Pain is non-positional. not
associated w/ food. takes ASA 81 daily. R>L leg swelling. Denies
fever, chills, URI symptoms. 1 week ago had nausea, emesis,
intense fatigue, now resolved. Had flu shot this season.
.
She was seen by her cardiologist Dr ___ this month
for exertional chest pain and jaw pain felt to be stable angina.
A stress echo in ___ was positive for symptoms and ECG
changes without echo evidence of ischemia. He felt that her
symptoms were due to stable angina, and medical management was
reasonable as long as her symptoms remained stable.
In ED initial VS were T: 97.8 BP 164/51 89 18 97%
CBC shows HCT 34.5(baseline 35). Cr 1.2 (baseline 1.0). D-dimer
700s. Trop neg x1. INR 0.8. A CT chest was negative for PE or
aortic pathology. ___ was negative for DVT. CXR was
negative.
EKG: sinus, HR 70, nl axis, q in V2 and V3. Unchanged compared
to prior.She was given asa 325mg and morphine IV and admitted to
medicine for further management.
Transfer vitals: 72 124/56 21
On arrival to the floor she endorses constant, stable mid chest
pressure. She did not take any SL nitrogen with onset of
symptoms. She denies current dyspnea.
Past Medical History:
1. CAD
- NSTEMI 40% mid-LAD, 70%OM1, 60%midcirc, 100%pRCA
with thrombus s/p PCI with thrombectomy of RCA with Cypher stent
to pRCA and MiniVision stent to distal RCA
- s/p PCI in ___ with 20% LMCA, 60% LAD, OM1 70%, and RCA with
diffuse disease with widely patent stent.
2. OSA - CPAP 7
3. DM2 x ___ years c/b mild proteinuria and peripheral neuropathy
4. HTN
5. Hypercholesterolemia
6. Mild centrilobular emphysema ___ CTA)
7. Hepatitis B cirrhosis - followed by Dr. ___
8. anti-c RBC alloantibody (can cause hemolytic transfusion
rxns)
9. Mild right hydronephrosis ___ CTA)
Past Surgical History
1. TAH
2. 4 benign breast masses removed
3. cholecystectomy
4. Hiatal hernia
Social History:
___
Family History:
There is a family history of premature coronary artery disease
or sudden death. Mother - DM2, CAD s/p CABG at ___, father - CVA
at the age of ___, son and grandaughter with hemachromatosis
Physical Exam:
Physical exam (admitted/discharged same day)
97.6 147/55 68 18 ___ RA 94.8kg
GENERAL: well appearing woman in NAD NT ND
HEENT: NC/AT, sclerae anicteric, MMM
NECK: supple, JVP approximately 13cm
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2, mildly TTP in mid sternum. No
erythema, no vesicles, no bullae.
CHEST: TTP, but does not reproduce symptoms that prompted
admission
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake, alert, fluent, linear, prompt, appropriate
Pertinent Results:
___ 12:35AM BLOOD WBC-6.3# RBC-3.58* Hgb-11.4* Hct-34.5*
MCV-96# MCH-31.9 MCHC-33.0 RDW-14.3 Plt ___
___ 09:24AM BLOOD WBC-5.3 RBC-3.39* Hgb-11.1* Hct-32.0*
MCV-94 MCH-32.9* MCHC-34.9 RDW-14.2 Plt ___
___ 12:35AM BLOOD Neuts-61.9 ___ Monos-5.4 Eos-1.7
Baso-0.6
___ 12:35AM BLOOD ___ PTT-28.2 ___
___ 12:35AM BLOOD Glucose-260* UreaN-26* Creat-1.2* Na-141
K-4.1 Cl-104 HCO3-24 AnGap-17
___ 09:24AM BLOOD Glucose-109* UreaN-23* Creat-1.0 Na-141
K-4.0 Cl-106 HCO3-27 AnGap-12
___ 12:35AM BLOOD cTropnT-<0.01
___ 09:24AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:24AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.7
___ 12:49AM BLOOD D-Dimer-763*
___ EKG: No ischemic changes.
___ LENIs:
IMPRESSION: No deep vein thrombosis in the right lower
extremity
___ CTPA:
1. No pulmonary embolism or aortic pathology.
2. Background emphysematous changes.
3. 4 mm right lower lobe and 5 mm left perifissural nodule are
stable since
___. No further followup needed.
4. Cirrhotic appearing liver.
___ CXR: No acute intrathoracic process
Brief Hospital Course:
___ yo with h/o HTN, HLD, CAD (sp DES to RCA in ___, has known
diffuse LAD 60%, OM1 70% from ___ cath) who presents with chest
pain.
ACTIVE ISSUES:
# Chest pain: The patient presented with known coronary disease
including diffuse LAD disease and OM1 disease. She has been
medically managed for chronic stable angina. She became pain
free in the hospital and was ruled out for myocardial infarction
by enzymes. Her EKGs were unremarkable. Her pain was not
consistent with other cardiac processes such as pericarditis.
Her presentation was not at all classic for angina and many
features were not cardiac (e.g. there was no exacerbation with
exertion). She did have an elevated d-dimer, but CTPA was
negative for pulmonary embolism, pneumonia, or pneumothorax.
There were no apparent aortic abnormalities seen. She denied
relation to food and this was unlike GERD symptoms. The patient
stated that she was recovering from a gastroenteritis, which had
entailed several recent episodes of vomiting. It was thought
likely that she had sustained a chemical/erosive esophgitis.
Other gastrointestinal causes (such as diffuse esophageal spasm,
gastritis, ulcer) were not consistent with her presentation. Her
chest was tender to palpation, bringing musculoskeletal etiology
into question. Although she stated that this did not exactly
reproduce her pain, she had been vomiting recently and there may
be an element of intercostal muscle strain. Given her cardiac
history, however, an order was placed for outpatient exercise
echocardiogram to evaluate for ongoing cardiac processes.
.
# Acute kidney injury: Cr on admission 1.2 but this resolved
within several hours to 1.0. ___ have been a mild pre-renal
component from recent emesis in the setting of gastroenteritis.
.
INACTIVE ISSUES:
# HTN: normotensive. continue metoprolol, lisinopril, HCTZ,
isosorbide mononitrate, nifedipine.
.
# HLD: Discharged without medication change (on vytorin).
.
# Hep B: per patient report viral load undetectable; continued
home baraclude.
.
# Left breast mass, s/p lumpectomy: showed intraductal papilloma
and usual ductal hyperplasia.
.
# DMII: Continued lantus, sliding scale. Held metformin.
.
# Pulmonary nodule: No interval change.
.
TRANSITIONAL ISSUES:
# CHEST PAIN, NOS: Patient should be followed for anginal
symptoms. We have ordered exercise echocardiogram to evaluate
for interval decline in cardiac function.
.
# PULMONARY NODULE: No interval change seen. Continue monitoring
as prior.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Entecavir 0.5 mg PO DAILY
3. Vitamin D 50,000 UNIT PO EVERY OTHER ___
4. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral
daily
5. Hydrochlorothiazide 25 mg PO DAILY
6. Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for BP <100, HR<60
8. NIFEdipine CR 60 mg PO DAILY
HOLD FOR bp<100, hr<60
9. Lorazepam 1 mg PO BID:PRN anxiety
hold for sedation, RR<12
10. Metoprolol Succinate XL 100 mg PO BID
11. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
12. Lisinopril 40 mg PO DAILY
hold for BP<100, HR<60
13. Omeprazole 20 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Entecavir 0.5 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for BP <100, HR<60
6. Lisinopril 40 mg PO DAILY
hold for BP<100, HR<60
7. Lorazepam 0.5 mg PO BID:PRN anxiety
hold for sedation, RR<12
8. NIFEdipine CR 60 mg PO DAILY
HOLD FOR bp<100, hr<60
9. Omeprazole 20 mg PO BID
10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
11. Metoprolol Succinate XL 100 mg PO BID
12. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral
daily
13. Vitamin D 50,000 UNIT PO EVERY OTHER ___
Discharge Disposition:
Home
Discharge Diagnosis:
GI illness
Chest pain NOS
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 while you were here at
___. You were admitted for chest pain that was concerning for
possible heart attack. Your EKGs and blood tests were negative
for this and you were no longer having chest pain as we watched
you. You had a very thorough lung scan as well, which was able
to rule out many other potentially dangerous causes of chest
pain. Your chest pain was likely due to irritation related to
vomiting recently. In addition, a component of chest pain was
reproduced when pressure was applied to your chest, suggesting
some component of musculoskeletal pain.
None of your medications have changed.
Followup Instructions:
___
|
10506944-DS-14 | 10,506,944 | 23,077,815 | DS | 14 | 2155-12-20 00:00:00 | 2155-12-21 15:52:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Seconal Sodium / Erythromycin Base / Doxycycline /
Latex / Adhesive Tape / Peanut / Tomato / raw fruit / morphine
Attending: ___
___ Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
none
History of Present Illness:
In brief, this is a ___ with a PMHx of CAD (DES to ___
RCA ___ and DES to ___ and mLAD ___, HTN, and mild
emphysema presented to ___ with worsening dyspnea on exertion
and transferred to ___ for NSTEMI.
Over last few months, patient has been having progressively
worse Dyspnea on exertion and leg swelling. Had been started on
PO furosemide with some effect. Does note some orthopnea.
However, over the last ___ days, her shortness of breath has
severely worsened to the point where she is symptomatic walking
to bathroom.
On arrival to ___, made Trop I .56, was given ASA 325,
heparin gtt, and lasix 10mg IV and sent to ___. Here she felt
better after lasix and was continued on heparin gtt.
Past Medical History:
(Per OMR, verified with patient)
1. CAD
- NSTEMI 40% mid-LAD, 70%OM1, 60%midcirc, 100%pRCA
with thrombus s/p PCI with thrombectomy of RCA with Cypher stent
to pRCA and MiniVision stent to distal RCA
- s/p PCI in ___ with 20% LMCA, 60% LAD, OM1 70%, and RCA with
diffuse disease with widely patent stent.
2. OSA - CPAP 7
3. DM2 x ___ years c/b mild proteinuria and peripheral neuropathy
4. HTN
5. Hypercholesterolemia
6. Mild centrilobular emphysema ___ CTA)
7. Hepatitis B cirrhosis - followed by Dr. ___
8. anti-c RBC alloantibody (can cause hemolytic transfusion
rxns)
9. Mild right hydronephrosis ___ CTA)
Past Surgical History
1. TAH
2. 4 benign breast masses removed
3. cholecystectomy
4. Hiatal hernia
Social History:
___
Family History:
There is a family history of premature coronary artery disease
or sudden death. Mother - DM2, CAD s/p CABG at ___, father - CVA
at the age of ___, son and grandaughter with hemachromatosis
Physical Exam:
ADMISSION PHYSICAL:
VS: T 98.7 BP 137/64 HR 86 RR 20 O2 95%2L, 89% RA
GENERAL: comfortable
HEENT: MMM
NECK: Supple, no JVD
CARDIAC: Regular, no S3 or S4.
LUNGS: CTA, no crackles/wheezes
ABDOMEN: Soft, NTND.
EXTREMITIES: Pitting edema to below knee, pulses 1+ bilaterally
DISCHARGE PHYSICAL:
Pertinent Results:
ADMISSION LABS:
___ 10:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:55PM URINE GR HOLD-HOLD
___ 10:55PM URINE UHOLD-HOLD
___ 10:55PM URINE HOURS-RANDOM
___ 10:55PM URINE HOURS-RANDOM
___ 11:30PM ___ PTT-59.1* ___
___ 11:30PM PLT COUNT-178
___ 11:30PM NEUTS-62.8 ___ MONOS-5.8 EOS-2.0
BASOS-0.4
___ 11:30PM WBC-7.2 RBC-3.39* HGB-10.4* HCT-31.6* MCV-93
MCH-30.7 MCHC-32.9 RDW-14.6
___ 11:30PM CALCIUM-8.6 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 11:30PM CK-MB-2
___ 11:30PM cTropnT-0.10*
___ 11:30PM CK(CPK)-105
___ 11:30PM estGFR-Using this
___ 11:30PM GLUCOSE-129* UREA N-16 CREAT-1.0 SODIUM-143
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-18
___ 11:39PM K+-3.4
DISCHARGE LABS:
STUDIES:
CXR ___: Bilateral effusions.
TTE ___
The left atrial volume index is mildly increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). 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) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Increased
PCWP. Moderate pulmonary artery hypertension. Mild-moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
increased PCWP, increased PA systolic pressure, and increased
mitral regurigtation are now present.
Stress Echo ___
The patient exercised for 7 minutes 0 seconds according to an
modified Gervino treadmill protocol ___ METS) reaching a peak
heart rate of 129 bpm and a peak blood pressure of 186/50 mmHg.
The test was stopped because of fatigue. This level of exercise
represents a poor exercise tolerance for age. In response to
stress, the ECG showed ischemic ST changes (see exercise report
for details). There is resting systolic hypertension. The blood
pressure response to stress was blunted. There was a normal
heart rate response to exercise.
.
Resting images were acquired at a heart rate of 100 bpm and a
blood pressure of 170/50mmHg. These demonstrated normal regional
and global left ventricular systolic function. Right ventricular
free wall motion is normal. There is no pericardial effusion.
Doppler demonstrated mild-to-moderate mitral regurgitation with
no aortic stenosis, aortic regurgitation or significant resting
LVOT gradient.
Echo images were acquired within 54 seconds after peak stress at
heart rates of 128-117 bpm. These demonstrated appropriate
augmentation of all left ventricular segments. There was
augmentation of right ventricular free wall motion.
IMPRESSION: Poor functional exercise capacity. Ischemic ECG
changes in the absence of 2D echocardiographic evidence of
inducible ischemia to achieved workload. Resting hypertension.
Abnormal hemodynamic response to physiologic stress.
Mild-to-moderate mitral regurgitation at rest.
Compared with the prior study (images reviewed) of ___,
exercise tolerance has declined. The severity of mitral
regurgitation has increased. Resting blood pressure is higher.
CARDIAC CATH:
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No angiographic CAD
LAD: Diffuse mid ___
LCX: serial 50% OM1
RCA: Diffuse mid with up to 70-80% stenosis. Proximal and
distal
stents patent.
1. Three vessel CAD
2. Successful drug-eluting stent RCA and LAD
3. ASA 325 mg daily x 3 months and then 81 mg daily; Plavix 75
mg daily for ___ year.
Brief Hospital Course:
___ F with DM, HLD, HTN, and CAD s/p PCI ___ with DES to RCA
and LAD presents with increased exertional dyspnea and unstable
angina with elevated troponin.
# DYSPONEA:
Patient has become progressively short of breath on exertion
with some effect from furosemide. Has oxygen requirement this
which is new. Last ECHO in ___ showed normal ejection
fraction and most recent on ___ shows the same. MR increased to
___ with increased PCWP and PA pressures compared to prior. No
recent severe illness, but patient does admit to very high salt
diet (mainly pickled olives). Patient's oxygen requirements
improved after being diuresed with intravenous lasix.
Patient was continued on home ACE. Patient was discharged on
furosemide 40mg daily and home dose metoprolol was increased to
150mg BID.
#NSTEMI:
PAtient made troponins, but they are currently downtrending. She
has not been experiencing the same crushing chest pain from when
she had her last stents. Likely all be from demand in setting of
heart failure. Patient was initiated on heparin drip which was
discontinued after 24 hours. Patient was maintained on aspirin,
Metop succinate 150mg bid, lisinopril 40mg, nifedipine ER 90mg,
imdur 60mg
# HTN
- contd home meds
# DM
- held metformin
- maintained on insulin sliding scale
TRANSITIONAL ISSUES:
[]CODE: full, confirmed
[] CONTACT: Patient, son ___ ___
[]please ensure cardiology follow up
[ ]Electrolyte check on new furosemide dose
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Entecavir 1 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Lorazepam 1 mg PO Q8H:PRN anxiety
6. NIFEdipine CR 90 mg PO DAILY
7. Vitamin D 50,000 UNIT PO EVERY OTHER ___
8. Clopidogrel 75 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. Vytorin ___ (ezetimibe-simvastatin) ___ mg Oral daily
11. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
12. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
dyspepsia
13. Metoprolol Succinate XL 100 mg PO BID
14. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
dyspepsia
2. Clopidogrel 75 mg PO DAILY
3. Entecavir 1 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Lorazepam 1 mg PO Q8H:PRN anxiety
7. NIFEdipine CR 90 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
10. Metoprolol Succinate XL 150 mg PO BID
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth Twice Daily
Disp #*180 Tablet Refills:*0
11. Vitamin D 50,000 UNIT PO EVERY OTHER ___
12. Vytorin ___ (ezetimibe-simvastatin) ___ mg Oral daily
13. Aspirin 81 mg PO DAILY
14. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth Twice Daily Disp #*60
Tablet Refills:*0
15. Glargine 80 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
16. Outpatient Lab Work
Congestive Heart Failure 428.0
___
Please have results faxed to Dr ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: CHF exacerbation, NSTEMI
Secondary:HLD, HTN, DM Type II
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 having you here at the ___
___. You were admitted here with shortness of breath and new
requirement for oxygen. You were found to have a large amount of
fluid in your legs and lungs. This was thought to occur from
eating a high salt diet. You were treated with intravenous
lasix which helped get the excess fluid off your lungs. Please
keep your follow up appointments below and refrain from having
salt in your diet.
We have increased the dose of your water pill (Furosemide) and
have increased the dose of your metoprolol to help control your
blood pressure.
We wish you the very best,
Your ___ medical team
Followup Instructions:
___
|
10507090-DS-2 | 10,507,090 | 21,629,841 | DS | 2 | 2196-02-03 00:00:00 | 2196-02-03 07:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___
Right chest tube placement
History of Present Illness:
___ with no significant PMH presents
with a right spontaneous pneumothorax from OSH. Patient was
outside this evening smoking a cigarette, after ___ puffs he
experienced the sudden onset of right sided chest pain. He went
to ___ ED where he was diagnosed with a spontaneous
pneumothorax, he refused treatment and requested that he be seen
at ___. He also declined an ambulance and was driven to ___
in a private car. In the ED a CXR confirmed the diagnosis of
spontaneous pneumothorax, a ___ chest tube was placed and a
post
procedure CXR confirmed that the right lung had reexpanded. The
patient endorsed mild SOB, chest pain at the site of the tube
and
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
Temp: 98.7 HR: 69 BP: 127/81 RR: 18 O2Sat:100
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[ ] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings: CTAB, mildly decreased breath sounds on
the right at the apex
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ CXR
Large right pneumothorax with complete collapse of the right
lung with signs of tension.
Brief Hospital Course:
Mr. ___ was admitted to the hospital after right chest tube
placement in the ED. His tube was initially of suction for 5
hours then placed to waterseal. He had no air leak with a good
cough and scant drainage. His chest tube was removed around
6:40AM on ___ and within minutes he was dressed and demanded
to leave. He refused to go to xray for a post pull film and
left the hospital.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Right spontaneous pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with a collapsed lung
requiring chest tube placement. Your lung re expanded and the
pneumothorax resolved. Your chest tube was removed this AM and
currently you need to have a chest xray to assure the lung
remains expanded.
* You have decided to leave the hospital against medical advise
but I urge you to go to Radiology first to have a chest xray.
* Keep the chest tube dressing in place for 48 hours then remove
if dry. If you have any shortness of breath, chest pain,
redness or persistent drainage from the chest tube site please
call Dr. ___ ___ or return to the Emergency Room.
Followup Instructions:
___
|
10507278-DS-13 | 10,507,278 | 28,394,904 | DS | 13 | 2190-08-07 00:00:00 | 2190-08-08 11:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough/Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ dementia and htn who presents with ongoing cough for 3
weeks. Cough began while visiting his daughter in ___,
___. He arrived there on ___, cough began on ___.
___ was febrile, had general malaise/fatigue, temp taken
was 102. He then went to physician in ___ who prescribed him
7 day course of QID antibiotic (he and his wife are unsure of
which antibiotic it was). Fevers subsequently resolved, but
cough and malaise persisted. Cough is non-productive, no
hemoptysis. From ___ he flew to ___, went on river
boat cruise and flew back this past ___. He was
seen by his PCP, ___, in clinic today, he was found to be
hypotensive with systolic in the ___, with rales left mid
thorax. Dr. ___ him to the ER d/t concern for pneumonia.
Of note, ___ wife reports he has had poor PO intake for
past 3 weeks since onset of his illness. He has not had nasal
congestion, rhinorrhea, or GERD symptoms with his cough.
In the ED, initial vs were: 98.8 73 86/49 18 96% RA. Triggered
for hypotenstion, ___ was given 1L NS with normalization of
blood pressures. Labs were remarkable for normal ___ count
6.9, H/H 11.4/35.4, BUN/Cr ___, lactate 1.3, negative U/A.
CXR was negative for pneumonia. ___ given 750 mg IV
levofloxacin for presumed pna.
On the floor, vs were: T97.8 P66 BP102/55 R18 O2 sat 96% RA.
___ was resting comfortably in bed, reports ongoing cough,
but otherwise without complaints.
Past Medical History:
-B12 deficiency
-Hypertension.
-Prostate cancer s/p radical prostatectomy in ___,
-Bilateral cataracts. He has had cataract extraction with
intraocular lens implants bilaterally, performed by Dr. ___. His most recent procedure was on the right eye on
___. His prior procedure was in ___ on the left eye.
-Dementia, alzheimer's type
-Colonic polyps. colonoscopy at ___ in
___. He had several polyps including an adenoma.
Social History:
___
Family History:
Mother with uterine and breast cancer, sister w/ h/o dementia
and was in a memory care unit in her later years
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================
Vitals: T97.8 P66 BP102/55 R18 O2 sat 96% RA.
General: Skinny elderly male, in NAD, resting comfortably,
minimally conversant
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or excoriations noted
Neuro: A&Ox1, CNII-XII grossly intact, follows commands, moving
all extremities
DISCHARGE PHYSICAL EXAM:
===================
Vitals: T97.8-98.5 P60 BP96-103/60-65 R18 O2 sat 100% RA.
General: Thin elderly male, in NAD, resting comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or excoriations noted
Neuro: A&Ox1, CNII-XII grossly intact, follows commands, moving
all extremities
Pertinent Results:
LABS:
=======
___ 02:20PM BLOOD WBC-6.9# RBC-3.57* Hgb-11.4* Hct-35.4*
MCV-99* MCH-31.9 MCHC-32.2 RDW-12.4 Plt ___
___ 07:00AM BLOOD WBC-3.9* RBC-3.20* Hgb-10.0* Hct-32.1*
MCV-101* MCH-31.4 MCHC-31.2 RDW-13.0 Plt ___
___ 02:20PM BLOOD Neuts-74.0* ___ Monos-6.7 Eos-0.4
Baso-0.2
___ 02:20PM BLOOD Glucose-100 UreaN-16 Creat-1.1 Na-134
K-3.9 Cl-98 HCO3-26 AnGap-14
___ 07:00AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-31 AnGap-9
___ 02:20PM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8
___ 07:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.7
___ 02:23PM BLOOD Lactate-1.3
___ 03:44PM URINE Color-Straw Appear-Clear Sp ___
___ 03:44PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
IMAGING/STUDIES:
=============
CXR (___): FINDINGS: PA and lateral views of the chest were
provided. The lungs are hyper inflated. The lungs are clear
bilaterally without focal consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal. The
imaged bony structures are intact. No free air is seen below
the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
MICRO:
=============
Blood Culture (___): Negative as of discharge date
Brief Hospital Course:
___ with ongoing cough after being treated with antibiotics for
presumed URI while visiting ___, found to be hypotensive in
clinic and rales on physical exam, sent to ED due to concern for
pneumonia.
# Cough: most likely post-viral tussive syndrome. ___ CXR
is without focal consolidation, lungs clear to auscultation, has
no ___ count and afebrile, making pneumonia unlikely. ___
without GERD symptoms, denies nasal congestion or allergies
making PND less likely etiologies of cough. He was given single
dose of IV levaquin in the ED. Given lack of objective findings
consistent with pneumonia, was not given antibiotics on arrival
to medical ward. ___ remained afebrile during admission.
Was prescribed guafenisen-dextromethorphan prn for cough.
# Hypotension: Hypotensive to ___ and ___ systolic at clinic and
in ED. SBPs 120s in ED after IVF. Given lack of fevers,
tachycardia, and no ___ count, ___ did not meet SIRS
criteria. Hypotension unlikely to be related to infection.
Most likely related to poor PO intake in setting of ongoing
dementia, recent travel, and acute illness and taking home
anti-hypertensive medications. ___ home lisinopril and
HCTZ were held during admission. He was discharged off these
medications with plan to reassess at ___ follow ___. ___ was
ambulating well on day of discharge and BPs were improved.
# Dementia: Alzheimer's type. Continued home donepezil and
memantine.
# Chronic diarrhea: Followed by Dr. ___ in GI clinic for this.
Unclear etiology. Takes Zenpep at home. This is non-formulary
here. As he was only hospitalized for one night, he was not
given any alternative agents.
# OSA: uses oral appliance at home. Per wife, has not been
using as is lost. Per sleep note from ___, no longer
having apneic episodes. No specific intervention was done
during this admission.
Transitional Issues
=====================
[ ]discharged off home anti-hypertenives, recommend reassessing
need for these on discharge follow-up appointment on ___
with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Memantine 10 mg PO BID
3. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID
4. Donepezil 10 mg PO HS
5. Hydrochlorothiazide 25 mg PO DAILY
6. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Memantine 10 mg PO BID
3. Cyanocobalamin 1000 mcg IM/SC MONTHLY
4. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID
5. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth
every six (6) hours Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bronchitis, viral, with persistent cough
Hypotension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaulation of cough and low blood pressure. Your cough is
likely a post-viral cough. You have no signs of an acute
infection that requires treatment at this time. Your low blood
pressures improved with IV fluids. The low blood pressures
likely occurred due to taking your blood pressure medications in
the setting of decreased food/liquid intake. Your blood
pressure medications (hydrochlorothiazide and lisinopril) were
stopped while you were in the hospital. You should not restart
these until you follow up with your primary care physician, ___.
___. In addition, it is recommended you drink plenty of
fluids when you return to home. Should you develop fever or
shortness of breath, please seek evaluation at a medical
facility or at your nearest emergency department.
We hope you continue to feel better.
- Your ___ Team
Followup Instructions:
___
|
10507402-DS-6 | 10,507,402 | 25,127,527 | DS | 6 | 2138-03-14 00:00:00 | 2138-03-14 21:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L foot and arm pain/swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of HTN, HBV, fibroid uterus, h/o ruptured
ectopic pregnancy, h/o fibroadenoma, h/o trichomonas and h/o
gonorrhea, who presents with L arm and leg swelling and
erythema.
Pt reports that 2d prior to admission, she developed L hand and
L leg swelling and erythema. The symptoms progressed and she
presented to ED 1d prior. She also noted erythema tracking up L
forearm. She also has a small pustule on LUE.
On ROS, pt endorses bl blurry vision which is chronic and for
which optometry recommended reading glasses as well as recent
chills and a chronic dry cough which she relates to her
lisinopril use. She denies fever, n/d, trauma, known insect
bites, recent travel, anima scratches (though she lives with a
cat), SOB, dysuria, diarrhea, CP, Raynaud's or oral ulcers.
In the ED, initial VS: 98.1, 90, 165/88, 18, 98%RA. Labs were
notable for WBC 11.4, UA with few bacteria and 1 epi. ___ US was
negative for DVT. Pt was given Vanc/Cefazolin without
significant improvement. Due to absent response, pt was admitted
for further treatment. Pt reports that edema in LUE actually
worsened while ___ erythema subsided and edema remained stable.
Past Medical History:
HTN, HBV, fibroid uterus, h/o ruptured ectopic pregnancy, h/o
fibroadenoma, h/o trichomonas and h/o gonorrhea
Social History:
___
Family History:
Mother- HTN
Father - HTN, gout
Maternal Aunt - SLE
Brother - DM
Physical Exam:
Admission Exam:
VS: 98.9, 138/90, 77, 20, 99%RA
Gen: NAD
HEENT: PERRL, EOMI, no sinus tenderness
Neck: Supple, no JVD
Lungs: LCTA-bl, no w/r/r
Heart: RRR, no MRG, nl s1 and s2
Abd: Soft, NTND, no HSM
Ext: L hand with erythema and slight limitation in ROM; 2+
radial pulse; LUE erythema tracking along forearm; sensation
intact in all digits; LLE with 1+ pitting edema; 2+DP pulse.
Strength 4+/5 in all digits on L, confounded by pain.
Neuro: CNII-XII intact; no focal deficits in strength or
sensation
Discharge Exam:
VS: 98, 131/73, 80, 18, 96%RA
HEENT: PERRL, EOMI
Neck: Supple, no JVD
Lungs: LCTA-bl, no w/r/r
Heart: RRR, no MRG, nl s1 and s2
Abd: Soft, NTND, no HSM
Ext: L hand with resolution of erythema, FROM, 2+ radial pulse;
resolution of LUE erythema; sensation intact in all digits; LLE
with no edema; 2+DP pulse. Strength ___ in all digits on L.
Neuro: CNII-XII intact; no focal deficits in strength or
sensation
Pertinent Results:
Admission Labs:
___ 07:44PM BLOOD WBC-11.4* RBC-4.14 Hgb-10.9* Hct-34.0
MCV-82 MCH-26.3 MCHC-32.1 RDW-18.0* RDWSD-53.7* Plt ___
___ 07:44PM BLOOD Neuts-76.4* Lymphs-18.1* Monos-3.7*
Eos-1.3 Baso-0.2 Im ___ AbsNeut-8.73* AbsLymp-2.07
AbsMono-0.42 AbsEos-0.15 AbsBaso-0.02
___ 07:44PM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-135 K-3.4
Cl-98 HCO3-27 AnGap-13
___ 07:44PM BLOOD ALT-10 AST-16 CK(CPK)-123 AlkPhos-73
TotBili-0.2
___ 07:44PM BLOOD Albumin-3.9
___ 07:44PM BLOOD %HbA1c-5.4 eAG-108
___ 07:44PM BLOOD TSH-1.9
___ 07:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:48PM BLOOD Lactate-1.3
Other Relevant Labs:
___ 07:30AM BLOOD ___ PTT-26.5 ___
___ 06:48PM BLOOD CRP-84.5* ESR 56
Discharge Labs:
___ 05:59AM BLOOD WBC-9.7 RBC-3.96 Hgb-10.5* Hct-32.7*
MCV-83 MCH-26.5 MCHC-32.1 RDW-17.3* RDWSD-52.3* Plt ___
___ 05:59AM BLOOD Neuts-69.8 ___ Monos-5.3 Eos-1.9
Baso-0.3 Im ___ AbsNeut-6.75* AbsLymp-2.15 AbsMono-0.51
AbsEos-0.18 AbsBaso-0.03
___ 05:59AM BLOOD Glucose-95 UreaN-11 Creat-0.8 Na-137
K-4.0 Cl-100
HCO3-25 AnGap-16
___ 05:59AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0
UA:
___ 12:28AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:28AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:28AM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 12:28AM URINE UCG-NEGATIVE
___ 12:28AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Micro Studies:
HBV Viral Load (Final ___:
1,700 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ 12:28 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ BCX NGTD
Imaging ___:
FINDINGS:
There is normal compressibility, flow, and augmentation of the
left common femoral, femoral, and popliteal veins. Normal color
flow and compressibility are demonstrated in the posterior
tibial and peroneal veins. There is normal respiratory variation
in the common femoral veins bilaterally. No evidence of medial
popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Hand XR ___:
FINDINGS:
There is a focal cortical in regularity with periosteal reaction
along the radial aspect of the left fourth metacarpal. There is
no subjacent fracture. Remaining bones appear normal. The
joint spaces are preserved. There is no embedded radiopaque
foreign body. There is moderate first CMC and triscaphe joint
osteoarthropathy.
IMPRESSION:
1. Focal cortical irregularity and periosteal reaction along the
radial aspect of the left fourth metacarpal is concerning for
osteomyelitis given the clinical suspicion for underlying
infection.
2. Moderate first CMC and triscaphe joint osteoarthropathy.
LUE US ___:
FINDINGS:
There is normal flow with respiratory variation in the bilateral
subclavian veins. The left internal jugular and axillary veins
are patent, show normal color flow and compressibility. The left
brachial, basilic, and cephalic veins are patent, compressible
and show normal color flow and augmentation. Marked edema is
noted within the left hand/wrist without evidence of superficial
thrombophlebitis.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Marked subcutaneous edema within the left hand/wrist.
MR ___ ___:
FINDINGS:
There is subcutaneous edema seen overlying the dorsum of the
hand and mild tenosynovitis of the extensor tendons.No
well-defined fluid collection. No evidence of osteomyelitis. No
joint effusions.
Within the region of concern along the radial aspect of the
fourth metacarpal shaft there is a T1 isointense to muscle
lesion that demonstrates STIR hyperintensity and enhancement on
postcontrast imaging. The region is centered along the cortex
and extends into the medullary cavity and the adjacent
musculature measuring approximately 4 x 2 x 4 mm (series 8,
image 31). The flexor and extensor tendons are intact. The
median nerve is normal in signal and size. ___ canal is
unremarkable. STIR hyperintense cystic changes are noted at the
base of the first and second metacarpal at the first and second
___ joints. These lesions demonstrate enhancement on post
contrast imaging and could represent small erosions.
IMPRESSION:
1. Cortically based enhancing 4 mm lesion at the distal fourth
metatarsal with
intramedullary and intramuscular extension on post contrast
imaging. Findings
are nonspecific and may represent a juxtacortical chondroma.
Follow up xray
is recommended in ___ months. Consider hand surgery consult for
further
evaluation.
2. Cellulitis and tenosynovitis of the dorsum of the hand. No
evidence of
osteomyelitis.
3. Cystic likely degenerative changes at the first CMC joint,
enhancement of
the lesions could represent early erosions and correlation with
labs is
recommended to exclude ___ inflammatory arthropathy component.
LLE XR ___:
FINDINGS:
No fracture or dislocation seen. There is dorsal spurring in
the midfoot ___ a
prominent enthesophyte at the Achilles insertion. Small plantar
calcaneal
spur. There is is a type 3 navicular. No ostia lie
cyosteolysis, no
periostitis, no subcutaneous air seen.
IMPRESSION:
No convincing radiographic evidence of osteomyelitis. If there
is ongoing
clinical concern for osteomyelitis, recommend MRI.
Brief Hospital Course:
___ with PMHx of HTN, HBV, fibroid uterus, h/o ruptured
ectopic pregnancy, h/o fibroadenoma, h/o trichomonas and h/o
gonorrhea, who presented with L arm and leg swelling and
erythema.
# Edema/Erythema in LUE and LLE:
Pt presented with findings concerning for cellulitis in LUE and
LLE. Etiology was not clear and presentation is atypical. She
denied trauma and had no evidence of skin breakdown to suggest
clear
source of infection (though blister on LUE). Per ID, ddx
included GC/CT related disease (tenosynovitis noted on MRI
though per Hand surgery this was felt to be reactive to
cellulitis. GC/Chlamydia cervical swab was obtained. Pt
underwent L hand XR which was initially concerning for osteo.
MRI hand did not show evidence of cellulitis but did show
possible tenosynovitis as well as a lesion which would require
follow-up (see below). Pt received Vanc/Cefazoling in ED (___)
with minimal improvement (not thought to be treatment failure
but rather insufficient time, per ID, given findings most
suggestive of strep SSTI). Pt was treated with Vanc/Zosyn
(___) and transitioned to cefazolin ___ with continued
improvement in sx. On ___ pt was dischagred on keflex per ID
recommendations with plan to complete a 14d course of abx.
# HTN: Continued home HCTZ-triamterene, Lisinopril. Amlodipine
held to avoid possibility of confounding (though clinically,
cellulitis much more likely than drug-related edema) and was
restarted on discharge.
# Constipation: Mag citrate provided
Transitional Issues:
- PLEASE REPEAT LEFT HAND X-RAY IN ___ MONTHS, unless sx worsen
- Please note, HBV VL 1700
- Please repeat ESR/CRP on follow-up
- Please follow-up CBC and consider eval of anemia
- Please ensure follow-up with Hand surgery
- Please repeat ESR/CRP on follow-up to ensure down-trending
- Consider HIV Ab
- Given evidence of arthritis, would consider follow-up with
Rheumatology (possible inflammatory arthropathy) and OT (pt
works as ___)
- Please repeat US on follow-up given hematuria
- Please follow-up GC/chlamydia swab
- Please note MRI findings: 4 mm lesion at distal ___ metacarpal
bone with intramedullary and intramuscular extension on post
contrast imaging, corresponding to a subtle area of abnormality
on the ___ radiographs. Findings are nonspecific, but
the radiographic appearance raises the question of a
juxtacortical chondroma or other juxtacortical lesion. Other
etiologies are not excluded, but focal osteomyelitis is
considered less likely given minimal surrounding soft tissue
changes. In the absence of progressive symptoms , follow up
xray is recommended in ___ months to assess for stability.
Consider hand surgery consult for further evaluation.
- Cystic likely degenerative changes at the first CMC joint.
Enhancement of the lesions could represent early erosions versus
prominent cystic change related to osteoarthritis. Correlation
with labs is recommended to exclude ___ inflammatory arthropathy
component. No other evidence of erosions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. triamterene-hydrochlorothiazid 37.5-25 mg oral DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. triamterene-hydrochlorothiazid 37.5-25 mg ORAL DAILY
4. Sarna Lotion 1 Appl TP QID:PRN itch
RX *camphor-menthol small amount every four (4) hours Disp #*1
Container Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
6. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*46 Capsule 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. ___,
It was a pleasure to participate in your care at ___. You were
admitted for cellulitis of the left hand and foot. You received
antibiotics and your symptoms improved. You were seen by
infectious disease and hand surgery doctors. ___ MRI of your hand
was done and showed: "Cortically based enhancing 4mm lesion at
the distal fourth metacarpal with intramedullary and
intramuscular extension on post contrast imaging. Findings are
nonspecific and may represent a juxtacortical chondroma. Follow
up xray is recommended in ___ months."
as well as "Cellulitis and tenosynovitis of the dorsum of the
hand. No evidence of osteomyelitis" and "Cystic likely
degenerative changes at the first CMC joint, enhancement of the
lesions could represent early erosions and correlation with labs
is recommended to exclude ___ inflammatory arthropathy
component." Thus we would recommend repeat imaging of the hand
and consideration of follow-up with a joint specialist (ie
Rheumatologist). If your symptoms worsen/recur please seek
prompt medical attention.
Best Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
10507458-DS-22 | 10,507,458 | 20,962,957 | DS | 22 | 2141-09-26 00:00:00 | 2141-09-28 17:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Epinephrine / Bactrim / Augmentin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Open sigmoid colectomy with handsewn anastomosis
___: VAC dressing
History of Present Illness:
___ who was recently admitted with complicated diverticulitis
with a 3x2cm abscess on ___. She was discharged on ___ on a
course of antibitotics. She made a full recovery and was seen in
clinic on ___ and was feeling well at that time. Two days ago
she had a hamburger and developed lower
abdominal pain. The pain was initially intermittent and cramping
in nature. She increased her fiber intake and noted that the
pain worsened and was more persistent burning lower abdominal
pain.
She denies fevers or chills but has had some loose stools in the
last 2 days. The pain is similar in nature to the pain she had
with the last episode of diverticulitis.
___ She presented to ___ and was transferred to ___
for evaluation and treatment of acute complicated
diverticulitis.
Past Medical History:
afib (on ASA 325' but otherwise not anti-coagulated),
hyperlipidemia, breast cancer s/p lumpectomy and radiation on
anastrazole
Social History:
___
Family History:
Grandparents had diverticulitis
Physical Exam:
Discharge Physical Exam:
VS: 98.7 F oral, 76, 133/56, 18, 98% RA
HEENT: unremarkable
N: A&Ox3. cooperative and interactive. NAD. PERRL. EOMs intact.
Moves all extremities equal and strong. Strength ___.
C/V: Irregular rate and rhythm. No murmur, clicks, or gallops
appreciated.
Resp: Breath sounds clear to auscultation.
GI/GU: BS active x4 quadrants. soft, non-distended. Mild
tenderness near midline incision as expected.
Skin: Grossly intact. Midline abdominal incision with wound vac
in place. Wound vac putting out serosanguinous drainage.
Ext: Warm and dry. No edema. calf soft, non-tender.
Pertinent Results:
___ 05:20AM BLOOD WBC-6.7 RBC-3.35* Hgb-10.1* Hct-32.0*
MCV-96 MCH-30.1 MCHC-31.6* RDW-14.1 RDWSD-49.3* Plt ___
___ 06:10AM BLOOD WBC-7.8 RBC-3.44* Hgb-10.2* Hct-32.5*
MCV-95 MCH-29.7 MCHC-31.4* RDW-14.2 RDWSD-48.4* Plt ___
___ 04:25AM BLOOD WBC-7.9 RBC-3.43* Hgb-10.3* Hct-32.5*
MCV-95 MCH-30.0 MCHC-31.7* RDW-14.0 RDWSD-48.2* Plt ___
___ 04:30AM BLOOD ___ PTT-33.4 ___
___ 06:10AM BLOOD Glucose-101* UreaN-3* Creat-0.6 Na-138
K-4.0 Cl-102 HCO3-25 AnGap-15
___ 04:25AM BLOOD Glucose-109* UreaN-3* Creat-0.6 Na-135
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 04:35AM BLOOD Glucose-112* UreaN-5* Creat-0.6 Na-135
K-4.1 Cl-99 HCO3-25 AnGap-15
___ 06:10AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
___ 04:25AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.0
___ CT Ab/Pelvis
1. Diverticulitis involving the sigmoid colon with moderate
surrounding fat stranding and a 1.1 cm central low-density
collection within the pelvis suggestive of a small fluid
collection/ abscess. Of note, this fluid collection is not
amenable to drainage due to its small size.
2. Thickening of the bladder wall adjacent to this area of
inflammation, however there is no air within the bladder to
suggest a fistulous connection.
3. No free air or large free fluid in the abdomen or pelvis.
___ CHXR
The cardiac silhouette is within normal limits and there is no
vascular congestion, pleural effusion, or acute focal pneumonia.
___ Abdominal XRay
Radiographic findings are consistent with ileus or early/partial
obstruction. Correlate clinically.
___ Abdominal XRay
Multiple dilated loops of small bowel and air-fluid levels with
relative paucity of gas in the large intestine is suspicious for
small bowel obstruction although ileus can not be excluded. CT
scan is recommended for
further evaluation.
___ CT Ab/Pelvis
Visualized loops of proximal and mid small bowel are distended
with fluid and minimally dilated, measuring up to 3 cm in
diameter, with collapsed small bowel seen within the right lower
quadrant likely reflecting distal ileum. An abrupt transition
point is not identified, and and therefore findings remain
nonspecific. but favor a postoperative ileus. No evidence of
free air,
pneumatosis or intra-abdominal abscess.
___ Dx Paracentesis
Uneventful diagnostic paracentesis from the left lower quadrant
fluid collection.
___ 8:53 am PERITONEAL FLUID GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO
GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 9:17 am STOOL
Source: Stool. **FINAL REPORT ___ C. difficile DNA
amplification assay (Final ___: Positive for toxigenic C.
difficile by the Illumigene DNA amplification.
Brief Hospital Course:
The patient is a ___ woman with unremitting, complicated
diverticulitis involving the sigmoid colon. She had failed
previous non-operative therapy. Her first episode was in
___, she had a 3 x 2 cm abscess. She was treated with a
course of antibiotics. She had a short period of time where she
was feeling better and presented again with recurrent pain. CT
demonstrating an unremitting sigmoid diverticulitis with
impending cool-vesical fistulization.
She was admitted to the hospital on ___ and was treated
again with a course of IV antibiotics. She appeared to improve
clinically to the point where she was thought a reasonable
candidate for a one-stage procedure assuming favorable anatomy.
She agreed to proceed with a sigmoid colectomy for definitive
management of her recurrent disease.
On ___ she was taken to the OR with Dr. ___ a
sigmoid colectomy. OR was uneventful (see operative note for
details). She was extubated and taken to the PACU until stable,
then transferred to the floor for observation and continued
management.
Neuro: The patient was alert and oriented throughout the
hospitalization. Her pain was initially managed with a dilaudid
PCA and she was transitioned to oral oxycodone and Tylenol for
pain management.
CV: The patient remained stable from a cardiovascular
standpoint; vitals were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. She was weaned to room air without difficulty. Good
pulmonary toilet, early ambulation, and incentive spirometery
were encouraged throughout hospitalization.
GI/GU: The patient was initially kept NPO. She developed
abdominal discomfort/nausea on post operative day 3 and an NGT
was placed and the patient was started on an IV PPI. A KUB
showed a partial SBO vs ileus and the patient was kept NPO. A CT
scan of the abdomen and pelvis on ___ was consistent with the
KUB and suggested ileus and also identified small amount of free
fluid in the abdomen. On ___ a sample of this fluid was
obtained and showed 1+ polymorphonuclear leukocytes. On ___ a
stool sample was sent and came back positive for c.diff.
Treatment with flaygl was initiated. On ___ a regular diet was
started and medications were transitioned to oral. On ___
the midline abdominal incision was opened for suspected
infection and a wound vac was applied on ___. A foley
catheter was initially placed in the OR on ___ and removed on
___. The patient had no issues with voiding. The patients
intake and output were closely monitored.
ID: The patients fever curves were closely watched for signs of
infection and they were treated as described above.
Heme: The patients blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin in ___
dyne boots were used during this stay.
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 portable wound vac is in place. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Follow up appointments were made.
Medications on Admission:
anastrozole 1mg, flecainide 200mg, metoprolol ER 100mg,
simvastatin 20mg, ASA 81mg
Discharge Medications:
1. Anastrozole 1 mg PO DAILY
2. Flecainide Acetate 100 mg PO BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
7. Ibuprofen 400 mg PO Q8H:PRN pain
please take with food
8. Ipratropium Bromide MDI 2 PUFF IH QID PRN AS NEEDED FOR CHEST
CONGESTION
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 17 mcg
once a day Disp #*1 Inhaler Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 13 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent sigmoid diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for evaluation of your abdominal pain and
diverticulitis. You were initially managed with IV antibiotics,
however your diverticulitis did not resolve. You then underwent
an open sigmoid colectomy with handsewn anastomosis to address
your diverticulitis. You developed a c. diff infection in your
intestines and are currently being treated with the antibiotic
flagyl. Your symptoms have improved and you are tolerating a
regular diet. Your abdominal wound was opened and cleared of the
infection and you will go home with a wound vac to help the
incision heal. You tolerated this procedure well and have
started to recover. You are now strong enough to be discharged.
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.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10507458-DS-23 | 10,507,458 | 20,983,156 | DS | 23 | 2141-11-15 00:00:00 | 2141-12-14 12:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Epinephrine / Bactrim / Augmentin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Incision and drainage of anterior abdominal wall
abscess as well as application of a wound VAC.
History of Present Illness:
This is a ___ female, who had an open sigmoidectomy on
___ for recurrent complicated diverticulitis complicated
by a superficial surgical site infection and Clostridium
difficile, who was initially treated with a VAC dressing and
p.o. Flagyl who presented again with wound pain and ulceration
on ___. Abdominal wound had been delayed secondary healer
status post colectomy in ___. The patient stated the ___
had been doing daily dressing changes with silver alginate, but
now had pain and bleeding from the wound surface. She denied
fevers, chills, nausea, vomiting. On initial exam, she had
evidence of her open incision with pink granulation tissue.
There was a deeper undermining layer that was roughly 5 cm in
the caudad region. There was a superior area of the wound just
above the umbilicus that showed some area of induration and
firmness suspicious for an abscess. A CT scan performed
showed a 1.___efect with associated fat
stranding, skin thickening, and a foci of air concerning for
infection. Superior to the abdominal wall defect was a 17 x 15
mm collection. Based on these findings, it was felt that she
needed an operation.
Past Medical History:
afib (on ASA 325' but otherwise not anti-coagulated),
hyperlipidemia, breast cancer s/p lumpectomy and radiation on
anastrazole, sigmoid colectomy
Social History:
___
Family History:
Grandparents had diverticulitis
Physical Exam:
Physical Exam:
Vitals: pain ___, T 97.8, HR 74, BP 135/79, RR 18, 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, obese, nondistended, nontender, no rebound or
guarding, normoactive bowel sounds, no palpable masses.
Incision
open with pink granulation tissue. Deeper area at superior
portion of wound measures approximately 4cm and does not seem as
if penetrates fascia when probed with Qtip. Some necrotic fat
at
base of wound. No foul smelling or purulent drainage
encountered. Superior to wound there is an area of cellulitis,
warm to touch, with induration. No fluctuance felt on exam.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 04:40AM BLOOD WBC-8.0 RBC-3.55* Hgb-10.7* Hct-33.6*
MCV-95 MCH-30.1 MCHC-31.8* RDW-13.5 RDWSD-47.2* Plt ___
___ 04:45AM BLOOD WBC-8.2 RBC-3.69* Hgb-11.0* Hct-34.5
MCV-94 MCH-29.8 MCHC-31.9* RDW-13.3 RDWSD-46.0 Plt ___
___ 04:50AM BLOOD WBC-8.7 RBC-3.63* Hgb-10.9* Hct-34.1
MCV-94 MCH-30.0 MCHC-32.0 RDW-13.6 RDWSD-46.5* Plt ___
___ 06:25AM BLOOD WBC-10.2* RBC-3.67* Hgb-11.0* Hct-33.9*
MCV-92 MCH-30.0 MCHC-32.4 RDW-13.6 RDWSD-46.4* Plt ___
___ 02:00PM BLOOD WBC-9.8 RBC-4.25 Hgb-12.6 Hct-38.6 MCV-91
MCH-29.6 MCHC-32.6 RDW-13.4 RDWSD-44.6 Plt ___
___ 06:25AM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-136
K-4.5 Cl-100 HCO3-28 AnGap-13
___ 02:00PM BLOOD Glucose-99 UreaN-18 Creat-0.7 Na-136
K-4.4 Cl-99 HCO3-28 AnGap-13
___ 04:45AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.3
___ 06:25AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.0
___ 02:00PM BLOOD Calcium-10.3 Phos-3.6 Mg-2.0
IMAGING:
___ CT A/P:
1. ___efect with associated fat stranding,
skin thickening, and foci of air, concerning for infection.
2. A focal 17 x 15 mm collection superior to the abdominal wall
defect likely represents an abscess. No communication between
this region and the peritoneum.
3. No acute intra-abdominal process specifically, left lower
quadrant
anastomosis appears intact.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain from her
non-healing surgical wound. Admission abdominal/pelvic CT was
concerning for an abscess with associated infection. The patient
underwent incision and drainage of anterior abdominal wall
abscess as well as application of a wound VAC, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating sips, on IV fluids, IV
analgesia for pain control, and antibiotics. The patient was
hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The VAC was changed on POD3.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with services for
wound care. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Medications - Prescription
ANASTROZOLE - anastrozole 1 mg tablet. 1 tablet(s) by mouth once
a day - (Prescribed by Other Provider)
FLECAINIDE - flecainide 100 mg tablet. 1 tablet(s) by mouth
twice
a day - (Prescribed by Other Provider)
METOPROLOL TARTRATE - metoprolol tartrate 100 mg tablet. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
SIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth
once
a day - (Prescribed by Other Provider)
Medications - OTC
ASPIRIN - aspirin 325 mg tablet. 1 tablet(s) by mouth once a day
- (Prescribed by Other Provider)
CALCIUM CARBONATE [CALCIUM 500] - Dosage uncertain -
(Prescribed
by Other Provider)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Anastrozole 1 mg PO DAILY
3. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*16 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
5. Flecainide Acetate 100 mg PO Q12H
6. Metoprolol Succinate XL 100 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
9. Simvastatin 20 mg PO QPM
10. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 14 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*56 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Complex abdominal wall abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with a non-healing abdominal wound
from your prior surgery. You were taken to the operating room
and underwent incision and drainage of anterior abdominal wall
abscess and application of a wound VAC. You tolerated this
procedure well. Your VAC dressing was changed on ___ and the
wound looks good. You are medically cleared to be discharged
home with the VAC dressing. You will have ___ services to assist
with VAC changes. 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.
Followup Instructions:
___
|
10507603-DS-17 | 10,507,603 | 22,786,097 | DS | 17 | 2144-12-09 00:00:00 | 2144-12-09 23:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Ciprofloxacin /
Latex / Vicodin / Niacin / Penicillins / morphine /
Nitrofurantoin
Attending: ___.
Chief Complaint:
Left Groin and Flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo women with HTN, COPD, CAD, CKD who developed severe left
groin/lower abdominal pain beginning last night at about ___
with nausea and vomiting. She presented to ___ where a
CT revealed LLL pna versus aspiration and small stones,
hydronephrosis, hydroureter, and possible caliceal rupture. The
pt was subsequently transferred to ___ for urology
consultation. Prior to transfer given CTX and azithromycin and
dilaudid for pain.
In ED here, pt given IVF, flomax, dilaudid dose for pain. The
pt reported that pain started at left flank then moved toleft
groin, lower quadrant. Pt evaluated by urology who felt that
this was a small stone that passed quickly. No need for any
surgical intervention. Suggest outpt repeat US in two weeks and
if hydro persistent, then will need contrast urogram to further
evaluate. Also recommended urine cytology as outpt given
smoking history.
Pt denies fevers, chills, headache, chest pain, cough, shortness
of breath. Denies history of known nephrolithiasis.
Past Medical History:
- Coronary Artery Disease s/p Stent x 3
- COPD
- Hypertension off meds now per son
- ___
- ___
- Extensive Tobacco history
- Right Macular Degeneration stable under surveillance
- Cervical Degenerative Disk Disease
- CKD
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her mother died of an MI in her late ___. Her
father had ___. Her older sister has hypothyroidism and
hyperlipidemia. She has 3 healthy children.
Physical Exam:
Admission Exam:
T 97.7 149/50 P 90 RR 18 96% 2L
Gen: Well appearing women in NAD
HEENT: MMM, no oral lesions
CV: RRR, ___ holosystolic murmur, nL S1 and S2
Lungs: CTA b/l
Groin/Flank: Minimal tenderness on left
Abdomen: Mild tenderness of L flank, no rebound or guarding
Ext: Warm and well perfused, no edema
Discharge Exam:
Vital Signs: 97.9 119/78 70 18 93%RA
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, ___ systolic murmur throughout
PULM: CTA B
GI: S/NT/ND, BS present
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 09:20AM BLOOD WBC-13.7* RBC-3.44* Hgb-11.0* Hct-33.0*
MCV-96 MCH-32.0 MCHC-33.5 RDW-14.0 Plt ___
___ 09:20AM BLOOD Neuts-87.5* Lymphs-9.1* Monos-2.9 Eos-0.3
Baso-0.3
___ 09:20AM BLOOD Glucose-86 UreaN-29* Creat-2.0* Na-140
K-3.5 Cl-104 HCO3-23 AnGap-17
___ 09:20AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8
Discharge Labs:
___ 06:50AM BLOOD WBC-9.5 RBC-3.95* Hgb-12.7 Hct-37.4
MCV-95 MCH-32.2* MCHC-34.0 RDW-13.9 Plt ___
___ 06:50AM BLOOD Glucose-93 UreaN-22* Creat-1.5* Na-139
K-4.0 Cl-105 HCO3-22 AnGap-16
___ 06:30AM URINE Color-Straw Appear-Clear Sp ___
___ 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:30AM URINE RBC-<1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-1
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
Blood Cx x 5 - PENDING
CXR - FINDINGS: There is increased opacity of both bases, right
greater than left. While some of this could be due to volume
loss aspiration or infectious pneumonia cannot be excluded the
remainder of the lungs are clear. The cardiac and mediastinal
silhouettes are normal. There is no effusion.
IMPRESSION: Volume loss versus infiltrate in the lower lobes
right greater
ECG - Sinus rhythm. Normal tracing. Compared to the previous
tracing of ___ no important change.
Renal Ultrasound - FINDINGS: The right kidney measures 9.3 cm.
The left kidney measures 9.8 cm. There is no hydronephrosis,
stones, or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. Note is
made of a 1 cm simple cyst in the interpolar region of the left
kidney.
The bladder is only minimally distended and can not be fully
assessed on the current study.
IMPRESSION: Normal renal ultrasound.
Brief Hospital Course:
___ yo women with HTN, COPD, CAD, CKD who developed severe left
groin/lower abdominal pain beginning ___ at about ___ with
nausea and vomiting most likely ___ movement of small kidney
stone through urinary system now bacteremic with proteus
#Proteus blood stream infection: Likely ___ acute urinary
obstruction from small kidney stone. Pt was not septic, did not
spike a fever. She appeared extremely healthy for having GNR
blood stream infection. She was initially started on CTX.
Sensitivities returned demonstrating sensitivity to
ciprofloxacin. The pt has a documented cipro allergy but on
futher discussion, it was determined this was not a true allergy
and she was monitored while on this medication with no incident.
She will complete a 2 week course.
#Left hydronephrosis, hydroureter, and calcyceal rupture: Pt
presented with left groin and abdominal pain. The etiology of
her intial presentation is unclear but is consistent with
passage of a small calculus that was not seen on intial CT. The
fact that the patient's pain resolved quickly is c/w spontaneous
stone passage. Given the
patient's long time smoking hx, interval imaging is needed to
ensure resolution of left hydronephrosis given that intial CT
was done without IV contrast. Urology saw the pt and recommended
urine cytology as an outpt (given smoking history). She will
have urology follow up.
# ? Aspiration: CT scan demonstrated left base airspace opacity.
She had no symptoms of pneumonia. This finding may be from
aspiration when she vomited.
# CAD s/p stent x 3: Continued home regimen of daily aspirin,
QOD plavix, statin, losartan.
# ___ on CKD: Likely from being dry in the setting of infection.
Possible from left sided obstruction in the setting of CKD.
Improvement after gentle IVF and presumed passing of stone.
Given improving renal function at the time of discharge, she was
instructed to have repeat Cr checked 2 days after discharge to
determine if cipro dosing will need to be change (results will
be sent to her PCPs office).
# COPD: Not active. Not on inhalers
# Hypertension off meds now per son
# ___
# Hypothyroidism: Levothyroxine
# Moderate AS: Asymptomatic. Avoided aggressive IVF
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO EVERY OTHER DAY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Cyanocobalamin 1000 mcg IM/SC QMONTH
8. Losartan Potassium 25 mg PO DAILY
9. Acetaminophen 500 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO EVERY OTHER DAY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Vitamin D ___ UNIT PO DAILY
8. bifidobacterium infantis 4 mg oral daily
9. Cyanocobalamin 1000 mcg IM/SC QMONTH
10. Docusate Sodium 100 mg PO BID
11. Estrogens Conjugated 0.625 mg PO EVERY OTHER DAY
12. Estrogens Conjugated 1.25 mg PO EVERY OTHER DAY
13. Famotidine 10 mg PO BID
14. Losartan Potassium 25 mg PO DAILY
15. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
16. Outpatient Lab Work
Please have your creatinine checked on ___. Results should
be faxed to Dr. ___ office at ___.
Diagnosis: urinary tract infection
Discharge Disposition:
Home
Discharge Diagnosis:
Proteus bacteremia
Occlusive nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for left groin pain which most likely occurred
from a kidney stone which passed quickly while you were in the
hospital. You were found to have a blood stream infection most
likely from acute urinary obstruction causing bacteria to move
from your urinary system into the blood. You were treated with
an antibiotic and will continue for a total 2 week course.
Followup Instructions:
___
|
10507603-DS-18 | 10,507,603 | 26,339,586 | DS | 18 | 2145-03-21 00:00:00 | 2145-03-25 00:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Latex / Vicodin /
Niacin / Penicillins / morphine / Nitrofurantoin
Attending: ___.
Chief Complaint:
LLE infection/redness
Major Surgical or Invasive Procedure:
___ I+D of abscess ___ ED
History of Present Illness:
Ms. ___ is an ___ year old lady with history of HTN, COPD,
CAD, CKD (baseline 1.7-2) presenting with LLE cellulitis and
abscess. Two weeks ago she had a car door strike her leg on
___. She was seen at ___ and ___ wound was closed
with stitches (told to remove 2 weeks after) and she was
discharged. She then returned on ___ after developing a
cellulitis, was admitted until ___ and was sent home on
cephalexin after redness improved. She re-presents with
worsening redness, new abscess area on leg. Today her leg became
more red and reports that she saw a "white area" coming up on
her leg. ___ the ED, her abscess was I&D'd at bedside w/ culture
sent. Started on vanc+ceftriaxone.
___ the ED, initial vitals:
- Exam notable for: 12:44 7 98.0 59 145/89 18 96% RA
- Labs notable for: cre 1.7
- Pt given: IV CeftriaXONE 1 gm, PO Acetaminophen 1000 mg,
Lidocaine Jelly 2% (Urojet), and IV Vancomycin 1000 mg
- Vitals prior to transfer:
On arrival to the floor, pt is eating her dinner and reports
that she refuses to go over her medications because she has
already done it several times this week. She initially refused
examination of her leg and reports no pain.
ROS: No fevers, chills, cough, no shortness of breath, no
dyspnea on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea or constipation. No dysuria
Past Medical History:
- Coronary Artery Disease s/p Stent x 3
- COPD. not on any inhalers
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Extensive Tobacco history
- Right Macular Degeneration stable under surveillance
- Cervical Degenerative Disk Disease
- CKD, recent baseline ___
- Proteus blood stream infection likely ___ acute urinary
obstruction from small kidney stone ___
Social History:
___
Family History:
per OMR no premature coronary artery disease or sudden death.
Her mother died of an MI ___ her late ___. Her father had
___. Her older sister has hypothyroidism and
hyperlipidemia. She has 3 healthy children.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.5 - 144/___ weight 51.5kg
General: elderly woman sitting ___ bed eating dinner
HEENT: mucous membranes moist, sclera anicteric
Lungs: clear
CV: regular rate and rhythm, soft systolic murmur heard
throughout precordium loudest at LSB
Abdomen: soft nt
Ext: LLE with ~7-8cm healing wound with stitches ___ place.
medial to wound there is a small 1cm incision with serous
drainage, slight fluctuance with yellow discoloration
surrounding incision (~2cm), with skin hyperpigemntation and
erythema surrounding these areas, mildly firm but not taut,
sensation intact, DP 2+ bilaterally, erythema is inside of line
drawn ___
DISCHARGE PHYSICAL EXAM
Vitals: 97.2 - 135/79 - 77 - ___ - 94RA
General: elderly woman, appears younger than stated age, sitting
___ bed
HEENT: mucous membranes moist, sclera anicteric
Lungs: clear
CV: regular rate and rhythm, soft systolic murmur heard
throughout precordium loudest at ___
Abdomen: soft, non tender
Ext: LLE with ~7cm healing laceration, hyperpigmentation ~2cm
over lac edge. medial to wound there is a 1x1cm circular wound
(previously an incision) central drying granulation tissue, no
drainage, surrounded by mild but improving erythema and no
fluctuance, mildly firm/shiny skin around area but not taut,
sensation intact, DP 2+ bilaterally, erythema is far inside of
line drawn ___
Pertinent Results:
ADMISSION LABS
===========
___ 03:25PM BLOOD WBC-8.8 RBC-3.85* Hgb-12.3 Hct-36.8
MCV-96 MCH-31.9 MCHC-33.4 RDW-13.7 Plt ___
___ 03:25PM BLOOD Neuts-69.8 ___ Monos-5.3 Eos-3.0
Baso-0.4
___ 03:25PM BLOOD Glucose-88 UreaN-28* Creat-1.7* Na-138
K-4.3 Cl-103 HCO3-23 AnGap-16
___ 03:47PM BLOOD Lactate-1.2
DISCHARGE LABS
===========
___ 07:00AM BLOOD Glucose-91 UreaN-29* Creat-1.7* Na-136
K-4.2 Cl-103 HCO3-22 AnGap-15
MICROBIOLOGY
==========
___ 5:00 pm SWAB Site: LEG Source: leg wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND 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.
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------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
CT LEFT LOWER EXTREMITY WITHOUT CONTRAST ___
FINDINGS: Evaluation is somewhat limited by lack of intravenous
contrast. The location
of erythema ___ the left lower leg is flanked by two skin
markers. Between
these markers, there is subcutaneous fat stranding consistent
with the history
of cellulitis. There is no fluid collection. There is no gas
amongst the soft
tissues. The underlying tibia appears normal, with no
periosteal reaction.
There is no fracture. There is no significant degenerative
change ___ the
knee. Diffuse osseous demineralization is noted. Cystic change
___ the femoral
condyles is likely related to trabecular rarefaction ___ the
setting of
demineralization. Mild enthesopathy is noted at the proximal
quadriceps
tendon insertion.
IMPRESSION: Subcutaneous fat stranding ___ the left lower leg
consistent with the stated
history of cellulitis. No fluid collection or gas within the
soft tissues.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
================
Ms. ___ is an ___ year old lady with history of HTN, COPD,
CAD, CKD (baseline 1.7-2) who presented with LLE cellulitis and
abscess associated with a healed laceration. She had an I+D of
the abscess ___ the ED and her surrounding cellulitis improved
greatly with IV vancomycin. Her sutures were removed on ___.
She underwent CT on the day of discharge to ensure there was no
fluid collection (CT was negative). She was discharged home on
clindamycin with planned total course of 10 days given abscess
and surrounding cellulitis, though course can be
shortened/altered based on clinical improvement.
ACTIVE MEDICAL ISSUES
===============
# LLE cellulitis with associated abscess, s/p I+D: Likely
secondary bacterial infection s/p abrasion or stitches ___
healthcare setting, and abscess/purulence was initially
concerning for MRSA, however microbiology after discharge grew
MSSA. Stitches removed on ___ and I+D was healing by time of
discharge with visible granulation tissue. Initially covered
with vancomycin given renal function, transitioned to PO
clindamycin (also sensitive). Her PCP ___ arrange wound care.
CHRONIC MEDICAL ISSUES
=================
# CAD s/p stent x 3: Continued home regimen of daily aspirin,
QOD plavix, statin, losartan.
# CKD: Near most recent baseline.
# Menopause. Continue Estrogens Conjugated 0.625 mg PO EVERY
OTHER DAY, estrogens Conjugated 1.25 mg PO EVERY OTHER DAY,
Vitamin D ___ UNIT PO DAILY
# GERD: Continued famotidine.
# COPD: Not on inhalers, monitor.
# Hypertension: Continued valsartan.
# Hyperlipidemia: Continued statin
# Hypothyroidism: Continued levothyroxine
# Moderate AS: Asymptomatic, cardiologist is Dr. ___.
TRANSITIONAL ISSUES
====================
- Code status: Full code.
- Emergency contact: Patient cell: ___.
Daughter/HCP: ___, cell ___
- Studies pending on discharge: ___ Swab and anaerobic
cultures, ___ blood cultures x2. We will follow up on
sensitivities (available ___ and call if clindamycin is not
optimal antibiotics.
- Please refer to wound care at f/u.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Align (bifidobacterium infantis) 4 mg oral daily
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Estrogens Conjugated 0.625 mg PO EVERY OTHER DAY
6. Estrogens Conjugated 1.25 mg PO EVERY OTHER DAY
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Acetaminophen 1000 mg PO "AS NEEDED"
9. Vitamin D ___ UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 1000 mcg IM/SC MONTHLY
12. Docusate Sodium 100 mg PO TID
13. Famotidine 10 mg PO BID
14. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO TID
5. Estrogens Conjugated 0.625 mg PO EVERY OTHER DAY
6. Estrogens Conjugated 1.25 mg PO EVERY OTHER DAY
7. Famotidine 10 mg PO BID
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Losartan Potassium 25 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Align (bifidobacterium infantis) 4 mg oral daily
13. Cyanocobalamin 1000 mcg IM/SC MONTHLY
14. Atorvastatin 20 mg PO DAILY
15. Clindamycin 300 mg PO Q6H Duration: 8 Days
Ends ___.
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 6 hours
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis, abscess
Leg laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part ___ your care at ___. You were
admitted because of cellulitis associated with a leg laceration,
with an associated abscess. Your small abscess was incised and
drained ___ the emergency department, and you were started on an
IV antibiotic. Your infection improved, and you were discharged
home to follow-up with Dr. ___ on ___ afternoon. You
should take an oral antibiotic until ___.
Final culture results will be available tomorrow morning. We
will call you if there needs to be a change ___ your antibiotics
and will call a script into your pharmacy.
Followup Instructions:
___
|
10507647-DS-14 | 10,507,647 | 26,638,523 | DS | 14 | 2132-12-02 00:00:00 | 2132-12-03 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meropenem
Attending: ___
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
___: Surgical Fixation of the Right Proximal Femur with Long
TFN
History of Present Illness:
CC: R hip fracture
HPI: Ms. ___ is a ___ yo F with a history of metastatic
leiomyosarcoma presenting with lytic R hip lesion and associated
pathologic fracture of R iliopsoas. Patient has had dull right
sided thigh pain for two weeks, which worsened acutely yesterday
while at the store with her daugther to the point that she is
now having difficulty walking. Patient was seen in an OSH where
she was subsequently sent to ___ for evaluation of DVT with an
ultrasound. While here, Ultrasound showed No evidence of DVT in
the right lower extremity, although one of the two peroneal
veins was not seen. No respiratory variation in the left common
femoral veins (done for comparison of the right) may reflect
more proximal obstruction. For this reason, a CT venogram was
performed which did not show a DVT, however it did show lytic
lesion in R intertrochanter with avulsion fracture of iliopsoas.
She was seen by orthopedics and admitted to OMED for further
evaluation.
Labs were insigificant, Patient was given IV morphine.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
-___: Outside hospital with a febrile illness in Initial
CT scan showed a large cystic mass within the left
retroperitoneum. She underwent percutaneous drainage on the
assumption that the lesion represented an abscess.
-Subsequent core needle biopsy: high-grade pleomorphic sarcoma
possibly a liposarcoma. Immunostaining at the time of initial
visit to ___ with Dr. ___ the lesion to be positive for
smooth muscle actin and negative for desmin.
-___: FDG-PET/CT scan: 9-cm FDG-avid mass was seen
within
the left retroperitoneum close to the kidney and colon. Stable
right apical abnormality likely chronic and inflammatory.
-5000 cGy of external beam radiotherapy by Dr. ___, and
finished on ___: Dr ___ en bloc resection of the
tumor with the adjacent left colon and kidney. Pathology
returned showing a 9-cm high-grade pleomorphic sarcoma involving
the colonic serosa and perinephric adipose tissue. All
surgical margins were negative.
**Pathology: high-grade pleomorphic lesion with features most
consistent with a leiomyosarcoma. (+)tumor for positive for
smooth muscle actin and desmin; negative stain on the core
biopsy.
-___: Postoperative FDG-PET/CT scan no clear-cut
evidence of metastasis or local recurrence. Diffuse uptake into
the thyroid with multiple hypodense nodules. Within the left
clavicular head, lucent area with a high SUV of 6. 1.3-cm
opacity between the rectus and transverse colon, which was FDG
avid. Within the nephrectomy bed, 1.9-cm lobulated collection
which was not FDG avid. Within the mid retroperitoneum, ovoid
area of fat stranding posterior to the duodenum with an SUV of
4.7. Within the left lower quadrant, she had a similar area
with
an SUV of 5. Most of these findings were thought to be
postoperative and representing probable evolving fat necrosis.
-___: Thyroid ultrasound a 2.5-cm left lower pole
heterogeneous nodule for which a FNA cytology was recommended.
In the right thyroid, she had two nodules measuring about 1.1-cm
each, for which a one-year followup study was recommended.
-___: Core needle biopsy of the left clavicular head.
**Pathology: bone with spindle cells showing quite a bit of
crush
artifact. Overall pathology was thought suggestive of
metastasis and stained positive for smooth muscle actin and
focally for caldesmon. Desmin negative.
-___: PET CT: Uptake in the left clavicular head has
decreased post biopsy. Uptake in the midline of the skull
anteriorly, not previous imaged is worrisome for metastasis. New
focus of uptake in a high right paratracheal lymph node.
Possible new sites of metastasis in the liver, the surgical bed,
and T6.
-___: MRI Abdomen: Ill-defined right hepatic mass within
segment VI corresponds to an FDG-avid lesion on the ___
examination, and appears new since the prior examination from
___, compatible with metastasis. Two right lower lobe
lung nodules, one appearing new, suspicious for metastases. No
tumor recurrence seen at the left nephrectomy site.
-___: Liver Biopsy:
**PATH: High grade sarcoma involving the liver, consistent with
patients previously diagnosed pleomorphic leiomyosarcoma.
Background liver parenchyma with portal mononuclear inflammation
and mild steatosis. By immunohistochemistry, the tumor cells are
positive for smooth muscle actin and caldesmon, focally positive
for desmin, and negative for MNF116 and S100.
-___:
*CT Chest/Abd/Pelvis:
-Persistent mild enlargement of the left thyroid lobe measuring
2 cm x 1.8 cm with cystic areas is unchanged from ___
-No supraclavicular, axillary, or hilar lymphadenopathy. FDG
avid enlarged paratracheal lymph node measures 1.5 cm x 1.5 cm
and is new from ___.
-Lung windows demonstrate stable right apical pleural scarring
There are multiple new bilateral rounded noncalcified
homogeneous
pulmonary nodules that are consistent with metastatic
disease;largest nodule measures 1 cm x 0.8 cm and is in the
basal segment of the right lower lobe
-lesions involving T5 and the left clavicular head are new from
___ and are FDG avid on PET. These are consistent
with metastatic disease
*CT Neck: No evidence for pathologic neck adenopathy.
*TTE: EF 55%. Mild MR
-___: CT Torso
*Slight interval increase in size of the right hepatic
metastasis
and pelvic mass.
*Stable size of the soft tissue nodule in the right nephrectomy
bed, right gluteal soft tissue nodule, left gluteal
intramuscular
nodule, left pelvic soft tissue nodule and prominent
retroperitoneal lymph node.
*Progression of the size of several pulmonary pre-existing
nodules. Other nodules are stable. No new nodules. Unchanged
appearance of the mediastinum. No pleural effusions. Unchanged
known osteolytic foci of T5 and left clavicle
-___: C3D1 of doxil
-___ to ___: 20 sessions ofXRT to pelvic mass Dr. ___
-___: CT C/A/P and Head
*Heterogeneous pelvic mass has decreased in size.
*Hepatic segment VII lesion, soft tissue nodule in the left
nephrectomy bed, and nodules in the left gluteus maximus muscle
and right gluteal subcutaneous fat are stable.
*Persistent lytic lesion in the T5 vertebral body with a new
fracture along the inferior endplate of T5.
*No new lesions are identified in the abdomen and pelvis.
*Stable pulmonary nodules consistent with metastatic disease. .
*New pathologic fracture at the inferior endplate of T5 with
unchanged underlying lytic lesion. The left clavicular head
lesion is also similar.
*Lytic lesion centered in the midline frontal bone with epidural
and subgaleal components, most likely a metastasis. Recommend
MRI
to evaluate for dural or parenchymal invasion
-___: MRI Head
*Mass in the frontal region involving the bone and extending to
the epidural space and also to the scalp soft tissues. The
superior sagittal sinus is displaced anteriorly or infiltrated
by
the mass with quesion intrinsic tumor thrombus. No parenchymal
metastatic lesions are identified. No midline shift is seen.
-___: 10 sessions of XRT to head lesion per Dr. ___
-___: CT Torso
*Several bilateral pulmonary nodules have increased in size
measuring 1.1 x 1.0 cm (3:279) (previously 0.9 x 0.9 cm);
1.7 x 1.1 cm (previously 0.9 x 1.0 cm) (3:210); 2.0 x 2.4 cm
(previously 1.2 x 1.1 cm) (3:66) within the right lower lobe,
superior segment of the right lower lobe and right
paramediastinal nodule. On the left, a 0.6 x 0.5 cm
(3:220) (previously 0.6 cm) within the left upper lobe, and 0.8
x
0.7 cm nodule (3:163) (previously 0.5 cm); within the left
upper
lobe.
*No filling defect to suggest pulmonary embolism
*Right lobe of the liver is approximately a 2.6 x 2.2 cm
(2B:102) (previously 3.0 x 1.8 cm) heterogeneously enhancing
lesion, which allowing for differences in technique and
positioning, is likely stable. No new hepatic lesions
*status post left nephrectomy with clips LLQ
*1.1 x 0.5 cm (previously 1.5 x 0.8 cm) (2B:105) soft tissue
lesion within the nephrectomy bed which has slightly decreased
in
size compared to prior study.
*Stable appearing 0.9 x 0.6 cm (previously 1.1 cm)
mesenteric lymph node (2B:124). No additional retroperitoneal
or
mesenteric lymph node enlargement.
*Interval decrease in a peripherally enhancing mass within the
right hemipelvis adjacent to the sigmoid colon measuring 2.9 x
2.8 cm (2B:144) previously 6.8 x 4.7 cm.
*1.5 x 1.4 cm soft tissue nodule within the right gluteal
subcutaneous fat closer to the skin surface is slightly
increased
in size (2B:147) (previously 1.1 x
0.9 cm).
*peripherally enhancing 1.9 x 0.8 cm (previously 1.3 x
0.7 cm) (2B:151) within the left gluteus maximus muscle has
slightly increased in size.
*Lytic lesion within the T5 vertebral body is similar
compared to prior study. Stable chronic fracture involving the
inferior endplate of T5. No additional lytic or blastic osseous
lesions.
PAST MEDICAL HISTORY:
-Dilated Right Breast duct noted on breast U/S (___) at
___ and ___ MMG ___
showed dilated retroareolar ducts
-GERD
-Osteopenia
-Dyslipidemia
-Seizure ___ meropenem
-s/p tubal ligation and TAH for fibroid uterus
-s/p benign neck mass excision in ___
Social History:
___
Family History:
significant for 2 brothers, one of whom may have had an
intra-abdominal malignancy. There are no other family members
that she is aware of with cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3 140/82 100 18 100RA
GENERAL: elderly female, lying in bed, sleepy but uncomfortable
CARDIAC: RRR, no mrg, port without erythema
LUNG: CTA ___ anteriorly, patient unable to sit up for posterior
exam
ABDOMEN: soft, nt, nd
EXTREMITIES: no CCE, warmth and swelling present over R hip
NEURO: no focal deficits, no facial droop
SKIN: clean, dry, no rashes
DISCHARGE EXAM:
Vitals: Tm 98.6, Tc 97.8, 120/60 (112-151/54-76), 70 (70-98),
18, 100% RA
I/O: 940+3177/3800+, 3 BM
GENERAL: elderly female, lying in bed, NAD
CARDIAC: RRR, no mrg, port without erythema
LUNG: CTA ___
ABDOMEN: NABS, soft, nt, nd
EXTREMITIES: no CCE, Mild swelling present over R hip with 3
d/c/i bandages over R lateral thigh. 2+ DP pulses b/l.
NEURO: no focal deficits, no facial droop
SKIN: clean, dry, no rashes
Pertinent Results:
ADMISSION LABS:
___ 05:30AM GLUCOSE-128* UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
___ 05:30AM estGFR-Using this
___ 05:30AM WBC-9.3# RBC-3.70* HGB-10.6* HCT-32.4* MCV-88
MCH-28.6 MCHC-32.6 RDW-15.7*
___ 05:30AM NEUTS-80.0* LYMPHS-13.0* MONOS-5.5 EOS-1.3
BASOS-0.2
___ 05:30AM PLT COUNT-201
___ 04:50AM URINE HOURS-RANDOM
___ 04:50AM URINE HOURS-RANDOM
___ 04:50AM URINE UHOLD-HOLD
___ 04:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
PERTINENT LABS (CBC trend):
___ 05:30AM BLOOD WBC-9.3# RBC-3.70* Hgb-10.6* Hct-32.4*
MCV-88 MCH-28.6 MCHC-32.6 RDW-15.7* Plt ___
___ 06:04AM BLOOD WBC-5.8 RBC-3.62* Hgb-10.2* Hct-31.8*
MCV-88 MCH-28.2 MCHC-32.0 RDW-15.9* Plt ___
___ 06:42AM BLOOD WBC-6.7 RBC-3.28* Hgb-9.1* Hct-28.8*
MCV-88 MCH-27.8 MCHC-31.7 RDW-15.7* Plt ___
___:41AM BLOOD WBC-7.7 RBC-3.17* Hgb-8.8* Hct-27.9*
MCV-88 MCH-27.8 MCHC-31.6 RDW-15.9* Plt ___
___ 05:32AM BLOOD WBC-8.6 RBC-3.04* Hgb-8.5* Hct-26.4*
MCV-87 MCH-28.0 MCHC-32.2 RDW-16.1* Plt ___
___ 06:00AM BLOOD WBC-6.4 RBC-2.79* Hgb-8.0* Hct-24.4*
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.8* Plt ___
___ 06:00AM BLOOD WBC-6.4 RBC-2.79* Hgb-8.0* Hct-24.4*
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.8* Plt ___
Repeat U/A (obtained because pt felt urgency):
___ 01:10AM URINE Color-Straw Appear-Clear Sp ___
___ 01:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:10AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
DISCHARGE LABS:
___ 06:00AM BLOOD Glucose-165* UreaN-11 Creat-0.9 Na-141
K-4.1 Cl-110* HCO3-22 AnGap-13
___ 06:00AM BLOOD ALT-6 AST-12 AlkPhos-83 TotBili-0.2
___ 06:00AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0
MICROBIOLOGY:
Blood cultures pending at discharge
Urine Culture:
___ 1:10 am URINE Source: ___.
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
IMAGING:
CTA PELVIS:
IMPRESSION:
1. No thrombus detected in the pelvic veins.
2. Lytic lesion in the lesser trochanter of the right femur
compatible with metastasis with associated pathologic avulsion
fracture of the iliopsoas.
3. Interval enlargement of soft tissue nodules in the left
gluteus maximus muscle and right gluteal subcutaneous soft
tissues. The peripheral enhancing soft tissue nodule in the
right hemipelvis is unchanged.
CT CHEST (___):
1. Interval progression disease with increase in size of 2
pulmonary nodules as well as a left supraclavicular soft tissue
and left anterior abdominal wall nodule. Remaining pulmonary
nodules are stable.
CT ABDOMEN (___):
1. Overall mixed progression of disease since ___.
Interval increase in size of segment VI/VII hepatic lesion with
new hepatic lesion in segment VII. Right pelvic mass is slightly
smaller. Nodule in the left nephrectomy bed and left gluteal
nodule are unchanged. The right gluteal subcutaneous nodule was
not included in the imaging field and should be re-evaluated on
follow up studies.
2. Post-surgical changes after right femoral intramedullary rod
placement.
3. Unchanged T5 lytic lesion since ___. Avulsion fracture
at the right lesser trochanter.
Brief Hospital Course:
Ms. ___ is a ___ yo F with a history of metastatic
leiomyosarcoma presenting with lytic R hip lesion and associated
pathologic fracture of R iliopsoas.
ACTIVE DIAGNOSES:
#Intertrochanteric Hip fracture and Iliopsoas fracture: The
patient was found to have a lytic lesion related to metastatic
disease. Orthopedic surgery stabilized her right hip by placing
an intramedullary nail on ___. She tolerated the surgery quite
well without post-op complications. Pain was well controlled
with IV dilaudid initially, then low-dose oxycodone and standing
Tylenol. She was started on calcium and vitamin D. She will need
radiation to the lesion 2 weeks following surgery (around ___. The patient will need to call for an appointment with her
radiation oncologist.
#Leiomyosarcoma: The patient has disease which is metastatic to
the liver (biopsy-proven), lungs and bone (T5 lesion). She was
initiated on palliative doxil for which she has completed 3
cycles, last given ___. She subsequently underwent 20
cycles of pelvic radiation as her pelvic mass was persistent on
imaging. Following this, she was noted to have an enlarging
cystic mass of the frontal bone. For this lesion, she also
received radiation treatment per Dr. ___ was completed in
___. Patient was scheduled to restart doxil chemotherapy on
the day of admission, however this was slightly delayed given
her fracture. She received Doxil on ___.
# Anemia: The patient has slowly downtrending hematocrit during
her hospitalization, likely related to aggressive IV hydration
as well as minor blood loss from surgery. Her
hemoglobin/hematocrit on the day of discharge was 8.0/24.4. A
repeat CBC should be drawn on ___ and the patient should be
transfused if hemoglobin less than 7 or hematocrit less than 21.
She did NOT require transfusions while hospitalized.
# Urinary Urgency: The patient noted urgency on ___ so a repeat
U/A was obtained which showed only 1 WBC. Urine culture of that
specimen grew ___ colonies enterococcus. The patient's
symptoms had resolved at the time of urine culture result so
antibiotics were not given.
# Urinary Incontinence: The patient had a couple of episodes of
incontinence at the time she was receiving fluid boluses to
treat orthostatic hypotension related to poor PO intake in
immediate post-op period. Since she received chemotherapy on
___, a urinary catheter was placed to prevent leakage of
potentially toxic urine. Her catheter should be removed at rehab
on ___.
CHRONIC, INACTIVE DIAGNOSES:
#GERD: Stable. She should continue pantoprazole and ranitidine.
CODE: full
EMERGENCY CONTACT: Daughter: ___ ___
TRANSITIONAL ISSUES:
-Needs repeat CBC on ___ to ensure stability of hematocrit.
Tranfuse for hematocrit less than 21.
-Remove urinary drainage catheter on ___.
-Patient needs to call and schedule radiation to right hip
lesion around ___ (2 weeks after surgery)
-Patient will be contacted with a follow-up appointment with her
oncologist.
-Patient will need post-op anticoagulation with Lovenox. The
decision of when to discontinue this medication will be deferred
to her oncologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
2. Pantoprazole 40 mg PO Q24H
3. Polyethylene Glycol 17 g PO DAILY
4. Ranitidine 150 mg PO BID
5. Vitamin D 400 UNIT PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 1250 mg PO TID
2. Vitamin D 800 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #*15
Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY
10. Ranitidine 150 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Avulsion fracture of iliopsoas
SECONDARY:
-Metastatic leiomyosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at ___
___. You were admitted with right hip pain and found
to have a fracture of your hip. The orthopedic surgeons repaired
the fracture and stabilized your right leg to prevent fractures
in the future. You will receive radiation treatment to your
right leg about 2 weeks after your surgery date. You received a
dose of Doxil (chemotherapy) on ___.
Please see below for instructions from you orthopedic surgeons:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight Bearing as Tolerated.
- Range of motion as tolerated.
Followup Instructions:
___
|
10507647-DS-17 | 10,507,647 | 29,958,464 | DS | 17 | 2133-05-03 00:00:00 | 2133-05-06 23:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meropenem
Attending: ___.
Chief Complaint:
Bloody stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo ___ speaking female w/ widely
metastatic (including brain) leiomyosarcoma s/p 8 cycles of
palliative Doxil (most recent ___ with pRBC transfusion), 20x
pelvic radiation with mets to lung/liver/bone presenting with 2
days of BRBPR and passing clots with her stool.
She states over the past two weeks, she has been having a daily
fever of 100.6F at 6pm nearly nightly. She has noted decreased
appetite and stomach cramps w/ eating the past two days. She has
tolerated liquids well. SHe also notes a dry cough the past two
days. In addition, she notes a teaspoon amount of blood on her
stool. She moved her stools six times on ___ and four times
yesterday, all were solid and formed, and all painless. She did
not have any constipation or diarrhea preceding this. Denied any
black stools or any changes in her medication sor nsaid use.
In the ED, she was found to have a normal external rectal exam
without any active bleeding. She passed stool that was light
brown, formed, with blood clots. She was hemodynamically stable
___, HR ___, SBP 150s/70s, 100%RA). Found to have incidental
PNA
and received Levofloxacin 750 mg IV at 22:18 and 2L NS Bolus at
17:42 and 21:27 for the IV for CT.
Past Medical History:
ONCOLOGIC HISTORY:
-___: Outside hospital with a febrile illness in Initial
CT scan showed a large cystic mass within the left
retroperitoneum. She underwent percutaneous drainage on the
assumption that the lesion represented an abscess.
-Subsequent core needle biopsy: high-grade pleomorphic sarcoma
possibly a liposarcoma. Immunostaining at the time of initial
visit to ___ with Dr. ___ the lesion to be positive for
smooth muscle actin and negative for desmin.
-___: FDG-PET/CT scan: 9-cm FDG-avid mass was seen
within
the left retroperitoneum close to the kidney and colon. Stable
right apical abnormality likely chronic and inflammatory.
-5000 cGy of external beam radiotherapy by Dr. ___, and
finished on ___: Dr ___ en bloc resection of the
tumor with the adjacent left colon and kidney. Pathology
returned showing a 9-cm high-grade pleomorphic sarcoma involving
the colonic serosa and perinephric adipose tissue. All
surgical margins were negative.
**Pathology: high-grade pleomorphic lesion with features most
consistent with a leiomyosarcoma. (+)tumor for positive for
smooth muscle actin and desmin; negative stain on the core
biopsy.
-___: Postoperative FDG-PET/CT scan no clear-cut
evidence of metastasis or local recurrence. Diffuse uptake into
the thyroid with multiple hypodense nodules. Within the left
clavicular head, lucent area with a high SUV of 6. 1.3-cm
opacity between the rectus and transverse colon, which was FDG
avid. Within the nephrectomy bed, 1.9-cm lobulated collection
which was not FDG avid. Within the mid retroperitoneum, ovoid
area of fat stranding posterior to the duodenum with an SUV of
4.7. Within the left lower quadrant, she had a similar area
with
an SUV of 5. Most of these findings were thought to be
postoperative and representing probable evolving fat necrosis.
-___: Thyroid ultrasound a 2.5-cm left lower pole
heterogeneous nodule for which a FNA cytology was recommended.
In the right thyroid, she had two nodules measuring about 1.1-cm
each, for which a one-year followup study was recommended.
-___: Core needle biopsy of the left clavicular head.
**Pathology: bone with spindle cells showing quite a bit of
crush
artifact. Overall pathology was thought suggestive of
metastasis and stained positive for smooth muscle actin and
focally for caldesmon. Desmin negative.
-___: PET CT: Uptake in the left clavicular head has
decreased post biopsy. Uptake in the midline of the skull
anteriorly, not previous imaged is worrisome for metastasis. New
focus of uptake in a high right paratracheal lymph node.
Possible new sites of metastasis in the liver, the surgical bed,
and T6.
-___: MRI Abdomen: Ill-defined right hepatic mass within
segment VI corresponds to an FDG-avid lesion on the ___
examination, and appears new since the prior examination from
___, compatible with metastasis. Two right lower lobe
lung nodules, one appearing new, suspicious for metastases. No
tumor recurrence seen at the left nephrectomy site.
-___: Liver Biopsy:
**PATH: High grade sarcoma involving the liver, consistent with
patients previously diagnosed pleomorphic leiomyosarcoma.
Background liver parenchyma with portal mononuclear inflammation
and mild steatosis. By immunohistochemistry, the tumor cells are
positive for smooth muscle actin and caldesmon, focally positive
for desmin, and negative for MNF116 and S100.
-___:
*CT Chest/Abd/Pelvis:
-Persistent mild enlargement of the left thyroid lobe measuring
2 cm x 1.8 cm with cystic areas is unchanged from ___
-No supraclavicular, axillary, or hilar lymphadenopathy. FDG
avid enlarged paratracheal lymph node measures 1.5 cm x 1.5 cm
and is new from ___.
-Lung windows demonstrate stable right apical pleural scarring
There are multiple new bilateral rounded noncalcified
homogeneous
pulmonary nodules that are consistent with metastatic
disease;largest nodule measures 1 cm x 0.8 cm and is in the
basal segment of the right lower lobe
-lesions involving T5 and the left clavicular head are new from
___ and are FDG avid on PET. These are consistent
with metastatic disease
*CT Neck: No evidence for pathologic neck adenopathy.
*TTE: EF 55%. Mild MR
-___: CT Torso
*Slight interval increase in size of the right hepatic
metastasis
and pelvic mass.
*Stable size of the soft tissue nodule in the right nephrectomy
bed, right gluteal soft tissue nodule, left gluteal
intramuscular
nodule, left pelvic soft tissue nodule and prominent
retroperitoneal lymph node.
*Progression of the size of several pulmonary pre-existing
nodules. Other nodules are stable. No new nodules. Unchanged
appearance of the mediastinum. No pleural effusions. Unchanged
known osteolytic foci of T5 and left clavicle
-___: C3D1 of doxil
-___ to ___: 20 sessions ofXRT to pelvic mass Dr. ___
-___: CT C/A/P and Head
*Heterogeneous pelvic mass has decreased in size.
*Hepatic segment VII lesion, soft tissue nodule in the left
nephrectomy bed, and nodules in the left gluteus maximus muscle
and right gluteal subcutaneous fat are stable.
*Persistent lytic lesion in the T5 vertebral body with a new
fracture along the inferior endplate of T5.
*No new lesions are identified in the abdomen and pelvis.
*Stable pulmonary nodules consistent with metastatic disease. .
*New pathologic fracture at the inferior endplate of T5 with
unchanged underlying lytic lesion. The left clavicular head
lesion is also similar.
*Lytic lesion centered in the midline frontal bone with epidural
and subgaleal components, most likely a metastasis. Recommend
MRI
to evaluate for dural or parenchymal invasion
-___: MRI Head
*Mass in the frontal region involving the bone and extending to
the epidural space and also to the scalp soft tissues. The
superior sagittal sinus is displaced anteriorly or infiltrated
by
the mass with quesion intrinsic tumor thrombus. No parenchymal
metastatic lesions are identified. No midline shift is seen.
-___: 10 sessions of XRT to head lesion per Dr. ___
-___: CT Torso
*Several bilateral pulmonary nodules have increased in size
measuring 1.1 x 1.0 cm (3:279) (previously 0.9 x 0.9 cm);
1.7 x 1.1 cm (previously 0.9 x 1.0 cm) (3:210); 2.0 x 2.4 cm
(previously 1.2 x 1.1 cm) (3:66) within the right lower lobe,
superior segment of the right lower lobe and right
paramediastinal nodule. On the left, a 0.6 x 0.5 cm
(3:220) (previously 0.6 cm) within the left upper lobe, and 0.8
x
0.7 cm nodule (3:163) (previously 0.5 cm); within the left
upper
lobe.
*No filling defect to suggest pulmonary embolism
*Right lobe of the liver is approximately a 2.6 x 2.2 cm
(2B:102) (previously 3.0 x 1.8 cm) heterogeneously enhancing
lesion, which allowing for differences in technique and
positioning, is likely stable. No new hepatic lesions
*status post left nephrectomy with clips LLQ
*1.1 x 0.5 cm (previously 1.5 x 0.8 cm) (2B:105) soft tissue
lesion within the nephrectomy bed which has slightly decreased
in
size compared to prior study.
*Stable appearing 0.9 x 0.6 cm (previously 1.1 cm)
mesenteric lymph node (2B:124). No additional retroperitoneal
or
mesenteric lymph node enlargement.
*Interval decrease in a peripherally enhancing mass within the
right hemipelvis adjacent to the sigmoid colon measuring 2.9 x
2.8 cm (2B:144) previously 6.8 x 4.7 cm.
*1.5 x 1.4 cm soft tissue nodule within the right gluteal
subcutaneous fat closer to the skin surface is slightly
increased
in size (2B:147) (previously 1.1 x
0.9 cm).
*peripherally enhancing 1.9 x 0.8 cm (previously 1.3 x
0.7 cm) (2B:151) within the left gluteus maximus muscle has
slightly increased in size.
*Lytic lesion within the T5 vertebral body is similar
compared to prior study. Stable chronic fracture involving the
inferior endplate of T5. No additional lytic or blastic osseous
lesions.
PAST MEDICAL HISTORY:
-Dilated Right Breast duct noted on breast U/S (___) at
___ and ___ MMG ___
showed dilated retroareolar ducts
-GERD
-Osteopenia
-Dyslipidemia
-Seizure ___ meropenem
-s/p tubal ligation and TAH for fibroid uterus
-s/p benign neck mass excision in ___
Social History:
___
Family History:
significant for 2 brothers, one of whom may have had an
intra-abdominal malignancy. There are no other family members
that she is aware of with cancer.
Physical Exam:
ON ADMISSION
VS: 148/69 HR 101 RR 18 T 97.9
GEN: AOx3, NAD
HEENT: PERRLA. dry tongue, moist buccal gutter. no LAD. no JVD.
neck supple. No cervical, supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB B/L on anterior and posterior chest
Abd: Pain to palpation on light and deep toucn LUQ and LLQ, and
on light touch RUQ and RLQ. No rebound tenderness, no guarding.
normoactive bowel sounds.
Skin: no rashes or bruising
Neuro: ___ strength in U/L extremities B/L. paterllar reflex 2+
___. sensation intact to LT, gait deferred
ON DISCHARGE:
VS: 146/70 HR 100 RR 20 T 98.9
GEN: AOx3, NAD
HEENT: PERRLA. dry tongue, moist buccal gutter. no LAD. no JVD.
Neck supple. No cervical, supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB B/L on anterior and posterior chest; no crackles, no
egophony noted.
Abd: Pain improved on deep and light palpation over LLQ and RUQ;
no rebound tenderness or guarding. Normoactive bowel sounds.
Skin: no rashes or bruising
Neuro: ___ strength in U/L extremities B/L. paterllar reflex 2+
___. sensation intact to LT, sharp touch. Gait deferred
Pertinent Results:
ON ADMISSION
___ 05:15PM WBC-3.7* RBC-2.67* HGB-8.1* HCT-24.5* MCV-92
MCH-30.3 MCHC-33.1 RDW-19.9*
___ 05:15PM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.4
MAGNESIUM-2.0
___ 05:15PM NEUTS-74.8* LYMPHS-11.6* MONOS-9.3 EOS-3.8
BASOS-0.6
___ 05:15PM ___ PTT-29.5 ___
___ 05:15PM PLT COUNT-103*
ON DISCHARGE
___ 06:02AM BLOOD WBC-2.3* RBC-2.84* Hgb-8.0* Hct-25.3*
MCV-89 MCH-28.1 MCHC-31.6 RDW-22.5* Plt Ct-79*
___ 06:13AM BLOOD Neuts-79* Bands-0 Lymphs-7* Monos-10
Eos-1 Baso-0 ___ Metas-2* Myelos-1*
___ 06:02AM BLOOD Plt Ct-79*
MICROBIOLOGY
___ 6:01 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Preliminary):
SENT TO STATE LAB FOR FURTHER IDENTIFICATION ___.
___ 10:31 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
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.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___:
SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT.
Less than 2 ml received.
PLEASE SUBMIT ANOTHER SPECIMEN.
TEST CANCELLED, PATIENT CREDITED.
Reported to and read back by ___ ___ (___) ___ AT
3:30PM.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ND CHEST
FINDINGS:
Again seen is a mottled appearance of the known midline lytic
lesion of the
frontal bone. The osseous portion of the lesion appears grossly
stable in
comparison to prior head CT obtained ___. There has been
a mild
interval increase in the size of the associated extracranial
soft tissue
component in comparison to prior CT. There are no new lytic or
other osseous
lesion seen.
Otherwise, there is no evidence of acute intracranial
hemorrhage, brain edema,
recent infarction, or shift of normally midline structures.
There is no
ventriculomegaly. The visualized paranasal sinuses and mastoid
air cells are
clear. There is no evidence of fracture.
IMPRESSION:
1. Unchanged appearance of the osseous component of known lytic
lesion
involving the frontal bone. Mild interval increase in size of
associated
extracranial soft tissue component.
2. No new lytic lesions identified. No evidence of intracranial
hemorrhage or
brain edema.
___ CT ABD AND PELVIS
FINDINGS:
THORAX: There is a small right pleural effusion. There are
numerous pulmonary
nodules seen within the lung bases, increased in size and number
from ___.
LIVER: There is a 2.6 x 4.1 cm ill-defined lesion in segment VI
concerning
with metastatic disease, increased in size from prior exam
(2:22). An adjacent
small 1.3 x 0.7 cm ill-defined hypodensity likely represents a
new metastatic
focus (2:22). The portal and hepatic veins are patent, and
there is no intra
or extrahepatic biliary duct dilatation.
GALLBLADDER: The gallbladder is unremarkable and contains no
radiopaque
gallstones.
SPLEEN: The spleen is normal in size and shape.
PANCREAS: The pancreas enhances homogeneously without ductal
dilation or
peripancreatic fat stranding. A 3.0 x 2.5 cm heterogeneous
lesion along the
distal pancreas appears increased in size from ___
when it measured
2.4 x 2.7 cm (2:21).
ADRENALS: The adrenal glands are normal in size and shape.
KIDNEYS: The patient is status post left nephrectomy. The right
kidney has
appropriate contrast enhancement and excretion. There is no
hydronephrosis or
perinephric stranding. A small hypodense focus appears
unchanged in the right
mid pole.
BOWEL: The stomach is decompressed and not well evaluated. The
small bowel is
without obstruction or focal wall thickening. The large bowel
contains feces
without wall thickening or evidence of obstruction. There is
no
intraperitoneal free air or free fluid.
LYMPH NODES: There are no pathologically enlarged
retroperitoneal or
mesenteric lymph nodes by CT size criteria.
PELVIS: The bladder is relatively well distended without focal
wall
thickening. There is no pelvic free fluid. There are no
pathologically
enlarged pelvic sidewall or inguinal lymph nodes by CT size
criteria. Rectal
wall thickening is again noted (2:75). A right pelvic sidewall
soft tissue
lesion appears increased in size measuring 3.3 x 3.1 cm compared
to 2.7 x 3.4
cm (2:67). A right lateral subcutaneous soft tissue lesion is
only partly
imaged but was present before, in addition to what appears to
represent
post-operative changes in the area.
VESSELS & SOFT TISSUE: There is moderateatherosclerotic disease
without
aneurysmal dilatation of the abdominal aorta. The aorta and its
major branches
are patent. There are no hernias. A 1.1 x 0.7 cm soft tissue
nodule in the
left anterior abdomen wall appears increased in size (2:23).
Nodule in the
left gluteal muscle appears increased in size measuring 2.6 x
1.7 cm,
increased from 1.4 x 2.2 cm (2:79). A right mass in the
subcutaneous right hip
is not well seen on this exam (2:65).
BONES: The patient is status post ORIF of a right hip fracture.
There are no
suspicious lytic or sclerotic osseous lesions to suggest
malignancy.
IMPRESSION:
1. Increase in size and number of metastatic lesions as
described above with
new small hepatic segment VI metastatic focus.
2. Rectal wall thickening likely represents proctitis.
Recommend clinical
correlation.
3. New small right pleural effusion.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Ms. ___ is a ___ yo ___ speaking female w/ widely
metastatic (including brain) leiomyosarcoma s/p 8 cycles of
palliative Doxil (most recent ___ with pRBC transfusion), 20x
pelvic radiation with mets to lung/liver/bone presenting with 2
days of BRBPR and passing clots with her stool. She states over
the past two weeks, she has been having a daily fever of 100.6F
at 6pm nearly nightly.
#BRBPR: On admission patient was hemodynamically stable with a
hematocrit of 24.5 that dropped to 21 overnight from
___. Patient subsequently had transfusion of 1 uPRBC and
had a subsequent hematocrit of 24.4. CT iamging of abdomen
showed possible proctocolitis, and patient was started on
vancomycin and metronidazole, later narrowed to metronidazole
and levo. GI was consulted, and colonoscopy was considered but
patient declined stating her bowel movements started to look
better. Patient was kept on conservative management with a ppi
and mesalamine enemas, and on day of discharge had hematocrit of
25.3 with no active bleeding.
# Fevers: Patient had reoccuring fever of 100.6 at nights for
two weeks prior to admission. Urine cx and blood bx were sent
which were negative, however initial xhest x-ray was concerning
for pneumomonia (see below). Stool cultures were negative and C
Diff was negative. Fevers ultimately thought to be related to
infectious vs. radiation proctitis.
# Possible pneumonia on imaging: Initial CXR was concerning for
LUL infiltrates consistent with pneumonia. Given patient's
history of low grade fevers and night sweats, and her history of
immigration from ___, 3 X sputum was sent for AFB which all
came back negative. Repeat CT imaging of chest and neck showed
changes in upper lobe consistent with radiation pneumonitis
(after confirming prior radiation fields per radiation
oncology). Decision was made to empirically treat for
possibility of supraimposed infection on radiation pneumonitis
with levaquin.
# Proctitis: As above, CT imaging of abdomen showed proctitis.
Patient was started on ciprofloxacin and metronidazole and
vancomycin, later narrowed to metronidazole with levofloxacin as
above for possible pneumonia. Proctitis thought to be related to
radiation, but infection not r/o. Patient was also started on
mesalamine enemas per GI recommendations.
# Leiomyosarcoma: Patient had staging CT of chest and neck in
house, and CT of head. Patient to follow up with Dr. ___
___ staging CT scans.
Transitional Issues
# Empiric tx of supraimposed PNA: Pt d/ced on levofloxacin to
cover potential PNA and infectious proctitis (10 day course to
be completed on ___
# Proctitis: Pt d/c on metronidazole and levo as above for 10
day course (___)
# BRBPR: Will follow up with GI in ___ weeks; until then will
continue home mesalamine enemas and ppi
# Leiomyosarcoma: Will F/U with Dr. ___ as above.
# Please f/u AFB cultures and M.Tb PCR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO QAM
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. ___ 200-25-400-40 mg/30 mL mucous
membrane qid odynophagia
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Pantoprazole 40 mg PO QAM
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
4. Mesalamine (Rectal) ___ID
RX *mesalamine [Canasa] 1,000 mg 1 suppository(s) rectally twice
a day Disp #*56 Suppository Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times daily Disp #*21 Tablet Refills:*0
6. ___ 200-25-400-40 mg/30 mL mucous
membrane qid odynophagia
RX ___ [FIRST-Mouthwash BLM] 400
mg-400 mg-40 mg-25 mg-200 mg/30 mL 30ml four times a day
Refills:*0
7. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
COLITIS
METASTATIC LEIOMYOSARCOMA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were brought to the hospital because you had loose stools,
fevers and bloody bowel movements. At the hospital you were
closely monitored and your bloody bowel movements resolved. You
were seen by our gastroenterologists who suggested having a
scope of your bowel to find a site of bleeding, but given your
lack of bleeding you declined the procedure. On imaging,
proctitis (inflammation of the rectum) was noted, and we started
you on antibiotcs out of concern for infection. Proctitis may
also be related to previous radiation. In addition, imaging of
your lungs were intially concerning for pneumonia, but further
imaging was consistent with lung changes with radiation. As a
result, we are discharging you with antibiotics to treat the
inflammation in your rectum (metronidazole), and if present,
possible pneumonia (levofloxacin). We ask that you follow up
with Dr. ___ our gastroenterologists as directed.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10507925-DS-13 | 10,507,925 | 21,980,509 | DS | 13 | 2186-01-13 00:00:00 | 2186-01-13 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids / Bactrim DS
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
___ Femoral Central Line Placement (discontinued ___ PICC Line Placement
History of Present Illness:
___ with HHT, HFpEF, post-capillary pulmonary
hypertension, atrial fibrillation s/p mini-maze procedure and
left atrial appendage removal, recently admitted for acute on
chronic diastolic CHF, now readmitted with altered mental status
and epistaxis and AFib w/ RVR to 180s.
The patient was just recently discharged from ___ after an
admission from ___ for acute on chronic diastolic heart
failure. It seems that she was IV diuresed from 84.5kg on
admission to 76.7 kg on discharge. Despite this she still had
___ bilateral lower extremity edema at time of discharge.
Per report, the patient started having recurrent epistaxis and
darker stools earlier today. Her husband noticed that her mental
status was also worsened and she was more delirious. He brought
her to an OSH ED for evaluation for this. A CT Head at the OSH
showed no acute bleeding. CXR revealed a patchy infiltrate at
the left base for which she was started on Zosyn. She was found
to be in AFib with RVR to 180s for which she was started on a
diltiazem gtt and transferred to ___.
In the ED, initial vitals: T 98.0, 142, 121/77, 18, 97% RA
- Exam: Confused, tachycardic, non-labored respirations. Brown
guiaic positive stool. Dry blood in both nares. Digoxin level
0.3. Lactate 3.5.
- Labs: WBC 7.9k, Hgb 9.6 (was 10.7 at ___, s/p 1L IVF during
EMS transport), Cr 2.1 (up from 1.8)
- Patient was started on amiodarone gtt for inadequate rate
control on diltiazem gtt. This had a good effect. Dilt gtt as
discontinued. A femoral CVL was also placed for access given
that she only had 1 PIV.
On arrival to the MICU, the patient is unable to provide
additional significant history due to confusion.
Past Medical History:
1. Hereditary hemorrhagic telangectasia, diagnosed age ___ in
setting of new epistaxis and skin telangiectasias, no hepatic
AVMs on prior ultrasound. s/p several laser photocoag for
epistaxis.
2. Atrial fibrillation s/p multiple DCCV and s/p Maze/PVI with
___ resection ___, with recurrence now maintained on
amiodarone, no anticoagulation due to epistaxis
3. Right heart failure with preserved ejection fraction
4. Diffuse pulmonary cysts of unknown etiology
5. Mild combined obstruction and restriction by PFTs
6. Hypertension
7. Asthma
8. Localized melanoma of LLE (negative LNs) s/p resection in
___ c/b lymphedema and multiple skin SCCs on LLE
9. Fe deficiency anemia
10. s/p R total knee replacement in ___
Social History:
___
Family History:
Adopted and has no children. Family history unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T 98.4, 127, 120/63, 26, 100% on RA
GENERAL: Alert, oriented x2 (knows place and self, not time),
perseverating, resting tremor.
HEENT: Sclera anicteric, MMM, oropharynx clear without blood in
posterior oropharynx but does have telangiectasias over roof of
mouth and lips.
NECK: supple, JVP elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, irregular 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+ bilateral lower extremity edema
NEURO: ___ strength in UEs and ___
DISCHARGE PHYSICAL EXAM:
=========================
Vitals 97.7 HR 102 BP 108/52 97-100 RA
Length of Stay Fluid Balance: -1.1 L, Discharge Weight: 81.0kg
(standing)
GEN: A&Ox3 but with slow responses to questions (dramatically
improved from admission though, no longer perseverating).
CV: Tachycardic, irregular rhythm.
LUNGS: Clear to auscultation.
EXT: ___ pitting edema to level of thighs bilaterally, chronic
L>R edema.
Pertinent Results:
ADMISSION LABS:
===================
___ 10:00PM BLOOD WBC-7.9# RBC-4.02 Hgb-9.6* Hct-33.0*
MCV-82 MCH-23.9* MCHC-29.1* RDW-31.8* RDWSD-88.7* Plt ___
___ 10:00PM BLOOD Neuts-66.6 Lymphs-14.7* Monos-18.0*
Eos-0.0* Baso-0.3 NRBC-0.3* Im ___ AbsNeut-5.25
AbsLymp-1.16* AbsMono-1.42* AbsEos-0.00* AbsBaso-0.02
___ 10:00PM BLOOD ___ PTT-25.7 ___
___ 10:00PM BLOOD Glucose-143* UreaN-65* Creat-2.1* Na-139
K-4.1 Cl-101 HCO3-20* AnGap-22*
___ 10:00PM BLOOD Calcium-9.7 Phos-3.9 Mg-2.0
PERTINENT LABS:
=========================
___ 05:45AM BLOOD CK-MB-4 cTropnT-0.02*
___ 04:35PM BLOOD CK-MB-4 cTropnT-0.04*
___ 10:44PM BLOOD CK-MB-3 cTropnT-0.03*
___ 05:45AM BLOOD ALT-27 AST-35 LD(LDH)-266* CK(CPK)-40
AlkPhos-332* TotBili-1.3
___ 11:57PM BLOOD ___ pO2-56* pCO2-28* pH-7.51*
calTCO2-23 Base XS-0 Intubat-NOT INTUBA
___ 05:45AM BLOOD TSH-2.2
___ 05:45AM BLOOD Digoxin-0.7*
___ 10:06PM BLOOD Lactate-3.5*
___ 05:08AM BLOOD Lactate-2.2*
___ 04:34PM BLOOD Glucose-141* Lactate-3.6* Na-134 K-3.5
___ 09:55PM BLOOD Lactate-1.9
___ 05:21AM BLOOD Lactate-1.5
DISCHARGE LABS:
===============
___ 05:34AM BLOOD WBC-5.4 RBC-3.26* Hgb-8.0* Hct-27.4*
MCV-84 MCH-24.5* MCHC-29.2* RDW-30.5* RDWSD-88.3* Plt ___
___ 05:34AM BLOOD Glucose-79 UreaN-31* Creat-1.1 Na-132*
K-4.3 Cl-100 HCO3-23 AnGap-13
CARDIOVASCULAR:
===============
___ EKG: Atrial fibrillation with rapid ventricular response
rate of 131 beats per minute. Early R wave transition.
Non-specific ST segment flattening diffusely consistent with
possible rate-related ischemia. Clinical correlation is
suggested. Compared to the previous tracing of ___ the
ventricular rate is markedly faster and the ST-T wave changes
are more pronounced.
___ ECHO: The left atrium is moderately dilated. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (biplane EF 85%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal biventricular cavity sizes and preserved regional with
hyperdynamic global biventricular systolic function. Borderline
pulmonary artery systolic hypertension. Biatrial enlargement. No
valvular pathology or pathologic flow identified.
Compared with the prior study (images reviewed) of ___,
the severity of tricuspid regurgitation is now slightly reduced.
IMAGING:
==========
___ EEG: This telemetry captured no pushbutton activations.
It showed a slow and disorganized background throughout,
indicative of a widespread
encephalopathy. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of prominent focal slowing, but encephalopathies may obscure
focal findings. There were no epileptiform features or
electrographic seizures.
___ ___ U/S:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ MRI/MRA Brain:
Interpretation of the study is limited by motion artifact.
There is no
evidence of hemorrhage, edema, masses, mass effect, midline
shift or
infarction. Multiple foci of subcortical and periventricular
white matter
hyperintensity that is nonspecific but is most likely related to
chronic small vessel ischemic disease. There is prominence of
the ventricles and sulci suggestive involutional changes.
MRA brain: Limited evaluation of the intracranial vertebral and
internal
carotid arteries and their major branches appear normal without
evidence of stenosis, occlusion, or aneurysm formation.
MRA neck:
Limited evaluation of the imaged cervical portions of the
vertebral arteries appear patent without stenosis. No carotid
stenosis by NASCET criteria.
IMPRESSION:
1. No acute intracranial hemorrhage or ischemia.
2. Limited evaluation of the intracranial vertebral, internal
carotid arteries and their major branches appear normal without
evidence of stenosis.
3. Limited evaluation of cervical portions of the vertebral and
carotid
arteries appear patent. No carotid stenosis by NASCET criteria.
___ CXR:
Right PICC terminates in low SVC. Prominent pulmonary vessels
are similar to before. There is no consolidation, pneumothorax,
or large pleural effusion. Moderately enlarged cardiac
silhouette is similar to before
Brief Hospital Course:
Mrs. ___ is a ___ female with ___
syndrome (HHT), HFpEF, chronic atrial fibrillation not on AC due
to recurrent bleeding issues who presented with AMS and AF with
high ventricular rates, managed in the MICU at ___.
#Encephalopathy: Patient initially presented with word finding
difficulty of sudden onset Neurology was consulted, with no
evidence of acute stroke found on CT and MRI. EEG without
evidence of seizures. Neurology felt that the etiology was
toxic/metabolic. Cardiology/EP was also consulted and felt that
the combination of new digoxin therapy and ___ may be
responsible for her altered mental status (i.e. digoxin
toxicity). Digoxin level was within the therapeutic range,
however this does not preclude toxic effects or altered mental
status from this medication. Digoxin was therefore discontinued.
Her mental status did improve over the course of several days.
#Atrial Fibrillation with Rapid Ventricular Rate: She was
initially placed on a diltiazem drip which she did not respond
to. She was then started on amiodarone for anti-arrhythmic but
was stopped in light of her chronic atrial
fibrillation and inability to anticoagulate. Once she was
tolerating PO, she was resumed on metoprolol tartrate 12.5 mg
every 6 hours, limited by hypotension as below. Per EP
recommendations, the team also discontinued digoxin as it could
have potentially led to neurological changes as above, even in
the setting of a normal digoxin level.
#HFpEF / RV Dysfunction c/b ___ edema: Chronically decompensated.
Did not diurese this admission due to hypotension requiring
levophed (started midodrine and let her run net positive for
this with good effect). On day of discharge, restarted diuretics
at substantially lower dose than pre-admission. She will need
close follow up in ___ clinic with Dr ___.
#Hypotension: Patient was persistently hypotensive during her
course of care, requiring initially pressor support, which was
difficult to wean off. She was started on midodrine 10mg Q8H
with improvement.
#Acute Kidney Injury on CKD: Cr 2.1 on admission. Improved with
temporarily holding diuresis. Cr 1.1 on discharge. Diuretics
restarted at lower dose on discharge.
#Reported Epistaxis/Dark stool: CBC stable, no active bleeding
noted during her course.
TRANSITIONAL ISSUES:
=======================
-Discharge Weight: 81.0 kg ("driest" weight tolerated thought to
be ~77kg - still has 2+ pitting edema bilaterally at this weight
but limited by kidney dysfunction and hypotension)
-Discharge creatinine: 1.1
-Discharge diuretic regimen: Torsemide 100mg PO qday
-New Medications: Midodrine 10 mg q8 for hypotension
-Discontinued Medications: Digoxin 0.0652 mg PO daily,
Spironolactone 100mg daily, Metolazone 2.5 mg PO 3/week PRN
weight gain, Metoprolol Succinate XL 50 mg QHS with 25 mg QAM
-Please monitor patient's STANDING weight DAILY and call her
heart failure team (Tel: ___ if her weight changes by
more than 1.5kg in either direction.
-Please check a CBC and complete metabolic panel every 3 days
(starting on ___. Please fax results to Dr. ___
___ (Fax: ___.
-Patient has PICC in place, placed due to difficult access and
need for frequent lab draws. Recommend keeping this during rehab
stay while we monitor response to diuretic therapy. Please
remove at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO QHS
2. Metoprolol Succinate XL 25 mg PO QAM
3. Estrogens Conjugated 0.625 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Potassium Chloride (Powder) 40 mEq PO TID
7. Torsemide 100 mg PO BID
8. Calcium Carbonate 500 mg PO QID:PRN heartburn
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. MedroxyPROGESTERone Acetate 5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Digoxin 0.0625 mg PO DAILY
14. Spironolactone 100 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Oxymetazoline 1 SPRY NU PRN nosebleeds
17. Metolazone 2.5 mg PO 3X/WEEK:PRN Weight Gain
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO Q6H
2. Midodrine 10 mg PO Q8H
3. Torsemide 100 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Levothyroxine Sodium 25 mcg PO DAILY
9. MedroxyPROGESTERone Acetate 5 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Oxymetazoline 1 SPRY NU PRN nosebleeds
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
You were admitted to ___ with altered mental status. We
believe this was due to a recent medication addition (digoxin).
This medication was discontinued and you slowly had improvement
of your mental status.
While you were admitted we made several changes to your
medications. It is very important that you weigh yourself every
morning and call your cardiologist (Dr. ___ if your weight
changes by more than 2 kg from your discharge weight of 81.0 kg.
It was a pleasure to take care of you during your stay.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10507925-DS-15 | 10,507,925 | 23,398,003 | DS | 15 | 2186-05-29 00:00:00 | 2186-05-30 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids / Bactrim DS /
lidocaine
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ with PMH HHT, HFpEF, post-capillary pulmonary hypertension,
atrial fibrillation s/p mini-maze procedure and left atrial
appendage removal, who presented with 1 day of AMS and word
finding difficulties.
The patient was unable to give any meaningful history, although
she was oriented to self in the ED and denied any complaints,
including chest/belly/head/joint pain, dyspnea, fevers,
nausea/vomiting.
Per husband's report, she was in normal state of health until
this morning when she was having difficulty following commands.
She was redirectable but noticed that several times she almost
walked into the wall and had difficulty finding where she was
going. She also had word finding difficulties. She had a similar
episode in ___ also with word finding difficulties and was
admitted to the ICU but no obvious etiology was found. Her
husband called EMS and she was transported first to the OSH ED
before being transferred to ___.
Her husband also reports that she has been slow to respond and
complete tasks since her last admission in ___.
In the ED, initial vitals: 98.3 99 106/71 12 97% RA. She was in
afib with RVR with rates 93-130.
Labs were significant for: absence of leukocytosis, baseline
anemia, mild ___ (creatinine 1.6, baseline 1.3-1.5). Urine tox
positive for oxycodone
Imaging was significant for: CXR with moderate pulmonary edema,
CT with apparent filling defect in the right transverse and
sigmoid sinus concerning for venous thrombosis but MRV negative
She received 100mg IV Lasix and 5mg IV metoprolol X 2
On arrival to the MICU, she was intubated and no longer sedated.
She was moving all extremities spontaneously but not following
commands.
Past Medical History:
1. Hereditary hemorrhagic telangectasia, diagnosed at age ___ in
setting of new epistaxis and skin telangiectasias, no hepatic
AVMs on prior ultrasound. s/p several laser photocoag for
epistaxis.
2. Atrial fibrillation s/p multiple DCCV and s/p Maze/PVI with
___ resection ___, with recurrence, no
anticoagulation due to epistaxis
3. Right heart failure with preserved ejection fraction
4. Diffuse pulmonary cysts of unknown etiology
5. Mild combined obstruction and restriction by PFTs
6. Hypertension
7. Asthma
8. Localized melanoma of LLE (negative LNs) s/p resection in
___ c/b lymphedema and multiple skin SCCs on LLE
9. Fe deficiency anemia
10. s/p R total knee replacement in ___
11. postcapillary pulmonary hypertension
Social History:
___
Family History:
Adopted and has no children. Family history unknown.
Physical Exam:
Admission Physical Exam:
========================
Vitals: 98.6 121 ___ 94% PSV
GENERAL: Sedated
HEENT: Sclera anicteric, MMM
LUNGS: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: Tachycardic, irregularly irregular, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended
GU: Foley in place
EXT: Warm, well perfused, b/l lower extremity edema L > R
SKIN: No lesions.
NEURO: Sedated, not following commands. Moving all extremities
equally
ACCESS: PIVs
Discharge Physical Exam:
========================
Vitals:97.9 PO 106/68 L Sitting ___ RA
I/O: 800/350+2BM (24hr); 680/660 (8 hr)
GENERAL: Lying flat in bed, no apparent distress.
HEENT: Sclera anicteric, dry mucous membranes, telangiectasias
over oropharynx and tongue
CV: mildly tachycardic, irregularly irregular rhythm, no
murmurs, gallops. JVP difficult to assess, ~7 cm
LUNGS: Fine bibasilar crackles, otherwise clear to auscultation,
no wheezes, rales.
ABD: soft, non-tender, non-distended, +BS
EXT: Warm, well perfused, 1+ b/l lower extremity edema
SKIN: area of erythema on RUE resolved. Nontender, not warm, not
raised, no lesions/vesicles.
NEURO: CN II-XII intact Resting tremor in both hands noted. Mild
asterixis. AAOx3. Has difficulty with days of week backwards
Pertinent Results:
Admission Labs:
===============
___ 01:10PM BLOOD WBC-4.8 RBC-3.95 Hgb-8.7* Hct-30.1*
MCV-76*# MCH-22.0*# MCHC-28.9* RDW-22.6* RDWSD-60.3* Plt ___
___ 01:10PM BLOOD Neuts-69.7 Lymphs-15.6* Monos-13.9*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-3.31 AbsLymp-0.74*
AbsMono-0.66 AbsEos-0.02* AbsBaso-0.01
___ 01:10PM BLOOD ___ PTT-27.2 ___
___ 02:29AM BLOOD ___ 11:15AM BLOOD Parst S-NEGATIVE
___ 03:35AM BLOOD Ret Aut-3.0* Abs Ret-0.12*
___ 01:10PM BLOOD Glucose-100 UreaN-54* Creat-1.6* Na-136
K-4.7 Cl-98 HCO3-22 AnGap-21*
___ 01:10PM BLOOD ALT-28 AST-30 AlkPhos-390* TotBili-1.9*
___ 03:35AM BLOOD ALT-30 AST-75* LD(LDH)-666* AlkPhos-372*
TotBili-2.3* DirBili-0.7* IndBili-1.6
___ 11:15AM BLOOD ALT-26 AST-33 LD(LDH)-253* AlkPhos-353*
TotBili-2.7* DirBili-1.2* IndBili-1.5
___ 01:10PM BLOOD proBNP-1136*
___ 01:10PM BLOOD Lipase-67*
___ 01:10PM BLOOD Albumin-3.6 Calcium-9.4 Mg-2.7*
___ 03:35AM BLOOD VitB12-___ Hapto-142
___ 03:35AM BLOOD TSH-4.7*
___ 03:40PM BLOOD T4-7.3
___ 01:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:23PM BLOOD Lactate-2.2*
Microbiology:
Lyme and Anaplasma serologies negative
RPR negative
Imaging:
========
___ OSH CT Head Reread:
Apparent filling defect in the right transverse and sigmoid
sinus, with some residual flow seen, may represent an acute or
chronic nonocclusive thrombus. Consider MRV for further
characterization.
___ CXR:
Enteric tube courses below the diaphragm, terminating in the
left upper
quadrant in the expected location of the stomach. Endotracheal
tube is not well assessed on this study, terminates above the
carina, but possibly just 2 cm above the carina. Cardiac
silhouette is moderately enlarged. Mediastinum is somewhat
prominent. There is moderate pulmonary edema. No large pleural
effusion is seen although small pleural effusion is difficult to
exclude.
___ MRV:
No evidence of dural venous sinus thrombosis. No filling defect
in the right transverse and sigmoid venous sinus as seen on the
prior CT examination, and this may have been artifactual. If
there is continued clinical concern, routine gadolinium-enhanced
MR of the head with MP-RAGE sequence would be definitive.
___ EEG:
This is an abnormal continuous ICU EEG monitoring study because
of diffuse background slowing indicative of a moderate
encephalopathy which is etiologically nonspecific. There are no
epileptiform discharges or electrographic seizures.
___ RUQ US:
Recommend multi phasic CT or MRI for further evaluation for
hepatic AVMs.
___ CT Abd/Pelvis w/ Contrast:
Innumerable arteriovenous shunts in the liver, consistent with
HHT. Few shunts in the pancreas. Suggestion of cirrhosis. Few
lesions in the liver have faster washout compared with
surrounding hepatic parenchyma on delayed images, largest lesion
measuring 4 cm, MRI recommended to exclude HCC.
There are small hepatic, splenic artery aneurysms. Suggestion
of small aneurysm adjacent to the pancreatic uncinate process.
Markedly enlarged right heart. Mild pleural effusions. Small
volume ascites.
Indeterminate enhancing lesion adjacent to the left kidney, has
decreased since ___.
Mild thickening of the rectosigmoid, with adjacent inflammatory
changes, consider inflammatory or infectious etiology.
Marked wall thickening of the contracted gallbladder,
differential considerations include systemic causes, including
edema, hypoproteinemia, reactive changes secondary to underlying
hepatic abnormalities, acute or chronic cholecystitis are less
likely unless clinically suspected.
Moderate compression of L1 vertebral body, it has worsened since
___.
Air within bladder, may be related to recent bladder
instrumentation ; if instrumentation was not performed, consider
infection, bladder enteric fistula.
Discharge Labs:
===============
___ 05:08AM BLOOD WBC-4.7 RBC-3.72* Hgb-8.3* Hct-29.4*
MCV-79* MCH-22.3* MCHC-28.2* RDW-25.8* RDWSD-70.0* Plt ___
___ 05:08AM BLOOD ___ PTT-29.5 ___
___ 05:08AM BLOOD Glucose-84 UreaN-21* Creat-1.2* Na-139
K-3.5 Cl-104 HCO3-21* AnGap-18
___ 05:08AM BLOOD ALT-36 AST-39 AlkPhos-570* TotBili-1.4
___ 05:08AM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.9 Mg-2.1
Pending at Discharge:
=====================
___ 05:08AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
___ 08:21AM BLOOD AMA-PND
___ 08:21AM BLOOD ___
___ 05:08AM BLOOD IgG-PND IgM-PND
Brief Hospital Course:
___ with PMH HHT, HFpEF, post-capillary pulmonary hypertension,
atrial fibrillation s/p mini-maze procedure and left atrial
appendage removal, who presented with 1 day of AMS and word
finding difficulties.
# Altered mental status: word finding difficulties, confusion,
likely subacute with acute worsening. Had very similar
presentation in ___ with unknown etiology. CT, CTA, and
MRV were without evidence of acute intracranial pathology. She
had no fevers or leukocytosis suggestive of infection. RPR and
B12 were normal. TSH was mildly elevated but T4 was normal.
There was some concern for tick borne illness given indirect
hyperbilirubinemia and elevated LDH suggestive of possible
hemolysis but Anaplasma and Lyme serologies and Babesia smear
were all negative. EEG was consistent with non-specific
encephalopathy. She underwent a RUQ US to further evaluate
hyperbilirubinemia which was notable for possible hepatic AVMs.
She then underwent a CT Abd/Pelvis for further evaluation, which
was notable for multiple hepatic AVMs and likely cirrhotic
liver. There was some concern that she may have hepatic
encephalopathy, worsened by underlying hepatic disease from from
hepatic AVMs causing decreased clearance of opioids in setting
of recent increase in dose. She was started on lactulose and
rifaximin and home opioids were held with resulting improvement
in mental status. Of note, lactulose is titrated to ___ BM/day
due to decreased mobility and risk of fall.
# Cirrhosis/hepatic AVMs: CT abdomen with multiple hepatic AVMs
and likely cirrhotic liver. She was evaluated by hepatology who
felt that diagnosis of cirrhosis was not definitive given lack
of nodular liver on CT and no evidence of portal hypertension.
They recommended lactulose and rifaximin. Hematology was
consulted for consideration of possible Avastin therapy for AVM
management given high output heart failure and liver changes. A
multidisciplinary conversation was had with all outpatient
specialist providers to help come up with a unified
recommendation regarding the use of Avastin v consideration of
heart-liver transplant in this patient, which is to be continued
in the outpatient setting.
# Hypoxic respiratory failure: intubated for MRV due to altered
mental status and agitation. Extubated the following morning.
She had evidence of pulmonary edema on CXR and was diuresed with
IV Lasix boluses and torsemide. Restored to home dose of
diuretics. Grossly euvolemic at discharge.
# Acute on chronic diastolic CHF/high output heart failure: LVEF
in ___ 85%, consistent with high output secondary to AVMs.
CXR with moderate pulmonary edema, creatinine slightly above
baseline likely cardiorenal. She was diuresed with IV Lasix
boluses
# ___: creatinine 1.6 on admission, likely cardiorenal. Improved
to 1.1 with diuresis, 1.2 at discharge.
# Atrial Fibrillation s/p mini maze procedure, left atrial
appendage removal: in afib with RVR on presentation. Continued
home metoprolol fractionated
# Anemia: has a history of pulmonary AVM and is followed for GI
telangiectasia. B12 was normal. Iron studies were consistent
with iron deficiency anemia. Continued home iron
CHRONIC ISSUES:
# Hypothyroidism: continued home synthroid
# Asthma: continued home fluticasone
# HHT: initially held home estrogen and medroxyprogesterone
given thrombotic risk while hospitalized, then restarted prior
to discharge
# Hypotension: unclear etiology.Continued home midodrine
TRANSITIONAL ISSUES:
====================
[ ] Medication changes:
- STARTED lactulose 30 ml daily and Rifaximin 550 mg BID
- HOLDING opioid medications at discharge until follow-up
outpatient. OK to give up to 2g Tylenol daily I/s/o liver
disease
[ ] Follow-up:
- With Liver clinic (Dr. ___ Dr. ___
- With Hematology (Dr. ___
- With Pulmonology (Dr. ___, Cardiology ___
___
- With PCP after discharge from rehab
[ ] We suggest that you consider seeing an ___ doctor. There is
an HHT center at ___, which you can reach at ___.
Alternatively, there is an ___ GI specialist at ___
___: Dr ___.
[ ] CT abdomen/pelvis revealed several lesions in the liver with
faster washout
compared with surrounding hepatic parenchyma on delayed images,
largest lesion
measuring 4 cm. Difficult to interpret in setting of AVMs, thus
MRI recommended to exclude HCC.
[ ] Obtain Chem7 on ___ and replete electrolytes as needed.
# Communication/HCP:husband ___
# Code: Full, assumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Midodrine 10 mg PO TID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Estrogens Conjugated 0.625 mg PO DAILY
5. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
6. Vitamin D 1000 UNIT PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
9. MedroxyPROGESTERone Acetate 5 mg PO DAILY
10. Metolazone 2.5 mg PO DAILY:PRN fluid retention
11. Metoprolol Succinate XL 75 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe
14. Potassium Chloride 40 mEq PO DAILY
15. Spironolactone 50 mg PO DAILY
16. Torsemide 40 mg PO QAM
17. Torsemide 100 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Lactulose 30 mL PO DAILY
Take lactulose daily or twice daily as needed for a minimum of 1
BM
3. Rifaximin 550 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Levothyroxine Sodium 25 mcg PO DAILY
9. MedroxyPROGESTERone Acetate 5 mg PO DAILY
10. Metolazone 2.5 mg PO DAILY:PRN fluid retention
11. Metoprolol Succinate XL 75 mg PO BID
12. Midodrine 10 mg PO TID
13. Omeprazole 20 mg PO DAILY
14. Potassium Chloride 40 mEq PO DAILY
15. Spironolactone 50 mg PO DAILY
16. Torsemide 40 mg PO QAM
17. Torsemide 100 mg PO QPM
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Severe This medication was held. Do not restart OxyCODONE
(Immediate Release) until your outpaitent doctors think it's
safe to dc
20. HELD- TraMADol 50 mg PO Q12H:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until your doctor
restarts it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
TOXIC METABOLIC ENCEPHALOPATHY
SECONDARY:
==========
HEREDITARY HEMORRHAGIC TELANGIECTASIAS
CHRONIC HEART FAILURE WITH PRESERVED EJECTION FRACTION
ATRIAL FIBRILLATION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure being a part of your care during your
hospitalization at ___!
Why were you hospitalized?
-Because you woke up very confused
What was done for you this hospitalization?
-You came in transfer from an outside hospital. Imaging of your
head at this hospital was concerning for a clot in one of the
veins in your head. Thus, when you came here we had to do a scan
called MRV. Because you were agitated from your confusion and
ongoing illness, you had to be intubated for the procedure. Your
scan did not show any clots or other concerning processes in
your brain.
-Neurology was consulted, and they found that your confusion is
due to encephalopathy, which is a diffuse process, rather than a
stroke, blood clot, or seizures.
-Because your liver tests were elevated, we obtained images of
your liver which showed many arteriovenous malformations as a
result of your HHT.
-We think that your confusion was due to increased dose of pain
medication that was not cleared well by your liver due to
underlying changes.
-We asked our liver doctors to ___, and they recommended
that you take two new medications, lactulose and rifaximin, to
help with the confusion
-We also involved Hematology and all your other outpatient
specialists in a discussion regarding how to best manage your
HHT given that it has shown effects in your heart and your
liver. This discussion will continue in clinic in the coming
months.
What should you do when you leave the hospital?
-Continue working on getting stronger at rehab!
-Follow up with the Liver and Hematology doctors
-___ suggest that you consider seeing an HHT doctor. There is an
HHT center at ___, which you can reach at ___.
Alternatively, there is an HHT GI specialist at ___
___: Dr ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10507969-DS-8 | 10,507,969 | 20,550,264 | DS | 8 | 2186-11-26 00:00:00 | 2186-12-29 13:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
atenolol / Labetalol / Toprol XL / Zestril
Attending: ___.
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
Left hand suturing (done at outside hospital)
History of Present Illness:
___ year old M, history of bipolar disease, who presents with abd
pain, s/p fall. Patient had a mechanical fall yesterday while
walking up to stairs. He struck his left side and left thorax.
He
was seen at OSH and CT head and c spine was done and facial fx
were seen. Steri-Strips to left eyebrow. He has multiple
stitches
to left hand. Bilateral knee abrasions.
CT chest with Mildly displaced left anterior fifth through
seventh acute rib fractures. CT head at OSH with facial
fractures. ENT at OSH saw patient and said non op.
Past Medical History:
HYPERTENSION
DIVERTICULOSIS
DEPRESSION
HYPERGLYCEMIA
ANEMIA
PROSTATE CANCER
MALE ERECTILE DISORDER
MICROSCOPIC HEMATURIA
CHRONIC MYELOMONOCYTIC LEUKEMIA
Physical Exam:
Admission Physical Exam:
Constitutional: NAD
HEENT: Left eyebrow with Steri-Strips in place
Resp: CTAB
Cardiovascular: RRR
Chest: Left lower rib crepitus
Abd: Soft, Nondistended, left upper quadrant abdominal
tenderness
GU: No costovertebral angle tenderness
MSK: Sutures to left hand. Bilateral knee abrasions, full knee
range of motion without point tenderness. Full strength and
sensation in both lower extremities. No midline C-spine
tenderness.
Skin: No rash, Warm and dry
Neuro: Alert and oriented to person, place, and time. Moving all
extremities.
Discharge Physical Exam:
VS: 98.4, 121/72, 88, 18, 94 Ra
Resp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding
Wound: [] incisions clean, dry, intact
Ext: [x] warm, [] tender, [] edema
Gen: A&O x3. sitting up in chair
Pertinent Results:
___ 04:53AM BLOOD WBC-16.5* RBC-4.49* Hgb-12.8* Hct-38.9*
MCV-87 MCH-28.5 MCHC-32.9 RDW-16.1* RDWSD-50.2* Plt ___
___ 05:30AM BLOOD WBC-15.9* RBC-4.40* Hgb-12.4* Hct-38.0*
MCV-86 MCH-28.2 MCHC-32.6 RDW-15.9* RDWSD-49.6* Plt ___
___ 06:17PM BLOOD WBC-18.8* RBC-4.28* Hgb-12.2* Hct-36.9*
MCV-86 MCH-28.5 MCHC-33.1 RDW-16.0* RDWSD-49.3* Plt ___
___ 04:53AM BLOOD Glucose-105* UreaN-17 Creat-1.0 Na-139
K-4.2 Cl-94* HCO3-30 AnGap-15
___ 05:30AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-137
K-3.3* Cl-97 HCO3-27 AnGap-13
___ 06:17PM BLOOD Glucose-100 UreaN-22* Creat-1.1 Na-138
K-4.2 Cl-99 HCO3-25 AnGap-14
___ 04:53AM BLOOD Calcium-9.8 Phos-3.2 Mg-1.9
___ 05:30AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.7
CT chest with Mildly displaced left anterior fifth through
seventh acute rib fractures. CT head at OSH with facial
fractures. ENT at OSH saw patient and said non op.
CT head: No gross CT evidence of acute intracranial pathology.
Left zygomatic-maxillary complex fracture.
CT C-spine: Degenerative cervical spine disease. No acute
cervical spine pathology identified.
Brief Hospital Course:
___ year old M s/p mechanical fall with rib and face fractures.
He was seen by plastics who recommended non-operative management
in the acute phase and follow-up in ___ weeks. They also
recommended sinus precautions. Ophthalmology was consulted for
the orbital wall fracture and did not find anything concerning
on exam. They recommended repeat ophthalmology exam in 2 weeks
and augmentin for 7 days. The patient was admitted for pain
control and ___ evaluation. ___ cleared him for discharge
home with services for home ___ evaluation.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Medications - Prescription
DIVALPROEX [DEPAKOTE] - Depakote 500 mg tablet,delayed release.
2
tablet(s) by mouth daily - (Prescribed by Other Provider)
LOSARTAN-HYDROCHLOROTHIAZIDE - losartan 100
mg-hydrochlorothiazide 25 mg tablet. 1 tablet(s) by mouth once a
day
OXYBUTYNIN CHLORIDE - oxybutynin chloride ER 10 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day
SILDENAFIL [VIAGRA] - Viagra 50 mg tablet. 1 tablet(s) by mouth
as needed once a day one hour prior to activity Case No ___
TAMSULOSIN [FLOMAX] - Flomax 0.4 mg capsule. 1 capsule(s) by
mouth 30 minutes after the same meal each day once a day
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit capsule. 1 capsule(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM Left rib fx's
RX *lidocaine 5 % 1 patch to left ribs once a day Disp #*15
Patch Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 17 gm by mouth once a day
Disp #*15 Packet Refills:*0
4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. amLODIPine 5 mg PO DAILY
6. Divalproex (DELayed Release) 1000 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Oxybutynin 5 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. Valsartan 320 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
[] Mildly displaced left anterior ___ acute rib fractures
[] Left zygomatic-maxillary complex fracture
[] Left lateral orbital fracture
[] Left eyebrow laceration
[] Left hand laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a mechanical fall. You
fractured several left-sided ribs and bones in the left side of
your face. You also sustained a laceration to your left eyebrow
and to your left hand. You have Steri-Strips to left eyebrow,
and multiple stitches to the left hand. You will need to
follow-up for the stitch removal. You were seen by Plastic
Surgery and they recommend follow-up in 2 weeks to discuss
surgical repair of the facial fractures. In the meantime, please
abide by "sinus precautions": no blowing your nose, sneeze with
your mouth open, no using straws, sleep with your head elevated.
You have been cleared for discharge home with home ___.
* Your injury caused multiple left sided rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10508020-DS-3 | 10,508,020 | 27,650,962 | DS | 3 | 2152-11-03 00:00:00 | 2152-11-03 19:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast- Oral and IV Dye / piperacillin /
ciprofloxacin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of disseminated Behcet's
vasculitis previously on biologic agents, chemotherapy via port,
gastric perforation, abdominal abscess, appendicitis treated
with IV antibiotics, chronic abdominal pain presenting with
severe right lower quadrant abdominal pain.
His symptoms returned quickly following discharge on ___. He
states that pain started on ___ and was periumbilical. On ___ he
started to develop nausea and vomiting with meals and was unable
to keep down PO. He states that his abdominal pain improved
after he was started on antibiotics. He has not had any bowel
movements for the last two days. ___, the abdominal pain
began to
migrate lower in the lower quadrant and into the right groin and
suprapubic area. The pain will also migrate into the right
flank. He states that this is very different from his Behcet's
flares, which have a more diffuse presentation across his
abdomen. He states the left side of his abdomen is more stable.
He has not had any fevers, chills, night sweats, diarrhea, chest
pain or
shortness of breath. He states that he does not always ___ a
fever when he has an infection. No past history of kidney
stones.
Of note, patient was recently admitted ___ for acute on
chronic RLQ pain. CTA A/P notable for stranding that could be
consistent with low grade vasculitis that would benefit from
treatment, however patient declined treatment at this time due
to his concern that he has an infection. Patient was started on
abx with ceftriaxone and flagyl (with 1 dose of vancomycin
overnight) to empirically treat an intra-abdominal infection,
ultimately completing a 7 day course of cipro/flagyl. He was
discharged on 30mg Prednisone daily.
In the ED, initial vitals were: T99.5 HR 98 BP128/82 PO2 97% on
room air
Exam notable for: mild tenderness to palpation in right lower
quadrant
Labs notable for:
-UA: Negative
-Lactate 1.2
-Chemistry: unremarkable
-LFTs: WNL
-CBC: WBC 12.3 Hgb 12.1 plt 304
Patient Given: 1L NS, 40mg IV methylpred
CXR ___: Tip of right chest Port-A-Cath terminates in the mid
to lower SVC. No acute cardiopulmonary process.
Vitals on Transfer: T98 HR 88 BP118/51 20 95%
On the floor, patient corroborated the above history and reports
ongoing abdominal pain that has increased since admission.
Past Medical History:
disseminated Behcet's vasculitis previously on biologic agents
(remicade), chemotherapy via port. Now on prednisone mono
therapy. c/b CVA per patient.
small fiber neuropathy
chronic pain disorder on opioids
steroid induced osteoporosis with prior compression fracture
illness-related anxiety disorder
history of gastric perforation, abdominal abscess
appendicitis treated with IV antibiotics
chronic abdominal pain
?heart failure per patient, liver failure (U/S- fatty liver)
Addison's disease
Social History:
___
Family History:
Found to be non-contributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T 99.0 BP 112/72 HR 86 RR 22 O2 sat 97 2L
General: Appears mildly uncomfortable, in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
edentulous.
Chest: Port R upper chest w/o erythema or fluctuance.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Hypoactive BS. Obese abdomen. NABS. noted midline
abdominal scar. abdominal striae. Diffusely tender with
guarding, no rebound tenderness. Increased TTP in RLQ (patient
not c/o pain when palpating himself to show where pain is). No
organomegaly. No hernias appreciated.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: scars on UE and ___ ___ vasculitis per patient
Neuro: CNII-XII intact, no focal neurologic deficits, A&Ox3,
moving all extremities.
DISCHARGE PHYSICAL EXAM:
VITALS: 98.5 PO 132 / 77 L Lying 95 18 96 3L
General: Appears comfortable, in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
edentulous.
Chest: Port R upper chest w/o erythema or fluctuance.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, breathing comfortably
Abdomen: NABS. Obese abdomen. Diffusely tender with minimal
palpation, no rebound
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: scars on UE and ___ ___ vasculitis per patient
Neuro: CNII-XII intact grossly, A&Ox3, moving all extremities.
Pertinent Results:
ADMISSION LABS:
============
___ 06:04AM BLOOD WBC-12.3* RBC-5.06 Hgb-12.1* Hct-39.2*
MCV-78* MCH-23.9* MCHC-30.9* RDW-19.4* RDWSD-54.4* Plt ___
___ 06:04AM BLOOD Neuts-62.9 ___ Monos-7.8 Eos-1.4
Baso-0.2 Im ___ AbsNeut-7.76* AbsLymp-3.32 AbsMono-0.96*
AbsEos-0.17 AbsBaso-0.03
___ 06:04AM BLOOD ___ PTT-28.6 ___
___ 06:04AM BLOOD Glucose-84 UreaN-7 Creat-0.5 Na-140 K-3.7
Cl-100 HCO3-25 AnGap-15
___ 06:04AM BLOOD ALT-19 AST-15 AlkPhos-47 TotBili-0.2
___ 06:04AM BLOOD Lipase-23
___ 06:04AM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.1 Mg-2.0
___ 06:04AM BLOOD CRP-2.9
___ 06:39AM BLOOD Lactate-1.2
___ 05:24PM BLOOD SED RATE-2
INTERIM LABS:
==============
___ 04:46AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 02:02PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 10:00AM BLOOD CRP-2.1
___ 10:18AM BLOOD Lactate-1.6
___ 12:31PM URINE Color-Straw Appear-Clear Sp ___
___ 12:31PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-12.5* RBC-4.76 Hgb-11.5* Hct-37.2*
MCV-78* MCH-24.2* MCHC-30.9* RDW-18.6* RDWSD-52.4* Plt ___
___ 05:30AM BLOOD Glucose-99 UreaN-9 Creat-0.5 Na-141 K-4.0
Cl-101 HCO3-29 AnGap-11
___ 05:30AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
MICROBIOLOGY:
===============
___ 8:27 pm STOOL C. difficile PCR (Final ___:
NEGATIVE.
___ 20:27 Helicobacter Antigen Detection, Stool:
PENDING
___ 8:27 pm STOOL
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
___ 12:31 pm URINE CULTURE (Final ___: NO GROWTH.
___ Culture, Routine-PENDING
___ URINE CLEAN CATCH.
URINE CULTURE (Final ___:
ENTEROCOCCUS FAECIUM. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
___ Culture x2, Routine-FINAL NO GROWTH
IMAGING:
=======
___ CXR
Tip of right chest Port-A-Cath terminates in the mid to lower
SVC. No acute cardiopulmonary process.
___ CT A/P W PO CONTRAST
No acute findings to account for right lower quadrant pain,
nausea and vomiting.
___ XR ABDOMEN
Contrast now within the large bowel from the cecum to transverse
colon.
___ CT HEAD W/O CONTRAST
No evidence of acute intracranial abnormality.
Brief Hospital Course:
Mr. ___ is a ___ man with history of progressive
multisystem Behcet's currently on prednisone monotherapy after
recent Remicade discontinuation due to patient's concerns about
adverse effects, recent admission to ___ for abdominal pain
___ without clear cause found, readmitted ___ with similar
abdominal pain.
ACUTE ISSUES:
==============
# Acute on Chronic Abdominal Pain
# Leukocytosis
# Flulike symptoms
Patient has a complicated history with Behcet's and abdominal
pain (see below). Recent admission to ___ for RLQ pain
initially raised concerns for vasculitis and patient was offered
treatment but declined because he thought he had an infection.
ID was consulted and had low concern for infection. He completed
a 5d course of ceftriaxone/flagyl (with 2 extra days of flagyl
for 7d course after discharge) for possible intra-abdominal
infection. He had a day or two at home where his RLQ remitted
and he felt better, but after stopping antibiotics the pain
returned so he came back. He has a remote history of fecolith in
the appendix treated with antibiotics previously, however CT A/P
w PO contrast on this admission after receiving pre-medication
for contrast allergy showed a normal appendix, no bowel
obstruction, perforation, appendicitis, or abscess. Only oral
contrast was used due to history of anaphylaxis to IV contrast.
CT is not the best study for assessing vasculitis (compared to
MRI) but CRP remained lower than it had been and a significant
flare seemed less likely in this setting per Rheumatology.
Patient was unable to undergo MRI to further evaluate due to an
implant.
ID was consulted, recommended ___ course of
ceftriaxone/flagyl (D1 = ___ for possible colitis, to be
completed outpatient with cefpodoxime/flagyl with the goal of
allowing him to move to ___ for a ___ opinion for his
Behcet's. Patient initially reported improvement on this regimen
and was planning for discharge, then reported flu-like symptoms.
He had an isolated fever of 100.7 early in his hospital course,
with one additional fever 100.9 on ___, with
chills/sweats/flu-like symptoms. Infectious workup with blood
and urine cultures revealed colonization of his urine with VRE.
Stool studies were sent due to a few episodes of loose stools,
but patient said these were in the setting of taking laxatives.
C diff was negative. He requested vancomycin, citing
documentation from OSH medical records as to why vancomycin
would be the only effective treatment for him to improve
symptoms and reduce his leukocytosis, which he attributed an
untreated infection. ID was again consulted regarding expansion
of treatment regimen given infectious workup remained
unrevealing and concern for antibiotic resistance. OSH records
were reviewed in depth. ID recommended not expanding the current
treatment plan with vancomycin given no infectious indication.
Patient's leukocytosis, which peaked at 17.3 after receiving
premedication for contrast, was thought partially due to
steroids, 12.5 on discharge.
# Behcet's Syndrome
# Illness-related Anxiety
Followed at ___ since ___ and previously at ___ and ___
and in ___ (see below for summary). Manifestations have
included oral and genital ulcers, vasculitis on skin biopsy,
uveitis, gastrointestinal ulcers, sore throat, fevers,
inflammatory polyarthritis, pericarditis w associated effusions,
stroke, panniculitis. He also has been diagnosed with small
fiber polyneuropathy based on skin biopsy and treated with IVIG.
On prior ___ admission, he was admitted on a prednisone taper
and was taking 20 mg daily, dose was increased to 30 mg daily.
On this admission, rheumatology was consulted and recommended
patient remain on 30 mg Prednisone daily given patient is moving
to ___ for a ___ opinion. CRP and ESR remained normal. He
continued Bactrim and omeprazole for prophylaxis. He plans to
establish care with Dr. ___ at the ___ in
___. Had significant anxiety related to his above illness,
his prior complications and missed diagnoses on previous
hospitalizations, the course of his Behcet's. Would recommend
followup for illness-related anxiety in ___.
# Chronic Pain
Patient takes large doses of opioids chronically, has had
syncope requiring narcan previously. Pain service was consulted
due to concern for possible hyperalgesia from opioids,
recommended continuing home regimen of Fentanyl Patch 300 mcg/h
TD Q48H, Gabapentin 300 mg PO BID, Morphine SR (MS ___ 30 mg
PO Q12H:PRN pain (takes Q8H at home), TraMADol 100 mg PO
Q6H:PRN. Patient routinely declined opioid for PRN, requested IV
Benadryl Q4H:PRN for pain, IV Tylenol. Home regimen was
continued on discharge. He was discharged with a prescription
for Narcan and advised to carry it at all times given his prior
complications with narcotics.
# Symptomatic hypoglycemia
Patient intermittently had fluctuations in blood sugar (lowest
65), previously followed at ___ by endocrine service. Preferred
treatment with IV dextrose.
# Chest Pain
Patient complained of left sided chest pain, burning sensation,
nonpleuritic, nonexertional, which woke him from sleep. Feels
like it's similar to when he had vasculitis in the past.
Received GI cocktail overnight without much improvement, but
pain remitted spontaneously. Troponin and EKG reassuring x2.
# Headache
# History of CVA
Patient complained of severe headache on day of discharge. Had
intermittent headaches previously during hospitalization. Given
past history of stroke and vasculitis, CT head was obtained,
showed no acute abnormality.
CHRONIC ISSUES:
================
# Chronic hypoxia on home O2: Pt reports he has been on oxygen
since ___, unclear underlying cause but cites multiple
surgeries have affected his lungs. Continued home ___ NC.
# Anemia: Hb at ___, consistent with level during his prior
admission at ___, likely his baseline.
# Steroid-induced osteoporosis with prior compression fractures:
Wheelchair bound for the last ___ years due to fragility
fractures. Continued home cholecalciferol ___ qd. ___
recommended home ___ based on patient's last hospitalization.
# H/o gastric perforation, complicated abdominal surgery
# Poor nutrition s/p full mouth extraction for possible oral
infection
# Nausea
Patient reported he only drinks smoothies and protein milkshakes
due to loss of all of his teeth, but that his shakes were
causing nausea. He was noted to have normal albumin and
electrolytes. Nutrition service was consulted and recommended
tube feeds. He declined due to prior abdominal complications,
but requested TPN, which was not started due to no way to
coordinate care for patient.
# Tachycardia: Continued Propanolol 10mg TID
TRANSITIONAL ISSUES:
================
[] Antibiotics: ___ Ceftriaxone/Flagyl -> Cefpodoxime/Flagyl
14d course to end ___
[] Patient to establish followup care for his Behcet's in
___ at ___ in ___ with Dr. ___
[] Colonized with resistant Enterococcus in urine, R to
ampicillin and vancomycin, S to Linezolid and Tetracycline; also
has history of VRE in rectal swabs from ___
[] Multiple prior hospitalizations for fevers with unrevealing
infectious workups, would be cautious with empiric antibiotics
without other signs of infection (see below)
[] Needs to set up PCP ___, until then patient will contact
Dr. ___ for any medical needs
[] Needs Nutrition followup in ___
[] Needs followup for Anxiety in ___
[] Discharged with narcan given on chronic high dose opioids
[] Recommended for home ___, once he establishes PCP please refer
[] H Pylori and stool culture pending on discharge, inpatient
team will follow up
SUMMARY OF PRIOR HISTORY FROM ___ RECORDS
"Past Medical History prior to entering the Partner's system
___: Daily fevers with measured temp up to 37.5
___: Diagnosed with Behcet's at age ___. Presented with sores
(fever, mouth, genital), pustular rash, inflammatory
polyarthritis, lymphadenopathy, GI inflammation, eye
inflammation, pericarditis and weight loss. Studies notable for
prior skin biopsies positive for vasculitis, positive pathergy
test, endoscopy revealing significant ulcers and positive
HLA-B51. Treated with colchicine and high dose solumedrol
___: Found to have a percardial effusion, pericarditis and
endocarditis. Treated with azathioprine, prednisone 100mg qDaly
and colchicine.
___: Was treated with pulse steroids (3500 hydrocortisone q3
months), cyclosporine, azathioprine, cyclophosphamide (2x in
___ with significant s/e) and infliximab. MTX accidentally
combined with cyclosporine > hepatitis (AST/ALT in ___
___: Upper endoscopy and colonoscopy iso steroids that
resulted in proximal perforation of stomach (found on PET scan,
CT scan with oral contrast demonstrating leakage). Treated with
NG tube, PPI, TPN, drain to create a controlled fistula c/b
bleed and intra-abdominal abscess, requiring laparotomy, splenic
vein embolization of AV fistula
___: CT and modified barium swallow demonstrated new active
shunt from fundus. Underwent collection drainage X 2 without
success. Transferred care from ___ to ___ and ___ (all records in ___ or currently unavailable). Per pt,
repeat capsule endoscopy could only visualize stomach due to
decreased motility. Otherwise, no evidence of ulceration.
___: Was treated with combination MTX and infliximab three
months prior to presentation with improvement of symptoms.
Infliximab was stopped due to unclear reasons and pt is
currently on single drug therapy, MTX. Brain imaging notable for
hyperattentuation in white matter. Eye exam notable for
scotomas.
Recent Hospitalization at Partners
-___: Admitted for panniculitis in the
superificial epigastric fat and omentum, secondary to
vasculitis. Treated with prednisone 60 and infliximab
-___: Admitted for fevers with extensive
infectious workup revealing no clear source. Treated with
vancomycin and cefepime X 1 week.
-___: Admitted for fevers and URI symptoms, found
to have parainfluenza. Treated supportively and received one
dose of infliximab.
-___: Admitted for fevers and abdominal pain,
found to have panniculitis and treated conservatively without
antibiotics. Also diagnosed with small fiber neuropathy on
biopsy.
-___: Admitted for fevers and neuropathic pain.
Placed port given difficult access. Stared IVIG for small fiber
neuropathy.
-___: Admitted for headaches and abdominal pain.
Found to have leukocytosis, elevated lactate and omental
stranding on CT. Treated with cefepime and vancomycin
-___: Admitted for headaches, acute on chronic
abdominal pain and intermittent fevers. Extensive infectious
workup was negative. Patient was treated with full mouth
extraction and Penicllin G > Unasyn + intermittent Vancomycin
for possible oral infection. Course complicated by episode of
syncope and ICU stay for large doses of narcotics and analgesia.
-___: Admitted for obstipation and constipation,
requiring fecal disimpaction.
-___: Admitted for viral symptoms with worsening
body aches and chills, sore throat, and congestion. Extensive
workup was negative for occult infection and pt was treated with
azithromycin X ___omplicated with
disagreements about treatment recommendations. Please see Psych
note from ___. Patient demanded to be discharged and due to
the lack of a therapeutic relationship, he was also discharged
from complex care and then transitioned to the Internal Medicine
Associates."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Lactulose 30 mL PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fentanyl Patch 300 mcg/h TD Q48H
5. Gabapentin 300 mg PO BID
6. Morphine SR (MS ___ 30 mg PO Q8H:PRN pain
7. Omeprazole 40 mg PO BID
8. Polyethylene Glycol 17 g PO BID
9. Propranolol 10 mg PO TID
10. Senna 17.2 mg PO BID
11. Sucralfate 1 gm PO QID
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. TraMADol 100 mg PO Q6H:PRN Pain - Moderate
14. Vitamin D ___ UNIT PO DAILY
15. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
16. Benzonatate 100 mg PO TID:PRN cough
17. Sarna Lotion 1 Appl TP QID:PRN itching
18. PredniSONE 30 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
end ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
end ___
RX *metronidazole 500 mg 1 tablet(s) by mouth three times per
day Disp #*22 Tablet Refills:*0
3. Narcan (naloxone) 4 mg/actuation nasal PRN
RX *naloxone [Narcan] 4 mg/actuation 3 mg nasal PRN overdose
Disp #*1 Spray Refills:*3
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Benzonatate 100 mg PO TID:PRN cough
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
7. Docusate Sodium 100 mg PO BID
8. Fentanyl Patch 300 mcg/h TD Q48H
9. Gabapentin 300 mg PO BID
10. Lactulose 30 mL PO DAILY
11. Morphine SR (MS ___ 30 mg PO Q8H:PRN pain
12. Omeprazole 40 mg PO BID
13. Polyethylene Glycol 17 g PO BID
14. PredniSONE 30 mg PO DAILY
15. Propranolol 10 mg PO TID
16. Sarna Lotion 1 Appl TP QID:PRN itching
17. Senna 17.2 mg PO BID
18. Sucralfate 1 gm PO QID
19. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
20. TraMADol 100 mg PO Q6H:PRN Pain - Moderate
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
acute on chronic abdominal pain
chronic steroids
hyperglycemia
VRE colonization
leuokocytosis
chest pain
headache
Secondary:
Behcet's Syndrome
Tachycardia
chronic pain
chronic hypoxia
ill-ness related anxiety
history of CVA
steroid-induced osteoporosis with prior compression fractures
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 ___,
You came to the hospital because of abdominal pain. You had
imaging and blood tests that did not reveal a cause for the
pain.
You were evaluated by our infectious disease team and they
recommended treating you for a possible bout of colitis with IV
ceftriaxone and flagyl. Your abdominal pain improved but you
continued to feel flu-like symptoms for which we did not find an
infectious cause, as you know, the only bacteria we found were
vancomycin-resitant enterococcus in your urine, but this was
colonization rather than infection. You also had a scan of your
brain because of a headache and it did not show a stroke or
other blood clot in your head.
You were seen by our rheumatology team for your Behcet's and we
made no changes to your prednisone because you are moving.
When you leave the hospital:
- Please finish your antibiotic treatment with pills through
___.
- Please take all of your other medicines as you normally do at
home.
We wish you the best of luck establishing your new rheumatology
care in ___.
Your ___ Team
Followup Instructions:
___
|
10508110-DS-6 | 10,508,110 | 26,864,913 | DS | 6 | 2175-04-06 00:00:00 | 2175-04-06 15:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ P
Attending: ___.
Chief Complaint:
Sepsis, dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a past medical history of
colon cancer s/p hemicolectomy c/b a new diagnosis of cerebellar
brain mets, COPD, AAA, CKD stage III, recent left hip fracture
s/p fixation (___) who presents from her rehab facility with
a fever. Patient was recently admitted for a hip fracture and
was discharged to rehab on ___. She was doing well until today
when she developed a fever to 102.5. She received acetaminophen
and was sent to the ED for evaluation. Of note, patient endorsed
having had dysuria and fevers at her rehab, but otherwise denies
SOB, cough, sputum production, abdominal pain, diarrhea, or
hematuria.
In the ED, rectal temp 103.4, HR 61, BP 97/50, RR 18, 98% RA.
Labs were notable for WBC 22.8, Hb 9.9, PLT 332. Na 130, BUN 39,
Cr 1.5 (baseline ~1.2). Lactate 2.0. UA revealed large leuks,
large nitrites, and >182 WBC. CXR was negative for an acute
cardiopulmonary process. Given the concern for sepsis, patient
received vancomycin/zosyn and 4L IVF. A central venous line was
placed. Ortho evaluated the patient given recent left hip
surgery and there was no concern for septic arthritis. Patient
was noted to have some abdominal pain on exam and a CT
abdomen/pelvis was ordered to evaluate for abscess, colitis, or
ischemic bowel. Abdominal imaging revealed an inflammed bladder
with a 4mm calculi in the right ureter with pyelonephritis. Also
revealed GB distention without CBD dilation. Urology was
consulted and recommended medical management with antibiotics
and tamsulosin 0.4 mg, which she received in the ED.
On arrival to the MICU, VS T 97.4, HR 80, 95% RA, BP 106/59 on
levophed. Patient was mentating appropriately and complained of
left hip pain.
Review of systems:
negative unless stated above in the HPI
Past Medical History:
-Colon Cancer s/p Hemicolectomy c/b metastatic disease to
omentum, cerebellum (plan to undergo neurosurgical intervention
in ___
-Cataracts
-Osteopenia
-Hypertriglyceridemia
-COPD
-Vitamin D Deficiency
-Renal Tubular Acidosis
-AAA
-CKD Stage 3
-left intertrochanteric hip fracture s/p fixation ___
-Bladder cancer
Social History:
___
Family History:
Sister with cancer, unknown type. Parents were healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T 97.4, HR 80, 95% RA, BP 106/59 on levophed
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, RIJ
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
at LUSB, no gallops
Back: no CVA tenderness, no ecchymosis
Abdomen: soft, suprapubic tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly, no palpable mass
GU: + foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema. Left hip with clean incision, staples and surrounding
ecchymosis. Left midline catheter.
DISCHARGE PHYSICAL EXAM:
VS: T 98.3 BP 118/74 P 74 R 20 Sat 100% on 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, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal. Finger to nose, heel to shin intact. Rapid
alternating movements somewhat impaired, but improved upon with
repetition.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 04:20PM PLT COUNT-332#
___ 04:20PM NEUTS-94.0* LYMPHS-2.8* MONOS-2.6 EOS-0.4
BASOS-0.3
___ 04:20PM WBC-22.8*# RBC-2.98* HGB-9.9* HCT-30.6*
MCV-103* MCH-33.2* MCHC-32.3 RDW-20.5*
___ 04:20PM ALBUMIN-3.3*
___ 04:20PM LIPASE-9
___ 04:20PM ALT(SGPT)-18 AST(SGOT)-23 ALK PHOS-79 TOT
BILI-0.9
___ 04:20PM GLUCOSE-114* UREA N-39* CREAT-1.5*
SODIUM-130* POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-21* ANION GAP-18
___ 04:38PM LACTATE-2.0
___ 06:49PM URINE RBC-11* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
___ 06:49PM URINE BLOOD-MOD NITRITE-POS PROTEIN-600
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG
___ 06:49PM URINE COLOR-DkAmb APPEAR-Cloudy SP ___
___ 06:49PM URINE OSMOLAL-355
___ 06:49PM URINE HOURS-RANDOM UREA N-494 SODIUM-25
POTASSIUM-56 CHLORIDE-17
___ 09:14PM O2 SAT-64
___ 09:14PM TYPE-CENTRAL VE TEMP-36.7 PO2-32* PCO2-31*
PH-7.44 TOTAL CO2-22 BASE XS--2
MICROBIOLOGY
------------
___ 4:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefepime sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ AT 7:30AM ON
___.
Additional blood culture ___: pending
Blood culture x ___:
___ 4:21 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
FROM ___.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Blood culture ___: pending, no growth to date
Blood culture ___: pending, no growth to date
___ 6:49 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
___ 5:18 am CATHETER TIP-IV Source: midline.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
___ 5:19 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING
-------
CXR PA/lateral ___
AP and lateral views of the chest. The lungs are grossly clear.
Increased interstitial markings throughout the lungs are more
suggestive of a chronic interstitial process. The
cardiomediastinal silhouette is within normal limits. No acute
osseous abnormality is identified. Proximal right humeral
orthopedic hardware is partially visualized.
IMPRESSION: No acute cardiopulmonary process.
CXR AP ___
Single portable view of the chest. There is interval placement
of
right-sided central venous catheter whose tip projects over the
mid-to-lower SVC. There is no pneumothorax. No other change
since prior.
CT abd/pelvis with contrast ___. Bladder is collapsed but has hyperenhancing mucosa and
pericystic fat
inflammation. Severe right-sided pyelonephritis with severe
diffuse urothelial thickening of the right ureter. No
hydronephrosis. At the level of the pelvic brim, a 4-mm calculus
is identified which is likely a gonadal vein phelbolith though a
non-obstructing ureteral stone is a less likely possibility.
Left renal parenchyma is slightly heterogeneous with mildly
hyperenhancing urothelium, although there is no frank striated
nephrogram on the left, bilateral ascending infection is a
consideration.
Given the degree of urothelial thickening recommend follow-up CT
once symptoms have resolved to rule out malignancy, or
comparison with prior imaging to assess the chronicity of
change.
2. Status post right cecectomy with a 3.5 cm soft tissue
density lesion with enhancing rim extends inferiorly from the
surgical site. Finding may reflect complex seroma; however,
given resection due to malignancy, cannot exclude metastatic
deposit. Finding could be assessed more confidently with
comparison to prior imaging.
3. Prior left intertrochanteric and inferior pubic ring
fracture with healing noted at the latter though the
intertrochanteric fracture line is still evident. Multilevel
compression deformities without retropulsion.
4. Significantly distended gallbladder with a 1.5 cm stone
within the fundus. No gallbladder neck stone identified. No CBD
dilatation. No gallbladder wall edema. The finding may reflect
remote last meal (fasting), however, cannot exclude
cholecystitis based on imaging alone. Please correlate
clinically.
5. Diffusely thickened bilateral adrenal glands, possibly
representing
hyperplasia. Unable to assess for underlying adenoma on this
contrast-enhanced CT.
RUQ US ___:
1. Cholelithiasis without evidence of cholecystitis.
2. Please note that the kidneys were not fully evaluated. On
recent CT
performed ___, there is a question of acute
pyelonephritis. In the setting of CT findings, the patient's
right upper quadrant pain may be renal in origin.
CXR ___:
FINDINGS: As compared to the previous radiograph, the left PICC
line is new. The tip projects over the mid SVC. There is no
evidence of complications, notably no pneumothorax. The right
internal jugular vein catheter has been removed. Unchanged
appearance of the lung parenchyma and the cardiac silhouette.
DISCHARGE LABS
--------------
___ 06:41AM BLOOD WBC-10.4 RBC-2.86* Hgb-9.1* Hct-29.6*
MCV-103* MCH-31.8 MCHC-30.8* RDW-20.6* Plt ___
___ 06:41AM BLOOD Glucose-103* UreaN-27* Creat-0.8 Na-141
K-3.7 Cl-108 HCO3-25 AnGap-12
___ 06:41AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ year old female with a past medical history
of colon cancer s/p hemicolectomy complicated by a new diagnosis
of cerebellar brain metastases, COPD, AAA, CKD stage III,
bladder cancer, recent left hip fracture s/p fixation (___)
who presents from her nursing home with a sepsis secondary to
pyelonephritis.
ACTIVE ISSUES
-------------
# Sepsis/pyelonephritis: Patient had a positive UA in the
setting of fevers, dysuria, leukocytosis and hypotension
requiring aggressive IVF resuscitation and vasopressors. CT
imaging revealed pyelonephritis. She was treated with vancomycin
and piperacillin/tazobactam and received a total of 4L IVF prior
to arrival. Patient was recently admitted for a left hip
fracture and did not have signs/symptoms suggestive of septic
arthritis. Although there was no cellulitis surrounding the left
midline catheter, this was removed and cultured. Additionally,
patient reportedly had abdominal pain in the ED and abdominal
imaging revealed a distended gall bladder. ICU abdominal exam
was benign, other than mild suprapubic tenderness. Subsequent
RUQ ultrasound showed cholelithiasis without cholecystitis.
Urine culture positive for ESBL and she was switched to
meropenem. Blood culture on ___ and ___ was growing gram
negative rods. However, the patient was only switched to
meropenem on ___ in the setting of speciation and thus her blood
culture from ___ reflected inadequate coverage. She was treated
with hydrocort 100mg q8hrs for 3 days given home dexamethasone
use for stress-dose steroids. She was weaned off of vasopressors
on ___, and called out to the floor on ___. She will
continue meropenem for full 14 day course. PICC is in place and
should be removed after antibiotic course is complete.
# Gonadal vein phlebolith versus renal calculus: Patient
appeared severely dehydrated on admission and was initially
thought to have a renal calculus. Patient does have a history of
RTA which may predispose to calculus formation. She received
IVF. Urology was consulted who initially recommended ___
consultation. However, final read of CT abd/pelvis showed "at
the level of the pelvic brim, a 4-mm calculus is identified
which is likely a gonadal vein phelbolith though a
non-obstructing ureteral stone is a less likely possibility."
Urology recommended no urologic intervention presently and, if
her clinical status worsened, reimaging to reassess the calculus
or to evaluate for a perinephric abscess.
# Recent left hip fracture s/p fixation: Patient was evaluated
by Orthopedic Surgery in the ED and surgical site looked
appropriate without signs suggestive of septic arthritis.
Oxycodone was given for pain control and she was placed on
heparin SC for DVT prophylaxis. She is weight bearing as
tolerated on the left lower extrmeity and should continue to
receive aggressive physcial therapy, as tolerated. Staples were
removed before discharge. She will follow up with Orthopedic
Surgery one month after discharge, appointment will need to be
scheduled.
# Metastatic colon cancer complicated by cerebellar brain
metastases: Recent diagnosis of metastatic disease to the brain.
Patient was evaluated by neurosurgery during her last admission.
Currently on dexamethasone with plans for neurosurgical
intervention within the next few months. Her home dexamethasone
2 mg BID was held while on hydrocortisone. PPI was continued.
She was placed on fall precautions. Dexamethasone was restarted
on ___ and hydrocortisone discontinued. Neurosurgery will
follow up with her after discharge, as well as Oncology to
discuss possible surgical options.
# Anemia: Hemoglobin dropped from 9.9 to 8.0 on arrival to the
ICU. Likely dilutional in the setting of IVF resuscitation. No
active source of bleeding on exam. Stool guaiac was negative.
Hip was monitored for signs of hemarthrosis. Hematocrit was
stable during her stay.
INACTIVE ISSUES
---------------
# Chronic kidney disease stage III: baseline Cr ~1.2: Pt was
given IV hydration given recent contrast load. Nephrotoxins were
avoided and creatinine was monitored daily.
# Hypertension: Held home amlodipine in the setting of sepsis.
# History of B12 deficiency: Continued home B12 supplementation.
TRANSITIONAL ISSUES
-------------------
# Bilateral adrenal gland thickening: Cannot assess for adenomas
on the available contrast-enhanced CT. Could be due to
hyperplasia. Recommend repeat imaging to better characterize.
PCP was notified by letter.
# Hyperenhancing urothelium: Recommend follow-up CT once
symptoms have resolved to rule out malignancy, or comparison
with prior imaging to assess the chronicity of change. PCP was
notified by letter.
# Inferior to right cecectomy surgical site, there is a 3.5 x
2.1 cm soft tissue density lesion with mild rim enhancement.
Cannot exclude metastatic deposit. Compare to prior imaging.
PCP was notified by letter.
# Repeat blood culture on ___ again given positive blood
culture on ___. Follow up is needed on surveillance blood
cultures
# Follow-up: patient will follow up with her oncologist and
neurosurgeon after discharge.
Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Cyanocobalamin 50 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Vitamin D 400 UNIT PO DAILY
5. Acetaminophen 1000 mg PO Q6H
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC BID
8. Senna 8.6 mg PO DAILY
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
10. Dexamethasone 2 mg IV Q12H
11. tetrahydrozoline 0.05 % ophthalmic BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Amlodipine 2.5 mg PO DAILY
3. Cyanocobalamin 50 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
8. Senna 8.6 mg PO DAILY
9. Dexamethasone 2 mg PO Q12H
10. Meropenem 500 mg IV Q8H
Last day of meropenem ___. tetrahydrozoline 0.05 % ophthalmic BID
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Right-sided acute pyelonephritis without apparent urinary
obstruction
Metastatic colon cancer with known cerebellar metastatic disease
Recent left hip fracture s/p TFN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your admission to ___.
You were admitted to the hospital with a severe right kidney
infection. You received antibiotics and slowly improved. You
will need to follow up closely with your neurosurgeon and
oncologist after discharge to discuss possible surgery of the
brain lesion recently discovered during your last
hospitalization. You are now being discharged to rehab. It is
important that you continue to take your medications as
prescribed and follow up with the appointments listed below!
Good luck!
Followup Instructions:
___
|
10508292-DS-19 | 10,508,292 | 27,502,530 | DS | 19 | 2153-12-27 00:00:00 | 2153-12-27 19:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
contrast dye
Attending: ___
Chief Complaint:
shortness of breath, dysarthria, dysphagia
Major Surgical or Invasive Procedure:
Intubation, Plasmapheresis x5 sessions
History of Present Illness:
The pt is a ___ gentleman with history of oculobulbar
myasthenia
___, on prednisone and recently added on azathioprine, who
presents with one day of worsening shortness of breath ___
setting
of one month of progressively worsening dysarthria, dysphagia,
ptosis, and diplopia.
The patient is ___ speaking and is accompanied by his son
who provides interpretation. The patient was diagnosed with
myasthenia ___ after onset of ocular and bulbar weakness ___
___ during a trip to ___, and ACh receptor
antibodies were positive. He was initially started on prednisone
and mestinon, which was stopped a year ago. Patient reports that
he had been well controlled on oral prednisone alone for the
past
year and had been slowly weaned down to 7.5mg daily with plan to
stop it by his primary neurologist. However ___ early ___,
he
had recurrence of his symptoms, namely left greater than right
ptosis, intermittent diplopia, and mild difficulty swallowing
and
speaking, with slurring of his words. He was seen by his
neurologist numerous times and ___ the ED once which resulted ___
incremental increase ___ prednisone to 30mg daily (currently) and
resumption of mestinon ___ late ___. His symptoms initially
improved with each increase, but overall continued to worsen. On
___ he was started on azathioprine (as mycophenolate was
rejected by insurance company).
Over the past 3 weeks, his symptoms have progressively worsened
to the point that he cannot tolerate solid foods and has been
limiting himself to soup and water. His ptosis and double vision
have become more constant. He is also easily fatigued and has
stopped working and ambulating as much. He describes it being
harder to get up and walk, which he attributes to a combination
of generalized weakness and dyspnea on exertion. His voice is
becoming softer and more slurred, per his son, but he has no
difficulty comprehending or producing language. His breathing
has
also been more difficult, and he cannot breathe when laying
flat,
which has led to insomnia. Over the past 24 hours, he felt that
his breathing has become more labored and became very worried,
therefore he presented to ___, where he was placed on
supplemental oxygen for mild desaturation to ___ and was
transferred here for further care.
ROS is otherwise significant for intermittent nonbloody diarrhea
for the past month attributed to the mestinon which improved
with
loperamide given by his PCP. He also endorses increased oral
secretions, but no cough or sputum, and no fevers, chills, night
sweats. He endorses mild frontal headache and visual symptoms as
described above. Denies focal weakness apart from what is
described above, dizziness, lightheadedness, vertigo, bowel or
bladder incontinence. He describes only tongue numbness, but no
other sensory loss or paresthesias. Denies chest pain, nausea,
vomiting, dysuria, urinary frequency.
Past Medical History:
Oculobulbar myasthenia ___, +AChR Abs
Diabetes mellitus
Hypertension
Hyperlipidemia
BPH
Social History:
___
Family History:
HTN, HLD. No family history of neurologic conditions.
Physical Exam:
=================
Admission Exam:
=================
Vitals: T 96.7, HR 98, BP 145/78, RR 20, spO2 92% on 4L O2
General: Awake, cooperative, NAD. Appears somewhat tired but
breathing comfortably without accessory muscle use.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted ___
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W. No accessory
muscle use. NIF -30, FVC 1650cc (~22cc/kg) ___ ED.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x3. Able to relate history
without difficulty. Attentive. 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 is
hypophonic and dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm and brisk. There is ptosis
bilaterally, left greater than right. Gaze is dysconjugate, with
exodeviation of left pupil. Extraocular movements were full
vertically, however he is unable to completely bury his sclera
on
right adduction, and he has impaired abduction and adduction of
the left. He has diplopia ___ all directions of gaze except
convergence, with the outer (phantom) image extinguishing on
covering the left pupil. Few beats of endlateral gaze nystagmus.
VFF to confrontation. Visual acuity ___ OD, ___ OS.
Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages.
V: Facial sensation intact to light touch.
VII: Weakness of forehead wrinkling, eye closure, smile, and
mouth closure bilaterally.
VIII: Hearing intact grossly.
IX, X: Palate elevates symmetrically.
XI: ___ strength ___ trapezii and SCM bilaterally.
XII: Tongue protrudes to the right.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Mild action tremor bilaterally. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 4 5 5 5 5 5 5
R 4+ ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, vibratory sense,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3 2+
R 2+ 2+ 2+ 3 2+
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred.
====================
Discharge Exam:
====================
VS Tmax 98.5F, BP 123-136/69-84, HR 77-87, RR 18, 93-96% on RA
General - NAD
Pulm - No respiratory distress
Mental Status - Alert and oriented x3
Cranial nerves - ___ 4 to 2mm briskly, Able to sustain upgaze
for greater than 15 seconds without diplopia. He did have some
mild right ptosis with upgaze, however.
Motor - No pronator drift. ___ ___ bilateral deltoids and IP's.
Otherwise ___ ___ Triceps.
Sensory - Intact to light touch ___ all four extremities.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 10:50PM BLOOD WBC-7.1 RBC-5.12 Hgb-15.7 Hct-45.3 MCV-89
MCH-30.7 MCHC-34.7 RDW-11.9 RDWSD-38.2 Plt ___
___ 10:50PM BLOOD Neuts-92.6* Lymphs-5.8* Monos-1.1*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.58* AbsLymp-0.41*
AbsMono-0.08* AbsEos-0.00* AbsBaso-0.01
___ 10:50PM BLOOD ___ PTT-28.3 ___
___ 10:50PM BLOOD Glucose-140* UreaN-12 Creat-0.9 Na-136
K-4.2 Cl-99 HCO3-25 AnGap-16
___ 10:50PM BLOOD ALT-24 AST-18 AlkPhos-57 TotBili-0.8
___ 10:50PM BLOOD Albumin-4.4 Calcium-10.1 Phos-3.4 Mg-2.0
___ 10:59PM BLOOD ___ pO2-48* pCO2-42 pH-7.43
calTCO2-29 Base XS-2
___ 10:59PM BLOOD Lactate-1.5
___ 10:59PM BLOOD O2 Sat-80
___ 05:21AM BLOOD freeCa-1.23
___ 10:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
===============
INPATIENT WORKUP LABS
================
___ 02:03AM BLOOD WBC-12.2*# RBC-5.03 Hgb-15.5 Hct-45.9
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.2 RDWSD-40.3 Plt ___
___ 04:20AM BLOOD WBC-15.1* RBC-4.56* Hgb-13.9 Hct-40.6
MCV-89 MCH-30.5 MCHC-34.2 RDW-12.4 RDWSD-40.2 Plt ___
___ 12:54AM BLOOD WBC-11.8* RBC-4.73 Hgb-14.4 Hct-42.0
MCV-89 MCH-30.4 MCHC-34.3 RDW-12.2 RDWSD-39.8 Plt ___
___ 02:03AM BLOOD WBC-12.7* RBC-4.33* Hgb-13.2* Hct-39.1*
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.4 RDWSD-40.9 Plt ___
___ 02:24AM BLOOD WBC-12.8* RBC-4.19* Hgb-12.9* Hct-38.1*
MCV-91 MCH-30.8 MCHC-33.9 RDW-12.5 RDWSD-41.1 Plt ___
___ 04:00AM BLOOD WBC-9.3 RBC-4.13* Hgb-12.6* Hct-37.7*
MCV-91 MCH-30.5 MCHC-33.4 RDW-12.6 RDWSD-41.4 Plt ___
___ 12:54AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:23AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 04:52PM BLOOD ___ pO2-47* pCO2-56* pH-7.38
calTCO2-34* Base XS-5
___ 02:15AM BLOOD ___ pO2-36* pCO2-55* pH-7.30*
calTCO2-28 Base XS--1
___ 12:27PM BLOOD Lactate-3.2*
___ 06:19PM BLOOD Lactate-2.0
___ 01:05AM BLOOD Lactate-1.8
Test Result Reference
Range/Units
TPMT ACTIVITY 17 nmol/hr/mL RBC
Reference Range for TPMT Activity:
>12 Normal
___ Heterozygote or low metabolizer
<4 Homozygote Deficient Range
THIS TEST WAS PERFORMED AT:
___
___ ___, ___
___, MD PHD
Comment: Source: Line-cvl
.
___ 4:55 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN G---------- S
.
___ 09:51AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:51AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 09:51AM URINE RBC-20* WBC-3 Bacteri-FEW Yeast-NONE
Epi-0
.
___ 9:51 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
___ 4:10 pm BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~8OOO/ML Commensal Respiratory Flora.
.
___ 4:10 pm BRONCHOALVEOLAR LAVAGE RIGHT UPPER LOBE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
Brief Hospital Course:
Mr. ___ is a ___ yo gentleman with history of oculobulbar
myasthenia, on prednisone and recently added on azathioprine,
who presented with one day of worsening shortness of breath ___
setting of one month of progressively worsening dysarthria,
dysphagia, ptosis, and diplopia. The precipitating cause for
this was unclear, but the subacute decline despite uptitration
of immunosuppressive medications was concerning and the patient
was admitted to the Neurology ICU.
# Myasthenia Crisis
The patient's exam showed significant bulbar and proximal
weakness over the course of many days and required intubation
shortly after admission to the hospital. He underwent
plasmapheresis x 5 sessions (___).
Neuromuscular specialists were consulted for treatment
recommendations, with the following changes: azathioprine 200 mg
daily, prednisone 60 mg daily, stop mestinon. TPMT activity
normal, CT chest negative for thymoma, per outpatient
neurologist.
.
Patient was initially NPO because of significant bulbar
weaknees, with NS @ 75cc/hr. Once the patient was intubated, an
OG was placed and TF were started. After extubation, he was
evaluated by speech and swallow and passed - able to tolerate a
regular diet which he will continue after discharge.
.
Physical therapy also worked with the patient and felt that he
had no deficits after several inpatient ___ deficits and was safe
for home discharge.
.
# Pulmonary - Respiratory failure, mixed
Patient was intubated on ___ due to respiratory muscle fatigue,
increasing O2 requirement, and increasing hypercarbia. He had
increased secretion despite discontinuing mestinon. There was
concern for aspiration pneumonitis causing elevated WBC but CXR
was negative for aspiration or atelectasis. The patient had
yellow mucoid secretions and was monitored closely for
pneumonia. BAL showed no growth. Antibiotics were given for
several days and then were discontinued.
.
# ID
The patient was febrile to 100.8 on ___. Respiratory and urine
cx were sent and returned negative. Empiric Abx with
vanc/cefepime were started but DCed once culures returned
negative.
.
# Blood pressure
Patient was on continuous telemetry monitoring, with no acute
events. Lisinopril was initially continued on admission but then
held because of soft pressures after intubation; he was on low
dose phenylephrine while on propofol, but the pressor was weaned
off after 3 days. He was resumed on his lisinopril on discharge.
.
# Endocrine
Home metformin was held due to need for multiple medication
changes and tests that could affect renal function. The patient
was treated with insulin SS. Metformin was reinstated and
tolerated well prior to discharge.
.
# TRANSITIONAL ISSUES #
- Increased prednisone to 60mg daily
- Increased azathioprine to 200mg daily
- Stopped Mestinon
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 30 mg PO DAILY
2. Pyridostigmine Bromide 60 mg PO BID
3. Azathioprine 50 mg PO BID
4. Lorazepam 0.5 mg PO BID:PRN anxiety
5. Citalopram 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
8. Omeprazole 20 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
10. Doxazosin 8 mg PO HS
11. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Azathioprine 200 mg PO DAILY
RX *azathioprine [Azasan] 100 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
2. Citalopram 20 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
5. Aspirin 81 mg PO DAILY
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
7. Doxazosin 8 mg PO HS
8. Lisinopril 5 mg PO DAILY
9. Lorazepam 0.5 mg PO BID:PRN anxiety
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1.) Myasthenia ___ Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted with symptoms of problems swallowing and
breathing difficulty that was secondary to an exacerbation of
your myasthenia as well as a possible side effect from the
mestinon that you were taking. You required a short term
intubation while you were admitted. You received several
sessions of plasmapheresis which helped your symptoms. Your
medications were also adjusted ___ order to better control your
myasthemia. These changes were made by neuromuscular specialists
who were consulted to help with your care.
MEDICATION CHANGES:
Prednisone increased to 60mg daily
Azathioprine started 200mg daily
STOPPED Mestinon
Please follow up with your neurologist shortly after discharge.
Followup Instructions:
___
|
10508874-DS-14 | 10,508,874 | 21,046,872 | DS | 14 | 2133-03-17 00:00:00 | 2133-03-17 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of Parkinsons who was discharged to rehab ___
with a stable small L frontal SDH ___ to mechanical fall on
stairs and re-presented to ___ ED within hours with decline in
mental status.
Patient initially presented to ___ 2 days
___. He apparently fell around 11am that day but did
not go to ED until later when his daughter found out he'd fallen
and encouraged him to go in. She was particularly concerned
because he reported vomiting x 1 after the fall. He denied LOC
before or after fall, however this cannot be verified. He also
denied chest pain, difficulty breathing, BBI, or asymmetric
motor weakness. After imaging at ___ showed 5mm L
frontal SDH, he was transferred to ___ for further workup, at
which time he was seen by neurosurgery. After stable imaging and
clinical exam x 24hrs he was discharged from ED observation to
rehab with home anticoagulation (ASA) held.
Within hours of arriving at rehab the patient reportedly
declined, with visual hallucinations and combative and verbally
abusive behavior toward staff after family left. Patient has no
recall of the details of these events. He was returned to ___
ED at that time, where repeat imaging confirmed SDH was stable.
Aside from these particularly acute events, the patient's
daughter reports concern regarding a number of more subacute
signs of decline. 2 weeks ago the patient told his daughter that
he had been having visual hallucinations for at least a couple
of months, and that they were getting more frequent. Daughter's
concern regarding the hallucinations prompted a call to his PCP
and neurologist, who felt they could potentially be a medication
side-effect and decreased his sinemet from 1 tab 100/25 TID to
0.5 tab 100/25 TID one week ago. A UA/TSH was also ordered. The
TSH was normal but UA was positive and he was started on Bactrim
___ (5 days prior to fall). That urine culture ultimately
grew as contaminated/mixed flora. A repeat UA sent after fall
was notable for 60WBC, but culture finalized with no growth.
The hallucinations were of normal scenes in inappropriate
places, for example a car driving inside the house, or a person
pushing a stroller by inside the house (where there was no such
person). The hallucinations had no reported auditory, tactile,
or olfactory component, and patient was aware that they were
hallucinations. Patient denies symptoms of time loss, unusual
motor activity, BBI associated with these events, and he is not
able to identify any precipitating factors other than perhaps
fatigue.
Patient has also had a 35 lb weight loss since ___. Patient
acknowledges that he and his wife both have had progressively
worse PO intake as shopping etc has become more challenging, and
also notes that he is losing his sense of taste and smell, which
he attributes to chronic sinusitis over the past year with thick
nasal discharge and post-nasal drip with headaches and facial
pressure without fever/diplopia/nausea/vomiting/urinary changes,
for which Flonase has not been helpful. (He has not been on
antibiotics for these symptoms). Atrius records corroborate this
weight loss, as well as the increased confusion. Patient is
aware of this increasing confusion/disorientation and finds it
distressing, saying it is more noticeable over the past 3
months.
Also noted to have ___ on initial ED visit with Cr to 2.0. As of
___ previous baseline .8-.9.
Patient discharged from ED at around 1700 on ___ and
represented at midnight ___.
Past Medical History:
___ disease (on sinemet/amantadine)
HTN
Hyperlipidemia
L Inguinal Hernia s/p repair x 2
R Hydrocelectomy (___ ___
R Inguinal Hernia s/p repair ___ ___
Prostate CA, s/p open prostatectomy, stable PSA x many years
(___)
Mild aortic insufficiency (___), EF 50-55%
Lumbar Spinal stenosis
Seronegative RA
___ Cataracts
Carpal tunnel syndrome w/o deficit
Benign colorectal polyps s/p polypectomy x 2 (___)
s/p L total knee replacement (___)
Social History:
___
Family History:
Fathers side - notable for heart disease w fatal MI at ___
Mother - diabetes, stroke
Physical Exam:
ON ADMISSION:
=============
Vitals: T 98.9 BP 135/73 HR 87 RR 18 O2. sat 100 RA
General: Elderly gentleman lying in bed, awake, NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, normal pulses, no clubbing, cyanosis
or edema. Pale nail beds.
Neuro: Oriented to self but not place or time. Answering
questions medical history and general knowledge questions mostly
appropriately/accurately, patient unable to recall 3 words after
5 minutes, able to do calculations, unable to recite months
backwards. CNII-XII intact, notable tongue fasciculations.
Slight dysarthria. Dysmetria notable, R > left. Poor alternating
movements. Asymmetric resting tremor RUE > L. ___ strength
upper/lower extremities, grossly normal sensation, 2+ reflexes
bilaterally. gait deferred.
ON DISCHARGE:
=============
Vitals: T 98.3 BP 145/72 HR 58 RR 16 SpO2 98%RA
I/O: NR
General: Elderly gentleman laying in bed comfortably , awake,
NAD.
HEENT: Sclera anicteric, slightly dry mucosa, oropharynx clear,
EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, L hydrocele, retracted penis w edema, meatus not
visible.
Ext: Warm, well perfused, normal pulses, no clubbing, cyanosis
or edema. Pale nail beds. No erythema or signs of pressure sores
on bilateral ankles.
Neuro: A&Ox3. Calm.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 02:55AM BLOOD WBC-10.3* RBC-4.26* Hgb-13.6* Hct-40.1
MCV-94 MCH-31.9 MCHC-33.9 RDW-12.6 RDWSD-43.0 Plt ___
___ 02:55AM BLOOD Neuts-63.7 ___ Monos-10.8 Eos-1.3
Baso-1.4* Im ___ AbsNeut-6.58* AbsLymp-2.35 AbsMono-1.12*
AbsEos-0.13 AbsBaso-0.14*
___ 02:55AM BLOOD ___ PTT-32.6 ___
___ 02:55AM BLOOD Glucose-82 UreaN-47* Creat-2.0* Na-136
K-4.1 Cl-99 HCO3-22 AnGap-19
___ 03:03AM BLOOD Lactate-3.3*
___ 02:55AM BLOOD Albumin-4.4
IMAGING:
========
EEG ___:
This is an abnormal EEG in the awake and drowsy states due to
the presence of a slow and disorganized background consistent
with a mild to moderate encephalopathy of toxic, metabolic,
and/or anoxic etiology. No focal or epileptiform features were
seen. Note is made of a slower than average cardiac rate.
CT HEAD ___: There is small left frontal subdural hematoma,
stable compared to 1 day prior.
RELEVANT COURSE LABS:
=====================
___ 06:20AM BLOOD WBC-10.0 RBC-4.49* Hgb-14.3 Hct-42.7
MCV-95 MCH-31.8 MCHC-33.5 RDW-12.5 RDWSD-43.7 Plt ___
___ 08:20AM BLOOD WBC-8.7 RBC-4.22* Hgb-13.4* Hct-40.3
MCV-96 MCH-31.8 MCHC-33.3 RDW-12.7 RDWSD-44.5 Plt ___
___ 07:37PM BLOOD Glucose-112* UreaN-29* Creat-1.3* Na-138
K-4.1 Cl-106 HCO3-21* AnGap-15
___ 06:20AM BLOOD Glucose-88 UreaN-25* Creat-1.2 Na-139
K-4.2 Cl-105 HCO3-20* AnGap-18
___ 08:20AM BLOOD Glucose-123* UreaN-15 Creat-1.1 Na-138
K-4.4 Cl-103 HCO3-24 AnGap-15
___ 06:20AM BLOOD calTIBC-233* VitB12-567 Folate-12.7
Ferritn-818* TRF-179*
LABS ON DISCHARGE:
==================
___ 08:20AM BLOOD WBC-9.6 RBC-4.31* Hgb-13.7 Hct-40.7
MCV-94 MCH-31.8 MCHC-33.7 RDW-12.6 RDWSD-44.2 Plt ___
___ 08:20AM BLOOD Glucose-135* UreaN-18 Creat-1.0 Na-138
K-3.7 (repleted) Cl-105 HCO3-22 AnGap-15
___ 08:20AM BLOOD Calcium-10.5* Phos-2.6* Mg-1.3*
(repleted)
Urine culture no growth
Blood cultures pending but NGTD
Brief Hospital Course:
___ with hx of Parkinsons who was discharged to rehab on
___ with a stable small L frontal SDH ___ to mechanical
fall on stairs ___ and re-presented to ___ ED within
hours with decline in mental status. At time of discharge to
rehab ___ he was also being treated with bactrim for a UTI
that began on ___, and had a pre-renal ___ with Cr 2.0.
Neurosurgery and ___ evaluated him in the ED prior to discharge
and he was AOx3.
# AMS - Delirium due combination of UTI, subdural hematoma, and
change of environment in addition to progression of ___
disease or other underlying dementia ___ body dementia likely
given visual hallucinations). CT with stable SDH and 20 min EEG
with non-specific encephalopathy and no epileptiform changes.
Home sinemet and amantadine continued.
- Symptoms cleared and without any delirium for 2 nights prior
to discharge. He was aaox3 prior to discharge.
-- Patient's daughter at bedside helped significantly to improve
the delirium symptoms
-- We avoided antipsychotics as these can worsen ___
symptoms
# Subdural Hematoma - small and stable, evaluated and cleared by
NSurgery. Neurology also evaluated patient and will see him in
follow up
--- ASA held per neurosurgery recommendations (to be restarted
___
-- Follow up with Neurology, appointment pending
# ___: Continued home sinemet and amantadine
# UTI: Diagnosed 6 days prior to this admission, received 5 days
of treatment with bactrim prior to admission. Repeat UA showed
60 WBC, no growth in culture. Antibiotic changed to ceftriaxone
(bactrim is deleriogenic) and completed 8 days for complicated
UTI.
-- Completed Bactrim / Ceftriaxone, total days was 8.
-- Normal WBC, afebrile and fully oriented on discharge without
urinary complaints
# ___: Due to poor PO intake and some Cr elevation likely d/t
Bactrim. Resolved with IVF. Recent creatinine on ___ at atrius
1.7. Previous baseline in ___ .8-.9. Patient Cr 2.0 on
admission ___, downtrended to 1.6 on readmission. Now
normalized to 1.1 on ___.
- Cr 1.0 on ___
- Encourage much better fluid intake
--- Lisinopril/chlorthiazone to be restarted as outpatient per
PCP
___, hydrocele: patient has history of L Inguinal Hernia
s/p repair x 2, R Hydrocelectomy (___ ___, and R Inguinal
Hernia s/p repair ___ ___ be putting him at risk for
recurrent UTI. Reports worsening of phimosis over past year or
so.
--- Urology outpatient appointment scheduled
# Actinic Keratoses on lower legs - daughter has scheduled
___ appointment and patient encouraged to keep this
# RA: continued home plaquinel
# HTN: held lisinopril, chlorthalidone given ___
# HL: continued home simvastatin
TRANSITIONAL ISSUES:
===================
## ASA can be restarted 1 week after bleed per neurosurgery
recommendations (___)
## Lisinopril and chlorthalidone held for ___, can be restarted
when Cr normalized
## ___ want to consider increasing sinemet dose back to 1 tab
100/25 TID given no improvement in sx w recent decrease
## Needs repeat non-contrast head CT 4 weeks from bleed
(___)
## Needs to f/u with neurosurgery as scheduled
## Needs to f/u with urology as scheduled
## Needs to f/u with PCP as scheduled
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 0.5 TAB PO 3X/DAY
2. Hydroxychloroquine Sulfate 400 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Amantadine 100 mg PO BID
5. Simvastatin 40 mg PO QPM
6. Lisinopril 20 mg PO DAILY
7. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES
___ dry eye
8. Aspirin 162 mg PO DAILY
Discharge Medications:
1. Amantadine 100 mg PO BID
2. Carbidopa-Levodopa (___) 0.5 TAB PO 3X/DAY
3. Hydroxychloroquine Sulfate 400 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
6. Docusate Sodium 100 mg PO BID
7. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
1) Encephalopathy
2) Subdural hematoma
3) ___ Disease
4) Acute Kidney Injury
5) Hydrocele
6) Phimosis
7) Pre-cancerous lesions on skin on leg (Actinic Keratoses)
Secondary diagnosis:
1) RA
2) HTN
3) HL
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were recently admitted to the ___ after you became more
confused and agitated at rehab. The bleeding around your brain
was checked and did not become worse. Our neurology team saw you
and felt that the confusion and agitation was due to your
urinary tract infection, the bleeding around the brain, and the
unfamiliar environment of rehab and the hospital. They
recommended not changing any medications for the time being and
having your outpatient neurologist make any needed adjustments
once your immediate illnesses had resolved. You were checked for
epilepsy as well since your hallucinations could have been due
to small seizures, but the tests didn't show any signs of
epilepsy. Finally, your UTI was treated with an antibiotic, and
you were hydrated with fluids through an IV. Your kidneys had
shown signs of injury from your dehydration but that resolved
quickly.
You also have fluid around one of your testicles, and tightening
of the skin at the tip of your penis. We would like you to see a
urologist once you are discharged to see if treatment would
reduce the chance of future urinary tract infections.
We recommend follow up as an outpatient with urology, your
neurologist, and your PCP.
We really enjoyed taking care of you!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10509294-DS-18 | 10,509,294 | 25,026,114 | DS | 18 | 2135-10-11 00:00:00 | 2135-10-11 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
nausea, emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with history of Crohn's disease
s/p panproctocolectomy & RLQ ___ ileostomy in ___ for
initially suspected ulcerative colitis. He has had a peristomal
abscess and enterocutaneous fistula s/p ___ & remicade
Rx ___ followed by multiple flares & EC fistulae c/b abdominal
wall cellulitis. This ultimately prompted an exploratory
laparotomy with extensive abdominal wall fistulotomies,
resection of an inflammatory mass in his RLQ and relocation of
his ileostomy to the LLQ in ___. Since then patient has
multiple admissions to the ED for SBO and abdominal pain, last
admission was on ___ for SBO. At that time he was managed
conservatevely with NGT and bowel rest. Patient presented this
admission for 1 week history of crampy abdominal pain and 3 day
history of bilious emesis associated with decreased ostomy
output and flatus.
Past Medical History:
PMH: Crohns disease, chronic bronchitis, asthma, hyperlipidemia,
anxiety
PSH:
-___ proctocolectomy, end ileostomy
-___ takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass, Segmental
enterectomy X2
-___ Exploratory laparotomy, control of multiple small
bleeding points.
Social History:
___
Family History:
No family history of IBD. Father with lung cancer.
Physical Exam:
Vitals: Temp 98.1, HR 88, BP 102/68, RR 20, 96% Room air
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes dehydrated
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
Left sited OStomy with parastomal hernia, normal brown ostomy
output, flatus in bag. Reducible large ventral hernia.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:45AM BLOOD WBC-10.7 RBC-6.01 Hgb-17.2# Hct-48.1
MCV-80* MCH-28.6 MCHC-35.8* RDW-14.0 Plt ___
___ 11:45AM BLOOD Glucose-108* UreaN-19 Creat-1.4* Na-129*
K-4.1 Cl-91* HCO3-25 AnGap-17
___ 01:04PM BLOOD Lactate-2.0
___ 07:20AM BLOOD WBC-9.5 RBC-5.87 Hgb-16.8 Hct-49.2 MCV-84
MCH-28.7 MCHC-34.2 RDW-14.1 Plt ___
___ 07:20AM BLOOD Glucose-107* UreaN-19 Creat-1.4* Na-137
K-4.2 Cl-97 HCO3-28 AnGap-16
___ CT abdomen/pel w/ contrast
IMPRESSION: ***Final report still pending***
1. Large complex ventral incisional hernia containing multiple
loops of small bowel with areas of focal caliber change,
particularly within the
hernia neck, likely as a result of adhesions. Distal loops of
small bowel
appear collapsed. These findings are suggestive of an early or
partial
small bowel obstruction.
2. Persistent swirling of the mesentery and proximal small bowel
with
associated fat stranding, mesenteric edema, and lymphadenopathy,
essentially unchanged from prior exam. Findings again may be due
to internal hernia/mesenteric torsion.
3. Fatty deposition in the liver.
___. ___
___. ___
___ read entered: ___ 3:47 ___
Brief Hospital Course:
___ was admitted for recurrent SBO on ___. A
nasogastric tube (NGT) was placed, and he was made NPO with IVF
repletion. His hernia was reduced in the emergency room. After
placement his NGT has minimal output, 200 cc, and put out only
200cc overnight. He began to pass flatus in his ostomy and had
normal ostomy output.
His NGT was discontinued on ___. He was advanced to sips and
then regular diet, which he tolerated well. He was not nauseous
and continued to make normal ostomy output with flatus in the
bag.
He was ambulating and had no pain at time of discharge. He was
given DVT prophylaxis with subcutaneous heparin while in house.
He had no complications during his hospital stay and was
discharged to home in good condition.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
you were admitted for management of small bowel obstruction
secondary to your hernia. Your hernia was reduced in the
emergency room and your bowels were decompressed using bowel
rest and a nasogastric tube. Your bowel function is now normal
and you are tolerating a regular diet. You are ready to return
to home.
Please look out for any recurrent nausea, abdominal pain,
failure to pass stool, decreased ostomy output, and new fever or
fatigue.
We enjoyed taking care of you and wish you well.
Followup Instructions:
___
|
10509294-DS-21 | 10,509,294 | 26,377,782 | DS | 21 | 2136-05-18 00:00:00 | 2136-05-20 07:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Bilious Vomiting, abdominal pain, decreased ostomy output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of Chron's disease s/p multiple abdominal operations
with recurrent bowel obstructions managed conservatively
presents
today with 2 days of worsening abdominal pain, nausea, vomiting,
and decreased ostomy output. He denies fever/chills. He has been
having multiple episodes of bilious emesis. No recent illness.
He
was recently admitted in ___ for bowel obstruction managed
conservatively and per patient this feels like his usual
obstructive symptoms.
Past Medical History:
PMH: Crohns disease, chronic bronchitis, asthma, hyperlipidemia,
anxiety
PSH:
-___ proctocolectomy, end ileostomy
-___ takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass, Segmental
enterectomy X2
-___ Exploratory laparotomy, control of multiple small
bleeding points.
Social History:
___
Family History:
No family history of IBD. Father with lung cancer.
Physical Exam:
On Admission:
Vitals: 97.2 126 ___ 97%
Gen: Alert, NAD
CV: RRR
Pulm: CTAB
Abd: Soft, mild distension, mild tenderness to palpation in
the RLQ. The midline incision is well healed. No overlying skin
changes. Ostomy in the LLQ with liquid stool, no significant
gas.
Ext: no c/c/e
On discharge:
Vitals: 99 98.8 77 110/60 96 RA
Gen: NAD, Alert
CV: RRR, Normal S1, S2
Pulm: CTAB
Abd: Large right hernia, reducible. Nontender. Soft,
nondistended. Ostomy in LLQ with pasty stool output and gas
production.
Extr: No c/c/e
Pertinent Results:
___ 11:46PM GLUCOSE-111* UREA N-36* CREAT-2.4*#
SODIUM-135 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18
___ 11:46PM CALCIUM-9.3 PHOSPHATE-4.8* MAGNESIUM-1.9
___ 11:46PM WBC-11.4* RBC-5.51 HGB-16.2# HCT-47.2 MCV-86
MCH-29.4 MCHC-34.4 RDW-14.9
___ 11:46PM PLT COUNT-303
___ 09:42PM LACTATE-1.3
___ 12:17PM LACTATE-5.2*
___ 12:00PM GLUCOSE-180* UREA N-39* CREAT-3.8*#
SODIUM-133 POTASSIUM-4.4 CHLORIDE-88* TOTAL CO2-15* ANION
GAP-34*
___ 12:00PM ALT(SGPT)-49* AST(SGOT)-34 ALK PHOS-102 TOT
BILI-1.3
___ 12:00PM LIPASE-120*
___ 12:00PM ALBUMIN-5.6*
___ 12:00PM WBC-18.1*# RBC-6.62*# HGB-19.7*# HCT-56.8*#
MCV-86 MCH-29.7 MCHC-34.7 RDW-15.2
Brief Hospital Course:
Mr. ___ was admitted to ___ Surgery for 2 days of
worsening abdominal pain, nausea, and bilious vomiting. CT scan
in the ED showed small bowel obstruction involving proximal
jejunum with dilated jejunal loop through ventral hernia.
Patient was admitted to ___ 3 surgery for conservative
management of SBO. He arrived on the floor NPO, IV fluids, NG
tube, and foley for urinary output monitoring. Patient's
creatinine in the ED was 3.8 consistent with renal insufficiency
for which he was given fluid rehydration. Additionally he had a
lactate of 5.2 and wbc of 18.1 at time of admission.
Hospital day 2: patient had flatus and stool in his ostomy bag.
Pain was better controlled and he was ambulating with no
difficulties. He was advanced to sips. He remained afebrile with
wbc of 11.4, renal function improved with Cr value of 2.4, and
lactate was at 1.3
Hospital day 3: Patient self removed his NG tube overnight. He
was doing well with sips. His ostomy bag was full of flatus and
he felt better.
Hospital day 4: Patient was advanced to fulls and IV fluids were
discontinued as he was toleating the diet. In the afternoon
patient began experiencing nausea and emesis. An NG tube was
reinserted which produced 2 L of bilious fluids upon insertion.
Ostomy bag was producing minimal flatus. Patient was
transitioned back to NPO, IV fluids, and IV medications. Foley
was removed and patient had no difficulties voiding afterwards.
Hospital day 5: Patient remained NPO,IVF, with NG tube.
Creatinine rose to 1.6 from 1.2 the day prior with a decrease in
urinary output for which patient received IV fluid boluses.
Urinary output responded appropriately to the boluses.
Hospital day ___: NGT with decreased output. Patient's ostomy
showed increased flatus and stool output. NGT was removed after
a successful clamp trial. Patient was out of bed. Improved
urinary output with creatinine of 1.3. Patient was started on
clears with continuing IV fluids given high ostomy output.
Hospital day ___: Patient started on regular diet which he
tolerated well. Patient was maintaining adequate urinary output
with creatinine of 1.3 and IV fluids were discontinued. Patient
had chronic contact dermatitis surrounding ostomy site for which
ostomy nurse evaluated the patient and left appropriate supplied
by bedside.
Hospital day ___: Patient was started on loperamide 2 mg TID
for increased ostomy output which decreased his ostomy
output,although it still remained high. Patient's loperamide was
increased to 2mg QID.Patient was taught to titrate his ostomy
output to 1.5L/day. He was also told to measure the output
daily. He was tolerating regular diet, producing good urinary
output, and ambulating.
Medications on Admission:
None
Discharge Medications:
1. Loperamide 2 mg PO QID
RX *loperamide [Anti-Diarrhea] 2 mg 1 tab by mouth four times
daily Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Acute Renal insufficieny due tovolume depletion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to West 3 surgery for treatment of small bowel
obstruction. You were treated conservatively and made NPO, IVF,
and an NG tube was inserted. Your small bowel obstruction
improved and at time of discharge you were passing flatus,
tolerating a regular diet, and ambulating. You are now ready to
continue your recover at home.
Followup Instructions:
___
|
10509294-DS-24 | 10,509,294 | 23,507,822 | DS | 24 | 2137-01-05 00:00:00 | 2137-01-05 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
Abdominal pain and emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with Crohn's disease s/p
ileostomy complicated by large ventral hernia and multiple
recurrent small bowel obstructions, who presented with 1 week of
SBO and some substernal pressure.
1 week ago his ostomy output decreased and he began to have
abdominal pain. He also experienced nausea, some vomiting, and
bloating during this time. He also had decreased urine output
and his urine appeared darker than normal. No dysuria or
hematuria noted. He does note having anxiety trouble at baseline
that can manifest as shortness of breath. He denies chest pain
or pressure, denies radiating pain to back, arm, jaw, or
exertional pain. Denies cough, fevers, chills. He states that he
still has reduced ostomy output at this time.
In the ED, initial vs were: 97.0 125 99/66 20 99%. Patient had 1
bout of emesis in the ED. Labs were remarkable for elevated WBC
(13.4, 84%N), hct 47.5, BUN 28, Cr 2.4 (baseline 1.1-1.2 in
___, Na 125 (last known Na+ 137 in ___, Cl 82, glucose 143,
trop negative x1. CXR showed no acute findings. ECG showed sinus
tachycardia (HR 120), left atrial enlargement, no ST segment
changes or TWIs. Patient was given ASA 325 and ativan and 1L NS.
Vitals on Transfer: 98.4 106 122/72 19 100% RA.
On the floor, the patient is comfortably resting but did
experience 1 additional bout of emesis overnight.
Past Medical History:
PMH:
-Crohns disease
-Chronic bronchitis
-Asthma
-Hyperlipidemia
-Anxiety
PSH:
-___: proctocolectomy with end ileostomy
-___: Takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass and segmental
enterectomy x2
-___: Exploratory laparotomy with control of multiple small
bleeding points
Social History:
___
Family History:
Family History:
No family history of IBD. Father with lung cancer.
Physical Exam:
ON ADMISSION PHYSICAL EXAM:
Vitals- T 98.4 BP 136/76 HR 105 RR 20 SaO2 100 RA
975/250 Since MN, 1000/0 24HRs, Ostomy 150 since MN
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, PERRLA, EOMI
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, slightly tender to deep palpation, mildly
distended at hernia sites with soft reducible bowel. Normal
bowel sounds, no rebound tenderness or guarding, no
organomegaly. Loose brown stool in ostomy.
GU- no foley
Ext- warm, well perfused, 2+ pulses in PTs, no clubbing,
cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal
ON DISCHARGE PHYSICAL EXAM:
VITALS
T 98.5 BP 114/66 HR 101 RR 18 SAO2 98
Below are the parts of the physical exam, that differed on
discharge than the admission.
350/710 Since MN, ___ 24HRs, Ostomy 900 since MN 615 24
HRs
Abdomen- soft, non-tender to deep palpation, mildly distended at
hernia sites with soft reducible bowel. Normal bowel sounds, no
rebound tenderness or guarding, no organomegaly. Soft brown
stool and gas in ostomy.
Pertinent Results:
LABS ON ADMISSION:
___ 05:35PM BLOOD WBC-13.4*# RBC-5.89 Hgb-17.7# Hct-47.5
MCV-81* MCH-30.0 MCHC-37.2* RDW-13.6 Plt ___
___ 05:35PM BLOOD Neuts-83.7* Lymphs-8.4* Monos-6.7 Eos-0.7
Baso-0.5
___ 05:35PM BLOOD Glucose-143* UreaN-28* Creat-2.4*#
Na-125* K-3.8 Cl-82* HCO3-26 AnGap-21*
___ 05:35PM BLOOD cTropnT-<0.01
PERTINENT LABS:
___ 07:40AM BLOOD WBC-6.4 RBC-4.48* Hgb-13.4* Hct-37.5*
MCV-84 MCH-30.0 MCHC-35.9* RDW-13.6 Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-1.3* Na-131*
K-3.1* Cl-96 HCO3-22 AnGap-16
___ 07:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:10AM BLOOD CK(CPK)-65
___ 07:40AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2
IMAGING:
CXR ___ - No acute findings in the chest.
KUB ___ - No overt evidence of obstruction or ileus. If
clinical suspicion of partial
small bowel obstruction persists, recommend abdominal CT for
further
evaluation.
ECG:
___ - Sinus tachycardia. Borderline left atrial abnormality.
Compared to the
previous tracing of ___ heart rate is increased. Otherwise,
no diagnostic
change.
Brief Hospital Course:
___ year old man w/o Crohn's disease s/p ileostomy c/b large
ventral hernia with multiple recurrent small bowel obstructions,
p/w shortness of breath, hyponatremia, ___, n/v, and abdominal
pain in the context of anxiety and likely partial SBO.
# Emesis: The patient p/w emesis and decreased ostomy output in
the setting of abdominal pain. He was treated for a Partial SBO
and placed on IVF, made NPO, and give Zofran for nausea. A CXR
ruled out free air under the diaphrapm and a KUB did not
demonstrate overt SBO or ileus. After bowel rest, he began
producing more stool, his pain decreased, and his nausea
dissipated. After tolerating a regular diet, he was discharged.
# ___: He was treated for presumed pre-renal (dehyrdration)
acute kidney injury, and was resuscitated with IV NS boluses.
His Cr steadily improved from 2.4 on ___ to 1.3 on ___, nearing
his baseline of 1.1-1.2.
# Hyponatremia: His hyponatremia was also due to dehydration and
he was resuscitated with IV NS. His Na corrected to the normal
range.
# Shortness of Breath: The shortness of breath was likely due to
anxiety, as a cardiac cause was r/o (ECG: sinus tach, negative
troponins) and pulmonary cause was also ruled out with a
negative CXR and the patient maintained his oxygen saturation
above 95% on RA throughout his hospitalization. He was treated
with Ativan and his baseline heart rate decreased to the normal
range. He has many psychosocial stressors as the patient is
currently homeless and living in a local YMCA. He was instructed
to follow up with his PCP regarding this issue.
# Transitional issues:
- Patient to follow-up with plastic surgery and ___ as
outpatient
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Hyponatremia
Acute kidney injury
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the ___.
You were admitted due to nausea, vomiting, abdominal pain and
decreased stool output into your ostomy concerning for a partial
small bowel obstruction. In the hospital, we controlled your
symptoms with medications and gave you IV fluids until the
obstruction resolved.
You will need close follow-up with Dr. ___
future treatment of your hernia.
Followup Instructions:
___
|
10509294-DS-28 | 10,509,294 | 22,767,725 | DS | 28 | 2138-03-18 00:00:00 | 2138-03-22 22:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Penicillins
Attending: ___.
Chief Complaint:
Increased ostomy output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH fistulizing Crohn's disease s/p proctocolectomy
with end-ileostomy in ___, presenting with increased ostomy
output.
Pt reports increased output started 48 hours prior to admission.
The output was initially light yellow, and has progressed to a
dark, foul-smelling green liquid. He has had to empty his ostomy
bag 40-50x per day compared to his normal ___ per day (last
changed his bag on ___. His output is normally watery
brown-beige with some solids. Has not been eating much since
this began, tried some saltenes, some OJ, and drank 1.5L prior
to coming into the ED.
He denies any abdominal pain changed from his baseline. Denies
fevers, chills, medication changes, or recent sick contacts. No
changes to his diets and tries to eat relatively healthy. He is
not taking the tincture of opium or loperamide prescribed to him
at his last discharge, as patient reports opium makes him itch
without benadryl, and benadryl is very expensive. Also notes
that he lives surrounded by a lot of drug abusers, and does not
want this to happen to him with the opium. He last took these
medications ___ months ago. He does have a small amount of
nausea which improves with burping. He self-medicates at home
with metamucil intermittently for looser stool consistency, last
took this a couple of weeks ago. He also complains of severe
calf/leg/arm/trunk cramping, which he says is similar to prior
admissions when he was very dehydrated from increased ostomy
output, also with decreased UOP over last 24 hours, slightly
darker in color.
Otherwise on remainder of ROS denies weight changes,
lightheadedness, sore throat, headaches, CP, palpitations, SOB,
abdominal pain that is changed or new, vomiting, hematuria, or
bloody ostomy output.
In the ED, labs notable for hyperkalemia to 5.7, hyponatremia
with Na 128, acidosis with bicarb of 14, ___ with Cr of 3.4
(baseline 1.8), WBC 12.1, lactate 2.5, s/p fluids in the ED as
well as ondansetron, IV PPI, and ativan.
Past Medical History:
-Crohns disease
-Chronic bronchitis
-Asthma
-Hyperlipidemia
-Anxiety
-GERD
PSH:
-___: proctocolectomy with end ileostomy
-___: Takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass and segmental
enterectomy x2
-___: Exploratory laparotomy with control of multiple small
bleeding points
-___: Exploratory laparotomy, control of multiple small
bleeding points
-___: Exploratory laparotomy, Small bowel resection, Small
bowel anastomosis for partial small bowel obstructions.
Social History:
___
Family History:
His family history is negative for inflammatory bowel disease.
His mother died of lung cancer related to smoking. Father died
of alcohol-related pathologies at age ___. Poor contact with 6
siblings; one dead of unknown causes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals: 97.8, 113/71, 97, 18, 96% RA
GENERAL: pleasant, lying comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM dry
CARDIAC: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, hyperactive BS with palpable
alimentation on exam, nontender in all quadrants, no
rebound/guarding. Left sided ostomy appears fleshy and pink with
copious green liquid output.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact. No focal deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==================
Vitals: 98.1, 80, 92/51, 20, 98%/RA
GENERAL: NAD, AOX3, pleasant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM remain dry
CARDIAC: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, hyperactive BS with palpable
alimentation on exam, nontender in all quadrants, no
rebound/guarding. Left sided ostomy appears fleshy and pink with
mixed green/brown output. Palpable known ventral hernia off to
R side of abdomen, soft. Abdominal scares well healed.
EXTREMITIES: warm and well perfused, 2+ peripheral pulses, no
peripheral edema.
NEURO: CN II-XII intact. No focal deficits. Moving all
extremities
SKIN: no excoriations, no rashes noted
Pertinent Results:
ADMISSION LABS:
============
___ 01:30PM BLOOD WBC-12.2* RBC-6.25*# Hgb-17.3# Hct-51.3#
MCV-82# MCH-27.8 MCHC-33.8 RDW-14.9 Plt ___
___ 01:30PM BLOOD Neuts-83.2* Lymphs-8.8* Monos-6.9 Eos-0.9
Baso-0.2
___ 01:30PM BLOOD Glucose-122* UreaN-40* Creat-3.4*#
Na-128* K-5.7* Cl-94* HCO3-14* AnGap-26*
___ 01:30PM BLOOD Calcium-9.8 Phos-4.1 Mg-2.0
___ 01:40PM BLOOD Lactate-2.5* K-4.6
___ 06:36PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:36PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
___ 06:36PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 06:36PM URINE CastHy-10*
___ 06:36PM URINE Mucous-RARE
DISCHARGE LABS:
============
___ 08:00AM BLOOD WBC-5.1 RBC-4.45* Hgb-12.6* Hct-36.8*
MCV-83 MCH-28.3 MCHC-34.2 RDW-15.2 Plt ___
___ 08:00AM BLOOD Glucose-86 UreaN-26* Creat-2.0* Na-138
K-3.6 Cl-104 HCO3-23 AnGap-15
___ 08:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
___ 08:00AM BLOOD CRP-9.1*
___ 08:00AM BLOOD SED RATE-PND
MICROBIOLOGY:
============
___ 11:33 pm STOOL CONSISTENCY: WATERY
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
___ 1:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
============
___ CT ABDOMEN/PELVIS W/O CONTRAST
IMPRESSION:
1. Large non-obstructing large ventral hernia containing small
bowel.
2. Fatty infiltration of the liver.
Brief Hospital Course:
___ with PMH fistulizing Crohn's disease s/p proctocolectomy
with end-ileostomy presenting with increased ostomy output,
diffuse muscle cramps, with dehydration, acidosis, ___ and
hemoconcentration.
ACTIVE ISSUES:
============
# Diarrhea/Increased Ostomy output/dehydration:
Patient presented with large amounts of ostomy output for 48hrs
prior to admission, with dark green liquid output (non-bloody,
no mucous), requiring ostomy emptying 50-60 times daily, as well
as decreased appetite and diffuse muscle cramping. This occurred
in the setting of not taking medications previously prescribed
for the patient to help with loose ostomy output, including
loperamide and tincture of opium. Patient self-medicates
intermittently with Metamucil while at home, but had not taken
this for 2 weeks prior to presentation. Infectious workup was
negative for c.diff, and other stool cultures as well as blood
cultures were NGTD, final results pending at time of discharge.
Patient with previous ischemic bowel from abdominal wall hernia,
however no pain or evidence on exam of incarcerated hernia or
necrotic bowel, and CT abdomen without evidence of obstruction.
Patient remained afebrile and without nausea/vomiting or
associated abdominal pain. Once C diff came back negative, the
patient was restarted on loperamide as well as psyllium as
bulking agents and to decrease gut motility. Given large volume
of fluid losses through loose ostomy output, patient was
supported with IVF while inpatient to replace losses, and his
muscle greatly improved. Initially some concern for possible
Crohns disease flare, despite lack of mucous output and lack of
bloody output, as patient with mildly increased inflammatory
markers at last GI visit in ___, however CRP this admission
downtrended (ESR pending), making a Crohns flare less likely.
Other considerations leading to increased ostomy output include
likely viral infection versus malabsorption and bacterial
overgrowth leading to loose stool and increased output. Ostomy
output improved and decreased, the patient's appetite improved
and he tolerated full diet on day of discharge, with improved
volume status.
Patient discharged with prefilled loperamide prescription,
however the pharmacy was unable to fill the psyllium as not
covered by patient's insurance, and the patient was supplied
with a prescription for each of these medications.
# Acute on CKD:
Admission Cr of 3.4 from baseline of 1.8 (unclear etiology of
CKD). Likely prerenal in the setting of high ostomy output.
Received IVF this admission given GI losses discussed above, and
the patient's Cr downtrended with fluids to 2.0 on day of
discharge. Given improved tolerance of PO intake on discharge,
expect Cr will continue to downtrend back to baseline.
# Anion gap acidosis:
VBG with pH of 7.25, pCO2 of 40, pO2 of 180, AG of 25, with
bicarb on admission of 14, and lactate of 2.5. Likely etiology
from high ostomy output and subsequent dehydration causing
lactic acidosis and ___. Patient improved with fluid
resuscitation and improvement in ostomy output.
# Hyponatremia:
Patient with sodium down to 128 on admission, likely hypovolemic
hyponatremia given clinical picture and large volume loss from
GI via ostomy, and evidence of hemoconcentration on labwork.
Normalized with fluid resuscitation.
# Fatty liver on CT:
LFTs in ___ wnl, nontender on exam. Negative hepatitis
serologies in ___, negative HIV in ___. Given low acuity,
further evaluation and management deferred to outpatient
setting.
# Psychosocial:
Lives in group housing at ___; concerned about
"addicts" living in nearby units regarding his at-home
medications (previously prescribed tincture of opium and patient
concerned others would steal it). Also patient without any
person to list as emergency contact. Recommend outpatient
social work for longer term relationship and follow up, to be
discussed with primary care physician.
CHRONIC ISSUES:
=============
# Fistulous Crohns Disease:
Per patient initially misdiagnosed with UC, s/p ileocolectomy
with ileostomy in RLQ in ___, complicated by multiple
enterocutaneous fistulas as well as ___ abscess, leading
to diagnosis of Crohns disease ___ years later, with surgical
management of abscess/fistulas and revision/relocation of
ileostomy to ___. Does not currently maintain disease w/
immune-modulating therapy but has in past for flair episodes w/
associated fistulas, including 3 Remicade doses for fistulous
disease in early ___, as well Pentasa and ___ in the remote
past. Currently seen by Dr. ___ at ___. Patient has
discussed possibility of starting Pentasa again, however per
notes is hesitant to take more pills. During recent admission
with small bowel resection in ___, pathology without evidence
of active Crohns disease. Of note patient missed most recent
appointment with Dr. ___ in ___. ESR/CRP most recently in
___ were slightly elevated at 30 and 24.2 respectively,
raising concern for possible recurrence/flare of Crohns disease,
however both downtrended on recheck this admission to 2 and 9.1
respectively. Patient rescheduled for follow up appointment with
Dr. ___ discharge given previously missed
appointment.
# Nutritional deficiencies:
Patient also noted to have low Vitamin D and low B12 on most
recent laboratory results, likely related to malabsorption
issues given Crohns Disease and bowel resections. Started on
Vitamin D supplement ___ units daily this admission, and
received IM Vitamin B12 injections 1000mcg daily while here.
Supplied with a prescription for Vitamin D, which was prefilled
at the pharmacy prior to patient discharge, and will likely need
more Vitamin B12 injections as outpatient, will defer management
to PCP.
# Multiple abdominal wall hernias:
With vascular congestion on imaging leading to partial small
bowel obstructions in the past, now s/p partial small bowel
resection in ___ (158 cm removed - 5 feet) following
admission for bowel obstruction, with closed loop obstruction on
CT and ischemic bowel found during surgery. Since surgery, his
hernia has been reduced in size, and not bothersome to him.
Current hernia is soft, nontender, low suspicion for necrotic
bowel, and absence of any evidence of obstruction on imaging.
GI outpatient providers have recommended the patient see a
plastic surgeon for abdominal wall mesh placement to prevent
recurrent hernia with ischemic bowel injury. Will defer to
outpatient providers to continue this discussion and for future
referral.
# GERD:
Stable, patient currently not endorsing symptoms, in the past
has taken Zantac with good effect.
TRANSITIONAL ISSUES:
===============
# Patient often lost to follow up, have scheduled follow ups
following this admission with his PCP as well as with his GI
specialist
# Sent out with loperamide, psyllium, and vitamin D
prescriptions
# Given 2 doses of IM Vitamin B12 given low levels on most
recent ___ need follow up with PCP, consider another B12
injection in office
# Per outpatient GI, recommending patient see plastic surgeon
for abdominal wall mesh placement to prevent recurrent hernia
with ischemic bowel injury, will defer to outpatient management
# Fatty liver noted on CT abdomen this admission, no history in
records of liver disease, last LFTs in ___ wnl, nontender on
exam. Further workup and management deferred to outpatient PCP.
# Patient has NO emergency contact, potentially would benefit
from social work as an outpatient
# Code: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Psyllium Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. LOPERamide 2 mg PO QID:PRN diarrhea
This is a new medication to treat your loose ostomy output.
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 mg by mouth
up to four times daily as needed Disp #*120 Tablet Refills:*2
2. Psyllium 1 PKT PO DAILY
RX *psyllium 1 packet(s) by mouth daily as needed Disp #*30
Packet Refills:*2
3. Vitamin D ___ UNIT PO DAILY
This is a new medication to treat your low vitamin D levels.
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Dehydration
Malabsorption
Acute on chronic kidney injury
Metabolic acidosis
Secondary Diagnoses:
Fistulous Crohn's 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 your during your recent
hospital stay. You came in with increased loose output into your
ostomy bag, without a clear trigger. You had not been taking any
medications recently for this, and became very dehydrated from
your fluid losses. You additionally had some muscle cramping,
some electrolyte abnormalities, and kidney injury from
dehydration, all of which improved with some intravenous
hydration and giving your stomach and intestines a rest from
food. You did not have any evidence of acute infection, and
there was no blood in your ostomy to suggest an acute Crohns
flare. Your inflammatory markers checked while you were here
were reassuringly low. Given you still had loose stool output in
your ostomy bag, and as you have had good results with metamucil
and immodium, these were restarted to help solidify your stool
and decrease your chance risk of dehydration in the future.
You were noted to have low levels of vitmamin D and vitamin B12
at your last visit to the clinic, so you were also given some
supplements while you were in the hospital. We are giving you a
prescription for Vitamin D supplements, and you should get
another Vitamin B12 injection at your next primary care doctor
visit.
Your future appointments and medication list are listed below.
It is very important that you take your medications to help
prevent dehydration in the future, and that you attend your
follow up appointments to ensure adequate control of your Crohns
Disease to prevent further damage to your intestines.
We wish you all the best with your health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10509294-DS-29 | 10,509,294 | 22,203,586 | DS | 29 | 2138-04-05 00:00:00 | 2138-04-12 21:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Penicillins
Attending: ___.
Chief Complaint:
nausea, vomiting, increased ileostomy output
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with a complicated history of fistulizing
Crohns disease s/p proctocolectomy with end ileostomy presenting
with 2 days of nausea, vomiting, and increased ostomy output.
At baseline, he has ___ ostomy bags per day with yellow/brown
liquid stool. For 2 days prior to admission, he has ~20 bags of
stool, dark green in color. Approximately 5 episodes of vomiting
per day, NBNB. He has not been taking his loperamide. He notes
prior to developing N/V/D he ate multiple large meals over the
___ holiday and his birthday. Subsequently, he had
decreased PO intake, and noted decreased urine output, dry
mouth, lightheadedness with standing, and muscle cramps in his
abdomen and upper and lower extremities. Denies fevers, chills,
urinary symptoms, URI-like symptoms, myalgias/arthralgias,
abdominal pain, chest pain, shortness of breath,
weakness/numbness/paresthesias.
Recent history notable for admission ___ for similar
symptoms, with ___, hyponatremia, felt to be due high ostomy
output from poor compliance with his anti-diarrheals. Resolved
with IVF and advancing of diet. He was started on vit-d for
malnutrition and received B12 injections. He was due to see his
GI doctor tomorrow.
In the ED initial vitals were: 98.0 135 ___ 96% RA. CT
abd neg for obstruction.
- Labs summarized below, notable for ___, AG acidosis, mild
hyperkalemia, leukocytosis to 18
- Patient was given 2L IVF, 4 mg zofran, 5mg IV morphine
Vitals prior to transfer were: 98.2 98 108/65 16 97% RA
On the floor, the patient is without acute complaints
Past Medical History:
-Crohns disease
-Chronic bronchitis
-Asthma
-Hyperlipidemia
-Anxiety
-GERD
PSH:
-___: proctocolectomy with end ileostomy
-___: Takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass and segmental
enterectomy x2
-___: Exploratory laparotomy with control of multiple small
bleeding points
-___: Exploratory laparotomy, control of multiple small
bleeding points
-___: Exploratory laparotomy, Small bowel resection, Small
bowel anastomosis for partial small bowel obstructions.
Social History:
___
Family History:
His family history is negative for inflammatory bowel disease.
His mother died of lung cancer related to smoking. Father died
of alcohol-related pathologies at age ___. Poor contact with 6
siblings; one dead of unknown causes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: 98.0, BP 133/77, HR 95, RR 20, SPO2 98RA
General: Alert, oriented, no acute distress, ambulatory in room
without difficulty
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear
Neck: Supple, JVP not elevated, no tonsillar or cervical
lymphadenopathy
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
and normo- to hyperactive, no rebound tenderness or guarding, no
organomegaly. Multiple surgical scars. Large RLQ hernia in
abdominal wall, reducible with no bowel loops palpated.
Ileostomy bag in place in ___ with dark green stool. Ext: Warm,
well perfused, 2+ pulses, no clubbing, cyanosis or edema
Skin: Large area, covering LLQ and extending onto left thigh,
of erythematous, moist, macerated skin with areas of scale.
Neuro: A/Ox3. CN2-12 intact. Strength ___ in upper and lower
extremities. Sensation intact to light touch in distal
extremities. Coordination intact to FNF. Gait normal
DISCHARGE PHYSICAL EXAM:
=========================
VS: T97.6, BP112/69 HR ___, RR18 SPO2 99RA
orthostatics:
--lying: BP 129/62, HR 85'
--standing: BP 124/79, HR 87
General: Alert, oriented, no acute distress, ambulatory in room
and floor without difficulty
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear
Neck: Supple, JVP not elevated, no tonsillar or cervical
lymphadenopathy
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
and normoactive, no rebound tenderness or guarding, no
organomegaly. Multiple surgical scars. Large RLQ hernia in
abdominal wall, reducible with no bowel loops palpated.
Ileostomy bag in place in LLQ with brown liquid stool
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Moderate area of irritated erythematous skin covering LLQ
and extending onto left thigh. Today appears dry and clean,
improved since admission
Neuro: A/Ox3. CN2-12 intact. Strength ___ in upper and lower
extremities. Sensation intact to light touch in distal
extremities. Gait normal
Pertinent Results:
IMAGING:
=================================
#CT ABD/PELVIS ___
CHEST: The visualized lung bases are clear. There is no pleural
or pericardial effusion. ABDOMEN: Evaluation of the
intra-abdominal solid organs is limited by lack of intravenous
contrast. The liver is low in density, compatible with hepatic
steatosis. The gallbladder is normal with subtle intraluminal
hyperdensity noted, possibly representing a tiny gallstone. The
common bile duct is normal in caliber. The pancreas is normal in
bulk with no stranding. The spleen is normal in size and
attenuation. The adrenal glands are normal bilaterally. The
kidneys are normal with no hydronephrosis or stones. The
distal esophagus appears normal. The stomach is unremarkable
though the anterior wall of the distal stomach is noted to
partially entering a ventral abdominal wall hernia. There is
evidence of prior bowel surgery with total colectomy and small
bowel anastomoses noted. There is an end ileostomy in the left
lower quadrant abdominal wall. A bowel containing hernia in the
anterior abdominal wall contains multiple outpouchings of fat
and bowel without evidence of obstruction. The left lower
quadrant ileostomy appears unchanged with a stable fat and small
bowel containing peristomal hernia. No ascites or free air.
PELVIS: The urinary bladder is unremarkable. The prostate and
seminal vesicles are normal. There is no pelvic free fluid or
lymphadenopathy. VESSELS: The aorta is normal in caliber.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion
concerning for malignancy. IMPRESSION: 1. Prior colectomy
with end ileostomy in the left lower quadrant abdominal wall. No
bowel obstruction. 2. Anterior abdominal wall hernia is again
noted. 3. Small parastomal hernia. 4. Hepatic steatosis.
ADMISSION LABS
=======================
___ 03:07AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:07AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:07AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:07AM URINE CastHy-7*
___ 08:00PM BLOOD WBC-18.8*# RBC-6.26*# Hgb-17.9# Hct-50.5#
MCV-81* MCH-28.5 MCHC-35.3* RDW-15.4 Plt ___
___ 08:00PM BLOOD Neuts-89.8* Lymphs-5.6* Monos-3.9 Eos-0.5
Baso-0.3
___ 08:00PM BLOOD ___ PTT-31.0 ___
___ 08:00PM BLOOD Glucose-151* UreaN-41* Creat-3.2*#
Na-131* K-5.6* Cl-95* HCO3-14* AnGap-28*
___ 08:00PM BLOOD ALT-46* AST-34 AlkPhos-159* TotBili-0.9
___ 08:00PM BLOOD Lipase-120*
___ 08:00PM BLOOD Albumin-5.5*
___ 06:35AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.7
___ 03:27AM BLOOD CRP-19.2*
PERTINENT LABS:
========================
SED RATE BY MODIFIED 9
___ 06:35AM BLOOD WBC-11.0 RBC-5.31 Hgb-14.9 Hct-42.9
MCV-81* MCH-28.0 MCHC-34.6 RDW-15.8* Plt ___
___ 07:10AM BLOOD WBC-6.5 RBC-5.17 Hgb-14.5 Hct-41.1
MCV-80* MCH-28.0 MCHC-35.2* RDW-15.5 Plt ___
___ 06:35AM BLOOD WBC-6.1 RBC-5.28 Hgb-14.5 Hct-42.2
MCV-80* MCH-27.4 MCHC-34.3 RDW-15.9* Plt ___
___ 06:35AM BLOOD Glucose-99 UreaN-37* Creat-2.4* Na-131*
K-3.8 Cl-98 HCO3-16* AnGap-21*
___ 07:10AM BLOOD Glucose-97 UreaN-26* Creat-2.0* Na-132*
K-3.7 Cl-101 HCO3-18* AnGap-17
___ 06:35AM BLOOD Glucose-125* UreaN-21* Creat-1.7* Na-132*
K-3.3 Cl-95* HCO3-23 AnGap-17
___ 07:10AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
___ 06:35AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.8
DISCHARGE LABS:
=========================
___ 07:20AM BLOOD WBC-6.1 RBC-5.02 Hgb-14.0 Hct-40.8
MCV-81* MCH-27.9 MCHC-34.4 RDW-15.1 Plt ___
___ 07:20AM BLOOD Glucose-90 UreaN-18 Creat-1.5* Na-137
K-3.4 Cl-102 HCO3-21* AnGap-17
___ 07:20AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.7
MICROBIOLOGY:
========================
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Blood Culture, Routine (Final ___: NO GROWTH
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Brief Hospital Course:
___ year of man with a history of fistulizing Crohn's disease s/p
proctocolectomy with end-ileostomy in ___, presenting with
increased ostomy output, nausea and vomiting.
ACTIVE ISSUES:
======================
# Nausea, vomiting, increased ileostomy output:
By the time of admission, his nausea and vomiting had resolved,
but he initially continued to have increased ostomy output.
Etiology was not clear, but suspected infectious cause given
concomitant nausea/vomiting, recent hospitalization, and
homelessness. Stool studies were negative for bacterial and
parasitic causes of diarrhea. Viral stool assay was negative,
although viral gastroenteritis could have explained his
symptoms. Patient noted that he had multiple large "binge"
meals in the days prior to admission, which also could have
caused his increased ostomy output. Crohn's flare and small
bowel bacterial overgrowth were also considerations, although
rapid improvement suggests against these etiologies. Lipase was
mildly elevated but he had no clinical or radiologic evidence of
pancreatitis. Patient is overall well-nourished as evidenced
by adequate maintenance of weight over time after his multiple
surgeries, indicating adequate absorptive function of the bowel.
He was supported with intravenous fluids, and advanced to a
regular diet, which he tolerated well. His ostomy output
decreased from ___ bag changes daily prior to admission to his
baseline of ___ on discharge.
#Acute kidney injury:
Patient presented with elevated creatinine at 3.2, with baseline
1.7 to 2. Likely due to hypovolemia from nausea, increased
ostomy output as creatinine rapidly declined to 1.7 with
intravenous fluid resuscitation. He also developed hyperkalemia,
without concerning EKG changes, which resolved with IV fluids.
Also with anion-gap metabolic acidosis on presentation, most
likely related to lactic acidosis with acute kidney injury due
to hypovolemia; this also resolved with IV fluids.
# ___ skin breakdown: Patient feels that this is related
to leaking of ostomy bag contents onto surrounding skin.
Possibly related to bile-salt irritation. Fungal infection also
possible given erythema/scale and significant skin maceration,
but was not concerning for bacterial cellulitis. Per the pt this
often happens when his ostomy output is high. This improved
with adequate ostomy care.
TRANSITIONAL ISSUES:
=========================
-After patient was discharged from the hospital, medical team
was notified of a blood culture with coagulase negative staph.
This blood culture had been ordered on admission but not drawn
until the day of discharge. Patient had no concerning signs for
bacterial infection, and was well appearing, without fever or
leukocytosis. Multiple attempts to contact the patient to
encourage him to come in for repeat evaluation, but were
unsuccessful. Patient was able to follow-up with his primary
care physician, who felt that the patient was well-appearing,
and that this positive blood culture was like contaminant, and
so no further work-up was done.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LOPERamide 2 mg PO QID:PRN diarrhea
2. Psyllium 1 PKT PO DAILY
3. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. LOPERamide 2 mg PO QID:PRN diarrhea
2. Psyllium 1 PKT PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Miconazole Powder 2% 1 Appl TP BID
RX *miconazole nitrate 2 % apply to affected area twice a day
Disp #*1 Spray Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Active issues:
-Dehydration
-Acute kidney injury
-Diarrhea (increased ileostomy output)
Chronic diagnoses:
-Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been our pleasure caring for you here at ___. You were
admitted for increased ostomy output. It is likely related to
your recent increased food intake. Stool samples did not show
any signs of bacteria, viral, or parasitic infection, and your
quick recovery without pain or bleeding is reassuring that this
was not a Crohn's flare. You should follow up with your primary
care provider ___ on ___ at 3:40pm (see info
below).
Wound care instruction:
Treat the peristomal skin with antifungal powder as you are
doing.
Brush in the powder and then brush off the excess powder and
seal
with No Sting ___ film #___. Air dry prior to pouch
application.
Suggest discontinue use of tape along the wafer borders and
instead apply ___ Strips.
Followup Instructions:
___
|
10509294-DS-36 | 10,509,294 | 22,978,122 | DS | 36 | 2141-12-25 00:00:00 | 2142-01-21 17:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Penicillins
Attending: ___.
Chief Complaint:
abdominal pain, increased output from ostomy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o M with PMHx of Crohn's disease, GERD, asthma,
anxiety, who presented with abdominal pain and increased ostomy
output.
Of note, the patient was recently admitted to ___ ___
with similar symptoms. Please refer to that discharge summary
for
further details. Briefly, the patient presented at that time
with
increased ostomy output and change in stool color / consistent
(stool was reportedly bilious). There was associated
hyponatremia
and ___ on CKD, both attributed to dehydration in the setting of
increased ostomy output. Stool cutlures were negative, and his
symptoms were ultimately attributed to viral GE given rapid
improvement with IVFs. Of note, he did have one blood culture
during that admission which grew micrococcus. There was no other
positive culture data, and this was ultimately attributed to
contaminant.
Since discharge, the patient reports that he was feeling well
until MN last night (~24 hours ago). He then developed
recurrence
of his previous symptoms, including increased abdominal bloating
and cramping. He noted increased ostomy output, which was
initially yellow but then became bilious in color. He denies any
blood in his stool. He endorses associated nausea and dry
heaves,
but no vomiting. He has felt warm. He also endorses a frontal
headache.
Past Medical History:
- Crohn's disease s/p proctocolectomy with end ileostomy (dx at
___, last GI visit in ___
- GERD
- asthma
- anxiety
- CKD III -> iso multiple hypovolemia episodes -> renal follows
- type 2 diabetes in remission
- multiple SBOs s/p exploratory laparotomy and small bowel
resection (most recently in ___
- ventral hernias
Social History:
___
Family History:
Mother had unspecified lung disease. Mother with serious mental
illness. Father was an abusive, with severe alcohol use
disorder.
Physical Exam:
GEN - Alert, NAD
HEENT - NC/AT, face symmetric, dry MM
NECK - Supple
CV - RRR, no m/r/g
RESP - CTA B, breathing appears comfortable
ABD - soft; L-sided ostomy with chronic surrounding erythema but
also a fresh wound;
green liquid stool in ostomy bag with some particulate matter;
R-sided ventral hernia; no
TTP throughout
EXT - No ___ edema; TTP of the legs bilaterally. Pt winces
significantly when he flexes his hands and fingers. No joint
swelling r erythema noted.
SKIN - No apparent rashes aside from erythema around ostomy as
above
NEURO - Ox3, ___ strength in all 4 extremities
PSYCH - Calm, appropriate
DISCHARGE PHYSICAL EXAM:
VS: Reviewed in eflowsheets
GEN: Alert, NAD
EYES: anicteric
HEENT: MMM, grossly nl OP
CV: RRR nl S1/S2 no g/r/m
CHEST: CTAB no w/r/r
ABD: soft, NT/ND. L-sided ostomy with chronic surrounding
erythema. Bag with air and liquid stool; R-sided ventral hernia;
EXT: WWP, no edema. TTP to legs b/l. No joint swelling/erythema
SKIN: Chronic erythema around ostomy
NEURO: alert and oriented, speech fluent, eyes conjugate, moving
all extreme to command and purpose.
PSYCH: Calm, pleasant, and appropriate
Pertinent Results:
___ 01:45PM BLOOD WBC-6.5 RBC-4.23* Hgb-12.3* Hct-36.2*
MCV-86 MCH-29.1 MCHC-34.0 RDW-13.3 RDWSD-41.1 Plt ___
___ 01:45PM BLOOD Glucose-118* UreaN-23* Creat-1.3* Na-135
K-4.3 Cl-101 HCO3-22 AnGap-12
___ 12:46AM BLOOD ALT-20 AST-27 AlkPhos-80 TotBili-1.3
- AXR ___: Markedly dilated stomach with air-fluid levels and
paucity of gas in the remainder of abdomen could indicate
obstruction. Consider follow-up imaging as clinically
indicated.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ y/o M with PMHx of Crohn's disease, GERD,
asthma, anxiety, who presented with abdominal pain and increased
ostomy output, with associated ___ on CKD and hyponatremia, all
in the setting of recent discharge for same.
# INCREASED OSTOMY OUTPUT
# BILIOUS DIARRHEA: The patient was admitted for the same
symptoms very recently.
Stool studies at that time were all negative. His symptoms
improved with IVF's at that time. ESR/CRP were elevated, raising
possibility of active Crohn's disease. GI consulted and
performed ileoestomy which did not show any signs of active
disease. As all infectious studies were negative, he was started
on immodium with improvement in ostomy output. He was
subsequently discharged to home, to follow up with GI re: ostomy
output management and Crohn;s symptoms.
# HYPONATREMIA: Hypovolemic hyponatremia in the setting of
increase ostomy output. This was further supported by dry MM on
exam and concurrent ___. The patient was started on IVF's with
improvement in sodium. Now off IVF. U. lytes suggestive of
hypovolemia. With IVF and appropriate oral intake, Na improved
and resolved to near normal. Patient was able to maintain
adequate input off IVF with stable Na, and was discharged to
home to follow-up with serial Na checks.
# MICROCOCCUS BACTEREMIA: Noted during prior admission. Likely
represents contaminant, given only 1 positive blood culture.
Repeat blood cultures sent on presentation were negative.
Time spent coordinating discharge > 30 minutes
Medications on Admission:
MEDICATIONS:
1. RisperiDONE 1 mg PO BID
2. Sertraline 25 mg PO DAILY
Discharge Medications:
1. LOPERamide 2 mg PO BID
RX *loperamide 2 mg 1 capsule by mouth twice a day Disp #*30
Capsule Refills:*0
2. RisperiDONE 1 mg PO BID
3. Sertraline 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
High Ostomy Output
Acute Hyponatremia
Acute Renal Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You presented with abdominal pain and increased output from your
ostomy. Your sodium and other electrolytes levels were found to
be low, and were provided IV fluids which helped improve the
sodium. Because we had concern for a possible Crohn's flare, you
had an ileoscopy, but we did not find any signs of active
disease.
After you are hospitalized, you should use Imodium and banana
flakes (which can be purchased over the counter) to help slow
your ostomy output.
You should see your primary care doctor in follow-up and have
your blood work checked.
Additionally, it is important that you see Dr ___ in follow-up
to help manage your ostomy output.
Followup Instructions:
___
|
10509319-DS-8 | 10,509,319 | 21,741,917 | DS | 8 | 2152-11-10 00:00:00 | 2152-11-10 13:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L temporal laceration s/p fall
Major Surgical or Invasive Procedure:
Laceration repair of left temporal laceration
History of Present Illness:
___ w/ dementia, afib on coumadin presents s/p fall. He
slipped and fell on the ice this morning resulting in a
laceration over his left temporal region. Went to ___, CT
shows small pontine hemorrhage, patient subsequently transferred
to ___.
Past Medical History:
PAST MEDICAL HISTORY:
A fib
Dementia
Prostate ca
HTN
High Cholesterol
Social History:
___
Family History:
NC
Physical Exam:
Vitals: 98.3, 78, 94/70, 18, 100RA
Gen: NAD, AOx3
HEENT: NCAT, healed lacerations to L temporal area, EOMI,
PERRLA, MMM
CV: RRR, no m/r/g
P: unlabored, CTAB
GI: soft, NTND, NABS
Ext: WWP, good pulses, no c/c/e, no deformities
Pertinent Results:
___ 04:50AM BLOOD WBC-6.6 RBC-2.63* Hgb-8.8* Hct-26.5*
MCV-101* MCH-33.4* MCHC-33.2 RDW-14.7 Plt ___
___ 04:50AM BLOOD ___
___ 04:50AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-140
K-3.8 Cl-109* HCO3-24 AnGap-11
___ 04:50AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1
Brief Hospital Course:
Patient was admitted to the ___ surgery service on ___ after
sustaining a fall and strike to his head on ice. His CT head
showed a small intraparenchymal hemorrhage, which was evaluated
by neurosurgery and determined to be stable and requiring no
intervention. He had a laceration to his L temporal scalp that
was sutured close. He was monitored over the next few days, and
had no changes in mental status. He worked with physical
therapy who determined the patient would be an appropriate
candidate for extended care. His coumadin was restarted on
___, and his INR was trended. His diet was advanced to
regular which he tolerated well. On ___, he was deemed
appropriate for discharge, and his scalp sutures were removed
prior to his discharge.
Medications on Admission:
Amlodipine 2.5 mg tablet
Aspirin EC 325 mg
donepezil 10 mg tablet
lisinopril 40 mg tablet
metoprolol tartrate 25 mg tablet
Vitamin D Oral
warfarin 2.5 mg tablet
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small intraparenchymal hemorrhage, small subdural hematoma, and
left temporal laceration.
Discharge Condition:
Mental Status: baseline AOx2 dementia
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service for your
head injury. You were observed overnight with no deterioration
in your neurological status and were safe for discharge. You had
a laceration on your left temple that was repaired. You also had
a very small amount of bleeding in your brain that was deemed
stable.
Please call your doctor or go to the emergency department if:
*You experience any changes in your neurological status, feel
confused, more sleepy, have any weakness of the arms or legs.
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
Followup Instructions:
___
|
10509415-DS-4 | 10,509,415 | 25,426,806 | DS | 4 | 2177-07-02 00:00:00 | 2177-07-02 16:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left face/arm/torso numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ambidextrous male with a history of hyperlipidemia
and poorly controlled hypertension who presents with acute
numbness of the left lower face, arm and torso. He was in his
usual state of health on the evening of ___ but awoke ___
with new onset numbness in his left face, arm, and lateral
torso. He did not notice any weakness or incoordination, and did
not drop anything with the left hand. No symptoms in the left
leg and no difficulty walking. No headache, nausea, photophobia
or migraine equivalent. No chest pain or palpitations. He went
to work but was limited by his numbness, at which point he
called his PCP who told him to present to the ED. While in the
ED, the patient reported that the symptoms were slowly
improving. On exam in the ED he had decreased sensation to
pinprick and cold over the left lower face and lateral aspect of
upper arm and left torso. amd decreased vibration and position
sense in the left upper extremity. He was admitted to the
Neurology service for MRI and stroke risk factor evaluation.
Past Medical History:
Hypertension (recent SBPs in 160s) w h/o of proteinuria and
elevated Cr
Elevated PSA
Hemorrhoids
Social History:
___
Family History:
Mother: IDDM
Father: IDDM, Stroke
Physical Exam:
ADMISSION EXAM:
- Vitals: 99.2 81 157/115 16 100% ra
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Able to register 3
objects and recall ___ at 5 minutes. Good knowledge of current
events. 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: decreased sensation to light touch and pinprick over left
lower face.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: decreased sensation to pinprick and cold over the
left
lower face and lateral aspect of upper arm and left torso.
Decreased vibration and position sense in the left upper
extremity. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: not tested.
DISCHARGE EXAM:
- Vitals: 98.3 BP: 154-86 HR: ___ RR:18 SaO2: 100RA
- General: Awake, cooperative, NAD
- HEENT: NC/AT
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Does ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. There were no paraphasic errors. Naming
intact. Speech was not dysarthric. Follows commands across
midline.
- Cranial Nerves:
I: Not assessed
II: PERRL 2 to 1mm and brisk. VFF to confrontation
III, IV, VI: EOMI without nystagmus
V: decreased sensation to light touch and pinprick over left
face
VII: Facial musculature symmetric at rest and with activation
VIII: Hearing intact to finger-rub bilaterally
IX, X: Palate elevates symmetrically
XI: ___ strength in trapezii and SCM bilaterally
XII: Tongue protrudes in midline
- Motor: Normal bulk, tone throughout. L pronator drift. 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: decreased sensation to pinprick over the left face
and lateral left arm and hand. Decreased proprioception in LUE.
No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was downward bilaterally
- Coordination: Dysmetria on L FNF. No intention tremor, no
dysdiadochokinesia noted.
- Gait: not assessed
Pertinent Results:
LABORATORY
- Na 139, K 4.6, Cl 104, HCO3 26, BUN 20, Cr 1.2, Glu 78
- Ca 8.9, Mg 2.3, PO4 3.8
- WBC 5.4, Hb 14.1, HCT 43.6, PLT 219
- ___ 10.9, PTT 31.5, INR 1.0
- AST 32, ALT 22, AP 64, Tbili 0.3, Alb 4.4
- Serum tox negative
- UTox negative
- UA bland
- Trop <0.01
- Lipids: PENDING
IMAGING
- ___ (___): No evidence of acute intracranial process
- MRI/MRA Head Neck (___): Area of restricted diffusion and
correlates hypointensity on ADC sequence consistent with acute
right thalamic stroke. Vessels of head appear patent however the
left vertebral artery appears severely attenuated at the level
of V4 segment.
- TTE (___): Normal biventricular cavity size and
global/regional systolic function. Normal right ventricular
cavity size and systolic function. No cardiac source of embolism
identified.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of
hyperlipidemia and poorly controlled hypertension. He presented
to the ED on ___ after developing acute numbness of left face,
arm, and torso. Given symtoms consistent with stroke, he was
admitted to the Neurology service for MRI and risk factor
evaluation. MRI imaging revealed a small R thalamic infarct
which is consistent with his symptoms of L face, arm, and torso
sensory loss and decreased LUE proprioception. His home blood
pressure medications were discontinued and his BP was controlled
to <200 with PRN hydralizine. His blood glucose was controlled
with QID fingersticks and insulin sliding scale. He was started
on ASA 81mg daily for secondary stroke prevention. Due to a
history of hyperlipidemia he was also started on Atorvastatin.
TTE showed no evidence of structural heart disease. His symptoms
improved throughout the duration of his stay. At the time of
discharge, he reported lingering L face and L arm numbness, and
was found to have a considerable defecit in LUE proprioception
on exam.
# NEURO:
- Symptoms and MRI consistent with acute ischemic R thalamic
stroke
- BP Control: Hold home BP medications to allow for permissive
hypertension post-stroke, patient to restart medications on ___
- Thrombophilia blood work: ESR, CRP, ___, anti-cardiolipin,
lupus anticoagulant pending; anti-b2 glycoprotein needs to be
done as outpatient
- ASA 81mg daily
- atorvastatin 40mg daily ___ LDL=146)
- A1C 5.6% when last checked on ___
# ___:
- Cardiac enzymes negative
- BP Control: Hold home BP medications to allow for permissive
hypertension post-stroke, patient to restart medications on ___
- TTE normal
# ENDO:
- HbA1c below threshold for diabetes
# Toxic/Metabolic:
- LFTs, Utox, Serum Tox all negative
# ID:
- UA and CXR negative
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes
- Bedside speech and swallow (___)
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes
- SQH on HD1
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes
- ASA on HD1
4. LDL documented (required for all patients)? (X) Yes
- LDL = ___. Results of ___ bloodwork pending
5. Intensive statin therapy administered? (X) Yes
- Atorvastatin 40mg on HD2
6. Smoking cessation counseling given? () Yes - (X) No
- Non-smoker
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes
- Verbal and written
8. Assessment for rehabilitation or rehab services considered?
() Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (X) Yes
- Atorvastatin 40mg daily
10. Discharged on antithrombotic therapy? (X) Yes
- ASA 81mg daily
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (X) No
- No evidence of Afib/Aflutter on ECG/TTE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Spironolactone 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic R thalamic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of numbness in the left
face, arm, and torso resulting from an ACUTE ISCHEMIC STROKE, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension ("high blood pressure")
Hyperlipidemia ("high cholesterol")
We are changing your medications as follows:
Aspirin 81mg by mouth daily
Atorvastatin 40mg by mouth daily
Please restart your home blood pressure medications on ___
(lisinopril, amlodipine, and spirinolactone ).
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10509507-DS-16 | 10,509,507 | 25,262,548 | DS | 16 | 2167-08-22 00:00:00 | 2167-08-23 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors
Attending: ___.
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o CKD, hypothyroidism, scolisis, IBS, HTN and AS
presenting with headache to ___. She reports she was
feeling well until ___ morning (1.5 days prior to admission)
when she reports that she felt more tired than usual. This
sensation cleared up and she felt back to her baseline. Then
___ morning, she woke up and knew immediately that she did
not feel well. She reports that 'everything was wrong'. Her
primary complaint was a headache that was primarily in the right
occipital/temporal region (but also present on L). She felt
dizzy and nauseated and reports that the whole room felt foggy
and her vision was blurry. She attempted to get out of bed and
continued to feel dizzy. Dizziness was described as instability
on her feet and light headedness, not the room spinning and
different then her previous vertigo. She was naturally
distressed about her symptoms and reports that she was concerned
she may have been having a TIA. Her BP at that time was 180s/96.
She took a full dose of aspirin, and she felt her symptoms
resolved in about 45 mins. She decided to call her PCP who
recommended she go to the ___ for further evaluation. She denies
CP or SOB. No vomiting, no change in her chronic back pain, no
visual changes or loss.
Of note, the patient reports that she sustained a fall
approximately 6 weeks prior. She had been standing in her
bathroom, brushing her teeth, and then believes she slipped on a
wet floor and fell backwards and hit the back of her head. She
denies dizziness/lightheadedness at that time. No confusion
prior to or following. Does not feel she lost consciousness at
that time.
In the ___, she underwent a NCHCT which was
reportedly negative for hemorrhage. A CT Cspine revealed a C1
___ fracture w/ single posterior arch fracture and 2 part
anterior arch fracture. She was then transferred to ___ for
further evaluation.
Upon arrival to the ___, her initial vitals were 98.2, 60,
150/74, 18, 98%. Her exam was notable for upper thoracic
tenderness and a subsequent CT Tspine was preliminarily negative
for fracture. She was evaluated by the ortho spine team who
recommended conservative management with a hard cervical ___
J) collar at all times and follow up in their clinic in ___
weeks. Labs notable for troponin < 0.01. Patient was given
acetaminophen for pain. VS prior to transfer: 98.1, 58, 144/54,
18, 100%.
On the floor, she reports feeling much better. She has no
complaints at this time. No additional headaches, no dizziness,
no visual changes, no numbness/tingling/weakness.
Past Medical History:
- HTN
- hyperlipidemia
- s/p AAA repair in ___
- hypothyroidism
- Vertigo ascribed to benign positional vertigo.
- Chronic back pain with scoliosis and spinal stenosis.
- Status post bilateral cataract repair.
- Osteoarthritis.
- Osteopenia.
- Macular degeneration.
- Mild aortic regurg
- Possible Tachy-Brady syndrome s/p pacer ___ yrs ago
- H/O UTIs
- Possible esophageal spasm
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Admission Physical Exam:
Vitals: 97.5, 150-170/70-79, 53-66, 16, 98% on RA, wt 58.3 hgs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: Hard cervical collar in place
Lungs: Clear to auscultation b/l, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1/S2, ___ late peaking
systolic ejection murmur, no rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses in RP and DP, no clubbing,
cyanosis or edema
Neuro: AAOx3, motor ___ throughout, sensation intact to light
touch, no focal deficits. Light headed with leaning forward.
Discharge Physical Exam:
Vitals: 97.6, 112-168/60-87, 59-96, 16, 97% on RA, wt 58.3 hgs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Hard cervical collar in place
Lungs: Clear to auscultation b/l, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1/S2, ___ mid-late peaking
systolic ejection murmur, no rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses in RP and DP, no clubbing,
cyanosis. 1+ pitting edema. Painful on palpation >L.
Neuro: AAOx3, motor ___ throughout, sensation intact to light
touch, no focal deficits. Light headed with leaning forward.
Pertinent Results:
ADMISSION:
___ 06:00AM BLOOD WBC-7.7 RBC-3.82* Hgb-11.1* Hct-33.0*
MCV-86 MCH-29.1 MCHC-33.7 RDW-14.8 Plt ___
___ 06:00AM BLOOD Glucose-112* UreaN-31* Creat-1.4* Na-139
K-3.9 Cl-104 HCO3-27 AnGap-12
___ 11:20PM BLOOD CK(CPK)-399*
___ 11:20PM BLOOD CK-MB-9 cTropnT-0.01
___ 06:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0
___ 12:56AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:56AM URINE RBC-0 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
DISCHARGE:
___ 06:35AM BLOOD WBC-6.7 RBC-3.89* Hgb-11.3* Hct-33.8*
MCV-87 MCH-28.9 MCHC-33.3 RDW-14.9 Plt ___
___ 06:35AM BLOOD Glucose-93 UreaN-31* Creat-1.4* Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
___ 06:35AM BLOOD CK(CPK)-299*
___ 06:35AM BLOOD Calcium-8.6 Phos-2.7
IMAGING:
CT C-spine (___): IMPRESSION:
1. ___ BURST-TYPE FRACTURE OF THE C1 VERTEBRAL BODY
WITH
EXPECTED DISPLACEMENT AND SPINAL CANAL WIDENING.
THOUGH THIS APPEARANCE IS NEW SINCE THE REMOTE HEAD CT OF
___, THE
OVERALL APPEARANCE OF THE FRACTURE SUGGESTS SOME DEGREE OF
CHRONICITY.
2. ADDITIONAL ALIGNMENT ABNORMALITY AT THE CRANIOCERVICAL
JUNCTION WITH NO EVIDENCE OF ODONTOID PROCESS OR OTHER C2
FRACTURE; THIS MAY REFLECT UNDERLYING UPPER CERVICAL LIGAMENTOUS
INJURY,
ASSOCIATED WITH #1, ABOVE, OR REPRESENT NORMAL VARIATION.
3. NO OTHER CERVICAL FRACTURE.
4. MULTILEVEL, MULTIFACTORIAL EXTENSIVE DEGENERATIVE
DISEASE WITH ASSOCIATED ALIGNMENT ABNORMALITIES AND VENTRAL
CANAL AND NEURAL
FORAMINAL NARROWING, PARTICULARLY AT THE C5-6 LEVEL.
CT T-Spine ___:
IMPRESSION:
1. No acute fracture or malalignment of the thoracic spine.
2. Rotatory thoracolumbar S-scoliosis, with multilevel
degenerative changes, most pronounced in the lower thoracic and
upper lumbar spine, with moderate left neural foraminal
narrowing at T11/12.
3. Moderately severe atherosclerotic disease of the
thoraco-abdominal aorta and coronary arteries, and aortic
valvular calcifications.
___ Cartoid Series:
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
___ TTE:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction. Right ventricular chamber size and
free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is borderline pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Normal biventricular size and hyperdynamic left
ventricular systolic function. Mild aortic stenosis. Mild aortic
regurgitation. Mild to moderate mitral regurgitation. Borderline
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
there is slightly more mitral regurgitation.
Brief Hospital Course:
___ with h/o CKD, hypothyroidism, scolisis, IBS, HTN and AS
presenting with headache, found to have C1 fracture.
ACTIVE ISSUES:
# C1 fracture: This likely occurred when she feel back and hit
her head 6 weeks prior. She denies neck pain or headaches prior
to ___. Her report of her fall implies that it was mechanical
and denies LOC, but given her vague symptoms, it is concerning
for syncope. CT at ___ with C1 Jeffersonian fracture, ortho
spine at ___ recommended conservative therapy. She reports
feeling better with the collar in place and has no complaints at
this time. Her neuro exam remained non focal. Her pain was well
controlled with acetaminophen, and she was receiving it
scheduled when she was sent home. Her final CT read mentions a
possible ligamentous injury at cervical-cranial junction which
can be followed up on if clinically indicated. She is to have
the ___ cervical collar on at all times and to follow up with
ortho spine in ___ weeks.
# Headache: Patient with R sided headache, mostly
occipital/temporal. CT ruled out bleed or mass effect due to
neoplsam. Likely due to her C1 fracture which could cause her
pain around her occiput as well as associated muscle spasm /
tension headache. Unlikely to be related to elevated BP. Her
pain was controlled with Tylenol. We also encouraged her to
increase her PO fluid intake. We controlled her blood pressure
with her home anti-hypertensives and she did not have any
further spikes in her pressure that represented a hypertensive
urgency.
# Dizziness/Presyncope: Patient with a vague complaint of
dizziness/light headedness. As above, her fall is also possibly
a syncopal event. Dehydration could be responsible for these
symptoms. With Jeffersonian fx, could be impingement on
Vertebral artery and be vertebral insufficiency. TIA is
unlikely as wouldn't expect the positional, waxing/waning
symptoms she is having. Mass effect ruled out. . Symptomatic
aortic stenosis is unlikely given that there was no progression
seen on echo from her mild stenosis noted in ___. Her overnight
telemetry was normal and did not show any lso, hx of mild AS,
could be progression of disease (last echo in ___. Overnight
tele was normal, and did not show any arrhythmias. Cardiac
interrogation of her pacer showed no arrhythmia as well. Carotid
U/S showed <40% stenosis. She was able to walk the floor on
discharge and physical therapy recommended home ___. Likely cause
of her presyncope is her orthostasis, probably less likely
caused by dehydration but autonomic instability given her blood
pressure spikes as well as orthostatic symptoms.
# Hypertension: Patient reports that her BP is normally very
well controlled and is distressed that it is elevated upon
admission. Possibly due to a catecholamine response to her
stress. She denies any missed doses of medications. Could
represent autonomic instability. We continued her home
medications amlodipine, metoprolol, and irbesartan (avapro); on
this regimen her BP waslargely well controled though she did
have some readings in the 160s systolic. No medication changes
were made during the admission for fear of causing hypotension,
however, this can be adjusted as an outpatient if continued high
readings are present.
#Elevated CK: Outpatient CK was elevated and statin stopped.
Asymptomatic.
- Continue to follow
CHRONIC ISSUES:
# Hypothyroidism: We continued with her levothyroxine
# Chronic kidney disease: Patient is currently followed by Dr.
___ at ___. Cr appears at baseline. Kidney
disease complicated by anemia and secondary hyperparathyroidism.
Her Creatinine was stable while she was an inpatient.
# Anemia: At her baseline (Hct 33). Due to CKD, says she has
received shots in the past if it gets too low (?epo).
- Continue to follow
# IBS: Patient reports this is well controlled by diet and prn
imodium.
# HLD: Patient reports that Simvastatin was recently held due to
elevated CK. Simvastatin was held while she was an inpatient and
this can be discussed as an outpatient.
TRANSITIONAL ISSUES:
-F/u with ortho spine, consider further imaging of ? ligamentous
injury
-F/u hypertension / BP control
-F/u elevated CK
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/CaregiverwebOMR.
1. Amlodipine 2.5 mg PO DAILY
2. Calcitriol 2.5 mcg PO DAILY
3. Avapro *NF* (irbesartan) 300 mg Oral daily
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO PRN SBP > 160
7. Simvastatin 20 mg PO DAILY
Currently held
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Aspirin 81 mg PO DAILY
10. Align *NF* (bifidobacterium infantis) 4 mg Oral qhs
11. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
12. Gaviscon *NF* (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn heartburn
13. Loperamide 2 mg PO PRN diarrhea
14. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet
Oral daily
15. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
unkown Injection prn
16. PreserVision *NF* (vit C-vit
E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) unknown
Oral daily
17. Meclizine 12.5 mg PO Q12H:PRN vertigo
18. Lactaid *NF* (lactase) 3,000 unit Oral prn prior to dairy
products
19. Clindamycin Dose is Unknown PO PRN prior to dental
appointments
20. Salsalate 500 mg PO TID:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amlodipine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Avapro *NF* (irbesartan) 300 mg Oral daily
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Align *NF* (bifidobacterium infantis) 4 mg Oral qhs
8. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
9. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral
daily
10. Gaviscon *NF* (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg ORAL PRN heartburn
11. Lactaid *NF* (lactase) 3,000 unit Oral prn prior to dairy
products
12. Loperamide 2 mg PO PRN diarrhea
13. Meclizine 12.5 mg PO Q12H:PRN vertigo
14. Simvastatin 20 mg PO DAILY
Currently held
15. Claritin *NF* 5 mg Oral daily
16. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
0 units INJECTION PRN anemia
Please continue to take as you were prior to coming to the
hospital
17. Metoprolol Tartrate 12.5 mg PO PRN SBP > 160
18. Calcitriol 0.25 mcg PO DAILY
19. PreserVision *NF* (vit C-vit
E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 1 capsule
ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Mechanical Fall
Cervical Spine Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because you were having a
headache and felt dizzy. On evaluation, you were found to a
fracture of your neck. This likely occurred several weeks ago
when you fell. We watched you and had physical therapy work with
you and we feel that it is safe for you to go home. You will
need to be in a neck brace for several weeks until you see the
orthopedic doctors. ___ also performed several studies to find
out why you were dizzy; all of which were negative.
It is very important that you stop taking benadryl as it can
attribute to your fogginess and dizziness. There are other
medications you can take for your allergies and you have
expressed interest with taking over the counter Claritin, which
is fine. Please take as directed.
Followup Instructions:
___
|
10509507-DS-17 | 10,509,507 | 28,375,570 | DS | 17 | 2168-05-17 00:00:00 | 2168-05-17 17:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman initially presnted to ___ with complaint of
multiple episodes of bright red blood in toilet. was unclear
where source was. (see ___ notes and labs in careweb).
Rectal negative, + brbp-vagina at ___ with HCT 34. Patient
was urinating blood and had suprapubic pain along with increase
in frequency and burning. reports chills x 1 day. No
lightheadedness or LOC.
In the ED, initial vs were: 97.6 72 158/52 18 98 %. Labs were
remarkable for lactate 1.2, normal coagulation profile. Foley
was placed and source of blood was confirmed to be from bladder
rather than vagina. CBI initiated in ED, urology aware. UA with
RBC > 182, WBC 64, few bact, large Leuks, Nit negative. WBC
12.1. Cr at ___ was 1.3 (baseline ___ since ___. Patient
was given 1 L NS, 1 gram Ceftriaxone IV, tylenol PO 650 mg x1.
Urine and blood culture sent. Vitals on Transfer: 97.8 77 154/77
16 96%
On the floor, pt is laying comfortably in bed, on CBI with frank
blood urine.
Review of sytems:
(+) Per HPI, also constipation (IBS)
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea, or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
- HTN
- hyperlipidemia
- s/p AAA repair in ___
- hypothyroidism
- Vertigo ascribed to benign positional vertigo.
- Chronic back pain with scoliosis and spinal stenosis.
- Status post bilateral cataract repair.
- Osteoarthritis.
- Osteopenia.
- Macular degeneration.
- Mild aortic regurg
- Possible Tachy-Brady syndrome s/p pacer ___ yrs ago
- H/O UTIs
- Possible esophageal spasm
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMIT
Vitals: 97.8 168/56 66 18 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, 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, ___ late peaking
systolic ejection murmur, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact no focal deficit, gait exam defered
GU: foley, dark red urine on CBI
DISCHARGE
98.0 144/53 hr 62 rr 18 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM moist, 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, ___ late peaking
systolic ejection murmur, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no CVA tenderness
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: pt able to ambulate without assistance
Pertinent Results:
ADMIT
=========================
___ 06:50PM BLOOD WBC-12.1*# RBC-3.92* Hgb-12.0 Hct-34.9*
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.4 Plt ___
___ 06:50PM BLOOD Neuts-77.3* Lymphs-17.4* Monos-3.6
Eos-1.5 Baso-0.2
___ 06:50PM BLOOD Plt ___
___ 09:09PM BLOOD ___ PTT-28.8 ___
___ 06:30AM BLOOD Glucose-91 UreaN-28* Creat-1.1 Na-142
K-3.7 Cl-111* HCO3-28 AnGap-7*
___ 06:55AM BLOOD CK(CPK)-188
___ 06:55AM BLOOD CK-MB-4 cTropnT-0.01
___ 06:30AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
DISCHARGE
============================
___ 07:00AM BLOOD WBC-7.7 RBC-3.44* Hgb-10.5* Hct-30.5*
MCV-89 MCH-30.5 MCHC-34.5 RDW-13.7 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-19 Creat-1.2* Na-140
K-4.5 Cl-104 HCO3-24 AnGap-17
___ 07:00AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
MICRO:
============================
___ URINE Cx
___ 7:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
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-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
============================
___ GU US
FINDINGS:
There is no hydronephrosis. The right kidney measures 8.1 cm
and the left kidney measures 8.3 cm. No stone or cyst or solid
mass is seen in either kidney. No perinephric fluid collection
is identified. The urinary bladder is collapsed on a Foley
catheter.
IMPRESSION:
Unremarkable GU ultrasound.
Brief Hospital Course:
___ with PMH HTN, HL, s/p AAA repair in ___, sick sinus
syndrome s/p pacemaker, stage 3 CKD comes with new hematuria and
E coli UTI.
# Hematuria: Pt was admitted for hematuria, and was found to
have a UTI with pansensitive E coli. She was initially treated
on ceftriaxone and transitioned to bactrim once her sensitivites
returned. Hematuria also resolved. Given her smoking hx, she
should also have follow-up with urology for a cystoscopy to r/o
bladder cancer. GU ultrasound was negative for any masses. Pt
never required transfusions for hematuria. She was initially on
continuous bladder irridation, which was DC-ed once her
hematuria had significantly decreased. As pt denied pain a/w
with hematuria, there was low suspicion for stones, so CT
urogram was not needed.
# Pan-sensitive E. coli UTI: Pt presented with urinary
frequency, dysuria, and episode of chills, found to have a +UA,
and E coli in her UCx. BCx wree no growth to date at discharge.
___ will be treated for 7d course, bactrim outpatient (and given
given ceftrixone inpatietn untiol speciation).
# HTN/sick sinus syndrome s/p pacer: Pt had episodes of eleated
SBPs in 180s-200s overnight during hospitalization while on BID
metoprolol and home dosing 5mg amlodipine and irbesartan. She
would spontaneously decrased from SBP 200s to 150s without
intervention during hospitalization.
# CKD stage 3: Cr 1.3 (baseline ___ since ___. Takes aranesp
injection as outpatient for anemia of chronic disease. Pt was
continued on home medications:
- continue calcitriol at home regimen
- continue calcium and vitamin D
# Hypothyrodism: continue levothyroxine 75 mcg daily
# Lower extremity swelling: pt reports taking lasix every other
day for edema.
# CODE: full ,confirmed with pt
# CONTACT: ___ daughter ___
# DISPO: medicine, pending above
TRANSITION ISSUES
# PCP should consider adding additional anti-HTN meds or
uptitrating
# f/u cystoscopy for hematuria to r/o bladder cancer (discussed
with PCP by phone; he will determine clinical indication for
this if she has recurrent hematuria)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Align *NF* (bifidobacterium infantis) 4 mg Oral daily
2. Aranesp (in polysorbate) *NF* (darbepoetin alfa in
polysorbat) 60 mcg/mL Injection PRN per Dr. ___
___
3. Aspirin 81 mg PO DAILY
4. Avapro *NF* (irbesartan) 300 mg Oral daily
5. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
8. Centrum *NF* (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
Oral daily
9. Docusate Sodium 100 mg PO BID constipation
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Guaifenesin ER 1200 mg PO Q12H
12. Amlodipine 5 mg PO DAILY
13. PreserVision AREDS *NF* (vitamins A,C,E-zinc-copper)
___ unit-mg-unit Oral dialy
14. Acetaminophen 325 mg PO Q6H:PRN pain
do not exceed 4 grams per day.
15. Clindamycin 75 mg PO Frequency is Unknown
16. Furosemide 20 mg PO QOD
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Salsalate 500 mg PO TID pain
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Avapro *NF* (irbesartan) 300 mg Oral daily
5. Calcitriol 0.25 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID constipation
7. Furosemide 20 mg PO QOD
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*5 Tablet Refills:*0
11. Align *NF* (bifidobacterium infantis) 4 mg Oral daily
12. Aranesp (in polysorbate) *NF* (darbepoetin alfa in
polysorbat) 60 mcg/mL Injection PRN per Dr. ___
___
13. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
14. Centrum *NF* (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
Oral daily
15. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies
16. Guaifenesin ER 1200 mg PO Q12H
17. PreserVision AREDS *NF* (vitamins A,C,E-zinc-copper)
___ unit-mg-unit Oral dialy
18. Salsalate 500 mg PO TID pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: UTI
Secondary:
- HTN
- hyperlipidemia
- s/p AAA repair in ___
- hypothyroidism
- Vertigo ascribed to benign positional vertigo.
- Chronic back pain with scoliosis and spinal stenosis.
- Status post bilateral cataract repair.
- Osteoarthritis.
- Osteopenia.
- Macular degeneration.
- Mild aortic regurg
- Possible Tachy-Brady syndrome s/p pacer ___ yrs ago
- EF > 75%
- H/O UTIs
- Possible esophageal spasm
- Anemia of chronic kidney disease
- Stage 3 CKD
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 ___,
___ was our pleasure to care for you at ___. You were admitted
for blood in your urine. We found evidence of infection, which
we treated, and the bleeding stopped. We also found no further
signs of infection although you had one episode of soft stool.
Please follow up with Dr. ___ in the next week.
Followup Instructions:
___
|
10510028-DS-15 | 10,510,028 | 28,317,114 | DS | 15 | 2173-09-15 00:00:00 | 2173-10-10 21:46:00 |
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, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old woman with a past medical history of
bipolar disorder, obesity s/p Roux-en-Y gastric bypass and prior
cholecystectomy who is referred from OSH after found to have
pancreatitis and an enlarged common bile duct on imaging.
The patient initially developed abdominal pain abut 4 days ago,
associated with nausea and vomiting. She developed epigastric
pain after eating a bag of chips, felt like "insides were torn
up", with nausea and non bloody non bilious emesis. She waited
two hours before trialing PO again with similar sxs. Since then
she has had very poor PO intake over the last 4 days. No BMs,
maintaining PO liquids. She presented to OSH today where her
labs were notable for elevated LFTs (AST 754, ALT 616, Tbili
2.7, Alk phos 387). CT showed findings of pancreatitis as well
as an enlarged common bile duct. Given these findings she was
transferred to ___ for possible ERCP. Before transfer, patient
was given morphine, zofran, famotidine as well as 4.5g zosyn at
OSH.
In the ED, initial VS were: 98.4 60 111/68 20 95% RA
ED physical exam was recorded as obese, poor dentition,
tenderness to palpation in the epigastric region. The abdomen is
soft and nondistended without rebound or guarding.
ED labs were notable for: WBC 12.7, ALT: 248, AST: 97, AP: 394,
Tbili: 3.9, Lip: 29, Lactate: 1.2
Patient was given: ___ 20:27 IVF 1000 mL NS 1000 mL
Transfer VS were: 98.0 53 133/74 16 98% RA
When seen on the floor, patient is asymptomatic. She's denying
any recent fever, chest pain, shortness of breath, dysuria. She
has not had a bowel movement in four days.
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
Bipolar disorder
Obesity s/p Roux-en-Y gastric bypass
Prior cholecystectomy
Social History:
___
Family History:
Mother had endometrial cancer
Aunt had colon, breast and lung cancer
Physical Exam:
On Admission:
Gen: NAD, 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, obese, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
On Discharge:
VITALS: 98.2 122/69 50 18 95% RA
GEN: Obese, lying in bed in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear, fair oral
dentition
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: Soft, nontender to deep palpation of the epigastrum and RUQ,
otherwise nontender throughout, normoactive bowel sounds
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
OSH Labs: ___ --> ___
TBili: 2.7 --> 4.4
Alk Phos: 387 --> 443
AST: 754 --> 152
ALT: 616 --> 347
Lipase 126
___ 08:45PM ___ PTT-29.9 ___
___ 08:20PM WBC-12.7* RBC-4.10 HGB-11.8 HCT-35.9 MCV-88
MCH-28.8 MCHC-32.9 RDW-14.6 RDWSD-47.1*
___ 08:20PM PLT COUNT-314
___ 08:20PM GLUCOSE-116* UREA N-7 CREAT-0.6 SODIUM-135
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
___ 08:20PM ALT(SGPT)-248* AST(SGOT)-97* ALK PHOS-394*
TOT BILI-3.9*
___ 08:20PM LIPASE-29
___ 08:20PM ALBUMIN-3.9
___ 08:20PM LACTATE-1.2
CT a/p at OSH:
Mild to moderate intrahepatic biliary ductal dilatation.
Mild to moderate hypodensity involving the pancreatic head and
neck, with mild surrounding mesenteric stranding, suggestive of
acute pancreatitis.
Small fat containing umbilical hernia
MRCP ___
1. Acute pancreatitis without evidence of parenchymal necrosis,
fluid
collections, or vascular complications. There is no evidence of
stones within the remnanant cystic duct or remnant CBD, pancreas
divisum, or other causes of pancreatitis.
2. A 3 mm side branch IPMN is seen in the pancreatic body. A
MRCP in ___ year is recommended for follow up.
RECOMMENDATION(S): A MRCP in ___ year is recommended.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history of
bipolar disorder, obesity s/p Roux-en-Y gastric bypass and prior
cholecystectomy who is referred from OSH after found to have
pancreatitis and an enlarged common bile duct on imaging,
consistent with possible gallstone pancreatitis.
# Abdominal pain
# Pancreatitis
# Enlarged common bile duct
# Elevated LFTs
The constellation of abdominal pain with associated findings of
pancreatitis, enlarged common bile duct and elevated LFTs in a
cholestatic pattern suggest possible gallstone induced
pancreatitis. She was treated with IVF and NPO overnight. By the
following morning her symptoms had resolved entirely. She
underwent MRCP which revealed acute pancreatitis without
evidence of parenchymal necrosis, fluid
collections, or vascular complications. There was no evidence of
stones, pancreatic divisum, or other causes of pancreatitis. Her
LFTS were downtrending by the second hospital day. Clinically
she felt very well and tolerated a regular diet without
difficulty. It is likely that she had a stone causing
obstruction that passed on its own.
She is discharged home but should schedule follow up with her
PCP ___ 1 week of discharge. She should have repeat LFTs at
that visit.
Of note, MRCP revealed a 3 mm side branch IPMN is seen in the
pancreatic body. A MRCP in ___ year is recommended for follow up.
# Bipolar disorder: The patient was continued on home
oxcarbazepine, risperidone,
benztropine, citalopram.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OXcarbazepine 600 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Sucralfate 1 gm PO QID
4. RisperiDONE 2 mg PO QHS
5. Benztropine Mesylate 1 mg PO BID
6. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Benztropine Mesylate 1 mg PO BID
2. Citalopram 40 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. OXcarbazepine 300 mg PO BID
5. RisperiDONE 1 mg PO QHS
6. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented with abdominal pain. Imaging revealed dilation of
your bile ducts and pancreatitis. Given concern for stones
causing inflammation of your pancreas you were admitted to ___
for possible stone extraction. Repeat imaging revealed normal
biliary system and no stones. It is likely that you passed the
stone that was causing you symptoms. At this time your symptoms
have resolved and your are being discharged home.
It was a pleasure to be a part of your care,
Your ___ treatment team
Followup Instructions:
___
|
10510161-DS-12 | 10,510,161 | 29,789,460 | DS | 12 | 2173-12-09 00:00:00 | 2173-12-10 20:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None - was on BiPAP
History of Present Illness:
Mr. ___ is a ___ year old M with history of COPD (hx 1ppd x
years), HTN, T2DM, substance use disorder (incl cocaine), HCV,
who is admitted to the ICU for BiPap.
He presented to the ED with several days of dyspnea and
wheezing. He reports that his breathing has been worse over the
last ___ days. Tried his inhalers without improvement. He
endorses cough spells. No increase in the amount of sputum
(color: white). No sick contacts.
Of note, he has been hospitalized about 4 times over the last 6
months for AECOPD. However, has never required ICU admission or
intubation. His symptoms feel similar to his last exacerbations.
He follows with his PCP and pulmonologist at ___.
Only on fluticasone inhaler and PRN nebulizer at home.
Past Medical History:
COPD (hx 1ppd x years)
HTN
T2DM
substance use disorder (incl cocaine)
HCV
Social History:
___
Family History:
DMII Father, maternal grandmother
Physical Exam:
FICU Admission ___ Exam:
VITALS: T100.5, HR128, BP107/75, 95% 2LNC
GEN: appears comfortable, no acute distress
HEENT: scab on lower lip, atraumatic, normocephalic, MMM, EOMI
CV: tachycardic, regular rhythm, no murmurs, rubs, gallops
PULM: Diffusely ronchorous, no crackles or wheezes appreciated,
on 2L NC
ABD: NABS, soft, NT, ND, no rebound or guarding
EXT: 2+ pitting edema of the bilateral lower extremities
NEURO: answering yes/no questions appropriately, moving
bilateral upper extremities spontaneously and with purpose
ACCESS: Double lumen PICC right arm, PIV L arm
FICU Discharge Exam:
VITALS: T100.5, HR128, BP107/75, 95% 2LNC
GEN: appears comfortable, no acute distress
HEENT: scab on lower lip, atraumatic, normocephalic, MMM, EOMI
CV: Regular rate, regular rhythm, no murmurs, rubs, gallops
PULM: lungs clear in anterior fields, on room air
ABD: NABS, soft, NT, ND, no rebound or guarding
EXT: 2+ pitting edema of the bilateral lower extremities
NEURO: answering yes/no questions appropriately, moving
bilateral upper extremities spontaneously and with purpose
ACCESS: Double lumen PICC right arm, PIV L arm
DISCHARGE EXAM
VITALS: T 97.4 HR 74 RR 18 BP 150/83 O2: 94% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Scattered wheezing, still tight. Breathing is non-labored
GI: Abdomen obese, +distention (pt reports at baseline), +BS,
tympanic, non-tender to palpation. Bowel sounds present. No
guarding or rebound. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: AOx3, no focal neurologic deficts, face symmetric, gaze
conjugate with EOMI, speech fluent, moves all limbs, sensation
to
light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ Admission Labs ___:
___ 08:16AM BLOOD ___ pO2-49* pCO2-64* pH-7.28*
calTCO2-31* Base XS-0
___ 08:00AM BLOOD WBC-9.5 RBC-5.07 Hgb-15.4 Hct-49.1 MCV-97
MCH-30.4 MCHC-31.4* RDW-13.8 RDWSD-48.9* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-100 UreaN-15 Creat-1.1 Na-144
K-4.4 Cl-102 HCO3-25 AnGap-17*
___ Discharge Labs: ___
___ 05:30AM BLOOD WBC-14.0* RBC-4.44* Hgb-13.8 Hct-41.4
MCV-93 MCH-31.1 MCHC-33.3 RDW-13.3 RDWSD-46.0 Plt ___
___ 05:30AM BLOOD Glucose-222* UreaN-19 Creat-0.9 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-11
Pertinent Imaging:
CXR ___:
Hyperinflated lungs compatible with COPD, unchanged. No
evidence of
pneumonia.
Labs Notable at Discharge
___ 07:15AM BLOOD WBC-8.8 RBC-5.14 Hgb-16.0 Hct-48.7 MCV-95
MCH-31.1 MCHC-32.9 RDW-13.7 RDWSD-47.8* Plt ___
___ 07:15AM BLOOD Neuts-42.4 ___ Monos-6.3 Eos-6.8
Baso-0.7 Im ___ AbsNeut-3.74 AbsLymp-3.86* AbsMono-0.56
AbsEos-0.60* AbsBaso-0.06
Brief Hospital Course:
___ Course ___:
___ year old M with history of HTN, DM, HCV, COPD p/w AECOPD not
responding to nebs requiring BiPAP with subsequent transfer to
the ___.
Patient was treated for an acute exacerbation of COPD and was
transferred to the unit due to his BiPAP requirement. Patient
was treated with 125 IV Methylprednisolone in the ED and
transitioned to 40mg Prednisone on ___ for a 5 day course.
The patient was weaned to room air while in the FICU. Patient
was started on a 5 day course of Azithromycin. Patient should be
evaluated by his PCP for his home regimen of medications as he
has frequent exacerbations.
Patient also has a history of HTN and was transitioned from his
home regiment of HCTZ, Lisinopril, Metoprolol, Amlodipine to
Metoprolol 100mg and Lisinopril 20mg.
Patient was maintained on home insulin regimen and had no
episodes of hypoglycemia. He should continue his regimen of
Metformin and Lantus.
On Discharge, patient stable off of oxygen on the floors, was
able to walk around the floor with no oxygen needs or
significant shortness of breath.
ACUTE/ACTIVE PROBLEMS:
#Hypoxic respiratory failure ___
#COPD exacerbation: Unclear trigger, possible recent animal
exposures/humidity in ___. Needs close follow up and
uptitrated his Fluticasone-VIlanterol to 200-25 mcg/day. Will
complete a 5 day course of azithromycin and prednisone, although
may need more prolonged prednisone taper in the future.
-Eosinophilia resolving with steroids
#Hypertension: uptitrated amlodipine to 5 mg daily, continued
lisinopril 20 mg (potassium elevated w/increase in dose),
Metoprolol XL 100 mg daily, ASA 81 mg daily and HCTZ 25 mg daily
#DMII - no change in medications
-continued Lantus 48 Units at bedtime with AISS
-continued Latonoprost 0.05% ophth 1 drop BID
TRANSITIONAL ISSUES
-recheck CBC w/differential to ensure eosinophilia resolved
-recheck potassium (was 5 at discharge), Lisinopril downtitrated
-repeat PFTs
-consider ___ combination - is near max therapy for COPD
-continue smoking cessation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
8. Lantus (insulin glargine) 48 units subcutaneous DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
10. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
11. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
Discharge Medications:
1. Azithromycin 500 mg PO Q24H
RX *azithromycin [Zithromax] 500 mg 1 tablet(s) by mouth every
day Disp #*4 Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY
Please take for 4 more days to complete a 5 day course of
prednisone
RX *prednisone 20 mg 2 tablet(s) by mouth Take 40 mg every day
Disp #*4 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
5. Aspirin 81 mg PO DAILY
6. Breo Ellipta (fluticasone-vilanterol) 200-25 mcg/dose
inhalation DAILY
RX *fluticasone-vilanterol [Breo Ellipta] 200 mcg-25 mcg/dose 1
puff inh daily Disp #*1 Disk Refills:*0
7. Hydrochlorothiazide 25 mg PO DAILY
8. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
9. Lantus (insulin glargine) 48 units subcutaneous DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Lisinopril 20 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute COPD exacerbation
Tobacco Dependence
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were diagnosed with a COPD exacerbation this hospitalization
that required hospitalization in the ICU for BIPAP. We are
concerned that you are frequently coming in with exacerbations.
We are increasing the doses of your home medications and made a
follow up for you with your pulmonologist in the next week. You
will complete 4 more days of azithromycin (an antibiotic) and
prednisone 40 mg daily.
The most important thing you can do to prevent these
exacerbations in the future is to stop smoking. Please ask your
primary care doctor for nicotine patches/gum or medications to
stop smoking if you decide you are unable to stop without
additional help.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10510161-DS-13 | 10,510,161 | 23,762,330 | DS | 13 | 2174-07-10 00:00:00 | 2174-07-11 09:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins
Attending: ___.
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
___ Intubation
___ Self-extubation
History of Present Illness:
Mr. ___ is a ___ year old male with a history of COPD, HTN,
DMII, hx of cocaine use disorder who presented to the ED for 2
days of worsening cough and shortness of breath with associated
headaches. He denied any myalgias, chest pain, nausea or
vomiting.
Per chart review he was recently seen by his PCP ___ 1 week
ago for worsening shortness of breath and a rhinorrhea. He was
prescribed a prednisone 20mg burst for 7 days and azithromycin.
He follows with his PCP and pulmonologist at ___.
He has been hospitalized multiple times (about 5X) in the past
year for acute COPD exacerbations and had his first ICU
admission to the FICU ___ for BIPAP.
In the ED, initial vitals:
HR 106 BP 190/85 RR 28 02 100% NEB
Patient was also placed on BIPAP in the ED for a brief reported
___ minute period of time.
Exam notable for: Tachypneic, increased WOB, ronchorous b/l
breath sounds. No JVD, no pedal edema
Labs notable for: CBC: WBC 11.3 hgb 16.3/50.7 plt 244 ca ___
BMP Na 141 K 5.0 BUN 18 Cr. 1.2
Trop <.01 proBNP: 61
7.28 pCO2 63 pO2 73 HCO3 31 Base XS 0
UA leuk neg, nitrite neg, WBC <1
Imaging:
CXR ___
Streaky atelectasis in the lung bases without focal
consolidation to suggest pneumonia
Patient received:
___ 16:04 IH Albuterol 0.083% Neb Soln 1 Neb
___ 16:04 IH Ipratropium Bromide Neb 1 Neb
___ 16:42 IV Azithromycin ___ Started
___ 17:53 IV Azithromycin 500 mg
___ 17:53 IV Vancomycin (1000 mg ordered)
___ 17:56 IH Albuterol 0.083% Neb Soln 1 NEB
___ 17:56 IH Ipratropium Bromide Neb 1 NEB
___ 19:00 IV Vancomycin
___ 19:45 IH Albuterol 0.083% Neb Soln 1 Neb
___ 19:45 IH Ipratropium Bromide Neb 1 Neb
___ 20:43 IV DRIP Nitroglycerin (0.5-5 mcg/kg/min
ordered)
___ 20:43 SL Nitroglycerin SL .4 mg
___ 21:42 IV Levofloxacin (750 mg ordered)
___ 21:42 IV LORazepam .5 mg
Past Medical History:
COPD (hx 1ppd x years)
HTN
T2DM
substance use disorder (incl cocaine)
HCV
Social History:
___
Family History:
DMII Father, maternal grandmother
Physical Exam:
ADMISSION EXAM:
VITALS: 97.7 85 132/71 11 100% CMV ___
GENERAL: older ___ male lying in bed intubated and
sedated
HEENT: Sclera anicteric, pin point pupils reactive to light
bilaterally, oral mucosa moist
LUNGS: decreased breath sounds throughout with expiratory wheeze
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Distended, non-tender, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
EXT: Cool, no cyanosis or edema
SKIN: No obvious rashes or lesions
NEURO: sedated
DISCHARGE EXAM:
VS: 98.3PO 138/94 89 18 96 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 04:05PM WBC-11.3* RBC-5.52 HGB-16.3 HCT-50.7 MCV-92
MCH-29.5 MCHC-32.1 RDW-13.9 RDWSD-47.2*
___ 04:05PM NEUTS-57.6 ___ MONOS-7.8 EOS-4.3
BASOS-0.7 IM ___ AbsNeut-6.49* AbsLymp-3.28 AbsMono-0.88*
AbsEos-0.48 AbsBaso-0.08
___ 04:05PM GLUCOSE-300* UREA N-18 CREAT-1.2 SODIUM-141
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
___ 04:05PM CALCIUM-10.8* PHOSPHATE-3.7 MAGNESIUM-1.9
___ 04:05PM proBNP-61
___ 04:05PM cTropnT-<0.01
___ 04:40PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:22PM ___ PO2-73* PCO2-63* PH-7.28* TOTAL
CO2-31* BASE XS-0
___ 05:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:15PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-100*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:15PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:15PM URINE MUCOUS-RARE*
PERTINENT STUDIES
-----------------
___ URINE: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
___ MRSA SCREEN: No MRSA isolated
___ 01:55AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 01:54AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-POS* amphetm-NEG oxycodn-NEG
IMAGING
-------
___ CTA CHEST
1. Endotracheal tube appears appropriate. Enteric tube
terminates just below the GE junction, and should be advanced
into the stomach.
2. Moderately limited examination due to respiratory motion
artifact,
particularly at the lung bases. Within these limitations, no
evidence of
pulmonary embolism.
3. Moderate centrilobular emphysema. Diffuse bronchial wall
thickening likely reflects chronic airways disease.
4. Left adrenal adenoma.
___ TTE
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Doppler parameters are indeterminate for left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
___ CXR
Streaky atelectasis in the lung bases without focal
consolidation to suggest pneumonia.
___ CXR
There has removal of the endotracheal tube and enteric tube
since the previous study. There has been worsening of the
bibasilar patchy opacities since the previous study. This may
represent atelectasis or aspiration. Follow up to resolution is
recommended. There are no pneumothoraces.
MICROBIOLOGY
------------
Blood culture x ___: negative
Urine culture ___: negative
___ 4:06 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
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..
___ 8:38 am THROAT FOR STREP
R/O Beta Strep Group A (Pending):
DISCHARGE LABS
--------------
___ 09:35AM BLOOD WBC-11.9* RBC-4.48* Hgb-13.3* Hct-41.0
MCV-92 MCH-29.7 MCHC-32.4 RDW-14.4 RDWSD-47.8* Plt ___
___ 09:35AM BLOOD Glucose-153* UreaN-12 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-24 AnGap-12
___ 06:40AM BLOOD ALT-23 AST-32 LD(LDH)-227 AlkPhos-85
TotBili-0.5
___ 09:35AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of COPD, HTN,
DMII, hx of cocaine use disorder admitted to the ICU for
hypercarbic/hypoxemic respiratory failure secondary to COPD
exacerbation, maybe lung injury secondary to inhaling cocaine
(utox was positive for cocaine).
#Hypercarbic/hypoxemic respiratory failure
#COPD exacerbation:
Patient with multiple exacerbation ~5 in the last year with
recent visit to PCP for worsening SOB and cough. His current
hypercarbic respiratory failure and is most consistent with his
prior COPD exacerbations. An underlying trigger is not yet clear
but he has been ruled out for PE, MI, and flu to this point. His
CT Chest was also reassuring showing no focal consolidations or
signs of infection. ___ be related to cocaine given positive
urine toxicology screen. S/p self extubation on ___ with
continuous improvement. Sputum culture was unremarkable. He
was placed on prednisone 40 mg with slow taper. He completed
levofloxacin 7-day course. Patient will be discharged on 20 mg
PO prednisone, with plans to further taper after discharge. He
will follow up with his PCP ___ ___ to further handle this. He
also will follow up with his outpatient pulmonologist.
# Acute kidney injury: possibly related to brief hypotensive
period in the ED when he was initiated on propofol. This was a
brief period of BP 70-80s and he was put on levophed briefly
before he recovered. Also was severely HTN in the ED could be
end organ damage from this transient period. Could be drug
induced on ACEi at home, also received multiple new meds in the
ED but none are classic for renal dysfunction. Could also be
related to cocaine use. His creatinine was 1.0 on discharge.
His lisinopril was restarted prior to discharge. Creatinine
should be recheck upon PCP ___.
# Cocaine abuse: patient with urine toxicology positive for
cocaine, and he admits smoking cocaine. Patient was counseled
about cessation, and how cocaine is likely affecting all of his
health problems. Social Work was consulted and arranged to get
him enrolled in an outpatient substance abuse program, which he
agrees to attend.
# Pharyngitis: patient reported near end of hospital stay, strep
testing pending on discharge. He was treated with cepacol
lozenges for symptoms. Strep testing will be followed up after
finalization following discharge.
# Hyperkalemia: Resolved. Sudden increase to 7.5 from 5 with
peaked T waves in the setting ___ as above and rapid sequence
intubation with succinylcholine which is known to cause an acute
transient hyperkalemia. Treated with insulin + Lasix/IVF.
# Diabetes: patient on lantus 52 units once daily, holding home
metformin XR during admission. Last A1C 7.2. At time of
discharge, patient was on his home dose of insulin glargine.
# Hypertension: essential HTN managed on multiple meds at home
including
HCTZ 25mg, Lisinopril 20mg and amlodipine 10mg. He was on
amlodipine and lisinopril during most of his stay, with HCTZ
being held. His lisinopril dose was increased during his
admission due to worsened hypertension, likely because of
steroid use. His HCTZ was restarted on discharge. His
metoprolol has been held due to his cocaine use. Restarting
this should be readdressed as an outpatient.
# Tobacco abuse: patient was counseled on smoking cessation
during his admission. He will be discharged with a prescription
for nicotine patch.
TRANSITIONAL ISSUES:
=================================
# ___: Patient will be discharged on 20 mg PO prednisone,
with plans to further taper after discharge. He will follow up
with his PCP ___ ___ to further handle this. He also will
follow up with his outpatient pulmonologist. Creatinine should
be recheck upon PCP ___. Patient has been enrolled in an
outpatient substance abuse program, which he agrees to attend.
Strep testing will be followed up after finalization following
discharge. His metoprolol has been held due to his cocaine use.
Restarting this should be readdressed as an outpatient.
# Code status: full code, confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation q4
H: PRn
3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
7. budesonide 180 mcg/actuation inhalation BID
8. Clotrimazole Cream 1 Appl TP DAILY
9. amLODIPine 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Glargine 52 Units Breakfast
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN Sore throat
RX *benzocaine-menthol [Cepacol Sore Throat ___ 15
mg-3.6 mg ___ lozenges every four (4) hours Disp #*20 Lozenge
Refills:*0
3. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*15 Patch
Refills:*0
4. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*16 Tablet
Refills:*0
5. Glargine 52 Units Breakfast
6. Lisinopril 30 mg PO DAILY
RX *lisinopril 30 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
8. amLODIPine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Budesonide 180 mcg/actuation inhalation BID
11. Clotrimazole Cream 1 Appl TP DAILY
12. Hydrochlorothiazide 25 mg PO DAILY
13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
14. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation q4
H: PRn
15. HELD- Metoprolol Succinate XL 100 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your PCP talks with you. You should not be on this while
using cocaine.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Pneumonia
Cocaine abuse
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization. You came for further evaluation of shortness
of breath. Further testing showed that you had a COPD
exacerbation and pneumonia. You are now being discharged.
It is extremely important that you no longer use cocaine. This
is affecting your heart, lungs and kidneys and making you sick,
and very well could kill you. Please do all you can to stop
using this substance.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck!
Followup Instructions:
___
|
10510639-DS-4 | 10,510,639 | 28,185,167 | DS | 4 | 2129-04-09 00:00:00 | 2129-04-09 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / amoxicillin
Attending: ___.
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of endometrial cancer on doxil and
avastin who is admitted with abdominal pain. The patient states
the abdominal pain, nausea, and vomiting started about a week
ago. She has had constipation for the last ___ days. She has not
been eating or drinking much. She thinks the nausea is due
recent
chemotherapy one week ago as the timing relates and she has had
nausea with chemotherapy before. She has been taking Compazine
and also some Zofran for that. The pain varies in characteristic
and is more upper and across her abdomen which she has had since
her cancer was diagnosed but it has been worse recently. She has
also had some gas and intermitted LLQ cramping pain that started
more recently. She denies any fevers, congestion, sore throat,
cough, shortness of breath, or dysuria. She does not have any
known sick contacts and has not had any medication changes
recently.
REVIEW OF SYSTEMS:
- All reviewed and negative except as stated in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Recurrent Serous Endometrial Cancer, st IV
___ Vaginal Bleeding.
___ pelvic ultrasound with endovaginal probe:
The uterus measures approximately 7 cm, there are several small
uterine fibroids and an exophytic fundal fibroid measuring 4 x
2.7 x 2 cm.
Endometrial thickness is 15 mm, abnormally thickened and
heterogeneous with cystic and solid components. Neither ovary
could be identified. There was no ascites.
___ CT urogram:
The kidneys enhance normally with normal opacification of the
collecting system.
However, there was a complex right adnexal mass, 4.2 x 3.3 cm,
and the uterus appeared heterogeneous with low-density areas
eventually compatible with the abnormal endometrium. In
addition, there is left retroperitoneal adenopathy, 1.6 x 1.2 cm
and adenopathy around the distal aorta and at the aortic
bifurcation measuring 1.9 x 1.2 cm. There is also bilateral
iliac adenopathy, 2 x 1 cm.
___, seen by Dr. ___ in the ___ office. An
endometrial biopsy was performed. The uterine cavity was about
7
cm: Cervix showed a sliver of polyp-appearing tissue.
PATHOLOGY: There was an endocervical polyp.
Endometrial biopsy showed adenocarcinoma, serous type with
psammoma bodies, minute fragments in the background of inactive
endometrium. Immunohistochemistry shows that the tumor cells
are
positive for P16 and P53.
The patient was informed and referred to Dr. ___ at ___.
___ Chest CT There was no adenopathy in the
supraclavicular,
axillary, mediastinal, or hilar regions. However, there is
irregular thickening of the left fissure and multiple nodules
less than ___s a 4-mm ground-glass nodule in the
right
lower lobe. A 3-month followup was recommended.
___, Exploratory laparotomy, total abdominal
hysterectomy,
bilateral salpingo-oophorectomy, radical debulking of bilateral
pelvic and periaortic lymph nodes and omental biopsy, Dr.
___.
PATHOLOGY:
Uterus, cervix and bilateral fallopian tubes and ovaries, total
hysterectomy and BSO: Serous adenocarcinoma. Histologic grade
III, the tumor size only 1.7 cm. However, the washings were
positive, and 16 of 16 pelvic and periaortic nodes were
positive.
An omental biopsy was negative. There was also extensive
lymphovascular invasion.
The patient had a ___ postoperative course, including an ileus
and retroperitoneal hematoma. She received a total of 5 units
of
packed cells while in the hospital. She also developed
significant edema and anasarca while being hydrated,which
eventually was mobilized.
___ Discharged home. Gradual recovery since then.
___ Start Carboplatin/Taxol
___ Cycle ___ Cycle #3
___ CHEST/ ABDOMEN/ PELVIS CT W/ CONTRAST
1. With respect to the chest, there are several indeterminate
pulmonary nodules, majority of which are without significant
change compared to prior study taking into account differences
in
technique. There is a 3 mm nodule in the right lower lobe which
has decreased in density/conspicuity. There is a 4 mm
groundglass
subpleural nodule in the right lower lobe not seen on prior
study
due to differences in slice selection and a 3.5 mm groundglass
subpleural nodule in the left upper lobe of trace increased
conspicuity. These should be
followed on future studies to assess for change.
2. Decrease in size of the left supraclavicular node when
compared to CT chest ___.
3. Status post hysterectomy and bilateral salpingo-oophorectomy.
Status post retroperitoneal lymphadenectomy. Tiny
low-attenuation
focus in the left para-aortic region may reflect a trace amount
of fluid (loculated) on a postoperative basis and can be
followed
on future studies to assess for change and exclude a necrotic
node in this region given lymphadenopathy had been present on CT
___. There is also a 1.2cm AP x 1.1cm transverse low
attenuation focus on along the left pelvic sidewall at the level
of the previously noted adenopathy which may reflect decrease in
size of node/post treatment changes versus a tiny loculated
pocket of fluid.
4. Low-attenuation fluid collection with peripheral
hyperdensity/enhancement at the level of the hysterectomy bed
has
decreased in size compared to CTs performed ___. This is
suspected to reflect a postoperative seroma which has decreased
in size in the absence of clinical findings to suggest a
walled off abscess.
5. Near complete resolution of the diffuse mesenteric edema and
anasarca within the abdomen and pelvis.
___ Cycle ___ Cycle ___ Cycle #6
___ FDG TUMOR IMAGING (PET-CT)
1. FDG avid left supraclavicular lymph node, concerning for
nodal
metastatic disease.
2. Asymmetric mildly increased FDG activity in the left adrenal
gland may be physiologic. Attention on followup is advised.
Dr ___ pelvic radiation in view of apparent systemic
disease. However the left supraclavicular node was present prior
to systemic therapy, small residual.
In view of low volume of disease and her well-being, decision
made to observe and repeat imaging.
___ CT Torso ___:
Stable appearance of the isolated, enlarged and FDG PET avid
left
supraclavicular lymph node when compared to ___. Multiple
sub 4 mm pulmonary nodules are stable in appearance. No growing
pulmonary nodules, lymphadenopathy or pleural disease.
No evidence of abdominopelvic metastasis or recurrence.
CA125 360 at that time.
___ epigastric pain, U/S at BID trace fluid in right pelvis
only.
___ L SCV Node FNA - Met endometrial cancer
___ CT Torso ___:
1. New, small region of fat stranding in the right pelvis with a
small amount of free fluid is of uncertain significance. Close
attention is recommended on follow-up imaging.
2. No definite metastases in the abdomen or pelvis.
3. Please refer to concurrent CT chest report for a complete
discussion of the thoracic findings.
4. No CT findings in the abdomen or pelvis to correlate with
reported history of upper abdominal pain.
However we reviewed this study with radiologist here, many areas
of disease noted in right lower quadrant and elsewhere, between
bowel loops, in mesentery and retroperitoneum.
___ PET/CT ___
FINDINGS:
HEAD/NECK: The previously seen FDG avid left supraclavicular
lymph node now measures 16 mm in short axis and demonstrates
significant FDG avidity, with SUV max of 7.8, previously 3.5.
There is asymmetric radiotracer uptake in the left C3 pedicle,
measuring an SUV max of 4.1, not definitively visualized on the
prior examination.
CHEST: Evaluation of the chest shows a new right lower lobe
linear opacity, which may represent an area of atelectasis. This
does not show increased FDG avidity. No suspicious, FDG avid
pulmonary nodules are identified. There is no definite axillary,
mediastinal, or hilar lymphadenopathy, though the nonenlarged
preaortic node does demonstrate an SUV max of 1.8.
ABDOMEN/PELVIS: Evaluation of the abdomen and pelvis shows
marked
disease progression with multiple FDG avid, hypodense hepatic
lesions, consistent with metastases. In addition, there is
significant peritoneal nodularity, particularly in the
perihepatic region, showing market FDG avidity, with an SUV max
of 12.7. In addition, numerous FDG avid mesenteric nodules and
lymph nodes are noted, for example, in the right lower quadrant,
measuring 1.1 cm in diameter and demonstrating a max SUV of 5.5.
Similar nodules are also seen in the pelvis, for example, in the
left presacral area, a 1.5 cm nodule demonstrates an SUV max of
6.7. Similar nodules line the bilateral pelvic sidewalls. The
loops of pelvic small bowel appear to be surrounded by high
density ascites versus disease involvement. The uterus is
surgically absent.
MUSCULOSKELETAL: Aside from the cervical spine findings
described
above, no other regions abnormal FDG uptake are seen within the
visualized osseous structures.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
IMPRESSION: 1. Findings consistent with widely metastatic
disease.
___ Start doxil/avasatin.
PAST MEDICAL HISTORY:
Anxiety, HTN, HLD, DM.
Social History:
___
Family History:
She thinks her mother had stomach cancer. There were 5 siblings
in her mother's family, none of whom had cancer. Her father had
heart disease. The patient has 2 siblings, her brother had
prostate cancer in his late ___ and was told of one colonic
polyp. No other history of cancer or colon cancer or polyps.
Physical Exam:
General: NAD
VITAL SIGNS: T 98.1 HR 93 BP 108/73 BP 100/70 O2 97%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, ND, diffuse mild tenderness to palpation, greatest
in
RUQ.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 01:26PM BLOOD WBC-8.6 RBC-4.20# Hgb-10.6*# Hct-33.3*#
MCV-79*# MCH-25.2*# MCHC-31.8* RDW-14.3 RDWSD-41.0 Plt ___
___ 07:15AM BLOOD WBC-6.7 RBC-3.63* Hgb-9.3* Hct-29.7*
MCV-82 MCH-25.6* MCHC-31.3* RDW-14.5 RDWSD-42.5 Plt ___
___ 01:26PM BLOOD Neuts-92.5* Lymphs-3.5* Monos-3.4*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.96* AbsLymp-0.30*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.01
___ 01:26PM BLOOD Glucose-114* UreaN-18 Creat-0.7 Na-133
K-3.9 Cl-92* HCO3-31 AnGap-14
___ 07:15AM BLOOD Glucose-89 UreaN-16 Creat-0.6 Na-136
K-4.2 Cl-105 HCO3-23 AnGap-12
IMAGING:
CT Abd/Pelvis:
1. No evidence of bowel obstruction or other acute
abdominopelvic
pathology.
2. Distal small bowel wall thickening with small volume pelvic
ascites is concerning for metastatic disease.
3. Omental thickening and mild retroperitoneal and mesenteric
lymphadenopathy are also concerning for metastatic disease, and
corresponds to sites of FDG avidity on the prior PET-CT.
4. Previously described FDG avid hepatic lesions are
suboptimally
assessed on this exam.
Brief Hospital Course:
___ yo female with a history of endometrial cancer on doxil and
avastin who is admitted with abdominal pain.
# Constipation: Abdominal pain was likely multifactorial
including constipation related and related to progression of
disease with possible peritoneal spread. Her constipation
improved with a bowel regimen.
# Abdominal pain: Pain improved with a three-day burst of
decadron, fentanyl patch and oral Dilaudid. Of note, the patient
had increased nausea with oxycodone.
# Endometrial cancer: She will follow up with Dr. ___ on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN Nausea
7. Ondansetron 8 mg PO Q8H:PRN Nausea
8. Lorazepam 0.5 mg PO Q6H:PRN Anxiety or Nausea
9. Pyridoxine Dose is Unknown PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Lorazepam 0.5 mg PO Q6H:PRN Anxiety or Nausea
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea
9. Pyridoxine 50 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 cap by mouth bid prn Disp #*30
Capsule Refills:*0
11. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour apple one patch q72hr Disp #*15 Patch
Refills:*0
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Do not take with alcohol. Do not drive while taking this
medication.
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4hprn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea and constipation. Your symptoms
improved with a bowel regimen. You had nausea with oxycodone, so
this was stopped and you were started on a fentanyl patch and
oral Dilaudid, which you tolerated well.
Followup Instructions:
___
|
10510639-DS-5 | 10,510,639 | 27,047,809 | DS | 5 | 2129-05-05 00:00:00 | 2129-05-11 13:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / amoxicillin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Ms. ___ is a very pleasant ___ year-old woman with
history
of endometrial cancer on doxil and avastin (last ___ who
presents with lower abdominal pain and unable to tolerate POs.
Of
note, she was recently admitted to ___ ___ for similar
symptoms and was discharged on fentanyl patch (12.5 mcg) and
dilaudid ___ mg q4 hrs. Since then, she was doing ok when she
saw
Dr. ___ she reports that has on and off days. She takes
her dilaudid and antiemetics, but then is complicated by
constipation. She backs off on the pain medications and takes
milk of magnesia and then gets diarrhea. over the past ___ days
pain worsened despite prn dilaudid and therefore she came to the
ED For pain control. She reports however that she takes it at
most twice a day.
In the ED her initial VS were: pain ___, T 97.6 F, HR 90 bpm,
BP 118/73 mmHg, RR 16, SpO2 100% RA. Physical exam showed: thin,
cachectic pleasant woman, NAD. diffusely TTP @ lower abdomen,
+splinting, no rebound or guarding. No CVAT. WWP, no c/c/e. Labs
were significant for WBC 6.8, HGB 10.5, PLT 403, Na 131, K 4, Cl
94, CO2 25, BUn 22, Cr 0.7, Glu 132, Ca 9.5, Mg 1.8, P 3.2, INR
1.2. CT was performed. Lactate was not checked. She received 0.5
mg of IV dilaudid. No fluid was given.
On review of systems, 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.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Recurrent Serous Endometrial Cancer, st IV
___ Vaginal Bleeding.
___ pelvic ultrasound with endovaginal probe:
The uterus measures approximately 7 cm, there are several small
uterine fibroids and an exophytic fundal fibroid measuring 4 x
2.7 x 2 cm. Endometrial thickness is 15 mm, abnormally
thickened and heterogeneous with cystic and solid components.
Neither ovary could be identified. There was no ascites.
___ CT urogram:
The kidneys enhance normally with normal opacification of the
collecting system.
However, there was a complex right adnexal mass, 4.2 x 3.3 cm,
and the uterus appeared heterogeneous with low-density areas
eventually compatible with the abnormal endometrium. In
addition, there is left retroperitoneal adenopathy, 1.6 x 1.2
cm
and adenopathy around the distal aorta and at the aortic
bifurcation measuring 1.9 x 1.2 cm. There is also bilateral
iliac adenopathy, 2 x 1 cm.
___, seen by Dr. ___ in the ___ office. An
endometrial biopsy was performed. The uterine cavity was about
7 cm: Cervix showed a sliver of polyp-appearing tissue.
PATHOLOGY: There was an endocervical polyp.
Endometrial biopsy showed adenocarcinoma, serous type with
psammoma bodies, minute fragments in the background of inactive
endometrium. Immunohistochemistry shows that the tumor cells
are positive for P16 and P53.
The patient was informed and referred to Dr. ___ at ___.
___ Chest CT irregular thickening of the left fissure and
multiple nodules less than ___s a 4-mm ground-glass
nodule in the right lower lobe.
___, Exploratory laparotomy, total abdominal
hysterectomy, bilateral salpingo-oophorectomy, radical
debulking of bilateral pelvic and periaortic lymph nodes and
omental biopsy, Dr. ___.
PATHOLOGY:
Uterus, cervix and bilateral fallopian tubes and ovaries, total
hysterectomy and BSO: Serous adenocarcinoma. Histologic grade
III, the tumor size only 1.7 cm. However, the washings were
positive, and 16 of 16 pelvic and periaortic nodes were
positive.
An omental biopsy was negative. There was also extensive
lymphovascular invasion. The patient had a ___ postoperative
course, including an ileus and retroperitoneal hematoma. She
received a total of 5 UPRBC. She also developed
significant edema and anasarca while being hydrated,which
eventually was mobilized.
___ Discharged home. Gradual recovery since then.
___ Start Carboplatin/Taxol
___ Cycle #2
___ Cycle #3
___ Cycle #4
___ Cycle #5
___ Cycle #6
___ FDG TUMOR IMAGING (PET-CT)
1. FDG avid left supraclavicular lymph node, concerning for
nodal metastatic disease.
2. Asymmetric mildly increased FDG activity in the left adrenal
gland may be physiologic. Attention on followup is advised.
Dr ___ pelvic radiation in view of apparent systemic
disease. However the left supraclavicular node was present
prior
to systemic therapy, small residual.
In view of low volume of disease and her well-being, decision
made to observe and repeat imaging.
___ epigastric pain, U/S at BID trace fluid in right pelvis
only.
___ L SCV Node FNA - Met endometrial cancer
___ PET/CT ___
FINDINGS:
HEAD/NECK: The previously seen FDG avid left supraclavicular
lymph node now measures 16 mm in short axis and demonstrates
significant FDG avidity, with SUV max of 7.8, previously 3.5.
There is asymmetric radiotracer uptake in the left C3 pedicle,
measuring an SUV max of 4.1, not definitively visualized on the
prior examination.
CHEST: Evaluation of the chest shows a new right lower lobe
linear opacity, which may represent an area of atelectasis.
This
does not show increased FDG avidity. No suspicious, FDG avid
pulmonary nodules are identified. There is no definite
axillary,
mediastinal, or hilar lymphadenopathy, though the nonenlarged
preaortic node does demonstrate an SUV max of 1.8.
ABDOMEN/PELVIS: Evaluation of the abdomen and pelvis shows
marked disease progression with multiple FDG avid, hypodense
hepatic lesions, consistent with metastases. In addition, there
is significant peritoneal nodularity, particularly in the
perihepatic region, showing market FDG avidity, with an SUV max
of 12.7. In addition, numerous FDG avid mesenteric nodules and
lymph nodes are noted, for example, in the right lower
quadrant,
measuring 1.1 cm in diameter and demonstrating a max SUV of
5.5.
Similar nodules are also seen in the pelvis, for example, in
the
left presacral area, a 1.5 cm nodule demonstrates an SUV max of
6.7. Similar nodules line the bilateral pelvic sidewalls. The
loops of pelvic small bowel appear to be surrounded by high
density ascites versus disease involvement. The uterus is
surgically absent.
MUSCULOSKELETAL: Aside from the cervical spine findings
described above, no other regions abnormal FDG uptake are seen
within the visualized osseous structures.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
IMPRESSION: 1. Findings consistent with widely metastatic
disease.
___ Start doxil/avasatin.
PAST MEDICAL HISTORY:
Anxiety, HTN, HLD, DM.
Social History:
___
Family History:
She thinks her mother had stomach cancer. There were 5 siblings
in her mother's family, none of whom had cancer. Her father had
heart disease. The patient has 2 siblings, her brother had
prostate cancer in his late ___ and was told of one colonic
polyp. No other history of cancer or colon cancer or polyps.
Physical Exam:
DISCHARGE EXAM:
VITAL SIGNS - 98.0 142/80 92 18 100%RA
GENERAL - chronically ill appearing, somnolent mostly but
arouses
to voice or stimulation, speech slowed but fluent and sensical
HEENT - MMM lips dry
CV: RRR
Lungs: clear, nonlabored
Ab: firm in lower quadrants, upper ab more soft, tender
throughout w/o rebound or guarding
Ext: no edema
Pertinent Results:
ADMISSION LABS:
___ 08:45PM BLOOD WBC-6.8 RBC-4.31 Hgb-10.5* Hct-33.3*
MCV-77* MCH-24.4* MCHC-31.5* RDW-15.4 RDWSD-41.7 Plt ___
___ 08:45PM BLOOD Neuts-83.3* Lymphs-5.0* Monos-11.0
Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.67 AbsLymp-0.34*
AbsMono-0.75 AbsEos-0.00* AbsBaso-0.02
___ 08:45PM BLOOD ___ PTT-28.5 ___
___ 08:45PM BLOOD Glucose-132* UreaN-22* Creat-0.7 Na-131*
K-4.0 Cl-94* HCO3-25 AnGap-16
___ 08:45PM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8
OTHER IMAGING:
CT abdomen/pelvis:
1. No definite acute intra-abdominal process.
2. A short segment of small bowel demonstrates fecalization of
the intraluminal contents with mild distention that does not
meet CT criteria for ___ dilatation. Consider short interval
follow-up abdominal radiographs or CT of the abdomen and pelvis
to exclude developing obstruction in this area
(02:55, ___:21).
3. Small volume ascites with extensive omental and peritoneal
studding and nodularity is grossly unchanged from the prior CT
consistent with metastatic disease.
Brief Hospital Course:
___ w/ endometrial cancer recently started on doxil and avastin
(first cycle ___ who presents with lower abdominal pain
and inability to tolerate PO intake.
# Abdominal pain - CT of her abdomen revealed small volume
ascites with extensive omental and peritoneal studding and
nodularity is grossly unchanged from the prior CT consistent
with metastatic disease. also mild dilatation of the small
bowel,
unable to r/o early SBO. AXR ___ w/ some dilated loops no
transition point. EGD ___ suggestive of delayed gastric
emptying from peritoneal carcinomatosis
- now on dilaudid PCA 0.36/hr, bolus 0.25 prn, now w/ reasonable
pain control, planning to cont PCA on discharge, hospice pump
set up prior to transfer
# Nausea
This is likely also from underlying disease. having constipation
w/ Zofran. compazine not helping and having difficulty w/ pills.
- initial improvement w/ dex unclear if helping but nausea worse
after stopping, will cont PO as long as able to tolerate pills
- cont zyprexa prn
- cont ativan PRN
# Constipation ___ narcotics and poor bowel motility from
peritoneal disease
- cont colace/miralax daily as able
- suppository/enema prn
# Failure to thrive
# Dehydration - giving IVF prn. avoiding parenteral nutrition
as risk for volume overload, does not want feeding tube
# Metastatic endometrial Ca
S/p TAH BSO ___, radical debulking of bilateral pelvic and
periaortic lymph nodes and omental biopsy. received 6 cycles
___. PET in ___ unfortunately marked progression now
extensive liver mets, peritoneal nodules and pelvic side wall
nodules. started doxil/avastin ___. However in light of
progression and poor tolerance to further therapies, patient and
Dr. ___ decided on ___ based approach. She was enrolled in
hospice and discharged to ___.
# HTN - stopped antihypertensives
Discharge Medications:
1. HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0.25 mg(s)/hour 1-hr Max Limit: 1.45 mg(s)
0.5mg/ml
for hospice care
RX *hydromorphone 60 mg/30 mL (2 mg/mL) per instruction
continuous Disp #*6 Bag Refills:*0
2. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily prn Disp
#*12 Suppository Refills:*0
3. Dexamethasone 2 mg PO ONCE Duration: 1 Dose
RX *dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*1
4. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Lorazepam 0.5-1 mg PO Q6H:PRN nausea, anxiety
use first
RX *lorazepam 0.5 mg ___ tablets by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*0
6. OLANZapine (Disintegrating Tablet) 5 mg PO BID
RX *olanzapine 5 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
7. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
use second
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours as needed Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Nausea and vomiting
Dehydration
Abdominal pain
Endometrial cancer
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 Ms ___ - ___ was a pleasure caring for you during your
stay at ___. You were admitted with worsening abdominal pain,
nausea, vomiting and difficulty tolerating oral intake.
Abdominal CT did not show obstruction. Your fentanyl patch was
increased and you also received IV pain medications. Your
nausea regimen was also adjusted. No further chemotherapy was
recommended and you have chosen to enroll in hospice services.
Followup Instructions:
___
|
10510857-DS-11 | 10,510,857 | 26,718,746 | DS | 11 | 2169-03-06 00:00:00 | 2169-03-13 11:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / adhesive tape / Motrin / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal pain, N/V, melena
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
Per admitting resident: ___ female with history
Roux-en-Y gastric bypass over ___ years ago and known
gastro-gastric fistula, s/p cholecystectomy presenting with
acute on chronic worsening epigastric pain and new onset of dark
stool since first noted a week ago. She describes the pain as
intermittent, occasionally severe, stabbing pain arising in her
mid epigastrium. She cannot relate any particular food intake
that triggers the pain, although notes that the frequency and
severity of these symptoms have increased over the last few
weeks. She has noted associated weakness, episodes of dizziness
and palpitations during this time. She has been followed by Dr.
___ since ___ for similar symptoms, which
initially responded well to PPI and Carafate for a few years.
However, these episodes have increased
in frequency and intensity since ___ and the dark tarry stools
is a new occurrence.
An endoscopy in ___ revealed the previous Roux-en-Y gastric
bypass with granularity, friability, erythema and congestion in
the stomach body compatible with gastritis. Pathology at this
time revealed chemical-type injury.
Past Medical History:
PMH:
hx obesity
back pain
hip pain
neck pain
gastro-gastric fistula
PSH:
RNY gastric bypass ___
Gastro-gastric fistula
hysterectomy
myomectomy for fibroids
open cholecystectomy
Social History:
___
Family History:
non contributory
Physical Exam:
T 98.9 P 64 BP 115/81 RR 18 02 99%RA
Gen: no acute distress
Cardiac: regular rate and rhythm, no murmurs appreciated
Resp: clear to auscultation, bilaterally; breathing non-labored
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding, well healed abdominal incisions
Ext: no lower extremity edema or tenderness
Pertinent Results:
LABS:
___ 12:10PM BLOOD WBC-3.9* RBC-3.06*# Hgb-7.9*# Hct-24.8*#
MCV-81* MCH-25.8* MCHC-31.9* RDW-15.9* RDWSD-47.4* Plt ___
___ 03:15PM BLOOD Hct-23.2*
___ 09:15PM BLOOD Hct-23.1*
___ 05:35AM BLOOD WBC-2.1* RBC-2.72* Hgb-7.1* Hct-22.1*
MCV-81* MCH-26.1 MCHC-32.1 RDW-15.8* RDWSD-47.0* Plt ___
___ 04:40AM BLOOD WBC-2.4* RBC-2.67* Hgb-7.0* Hct-21.9*
MCV-82 MCH-26.2 MCHC-32.0 RDW-15.9* RDWSD-48.2* Plt ___
___ 06:00PM BLOOD Hct-27.9*#
___ 05:35AM BLOOD PTH-88*
___ 05:35AM BLOOD Triglyc-73 HDL-55 CHOL/HD-3.3 LDLcalc-114
___ 05:35AM BLOOD calTIBC-277 VitB12-386 Folate-8
Ferritn-6.5* TRF-213
___ 05:35AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.3 Mg-1.9
Iron-26* Cholest-184
___ 05:35AM BLOOD VITAMIN B1-WHOLE BLOOD-PND
IMAGING:
___
EGD: Evidence of a previous Roux-en-Y gastric bypass was seen.
There was a gastro-gastric fistula seen which allowed the
endoscope to enter into the gastric remnant. The mucosa in
gastric remnant appeared normal and no Ulcer was noted. Normal
mucosa in the duodenum At the site of GJ anastomosis, there was
about 2 cm clean based ulcer with heaped up, erythematous mucosa
surrounding the same. The alimentary limb was traverses and
appeared normal. JJ anastomosis could not be reached.
Otherwise normal EGD to jejunum
Brief Hospital Course:
The patient presented to the Emergency Department on ___ with worsening epigastric pain and melena; admission hct
24.9, however, the patient remained hemodynamically stable.
Given concern for gastro-intestinal bleeding, the patient was
admitted to the ___ where she was placed
on bowel rest, given intravenous fluids and pantoprazole and had
serial hematocrit levels monitored.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed intravenous morphine and
acetaminophen. At the time of discharge, the patient reported
significant improvement of her abdominal pain and reported no
pain with intake of solid food.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, and ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO with
administration of intravenous antacid medication q 12 hours. On
HD3, she underwent upper endoscopy which revealed a 2 cm
marginal ulcer and confirmed the presence of a gastro-gastric
fistula. Post-procedure, the diet was advanced to a Regular
diet, which was well tolerated with abdominal pain, nausea or
vomiting. Patient's intake and output were closely monitored.
Of note, on HD4, the patient had an episode of symptomatic
hypoglycemia which she had been experiencing prior to admission.
The ___ was consulted for evaluation of
post-RNY bypass hypoglycemia. She will be discharged with a
glucometer, follow-up with her PCP within one as discussed with
her and Dr. ___ at the ___.
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. On HD3,
she did receive 2U PRBCs with an appropriate response in her
hematocrit levels. Hct remained stable for the remainder of the
hospitalization.
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. Pregabalin 100 mg PO BID
2. Fish Oil (Omega 3) 1000 mg PO BID
3. LORazepam 1 mg PO TID:PRN Anxiety
4. Docusate Sodium 100 mg PO TID:PRN Constipation
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 20 mg PO Q12H
7. Escitalopram Oxalate 10 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Modafinil 200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. calcium citrate-vitamin D3 500 mg calcium -400 unit oral BID
3. cyanocobalamin (vitamin B-12) 500 mcg sublingual DAILY
4. FreeStyle Lite Meter (blood-glucose meter) 1 unit
miscellaneous ASDIR
RX *blood-glucose meter 1 kit AS DIR Disp #*1 Kit Refills:*0
5. FreeStyle Lite Strips (blood sugar diagnostic) 1 box
miscellaneous ASDIR
RX *blood sugar diagnostic [FreeStyle Lite Strips] 1 box AS DIR
Disp #*1 Box Refills:*5
6. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*3
7. Multivitamins 1 TAB PO BID
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
9. Docusate Sodium 100 mg PO TID:PRN Constipation
10. Escitalopram Oxalate 10 mg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO BID
12. LORazepam 1 mg PO TID:PRN Anxiety
13. Modafinil 200 mg PO DAILY
14. Pregabalin 100 mg PO BID
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Marginal ulcer
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with pain, nausea, vomiting
and blood in your stool. Also, your blood count was very low
reflecting bleeding from your GI tract. Given your
signs/symptoms, you received a blood transfusion and underwent
an upper endoscopy, which showed an ulcer just below your
gastric pouch. You were treated with high doses of antacids
(pantoprazole) and a coating medication (sucralfate) and
discharged to home. You will need to have a repeat endoscopy in
12 weeks to document healing of your ulcer; this has been
scheduled for you and is reflected under follow-up appointments.
You are now preparing for discharge to home with the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*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. You must avoid NSAIDS
(examples include, but are not limited to Aleve, Arthrotec,
aspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen,
Indocin, indomethacin, Feldene, ketorolac, meclofenamate,
meloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen,
Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren. If
you are unclear whether a medication is considered an NSAID,
please ask call your nurse or ask your pharmacist. Additionally,
avoid alcohol, smoking or exposure to second-hand smoke.
Followup Instructions:
___
|
10511716-DS-22 | 10,511,716 | 23,446,545 | DS | 22 | 2183-06-23 00:00:00 | 2183-06-23 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Betadine Spray / adhesive tape
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ with PMH dementia, alpha strep
endocarditis, COPD, prostate cancer, autonomic dysfunction, CAD
who presented for the evaluation of syncope.
Per ED notes: On the day of admission, the patient's partner
heard a thump and then the patient called her name. He was found
in the bathroom on his side not complaining of pain. She called
EMS who brought him to ___. He denies fevers/chills, chest
pain, dyspnea, palpitations or dysuria. He denies any pain. Per
patient's partner, the patient's baseline heart rate is in
___. Also, he had work up for "mycobacterial infection of
his lung" given abnormal chest imaging findings.
Patient does not remember the circumstances surrounding the
fall. He denies any symptoms of chest pain or SOB at this time.
His troponin is mildly elevated at 0.06. His EKG shows sinus
bradycardia with IVCD in a RBBB like pattern and TWI anteriorly.
Prior EKG is from over ___ years ago so difcult to use as
comparison. Given his lack of symptoms and minor troponin
elevation, this is more likely demand ischemia. Further, he is
DNR/DNI and invasive procedures do not seem in line with his
desired care.
In the ED initial vitals were: 96.9 47 134/42 18 98% RA 127
ECG: Irregular bradycardia, at a rate of 44. RBBB unchanged. AV
delay PR 240 QRC 157 QTc 588 anterior TWI.
CXR showed possible pneumonia, started doxycycline given
penicillin allergy and prolonged QTc.
CT head and spine did not show any fracture.
Physical exam: AAOx1, mentating at baseline, lying on side,
comfortable. No facial trauma or pain on palpation. R pupil
irregular, left reacts to light.
RRR no MRG.
No increased WOB, right sided crackles, left side clear. NTND.
GU: normal tone, guiac negative brown stool
Neuro: moves all extremeties, no facial asymmetry
MSK: no TTP, no instability or step offs on face, clavicles,
chest wall or pelvis. Spine no TTP
Skin: abrasion left shoulder
Labs/studies notable for: elevated troponin to 0.06,
Patient was given: Atorvastatin, aspirin, doxycycline
The cardiology fellow was consulted. Given elevated trop at
0.06 with anterior TWI, decision was to admit to ___ for
NSTEMI. In the ED had sinus pauses on monitor ~2 seconds during
his sleep. Also, prior to transfer patient had 2 episodes of
bradycaria to the 30's during his sleep, these were thought to
be vasovagal.
Vitals on transfer: 0 53 135/60 19 94% RA
On the floor, patient is unable to recall event. He denies F/C,
N/V, SOB, Chest pain, abdominal pain, constipation. He does
endorse dizziness.
Past Medical History:
1. CARDIAC RISK FACTORS - History of CAD: Moderate
non-obstructive CAD, found on cardiac catheterization of
___ - Hypertension
2. CARDIAC HISTORY - CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
AV endocarditis complicated by aortic insufficiency
Lung nodule
COPD
Bronchiectasis
"Bronchiolitis on imaging with extensive ___ opacities"
c/f MAC
Dementia
Insomnia
Seborrheic keratosis
Actinic keratosis
Anxiety
Glaucoma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission physical exam:
=========================
VS: 97.9 PO 134 / 58 55 18 97 ra
GENERAL: NAD. Sleeping but easily rousable.
HEENT: NCAT. Sclera anicteric. R pupil deformity. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple no JVD
CARDIAC: Distant heart sounds. RRR, normal S1, S2. No
murmurs/rubs/gallops noted.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Trace wheezes.
ABDOMEN: Soft, NTND.
Neuro: A&O to self, location, but not circumstances. He is
moving all extremities and following commands.
EXTREMITIES: No c/c/e.
Discharge physical exam:
=========================
VS: T 98.2, BP 128/59, HR 51, RR 18, SpO2 98/RA
Weight: 59.6 kg (admit wt: 62.7 kg)
I/O: not recorded
Tele: sinus rhythm, intermittent pauses of ___ sec. Occasional
PACs.
GENERAL: elderly gentleman, lying in bed. Very hard of hearing.
NAD.
CARDIAC: RRR, S1+S2, no M/R/G
LUNGS: CTAB, no W/R/C
ABDOMEN: non-distended, soft, non-tender
EXTREMITIES: WWP, no edema
Pertinent Results:
Admission labs:
=================
___ 11:40AM BLOOD WBC-6.3 RBC-5.12 Hgb-14.3 Hct-45.5 MCV-89
MCH-27.9 MCHC-31.4* RDW-15.5 RDWSD-50.3* Plt ___
___ 11:40AM BLOOD Glucose-119* UreaN-30* Creat-1.3* Na-140
K-5.0 Cl-104 HCO3-25 AnGap-16
___ 11:40AM BLOOD cTropnT-0.06*
___ 06:54PM BLOOD CK-MB-4
___ 06:54PM BLOOD cTropnT-0.05*
___ 11:40AM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.0 Mg-2.2
Discharge labs:
=================
___ 06:55AM BLOOD WBC-7.5 RBC-4.99 Hgb-14.1 Hct-43.8 MCV-88
MCH-28.3 MCHC-32.2 RDW-15.2 RDWSD-48.8* Plt ___
___ 06:55AM BLOOD Glucose-91 UreaN-28* Creat-1.4* Na-144
K-3.8 Cl-103 HCO3-26 AnGap-19
Imaging:
=================
CT head ___
1. No hemorrhage or fracture.
2. Left frontal lobe white matter hypodensity with preserved
overlying cortex is age indeterminate in the absence of a prior
exam but favored chronic given well-defined gray-white
differentiation. Correlate with clinical assessment and if
concern for acute stroke corresponding to this area of the
brain, MRI could be considered as a more sensitive test.
3. Probable sequelae of mild chronic small vessel ischemic
disease.
4. Cortical atrophy, likely age-related.
CT C-spine ___
1. No evidence of cervical spine fracture.
2. Multilevel degenerative changes, progressed since ___ with
multiple levels of central disc bulges indenting the anterior
thecal sac.
3. Status post C4-C5 anterior spinal fusion without definite
evidence of
hardware complication.
4. Thickened upper esophageal wall could be sequelae of chronic
esophagitis and reflux in the appropriate clinical situation.
CXR ___
1. Right middle lobe pneumonia. Follow-up radiograph after
treatment to
ensure resolution.
2. Findings suggestive of volume overload and/or heart failure
with small
pleural effusion, mild cardiomegaly, and mild interstitial
edema.
3. Low lung volumes and by basilar atelectasis.
Brief Hospital Course:
___ with dementia, non-obstructive CAD, who presents following
unwitnessed syncopal episode, found to be bradycardic with sinus
pauses on arrival.
#BRADYCARDIA:
#SINUS PAUSES:
#FALL: pt has history of bradycardia, and appears to have
baseline HR in ___ range. The exact nature of his
fall/syncopal event is unclear (including any transient LOC),
but suspect it was syncopal in the setting of long pause and/or
symptomatic bradycardia. Pt is largely asymptomatic now, though
continues to have pauses ___ sec on telemetry. Pt's
condition/management options discussed with HCP/partner, who is
clear that the patient would not want an invasive procedure (has
this in writing in living will), such as a pacemaker. Not on any
bradycardia-inducing medications. No further intervention to
make on this issue. Patient was evaluated by ___, who recommended
rehab for the patient.
#NSTEMI: Given his lack of symptoms and minor troponin elevation
(peaked at 0.06 and subsequently downtrended), this was more
likely demand ischemia, potentially in the setting of
bradycardia/sinus pauses. Continued home aspirin 81mg.
#?PNA: CXR on admission showed "increased opacity in the area of
the right middle lobe on the lateral view may suggest a
component of infection in the appropriate clinical situation.".
Given one dose of doxycycline in ED, given pt's penicillin
allergy and prolonged QTc (as opposed to levo, given QTc 500s).
However, patient is without fever, cough, SOB, or leukocytosis -
all making PNA less likely. It was decided not to continue
antibiotics; pt did not develop any further signs or symptoms of
PNA.
#LOW-NORMAL EF: LVEF 50% in ___. Is on Lasix at home. CXR w/
some e/o volume overload but no edema or crackles; otherwise
appeared euvolemic on exam. Continued home furosemide 20mg
daily.
#DEMENTIA: unclear what type of dementia patient has. Baseline
mental status - some confusion, poor memory but able to speak
and follow commands. Avoided deliriogenic medications and
managed with delirium precautions while admitted.
#COPD: Mild wheeze on presentation with forceful expiration. No
SOB or cough to suggest exacerbation. Continued home
Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID.
#GLAUCOMA: Continued home Dorzolamide 2%/Timolol eye drops.
#GERD: CT from admission (trauma work-up) with "Thickened upper
esophageal wall could be sequelae of chronic esophagitis and
reflux." Continued home omeprazole 20mg daily.
# Goals of care: patient, health care proxy (partner ___, and
daughter have been very clear that he would not want aggressive
measures such as CPR, invasive procedures, dialysis, artificial
nutrition/hydration, or re-hospitalization unless needed for
comfort. MOLST form was filled out to document this.
TRANSITIONAL ISSUES
===================
[ ] Pt is at increased risk of falls and syncope, given known
bradycardia/sinus pauses and decision not to treat with
pacemaker.
[ ] Nodal-blocking agents should be avoided in this patient.
[ ] consider palliative care referral as outpatient
# CODE: DNR/DNI (no re-hospitalization unless needed for
comfort). MOLST form completed.
# CONTACT: HCP Dr. ___ (partner, used to work as
___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Escitalopram Oxalate 10 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Furosemide 20 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Omeprazole 20 mg PO DAILY
7. TraZODone 50 mg PO QHS
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Aspirin 81 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. lutein 20 mg oral DAILY
12. Multivitamins 1 TAB PO DAILY
13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID:PRN constipation
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
5. Aspirin 81 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
7. Escitalopram Oxalate 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
9. Furosemide 20 mg PO DAILY
10. lutein 20 mg oral DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Omeprazole 20 mg PO DAILY
14. TraZODone 50 mg PO QHS
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sinus bradycardia with pauses
Non-ST elevation myocardial infarction
Coronary artery disease
Dementia
Discharge Condition:
Mental Status: Clear and coherent, though poor recall/memory.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You fainted at home and were found to have a very slow heart
beat.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- Your heart rate and rhythm were monitored.
- We decided with you and ___ that you would not get a
pacemaker.
- You were seen by our physical therapy team, who felt it would
be most beneficial for you to go to rehab.
- Your health care proxy filled out a MOLST form documenting
your end of life decisions
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will go to rehab to get stronger.
- Continue to take all of your medicines as prescribed.
Followup Instructions:
___
|
10511804-DS-18 | 10,511,804 | 28,712,418 | DS | 18 | 2125-04-21 00:00:00 | 2125-04-21 10:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
appendicitis
Major Surgical or Invasive Procedure:
laparoscopic appendectomy ___
History of Present Illness:
___ p/w midepigastric pain radiating to RLQ x 3days, started
after eating burger ___. +Nausea, Vomiting, NB.NB. No f/c/ns.
No hematochezia/melena. No urinary symptoms
Past Medical History:
PMH: none
___: none
ALL: NKDA
Family History:
non-contributory
Physical Exam:
PE: Vitals:
Gen: NAD
CV: RRR
Abd: mildly distended, TTP RLQ
Ext: no c/c/e
Pertinent Results:
___ 05:25AM BLOOD WBC-17.3* RBC-5.33 Hgb-16.4 Hct-47.9
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.0 Plt ___
___ 05:25AM BLOOD Glucose-138* UreaN-10 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-22 AnGap-18
Brief Hospital Course:
Mr. ___ was admitted to the ACS service and taken to the
operating room for a laparoscopic appendectomy. He tolerated the
procedure well and was subsequently transferred to the floor.
His diet was advanced, which he tolerated well. On the day of
discharge he was well appearing, afebrile with stable vital
signs. As his appendix was perforated he was contintued on
antibiotics. He was able to ambulate and urinate without
difficulty, and his pain was controlled on PO pain medication.
He was tolerating a regular diet and passing flatus.
Discharge Medications:
1. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h prn Disp #*30
Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*11 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10511944-DS-17 | 10,511,944 | 29,843,160 | DS | 17 | 2167-12-05 00:00:00 | 2167-12-05 10:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Norvasc / Verapamil
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yr old male with hx of DVT on lovenox, CKD, HTN,
CAD s/p CABG ___ w/ cardiomyopathy and metastatic pancreatic
cancer with progression of disease on recent scans who presents
with fever and abdominal pain. Pt reported
fever 100.7 last night with night sweats and vague abd
discomfort and was advised to present to the ED. Feels bloated.
relief with burping. No change in BM or n/v. Endorses decreased
appetite. He specifically denies chest pain. He states this
abdominal pain was present during his past admission and has
just
continued and worsened a bit since his discharge. He is passing
gas and having bowel movements (nonbloody no melena) daily. Pain
is generalized but also largely left sided (not clearly RUQ).
Note that pt was recently admitted ___ for chest pain.
Etiology for chest pain was not found. Trops negative. CTA
showed
no acute PE but he had a chronic PE for which he is on lovenox.
He had no signs/symptoms of infection and nodules seen in the
lungs were felt to be metastatic. He also has liver mets. He did
have an elevated WBC which was attributed to a recent gout
attack. He had small bilateral pleural effusions. Pain resolved
without any specific intervention. Note he also has a biliary
stent. Regarding his pancreatic cancer he has been on palliative
gem/abraxane with last chemo held ___ due to neuropathy.
ED COURSE:
PE: TTP of epigastric and RUQ, distended but not tense, no
rebound pain or guarding, lungs clear
+ Triage ___ 98.4 66 133/55 16 98%
- labs: Lactate:1.8, chem notable for elevated BUN/creat of
___. LFTs slightly elevated compared to prior with AP up to
212 (form 160) and AST up to 55 frmo normal, TBili 0.5. CBC
notable for WBC of 25.8, Hct 31.5, PLT 197. 90% pmns
- imaging: RUQ u/s showed echogenic, heterogeneous liver, CBD
stent in place measuring 0.6cm in diameter. Dilated pancreatic
duct of 1.4cm is similar in appearnce to prior CT exam.
- interventions: got 5mg oxycodone
v/s prior to admission: Today 17:29 2 98.0 69 125/62 16 97% RA
On arrival to the floor pt is comfortable and states he feels
well.
REVIEW OF SYSTEMS:
GENERAL: No night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation, No recent
change
in bowel habits, 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.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
He was incidentally diagnosed in ___ with metastatic
pancreatic adenocarcinoma during work-up for pulmonary nodules
identified on screening CXR at OSH for significant smoking
history. CT Chest (___) demonstrated a 2.6 X 1.6 cm RLL
lobulated mass consistent with a cyst and multiple low density
lesions in liver. CT (___) demonstrated atrophy at head and
uncinate process of pancreas with dilation of pancreatic duct
and liver lesions too small to characterize. PET-CT (___)
showed increased uptake in the pancreas head (SUV max=7.3) but
no
significant FDG uptake in RLL mass. EUS FNA (___) showed a
>2 cm head of pancreas mass and FNA positive for malignant cells
c/w pancreaticobiliary adenocarcinoma. Biopsy of liver lesions +
for pancreatic adenocarcinoma. Biliary stent in place. Biopsy of
lung lesion negative for cancer. Signed consent for trial
___
and randomized to standard of care arm with gemcitabine and
abraxane.
Initiated systemic therapy for metastatic disease (palliative
intent) on ___. 50% decrease in ___ after one cycle.
Dose reduced abraxane for neuropathy ___. Improvement in
disease burden on imaging ___. Admission ___ to
___ for incidentally noted left DVT and asymptomatic PE.
2nd
dose reduction of abraxane for neuropathy ___ and first
dose
reduction gemcitabine for thrombocyopenia and neuropathy
___. Mixed response on imaging by central review ___ but clinically feeling well. Decision to continue with SOC
treatment but taken off study. Significant neuropathy at the
end
of ___ led to decision to discontinue treatment with
Gem/Abraxane and start on FOLFOX.
Treatment was held ___ due to neuropathy that was affecting
his ADLs and balance
PAST MEDICAL HISTORY:
- Ischemic heart disease s/p CABG x4 (___). Echo ___ with EF>
65% and + mild ___
- HTN
- CKD
- Afib
- Bilat total knee arthroplasty (___)
- gout
- nephrolithiasis (distant)
- colonic polyps removed with colonoscopies.
- 3cm distal AAA on imaging ___
- high cholesterol
- DVT and PE incidentally noted ___
Social History:
___
Family History:
Mother: lung cancer (dx > ___ yrs old)
Five (5) maternal aunts: Lung cancer (dx > ___ yrs old)
Sister recently passed from gastric cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: T 97.4 BP 131/57 HR 72 RR 18 94% 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+, soft, diffusely mild tenderness to palpation and
especially in left upper and lower quadrants, no guarding or
rebound
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+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; gait is normal, coordination
is intact.
DISCHARGE EXAM
Not monitoring vitals given CMO
GEN: Alert, oriented to self only, appears comfortable, not
oriented to location or year. Mildly tachypneic.
HEENT: NCAT, Pupils pinpoint but equal and reactive, sclerae
non-icteric, MMM. bilateral hearing aids
Neck: Supple
CV: normal S1S2, reg rate and rhythm, no murmurs, rubs or
gallops. occasional early beats. JVD noted almost halfway up to
the jaw in the upright seated position
RESP: crackles at bases bilaterally, scant expiratory wheezing
diffusely. On 3L NC. Slighly tachypneic though appears
comfortable and can speak in full sentences
GI: Soft, mildly tender in epigastrium, non-distended, no
rebound or guarding
DERM: No active rash
EXT: bilateral lower extremity edema, 1+
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
___ 01:15PM BLOOD WBC-25.8*# RBC-3.28* Hgb-9.9* Hct-31.5*
MCV-96 MCH-30.2 MCHC-31.4 RDW-17.1* Plt ___
___ 05:52AM BLOOD WBC-43.9* RBC-2.62* Hgb-7.7* Hct-25.2*
MCV-96 MCH-29.4 MCHC-30.6* RDW-18.6* Plt ___
___ 05:52AM BLOOD ___ PTT-29.5 ___
___ 01:15PM BLOOD Glucose-98 UreaN-29* Creat-1.7* Na-135
K-4.4 Cl-102 HCO3-23 AnGap-14
___ 01:46PM BLOOD Glucose-103* UreaN-72* Creat-3.4* Na-136
K-5.2* Cl-104 HCO3-21* AnGap-16
___ 01:15PM BLOOD ALT-38 AST-55* AlkPhos-212* TotBili-0.5
___ 06:20AM BLOOD ALT-56* AST-76* LD(LDH)-409* AlkPhos-268*
TotBili-0.5
___ 05:52AM BLOOD ALT-49* AST-68* LD(LDH)-379* AlkPhos-280*
TotBili-0.6
___ 02:55PM BLOOD GGT-153*
___ 06:07AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.7
___ 01:46PM BLOOD Calcium-11.1* Phos-5.6* Mg-1.9
___ 02:55PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 02:55PM BLOOD HCV Ab-NEGATIVE
___ 02:50PM BLOOD freeCa-1.54*
IMAGING:
CXR ___:
IMPRESSION:
There has been interval increase in the bilateral lower lobe
infiltrates over worrisome for bilateral pneumonia. The right
lower lobe nodular opacity is unchanged
MRCP ___
IMPRESSION:
1. 8.1 x 3.1 cm collection medial to the intrahepatic IVC with
signal
characteristics of simple fluid. The exact location of this
collection is
difficult to delineate and is either subcapital or adjacent to
the medial
aspect of the liver. The signal characteristics of this fluid
collection would
be unusual for abscess given lack of restricted diffusion,
however early
infection cannot be excluded. The differential also includes
biloma, though
this would be atypical in the absence of any recent biliary
intervention.
2. No biliary dilatation.
3. Multiple hepatic metastases and enlarged peripancreatic and
portacaval
lymph nodes are minimally changed since the CT from ___.
Brief Hospital Course:
SUMMARY OF HOSPITAL COURSE:
___ yr old male with hx of DVT on lovenox, CKD, HTN, CAD s/p CABG
___ w/ cardiomyopathy and metastatic pancreatic cancer with
progression of disease on recent scans who presents with fever
and abdominal pain now resolved but with worsening ___ on CKD,
shortness of breath, and encephalopathy.
# Renal insufficiency/Oliguria - acute decompensation on known
CKD. Cr has ranged from 1.2-2.1 over the last few months.
Initially pt was resuscitated with IVF and home lasix held, but
creatinine worsened and ___ pt appeared overloaded, c/f with
possible poor forward flow as etiology at this point (h/o
diastolic dysfunction). Pt had Ulytes ___ which suggested FeNa
of 0.18% and given clinical picture of overload this seemed c/w
third spacing. Weight was also up 4 pounds at that time. He had
only modest diuresis with very high doses of lasix and including
lasix with diuril. His creatinine peaked at 3.4. Renal was
consulted and felt there may be a component of ATN. He did have
a contrast CT scan on ___ so that could have contributed but
given the low FENA it seemed more likely due to third spacing/vs
early ATN. MRCP showed no hydroneprhosis or renal vein
thrombosis. Given the failure to improve and the contribution to
respiratory status, nausea, volume overload, and discomfort, he
decided to be CMO and go home on hospice.
# Dyspnea/acute on chronic diastolic heart failure/HCAP - Likely
worsening dyspnea during admission was from underlying
progressive lung involvement of malignancy with component of
HCAP, volume overload, and chronic PE. Despite attempts at
diuresis and broad spectrum antibiotics his respiratory status
worsened. His anticoagulation was stopped given comfort oriented
goals. He was sent home on liquid oxycodone and prn morphine for
dyspnea relief.
# Encephalopathy - developed during the hospitalization, pt not
oriented to location but could express his wishes and feelings.
Likely multifactorial from infection, renal failure, and nothing
focal on exam.
# Fever/Leukocytosis/Hepatic Fluid Collection - on admission
fever to 100.7 w/ night sweats but remained afebrile but ___
clnical worsening with tachypnea, worsening leukocytosis >30K,
significantly worse confusion, in setting of stopping levoflox
So he was put on broad spectrum antibiotics for possible HCAP.
MRCP ___ showed 3cm by 8cm hepatic fluid collection, could not
rule out abscess though less likely, and ___ stated it would be
too dangerous to try to drain with low benefits. Per ID recs,
will send pt home with po cipro/flagyl in case there is some
component of infection there (indefinite course, can DC cipro if
confusion worsening)
# Hypercalcemia- likely in setting ___ and diuresis. Improved
s/p calcitonin started ___ to 10.8 but then worsened. Couldn't
use pamidronate given renal
failure or IVF given volume overload.
# Goals of care - on ___ with discussion with primary oncologist
and entire family pt articulated he wished to be focused on
comfort care. he went home with hospice.
# h/o AFib - sinus on admission. DCd sotalol as contraindicated
with such impaired renal function.
# Pancreatic CA - metastatic to lung, liver. Pt recently on
gem/abraxane but on hold due to bad neuropathy. Dr. ___ spoke
with family regarding no further options for
chemotherapy/treatment.
# CAD - s/p CABG. no acute issues
# Chronic PEs on lovenox - DCd lovenox in favor of heparin gtt
to start this AM given impaired renal function which was
ultimately stopped given goals of care.
# Neuropathy - pt felt drowsy w/ increased dose of gabapentin
600
at home so reduced it to 300mg BID.
# PAIN - given renal failure, pain/ SOB treated with liquid
oxycodone rather than morphine.
Greater than 30 minutes were spent on discharge planning and
execution.
TRANSITIONAL ISSUES:
If develops worsening confusion/mental status, discontinue
cipro.
Please use liquid oxycodone prn for pain/SOB. If SOB worsens as
pt nears end of life, would be fine to use morphine if pt needs
escalating doses.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO BID
2. Cyanocobalamin 500 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Enoxaparin Sodium 90 mg SC Q12H
5. Felodipine 10 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Lisinopril 10 mg PO DAILY
8. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety or insomnia
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
11. Pancrelipase 5000 3 CAP PO QIDWMHS
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Pyridoxine 100 mg PO DAILY
14. Senna 8.6 mg PO BID:PRN constipation
15. Sotalol 120 mg PO BID
16. TraZODone 100 mg PO HS:PRN insomnia
17. Vitamin D ___ UNIT PO DAILY
18. Furosemide 20 mg PO 3X/WEEK (___)
19. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inhaled every
six hours Disp #*100 Vial Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob/hypoxia
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 vial every 2 hours
as needed Disp #*20 Vial Refills:*0
3. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhaled every
6 hours Disp #*50 Vial Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*0
5. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN nausea
RX *olanzapine 2.5 mg 1 tablet(s) by mouth twice a ___ Disp #*14
Tablet Refills:*0
6. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q4H:PRN
sob/dyspnea/pain
RX *oxycodone 5 mg/5 mL 5 mL by mouth every 4 hours as needed
for shortness of breath or pain Refills:*0
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth ever 6
hours as needed Disp #*30 Tablet Refills:*0
8. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
9. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Gabapentin 300 mg PO BID
12. Senna 8.6 mg PO BID:PRN constipation
13. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety or insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
metastatic pancreatic cancer
SECONDARY:
pulmonary embolism
renal failure
abdominal intrahepatic fluid collection
volume overload
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital and had kidney failure,
shortness of breath, a clot in your lungs, and a possible
abscess in the liver and possible pneumonia. All of these things
were caused by your underlying cancer which is worsening and for
which there is no further treatment. You strongly wished to go
home as soon as possible to be comfortable at home with your
family. you will have hospice services at home.
Please use the oxycodone liquid as needed for pain or shortness
of breath as directed.
Followup Instructions:
___
|
10512064-DS-22 | 10,512,064 | 29,770,322 | DS | 22 | 2190-04-12 00:00:00 | 2190-04-12 17:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Compazine
Attending: ___.
Chief Complaint:
Abdominal pain, maroon stools
Major Surgical or Invasive Procedure:
Endoscopy with biopsy ___
History of Present Illness:
VS- Tm 99.1 tc 98.3 BP 102/67 HR 79 RR 18 O2 100% RA
Gen- well nourished female in NAD
HEENT- oropharynx clear, no edema/exudate
Neck- no lymphadenopathy
CV- RRR, normal S1/S2, grade II/VI holosystolic murmur best
heard at apex, possible rub on exam
Pulm- CTA bilaterally, bibasilar crackles right>left, diffuse
inspiratory and expiratory wheezes
Abd- +BS, nondistended, soft, NT, no hepatosplenomegaly palpable
Ext- WWP, no edema/cyanosis, no ___ nodes ___
lesions, no pain to palpation along spinal processes.
Neuro- A+O x3, CN II-XII intact, strength ___ bilaterally
Access- R PICC packed with guaze, nontender
Past Medical History:
s/p CCY
s/p appendectomy
s/p C-section x 2
uterine fibroids, s/p myomectomy
h/o small bowel obstruction, s/p LOA ___
h/o gastric ulcer in college
Social History:
___
Family History:
Denies family history of cancer, heart disease, or diabetes
mellitus
Physical Exam:
Admission Physical Exam:
Vitals: 97.6 BO 125/71 HR 85 RR 18 O2 95% RA
General: Young female, somnolent, actively vomiting and dry
heaving, but maintaining airway
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 m/r/g
Abdomen: absent BS, tender to palpation in epigastrium and RUQ,
soft in upper quadrants, firm masses palpable in bilateral lower
quadrants
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Discharge Physical Exam:
Vitals: 98.6 BP 130/78 HR 81 RR 18 O2 98% RA
General: Comfortable in NAD
Abd: +BS, mild tenderness to palpation in RUQ/epigastrium
without rebound, guarding.
Exam otherwise stable
Pertinent Results:
Admission Labs:
WBC 5.0 Hgb 8.5 Hct 30.5 Plts 321
N:64.8 L:28.3 M:5.1 E:0.9 Bas:0.8
.
___: 12.5 PTT: 32.3 INR: 1.2
.
138 103 9
-------------< 88
3.8 27 0.7
.
Trop-T: <0.01
ALT: 9 AP: 41 Tbili: 0.5 AST: 21 Lip: 27
.
U/A- negative
Urine hcg- negative
Images:
Abdominal x-ray ___- Nasogastric tube terminating in the
stomach. Gasless abdomen, which could be compatible with
obstruction but is not diagnostic.
EGD ___- Normal mucosa in the esophagus
Erythema, congestion, and nodularity in the fundus (biopsy)
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Biopsy of fundus ___- Fundal mucosa with changes of chemical
gastropathy.
CT torso ___. Markedly enlarged fibroid uterus with an enlarging
degenerating fibroid which may be contributing to the patient's
current pain.
2. Limited evaluation of the bowel without IV contrast, however,
there is no evidence for small bowel obstruction or ileus.
3. Stable appearance of multiloculated intra-abdominal fluid
collections compared to CT scan dating back to ___.
EKG- NSR, no ST-T wave abnormalities
Brief Hospital Course:
___ yo F with h/o multiple abdominal surgeries and SBO presenting
with nausea, vomiting and epigastric pain.
# Abdominal pain, nausea/vomiting- Patient with long history of
multiple SBOs with lysis of adhesions. Presenting symptoms
(nausea/vomiting, absent bowel sounds, no passing of flatus)
seemed most consistent with small bowel obstruction. NG tube
placed initially for decompression with improvement in symptoms.
Following EGD, patient no longer required NG tube, symptoms
improved and bowel sounds/flatus returned. Likely was partial
SBO that resolved with decompression. CT scan showed no
transition point, however, did show enlarging uterine fibroids
which may also be causing abdominal pain and intermittent
obstruction. Patient will follow-up with ob/gyn. Symptoms were
controlled with zofran and lorazepam. With multiple dose of 8mg
IV zofran and compazine patient had a possible dystonic
reaction, however, this was thought to be due to compazine not
zofran. Zofran was continued orally at 4mg and patient had no
ongoing complications. She was able to tolerate fluid and oral
intake at the time of discharge.
# Maroon stools- NG lavage and rectal guaiac both negative on
admission. EGD was performed on HD1 and did not note any areas
of active bleeding, but did see an area of abnormal mucosa in
the fundus. Biopsy consistnet with chemical gastropathy.
Patient was placed on PPI BID and will follow-up with
gastroenterology. In addition, she was scheduled for outpatient
colonoscopy given longstanding anemia.
# Transitional issues-
- GI follow-up re: results of EGD biopsy
- OB/GYN follow-up re: enlarging uterine fibroids
- Colonoscopy scheduled for ___
Medications on Admission:
Calcium
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
3. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
# partial small bowel obstruction
# abnormal gastric mucosa
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission.
You were admitted with abdominal pain, nausea and vomiting. In
addition you reported maroon stools, concerning for a bleed in
your gastrointestinal system. An endoscopy did not show any
signs of upper bleeding, but did see an area of abnormal stomach
wall which was biopsied. You will follow-up with the GI doctors
regarding the results. In addition, you will have a colonoscopy
in two weeks (see date below).
Your nausea and vomiting improved and you were able to tolerate
some food. You likely had some obstruction, which resolved on
its own. A CAT scan of your abdomen showed that the fibroids in
your uterus are enlarging. You will need to see your outpatient
ob/gyn for follow-up.
Please continue a BRAT (banana, rice, applesauce, toast) diet
until you are feeling better.
The following changes were made to your medication regimen:
- START prilosec twice a day to decrease acid production in your
stomach
- you may take lorazepam (ativan) as needed for nausea. Please
be aware that this may make you drowsy. Do not operate a car
while taking this medication
- you may also take ondansetron (zofran) as needed for nausea
- for pain control take tylenol only. Do not take NSAIDs
(ibuprofen, motrin, advil) as these can irritate your stomach
Followup Instructions:
___
|
10512520-DS-16 | 10,512,520 | 22,081,856 | DS | 16 | 2178-05-04 00:00:00 | 2178-05-04 21:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Shellfish Derived / Niacin
Attending: ___.
Chief Complaint:
gangrene right ___ toes
Major Surgical or Invasive Procedure:
Right lower extremity diagnostic angiogram
History of Present Illness:
___ with history of a-fib (not on Coumadin), DM, CAD and AS
s/p CABGx3, AVR, and MV repair referred to ED from OSH for RLE
toe gangrene. History obtained with assistance of patient's two
sons. Three months ago, patient tripped over nasal cannula
tubing
and sustained a diffuse RLE hematoma in setting of Coumadin use
for a-fib requiring transfusion but no ___ intervention.
Ecchymosis eventually resolved but he developed a "blood
blister"
at the right toes which was drained by a podiatrist but he
subsequently developed gangrene of his right ___ and ___ toes
about 3 weeks ago. Per patient's sons, gangrene initially
appeared wet and with spreading erythema. After a course of
antibiotics recently, gangrene became drier and cellulitis
significantly improved. Patient was planned to undergo a CTA of
his lower extremities per his PCP but study was cancelled when
labs showed elevated Cr. PCP called Dr. ___
and
was directed to the ED for further evaluation.
At present, patient sons report his gangrene and cellulitis
appears much better today than it has had in previous weeks.
Patient denies pain in his foot or toes. He occasionally has
pain
in his leg when he walks as well as right foot pain when he lays
down at night that improves after he rubs it with a cream and he
is able to easily return to sleep.
Past Medical History:
Hypertension
Diabetes mellitus type ___
Mitral Regurgitation
Aortic stenosis
Hyperlipidemia
Social History:
___
Family History:
father deceased ___ myocardial infarction
mother deceased ___ myocardial infarction
diabetes
Physical Exam:
At admission:
VS - 98.4, 78, 122/59, 18, 98% RA
Gen: NAD, well-appearing, alert & oriented
CV: RRR, no murmurs
Pulm: Unlabored effort, CTAB
Abd: Soft, non-tender, non-distended
Ext: Right foot swollen compared to left with erythema on dorm.
Warm bilaterally. Right ___ and ___ toes with dry gangrene from
IP joint to tip - no drainage.
Pulses - fem / pop / DP / ___
R: P D D D -signals biphasic
L: P D D D -signals all monophoasic
At discharge:
Gen: NAD, well-appearing, alert & oriented
CV: RRR
Pulm: non-labored breathing
Abd: Soft, non-tender, non-distended
Ext: Right foot swollen compared to left with erythema on dorm.
Warm bilaterally. Right ___ and ___ toes with dry gangrene from
IP joint to tip - no drainage.
Pulses - fem / pop / DP / ___
R: P D D D -signals biphasic
L: P D D D -signals all monophoasic
Pertinent Results:
Angiogram (___):
ANGIOGRAPHIC FINDINGS:
1. Patent infrarenal abdominal aorta.
2. Patent bilateral common and external iliac arteries.
The hypogastric arteries appeared to be occluded. There
was evidence of calcified plaque at the origins of the
bilateral common iliac arteries that do not appear to be
significantly flow limiting.
3. The right common femoral artery is patent. The profunda
femoris is patent but has a lesion of calcified plaque
at its origin. The right superficial femoral artery is
occluded at its origin.
4. There is a short segment of reconstitution of the behind-
the-knee popliteal artery before reocclusion.
5. The right anterior tibial and posterior tibial arteries
are both occluded in the leg and foot. The right
peroneal
artery provides vessel runoff to the foot. All 3 tibial
vessels are heavily calcified.
Brief Hospital Course:
Mr. ___ presented to ___ ED on ___ for evaluation of
right toe gangrene. He was admitted to the Vascular Surgery
service and started on IV antibiotics. He was taken to the angio
suite on ___ where he was found to have an occlusion of his
SFA. No interventions were undertaken. For full details of the
procedure, please see the separately dictated Operative Report.
He was monitored closely after the procedure and groin remained
soft.
Foley was removed after the patient was off bedrest and patient
had no issues voiding spontaneously. He was advanced to a
regular diet which he tolerated well. Antibiotics were
transitioned to oral (Augmentin), which he will complete a 10
day course of. He was discharged home with plans to schedule
outpatient follow up to arrange an angiogram to address the SFA
occlusion.
Physical therapy was consulted while patient was in house and
recommended home with ___.
He was discharged home on ___ with home physical therapy
services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*16 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Peripheral artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You underwent a diagnostic angiogram for evaluation of your
blood flow to your right foot. You need blood flow in order to
heal the wounds on your right foot. Unfortunately, the vascular
disease in the arteries of your right leg was quite extensive,
and the arteries were unable to be opened. You will be brought
back to the angiography suite to make another attempt at opening
the arteries in your leg using a different technique. You will
be called to schedule that procedure.
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10513093-DS-3 | 10,513,093 | 27,347,629 | DS | 3 | 2196-03-29 00:00:00 | 2196-03-29 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission labs:
===============
___ 01:51AM BLOOD WBC-11.7* RBC-4.47* Hgb-13.7 Hct-39.5*
MCV-88 MCH-30.6 MCHC-34.7 RDW-12.3 RDWSD-39.8 Plt ___
___ 01:51AM BLOOD Neuts-73.5* Lymphs-14.7* Monos-10.9
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.59* AbsLymp-1.72
AbsMono-1.27* AbsEos-0.01* AbsBaso-0.05
___ 01:51AM BLOOD Glucose-102* UreaN-18 Creat-1.0 Na-123*
K-4.0 Cl-92* HCO3-18* AnGap-13
___ 04:50PM BLOOD ALT-65* AST-147* CK(CPK)-6540* AlkPhos-48
TotBili-1.0
___ 04:50PM BLOOD Calcium-9.8 Phos-3.7 Mg-2.2
___ 01:51AM BLOOD Osmolal-260*
___ 01:51AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
.
.
Notable labs:
============
___ 06:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 06:40AM BLOOD HCV Ab-POS*
___ 06:40AM BLOOD CHCV VL-PND
___ 10:45 AM Urine studies:
___ 206
___ Na < 20
.
.
Micro:
======
-___ UCx: no growth (final).
.
.
Imaging:
========
-___ CXR: Impression: "no acute cardiopulmonary abnormality"
-___ Abd u/s
"IMPRESSION: No sonographic evidence of cirrhosis. Mildly
enlarged splenic size up to 13.3 cm. No ascites. The
gallbladder is collapsed and contains either a small amount of
sludge or a 3 mm polyp. An elective right upper quadrant
ultrasound to evaluate the gallbladder could be considered with
the patient fasting."
.
.
Brief Hospital Course:
# Hyponatremia: resolved
Was most likely hypovolemic hyponatremia given the history,
urine studies and his excellent response to IVF volume
resuscitation.
# Bilateral hip pain: resolved
# Rhabomyolysis: resolved
Unclear etiology, given the temperature recently unlikely to
have had hyperthermia as cause for rhabdo, more likely prolonged
exposure to hard surface/ground; could explain leg muscle
cramps/pain he reported initially, which have resolved. CK ~6500
on initial presentation, improved w/ IVF and now less than the
threshold of 5000 that is typically associated with risk of ___.
No longer requiring IVF and not having any leg pain. No further
evaluation indicated at this time.
# Leukocytosis: mild, neutrophilic, new c/w ___ now
resolved.
-CXR without focal abnormalities
-UA was clean with no evidence for inflammation/infection
# Transaminitis (AST >> ALT): improving
New compared with normal transaminases on ___. Improving
since admission. He Denied any EtOH use since recent discharge
and serum EtOH was undetectable on admission. Abdominal u/s
without acute abnormalities to explain a transaminitis.
Hepatitis panel was checked: Hep B panel pan-negative*, Hep A Ab
negative, and Hep C Ab positive (as expected). Most likely
etiology at this point is probably transaminitis from muscle
breakdown / rhabdo. Improving and at this point nothing further
to do while inpatient.
[] repeat LFTs in ~2 weeks
# Hep B non-immune
[] Please initiate Hep B vaccination series as outpatient
# Splenomegaly: mild, 13.3 cm on abd u/s
[] outpatient f/u
# HTN
In setting of hypovolemia he was borderline hypotensive and home
amlodipine was held on ___, but as he is now volume replete
with improved BP, it was felt reasonable to continue this home
medication
-continued home amlodipine 10 mg daily
# Housing insecurity
# Schizophrenia: decompensated
-followed by DMH
-Psychiatry was consulted
-continued home Benztropine, Divalproex, Risperidone, & PRN
Ativan
-was maintained on ___ without requiring 1:1 sitter
-initiated inpatient psychiatry bed search on ___
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 1500 mg PO QHS mood disorder
2. OLANZapine 20 mg PO QHS
3. amLODIPine 10 mg PO DAILY
4. Benztropine Mesylate 1 mg PO QHS
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
7. LORazepam 1 mg PO DAILY:PRN severe anxiety, restlessness
8. RisperiDONE 4 mg PO QHS psychosis
9. RisperiDONE Long Acting Injection 25 mg IM EVERY 2 WEEKS (WE)
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Thiamine 100 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. amLODIPine 10 mg PO DAILY
5. Benztropine Mesylate 1 mg PO QHS
6. Divalproex (EXTended Release) 1500 mg PO QHS mood disorder
7. LORazepam 1 mg PO DAILY:PRN severe anxiety, restlessness
8. OLANZapine 20 mg PO QHS
9. RisperiDONE Long Acting Injection 25 mg IM EVERY 2 WEEKS
(WE)
10. RisperiDONE 4 mg PO QHS psychosis
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
# Hyponatremia: resolved
# Bilateral hip pain: resolved
# Rhabomyolysis: resolved
# Leukocytosis: mild, neutrophilic, new c/w ___ now
resolved.
# Transaminitis (AST >> ALT): improving
# Hep B non-immune
# Splenomegaly: mild, 13.3 cm on abd u/s
# Schizophrenia: decompensated
# HTN
# Housing insecurity
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital because you were were found to
be severely dehydrated and had electrolyte abnormalities. These
resolved with administration of IV fluids. You are being
discharged to an inpatient psychiatric facility to help treat
your schizophrenia. We wish you the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10513104-DS-19 | 10,513,104 | 23,623,594 | DS | 19 | 2183-11-29 00:00:00 | 2183-11-29 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Coronary Angiography with PCI
History of Present Illness:
___ man with PMH of HTN, ETOH use in remission and tobacco use
presented with 24 hours of substernal chest pain. He first
noticed the pain yesterday morning (___) when he woke up. The
pain continued intermittently throughout the day, despite his
efforts to rest. He attributed these symptoms to congestion from
smoking. This morning, the pain was worse and was radiating to
the jaw. He also developed diaphoresis and some nausea and went
to the ED. He had never had pain like this before and did not
take any daily medication. Denies abdominal pain, vomiting,
diarrhea, fevers, chills, shortness of breath. He has been
coughing. Patient's history and EKG concerning for acute STEMI.
Code STEMI was called immediately from triage. Cardiology
arrived promptly at the bedside.
In the ED,
- Initial vitals were: Temp 97, HR 95, BP 189/141, RR 18, 95%
RA
- Exam notable for: diaphoresis
- Labs notable for: Troponin 0.09
- Studies notable for:
EKG: NSR, rate 86, left axis deviation, ST elevations in leads
V2 through V6, < 1mm ST elevations in leads I and aVL
- Patient was given: 324 aspirin, 180 ticagrelor, heparin
bolus, SL nitro with minimal relief, and nitro drip.
After initial evaluation in the ED, the patient was taken
urgently to cath lab for revascularization via right radial
access. He had total occlusion of the mid-LAD. He underwent
stent placement without complications.
On arrival to the CCU, the patient appears anxious. He is having
chest pain ___. He is completely surprised by this event. He
says that he has never had chest pain like this before, and
thought his symptoms were related to smoking. He denies
exertional chest pain. He did note that over the past six
months, he has had dyspnea on exertion and occasional orthopnea
that improves with sitting up. He can climb about 20 steps
before he
has to stop and catch his breath. He has also noticed weight
gain
during this time as well: he usually weights about 180 lbs, and
recently his weight had gone up to 210. He denies any swelling
in
his legs or abdomen. He has a history of heart disease in his
family: father had MI in his ___ and CABG.
He has no known medical problems otherwise. He recently saw a
PCP
for smoking cessation. He also had an outpatient sleep study
done
with results pending. He takes no medications at home.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
Cardiac History:
- None
Other PMH:
- Hyperlipidema
- Smoking
- Daily alcohol use since his ___, two pints of alcohol daily
most recently in ___ but has not drank since then per
report
- Hypertension
- OSA: sleep study pending
- Alcoholic hepatitis
- C diff
Social History:
___
Family History:
Father- CABG, MI in his ___. DM and EtOH use disorder.
Mother- died of aneurysm rupture
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: Temperature 97.5, HR 75, BP 177/124, RR 19, SPO2 98% RA
GENERAL: Overweight, middle-aged gentleman. Appears slightly
anxious but otherwise in NAD.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple, JVP flat.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: Breathing comfortably on room air. Bilateral low field
wheezing
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: Alert and oriented x3; cranial nerves grossly intact;
moves all extremities spontaneously
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
PHYSICAL EXAMINATION:
VS: Reviewed in Metavision
GENERAL: Overweight, middle-aged gentleman in NAD
NECK: JVP just above the clavicle at 45 degrees
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No crackles audible
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
PULSES: Distal pulses palpable and symmetric.
NEURO: Alert and conversing appropriately
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 11:40AM BLOOD WBC-11.3* RBC-5.39 Hgb-16.8 Hct-49.3
MCV-92 MCH-31.2 MCHC-34.1 RDW-12.9 RDWSD-43.2 Plt ___
___ 11:40AM BLOOD Neuts-77.1* Lymphs-17.3* Monos-4.6*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.70* AbsLymp-1.95
AbsMono-0.52 AbsEos-0.03* AbsBaso-0.03
___ 11:40AM BLOOD ___ PTT-29.1 ___
___ 11:40AM BLOOD Glucose-148* UreaN-9 Creat-0.7 Na-142
K-4.2 Cl-103 HCO3-23 AnGap-16
___ 11:40AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
___ 08:00PM BLOOD Triglyc-103 HDL-51 CHOL/HD-3.7
LDLcalc-116
___ 12:20PM BLOOD Lactate-1.9
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 11:40AM BLOOD cTropnT-0.09*
___ 08:00PM BLOOD cTropnT-6.34*
___ 05:30AM BLOOD cTropnT-3.48*
===========================
REPORTS AND IMAGING STUDIES
===========================
___ TRANSTHORACIC ECHOCARDIOGRAM
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
moderate regional left ventricular systolic dysfunction with
severe hypokinesis to akinesis of the mid to distal anterior,
anteroseptal, septal walls and distal LV/apex (see schematic)
and preserved/normal contractility of the remaining segments. No
thrombus or mass is seen in the left ventricle. Quantitative
biplane left ventricular ejection fraction is 45 %. Left
ventricular cardiac index is low normal (2.0-2.5 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Tissue Doppler suggests an increased left ventricular filling
pressure (PCWP greater than 18mmHg). There is Grade II diastolic
dysfunction. Mildly dilated right ventricular cavity with focal
hypokinesis of the apical free wall. The aortic sinus is mildly
dilated with normal ascending aorta diameter for gender. The
aortic valve leaflets (?#) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral regurgitation. The
tricuspid valve leaflets are mildly thickened. There is
physiologic tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate regional systolic dysfunction most consistent with LAD
distribution coronary artery disease, with mildly depressed
ejection fraction. Elevated PCWP and diastolic dysfunction
suggested. Right ventricular apical hypokinesis. Mild pulmonary
hypertension.
Compared with the prior TTE (images reviewed) of ___, LV
regional wall motion abnormalities are present and systolic
function is lower.
___ CORONARY ANGIOGRAPHY AND PCI
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a 50% stenosis in the
proximal segment. There is a 100% stenosis in the proximal
segment. There is a
40% stenosis in the mid segment. The Septal Perforator, arising
from the proximal segment, is a small caliber vessel. The
Diagonal, arising from the proximal segment, is a medium caliber
vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. The ___ Obtuse Marginal, arising from the
proximal segment, is a medium caliber vessel. The ___ Obtuse
Marginal, arising from the mid segment, is a medium caliber
vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. The Acute Marginal, arising from the
proximal segment, is a small caliber vessel. The Right Posterior
Descending Artery, arising from the distal segment, is a medium
caliber vessel. The Right Posterolateral Artery, arising from
the distal segment, is a medium caliber vessel.
The LAD had mid total occlusion, crossed and dilated then
stented with 0% residual. proximal 50% left alone. Diag was
compromised (70% stenosis) by stent, and was dilated with 2.0 mm
balloon with 40% residual
TTE ___
-----------------
CONCLUSION:
The left ventricle has a normal cavity size. There is mild
regional left ventricular systolic dysfunction with near
akinesis of the distal inferior and septal walls and mild
dyskinesis of the apex (see schematic) and preserved/ normal
contractility of the remaining segments. The visually estimated
left ventricular ejection fraction is 50%. Normal right
ventricular cavity size with focal hypokinesis of the apical
free wall.
IMPRESSION: Normal left ventricular cavity size with regional
biventricular systolic dysfunction most c/w CAD (distal LAD
distribution).
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
============
MICROBIOLOGY
============
None
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
___ man with PMH of HTN, ETOH use in remission and tobacco use
presented with 24 hours of substernal chest pain, found to have
anterolateral STEMI, now status post PCI to mid LAD.
====================
ACUTE MEDICAL ISSUES
====================
#ST-Elevation Myocardial Infarction
No history of chest pain. Risk factors include family history,
active smoking, obesity. Initial EKG with ST elevations in I,
AVL, and V2-5 consistent with anterolateral infarct in LAD
territory. Troponin peaked to 6.34. He underwent placement of
Promus ELITE stent to the LAD on ___. He will need repeat
lipid panel in 3 months to ensure LDL <70. Would also recommend
HBA1C and cardiac rehab in 6 weeks time.
Lipids notable for Chlesterol 180, HDL 47, Calculated LDL 107.
ACEi: Lisinopril 10 mg
Neurohormonal Beta-Blockade: Metoprolol succinate 25 mg daily
Statin: Atorvastatin 80 mg daily
Antiplatelet agents: Clopidogrel 75 mg daily, Aspirin 81 mg
daily
#Acute heart failure with reduced ejection fraction
#Apical Akinesis
His TTE was notable for LVEF 45% with apical akinesis and he was
therefore started on warfarin with goal INR ___ for LV thrombus
prophylaxis. He was continued on aspirin 81mg daily. Although he
was initially treated with ticagrelor 90mg BID, this was
converted to Plavix 75mg daily (after 150mg load) after his
apical akinesis was discovered. A contrast TTE found no LV
thrombus. He did not require diuretic therapy while
hospitalized.
======================
CHRONIC MEDICAL ISSUES
======================
# Hypertension
Per patient, he was formerly taking HCTZ but has not taken it
for some time. Arrived to CCU on nitro gtt, though continued to
by hypertensive to 170/120s, necessitating addition of
captopril. His blood pressure was subsequently better
controlled. His discharge regimen was Lisinopril 10 mg daily and
metoprolol succinate 25 mg daily.
# Tobacco use
Smokes about 1 pack/day. Working with PCP on smoking cessation
prior to admission. He was treated with a nicotine patch, 14
mg/day (lower dose due to CV disease).
# History of alcohol use
Last used in ___, was drinking 2 pints liquor/daily. Has
previously been admitted for withdrawal requiring phenobarbital
but no seizures of DT. Denies recent use. Did not have any
symptoms of withdrawal on this admission.
# Leukocytosis
Suspect likely inflammatory reaction secondary to STEMI. No
localizing signs of infection and no fevers.
# Transaminitis
AST elevation likely secondary to infarct and cell necrosis,
although with previous EtOH misuse history could represent
underlying baseline liver dysfunction. Admission ALT/AST were
69/313, trended down to 46/136.
===================
TRANSITIONAL ISSUES
===================
[ ] Patient is amenable to smoking cessation and should be
provided with further resources for this - discharged with 14
mcg patches
[ ] repeat ECHO to see if apical akinesis has recovered,
discharged on warfarin (2.5 mg daily) not therapeutic at
discharge, but no indication for bridging
[ ] Follow with ___ clinic
[ ] LFTs found to be abnormally elevated, which may warrant
periodic monitoring
[ ] Arrange Sleep clinic ___ to evaluate results of recent sleep
study, likely requires PAP (was intermittently hypoxic w/ normal
Xray and exam)
[ ] F/U with PCP for smoking cessation and medication management
(will need INR monitoring)as well as repeat lipid panel and A1C
in ___
[ ] F/U with Cardiology for post-STEMI care
[ ] Cardiac rehab in 6 weeks, no acute ___ needs
Discharge weight: 99.1 kg
Discharge INR: 1.1
HCP: ___ sister ___
Code status: Full
Medications on Admission:
No pre-admission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nicotine Patch 14 mg/day TD DAILY
7. Warfarin 2.5 mg PO daily, dose adjustments for ___
Anticoagulation Management services
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
ST-Elevation Myocardial Infarction
===================
SECONDARY DIAGNOSES
===================
Acute heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having chest pain and we found that you were having a
heart attack.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We put a stent in the blockage in your heart to stop the heart
attack
- We treated you with medications for your heart attack and
medications to keep your stent open.
- We found that part of your heart was not moving normally, so
we started you on blood thinners to prevent the formation of a
clot.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Carefully review the attached medication list as we may have
made changes to your medications.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10513485-DS-10 | 10,513,485 | 20,392,103 | DS | 10 | 2169-04-02 00:00:00 | 2169-04-04 10:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / adhesive
Attending: ___.
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
This is a ___ with PMH significant for significant CAD, stage IV
endometrial cancer, and prior GIB attributed to GAVE s/p APC
that presents with 1 week h/o worsening melena and 1 day h/o
BRBPR. Patient was previously admitted in ___ for
melena and GIB. EGD revealed GAVE and colonoscopy was
unremarkable, though the prep was poor. She was readmitted from
___ with persistent hematochezia, but flex sig only
revealed internal hemorrhoids and no other obvious source of
bleeding. Since then, she has been doing well until ~1 week ago
when stools were noted to be darker with reported melena. She
also reports worsening lethargy and fatigue. On the day prior to
admission, she noted for the ___ time that she had light blood
mixed with stool (about 1 cup's worth). She called her PCP who
referred her to the ED.
In the ED, VS 98.9 60 128/59 18 100% ra. Labs were remarkable
for hct 27.8 from 26.6 on last admission (baseline in the upper
___. Patient was given pantoprazole 40mg IV and started on NS.
GI consulted with recommendation to admit for further work-up.
Per the patient, a DRE was performed which revealed blood on the
finger.
On the floor, pt reports generalized lethargy and fatigue. She
has had some dizziness/lightheadedness for a long time, but has
not noticed any worsening of orthostatic symptoms over the past
week. She reports that she had some chills yesterday associated
with some RLQ abdominal pain (felt like a "stitch") and two
episodes of dry heaves. She has not had any CP, palpitations,
SOB, DOE, back pain, focal weakness, or paresthesias. She has
had decreased appetite for several days, but is able to tolerate
PO intake. She has had a single non-bloody BM since arrival
onto floor.
Of note, pt is followed by Dr. ___ at ___ for her
oncologic care. B/c of her low blood counts, she did have a BM
biopsy last month which, per pt, was normal.
Review of sytems:
Please refer to HPI for pertinent ROS.
Past Medical History:
Endometrial cancer: Diagnosed ___, Stage IV, s/p hysterectomy
and radiation (last dose ___, on anastrazole (since
___
DM2: Latest HbA1C 4.5 (___)
CAD: NSTEMI ___, underwent cardiac catheterization
without intervention
Chronic respiratory failure: 2L home oxygen
CKD stage 3
HTN
hypothyroidism
thrombocytopenia
anemia
depression
Social History:
___
Family History:
Father died at ___ after ___ MIs
Mother died at ___, had CHF
Sister died of breast cancer
Physical Exam:
ADMISSION:
Vitals- 99.0 139/72 66 18 97%RA
General- Pale appearance, Alert, orientedx3, in no acute
distress
HEENT- Sclera pale, MMM, oropharynx clear, conjunctiva pink
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally. Decreased breath
sounds diffusely. No adventitious breath sounds.
CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- large pannus. soft, minimal TTP of R abdomen ___ in
severity). No rebound or guarding. Normoactive bowel sounds.
GU- no foley
Ext- Extremities WWP, significant lymphedema of BLE with 1+
pitting edema
DISCHARGE:
Vitals- 100.5, 98.2, 107/53 (107-118/53-60), 84 (84-98), 98% on
RA.
General- Pale appearance, in no acute distress
HEENT- Sclera pale, MMM, oropharynx clear, conjunctiva pink
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally. Decreased breath
sounds diffusely.
CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- large pannus. soft, NTND. No rebound or guarding.
Normoactive bowel sounds.
GU- no foley
Ext- Extremities WWP, significant lymphedema of BLE with 1+
pitting edema to knees
Neuro: AOx3
Pertinent Results:
ADMISSION:
___ 08:45PM BLOOD WBC-4.0# RBC-3.37* Hgb-9.2* Hct-27.8*
MCV-83 MCH-27.3 MCHC-33.1 RDW-14.5 Plt Ct-96*
___ 08:45PM BLOOD Neuts-88.5* Lymphs-5.5* Monos-5.0 Eos-0.5
Baso-0.5
___ 08:45PM BLOOD ___ PTT-31.2 ___
___ 08:45PM BLOOD Glucose-88 UreaN-18 Creat-0.9 Na-141
K-3.6 Cl-103 HCO3-33* AnGap-9
___ 08:45PM BLOOD ALT-17 AST-27 AlkPhos-223* TotBili-0.6
___ 08:45PM BLOOD Lipase-8
___ 08:45PM BLOOD Albumin-3.3*
DISCHARGE:
___ EGD
Findings:
Esophagus:
Mucosa: Normal mucosa was noted in the whole esophagus.
Other Benign appearing polypoid lesion seen in midesophagus.
Stomach:
Mucosa: Abnormal mucosa was noted in the antrum and pylorus
consistent with gastritis. Cold forceps biopsies were performed
to assess for H. pylori.
Excavated Lesions A single large cratered non-bleeding
clean-based ulcer was found in the antrum.
Duodenum:
Mucosa: Abnormal mucosa was noted throughout the duodenum
suggestive of duodenitis.
Impression: Normal mucosa in the whole esophagus
Abnormal mucosa in the stomach (biopsy)
Ulcer in the antrum
Abnormal mucosa in the duodenum
Benign appearing polypoid lesion seen in midesophagus.
Otherwise normal EGD to third part of the duodenum
___ 05:45AM BLOOD WBC-1.3* RBC-2.85* Hgb-7.8* Hct-23.5*
MCV-82 MCH-27.5 MCHC-33.3 RDW-14.7 Plt Ct-66*
___ 05:45AM BLOOD Neuts-70.9* Lymphs-17.2* Monos-7.7
Eos-2.3 Baso-1.9
___ 05:45AM BLOOD Glucose-77 UreaN-15 Creat-0.9 Na-139
K-3.0* Cl-101 HCO3-31 AnGap-10
___ 05:45AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.5*
___ 12:45PM BLOOD Hct-26.4*
Brief Hospital Course:
___ with PMH significant for GIB attributed to GAVE and
hemorrhoids presents with recurrent BRBPR x24 hours in addition
to worsening melena x 1 week with associated
dizziness/lightheadedness.
ACTIVE ISSUES:
#GI bleed: The most likely source of the patient's BRBPR is the
patient's internal hemorrhoids given her hemodynamic stability
and prior flex sig and colonoscopy findings from her recent
hospitalizations. The patient was evaluated by Gastroenterology
and underwent upper endoscopy which shows a large clean-based
ulcer in the gastric antrum with no evidence of active bleeding.
The patient received transfusion with 1u pRBCs and was started
on high dose PPI. Her home metoprolol and aspirin were
initially held for concern of ongoing GI bleed, but both were
restarted at discharge.
#Abdominal pain: The patient reported RLQ pain for ___s temp to 99 prior to admission. While this may be related to
ongoing GIB, this could also have been ___ an infectious
etiology. However, she had no leukocytosis and denied any
abdominal pain during this hospitalization. Therefore, she was
not started on any empiric antibiotics.
CHRONIC ISSUES:
#CAD: Currently chest pain free. Prior hospitalization c/b
significant angina in setting of anemia. The patient's home
metoprolol and aspirin were initially held for concern of
ongoing GI bleed. She was continued on her home simvastatin and
imdur. Her aspirin 81 and metoprolol 100 mg BID were both
restarted at discharge.
#HTN: Stable. Continued on home lisinopril 5mg daily. Her home
metoprolol was restarted at discharge.
#DMII: Continued on standing NPH and SSI. Patient will be
discharged on home insulin.
#H/o endometrial cancer: The anastrazole was initially held for
concern for that it might have contributed to her neutropenia.
However, her neutropenia was stable after withholding it, so the
patient will restart anastrazole post-discharge.
#Hypothyroidism: Continued on home synthroid.
TRANSITIONAL ISSUES:
# CODE: Full confirmed
# Will have follow-up as outpatient with GI
# Will follow-up with oncologist as scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. anastrozole 1 mg Oral daily
2. Aspirin 81 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO BID
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Simvastatin 20 mg PO DAILY
12. TraZODone 25 mg PO HS
13. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO BID
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice daily Disp #*120 Capsule Refills:*0
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Simvastatin 20 mg PO DAILY
12. TraZODone 25 mg PO HS
13. anastrozole 1 mg Oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Upper GI bleed
Lower GI bleed
Anemia
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 ___
___. You were admitted to the hospital
because you had bright red blood in your stools. You were
evaluated by gastroenterologists in the hospital and received an
upper endoscopy. We found that you had a large ulcer in your
stomach that did not appear to be actively bleeding. You
previously had a flexible sigmoidoscopy during your last
hospitalization which showed that you had hemorrhoids. We
believe that the bright red blood you had in your stools was due
to irritation of your hemorrhoids. However, you may have been
having some slower bleeding from this new ulcer. You also
received a blood transfusion since your blood counts were a
little low.
You will continue your home medications following discharge. We
increased your home omeprazole from 40 mg daily to 40 mg twice
daily. Please follow-up with your outpatient providers as
instructed below.
Thank you for allowing us to participate in your care. Best
wishes with your recovery.
Followup Instructions:
___
|
10513485-DS-8 | 10,513,485 | 20,670,613 | DS | 8 | 2169-01-15 00:00:00 | 2169-01-15 21:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pcn / adhesive tape
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
___ with known CAD, Stage IV endometrial cancer (on
anastrazole), ___ DM2, chronic respiratory failure
on home O2 who presents with ___ stools and anemia.
On the day of admission, the patient saw her PCP ___
___, who referred patient to the ___ ED with concern for
GI bleeding. The patient reports that she has experienced "dark
stools" since her recent discharge from ___. She endorses ___
loose DMs daily, which has been stable since completing
radiation treatment in ___. She denies any bright red blood
per rectum or any blood on the toilet paper. The patient denies
CP, SOB, nausea, vomiting, fever, rashes, dysuria, and urinary
frequency. She has no increased home O2 requirements. She does
andorse an increase in ___ swelling, though this has been stable
since discharge. Denies orthopnea, PND.
The patient was recently admitted from ___ with chest
pain, EKG changes, and elevated troponin in the setting of GI
illness. The patient's cardiac issues were felt to represent
demand ischemia in the setting of hypovolemia. GI symptoms were
felt to be result of a viral or bacterial gastroenteritis. Stool
studies and C. diff testing were negative. Her hospital course
was complicated by ___ E.Coli bacteremia for which she
was discharged on CTX (via PICC line) to complete a 14 day
course (Day 8 of 14 today).
Past Medical History:
Endometrial cancer: Diagnosed ___, Stage IV, s/p hysterectomy
and radiation, on anastrazole
DM2: Latest HbA1C 4.5 (___)
CAD: ___ ___, underwent cardiac catheterization
without intervention
Chronic respiratory failure: 2L home oxygen
CKD stage 3
HTN
hypothyroidism
thrombocytopenia
anemia
depression
Social History:
___
Family History:
Father died at ___ after ___ MIs
Mother died at ___, had CHF
Sister died of breast cancer
Physical Exam:
Admissions Exam:
PHYSICAL EXAM:
Vitals: T: 98.5 BP: 139/63 P: 51 R: 18 O2: 95%RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP difficult to assess given neck size
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Heart sounds distant, RR, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, ___, bowel sounds present,
no rebound tenderness or guarding
Ext: 2+ edema b/l, venous stasis changes bilaterally, L>R
Discharge Exam:
Vitals: T: 98.2 116/50 62 18 O2: 95% 2 L
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP difficult to assess given neck size
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Heart sounds distant, RR, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, ___, bowel sounds present,
no rebound tenderness or guarding
Ext: 2+ edema b/l with R>L, venous stasis changes bilaterally
L<R
Rectal exam (from ___: no fissures, normal appearing
hemorrhoid cushions with no pain on palpation. No frank blood.
No palpable masses along the internal anal sphincter. Guiac (+)
x 2 from stool samples (on admission)
Pertinent Results:
___ 06:30PM BLOOD ___
___ Plt ___
___ 12:49AM BLOOD ___
___ 01:00PM BLOOD ___
___ Plt ___
___ 05:00AM BLOOD ___
___ Plt ___
___ 06:02AM BLOOD ___
___ Plt ___
___ 06:30PM BLOOD ___
___
___ 07:39PM BLOOD ___ ___
___ 06:30PM BLOOD ___
___
___ 08:00PM BLOOD CK(CPK)-99
___ 06:30PM BLOOD ___
___ 06:30PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD ___ cTropnT-<0.01
___ 05:52AM BLOOD ___
___ 05:52AM BLOOD ___
___ 05:03AM BLOOD ___
___ Plt ___
___ 05:03AM BLOOD ___
___
CXR
FINDINGS: A right upper extremity PICC terminates in the lower
SVC.
The cardiac silhouette is moderately enlarged, likely in part
due to the
presence of mediastinal fat. The pulmonary vascularity is
normal. The
mediastinal contours are stable. There is no definite pleural
effusion or
pneumothorax. There is no focal consolidation worrisome for
pneumonia.
IMPRESSION: No pulmonary edema or other acute process.
___ U/S
IMPRESSION:
No evidence of deep vein thrombosis in either leg. Note is made
of limited visualization of the right calf veins.
Brief Hospital Course:
___ with known CAD, Stage IV endometrial cancer (on
anestrazole), ___ DM2, chronic respiratory failure
on home O2 who presents with ___ stools, transfused 3
units of blood throughout hospitalization with EGD revealing
gastric antral vascular ectasia.
# Melena due to gastric antral vascular ectasia: Patient
reported diarrhea following XRT for endometrial cancer in ___. Since her discharge from the previous admission (___) she
noticed dark stools. Her admission HCT was 25.9. Over the course
of an 8 day hospitalization, her lowest Hct was 22.3 and highest
29.8. Her discharge Hct was 27.5 Patient's hospitalization was
prolonged due to extensive evaluation of patient's cardiac risk
factors for endoscopy (see Chest pain CAD below). On ___
the patient underwent endoscopy. Colonoscopy remarkable for
internal and external hemorrhoids with no sources of bleeding,
but bowel prep was not optimal. EGD revealed gastric antral
vascular ectasia that was treated with argon plasma coagulation.
Due to risk for future bleed and underlying chronic anemia
patient should be followed by GI, Oncology and PCP.
# Chest pain/CAD: Patient had NSTEMI ___ and underwent
cardiac catheterization without intervention. She takes high
dose metoprolol and isosorbide mononitrate at home with NTG PRN,
asa, and simvastatin. On ___ endoscopy was cancelled by
anesthesia due to active chest pain prior to the procedure. When
arriving back to the floor she continued to have this pain,
which was relieved by NTG. A 12 lead ECG was negative for
ischemic changes and ___ were troponin (-). She experienced
chest pain the morning of ___. Again ECG and troponins were
(-). After further evaluation by Cardiology, we temporarily
increased her isosorbide mononitrate to decrease the chances of
angina, but made no permanent changes in her medical regimen.
# Perioperative risk asssesment: Following the cancellation of
the endoscopy case on ___, cardiology was consulted for
___ risk assessment and determined her to be
___, but with no further workup or treatment required
for optimization. After carefully weighing the risks and
benefits of the procedure with the patient and all involved
providers, the decision was made to continue with endoscopy. We
determined that the risk for cardiac complications discharging
her without a diagnosis and the risk for continued bleeding
potentially difficult to manage as an outpatient was sufficient
for endoscopy in house. Furthermore, the team reasoned that the
procedure could be done under safer conditions in this admission
adequately transfused and with providers that knew her well
rather than in an emergency situation that could potentially
unfold as an outpatient. She tolerated the procedure very well
and had no chest pain afterwards.
# Pancytopenia: Per OSH note (___) all lines are down at
baseline. Perhaps due to bone marrow process vs. bone marrow
suppression vs. medication effects. This was confirmed with her
oncology nurse and will be followed up as an outpatient.
# Stage IV Endometrial cancer: Diagnosed ___, s/p hysterectomy
and radiation, on anastrazole. Not a chemo candidate per
records. She was continued on anastrozole
# ___ edema: Likely due to impaired cardiac function, volume
overload and hypoalbuminemia in the setting of resucitation for
GNR bacteremia from the ___ admission. Lower extremity u/s (-).
# DM2: Latest HbA1C 4.5 (___). She was continued on Humulin
N 15 Units Breakfast and Humulin N 15 Units Bedtime with
correctional insulin
# Chronic respiratory failure: On 2L home oxygen, which was
continued here.
# HTN: continued on lisinopril 5 mg PO daily
# Hypothyroidism: continued on Levothyroxine Sodium 100 mcg PO
DAILY
# Depression: continued on Fluoxetine 40 mg PO daily
Transitional Issues
- Oncology appointment
- PCP appointment
- GI follow up: Final EGD and colonoscopy results, GI
appointment. Patient may need follow up EGD if bleeding due to
vascular ectasia continues
- Cardiology appointment
- Patient ___ on home isosorbide 120 prior to discharge
but she did well with 150 mg in house. Consider uptitrating
given CAD
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. anastrozole *NF* 1 mg Oral daily
2. Aspirin 81 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO BID
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Simvastatin 20 mg PO DAILY
13. TraZODone 25 mg PO HS
14. Naproxen 220 mg PO Q8H:PRN pain
15. CeftriaXONE 2 gm IV Q24H
Discharge Medications:
1. anastrozole *NF* 1 mg Oral daily
2. Aspirin 81 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Humulin N 15 Units Breakfast
Humulin N 15 Units Bedtime
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO BID
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Simvastatin 20 mg PO DAILY
13. TraZODone 25 mg PO HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastric antral vascular ectasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hello Ms. ___,
You came to the hospital because of bleeding from your
gastrointestinal tract. We gave you blood transfusions and due
to concerns for ongoing bleeding the gastrointestinal doctors
also performed ___ to look for the source. They found and
treated bleeding blood vessels in your stomach. As these vessels
have the potential to bleed again you will need to follow up
with the gastrointestinal doctors, your PCP and oncologist.
It was a pleasure to take care of you.
Followup Instructions:
___
|
10514013-DS-20 | 10,514,013 | 29,639,378 | DS | 20 | 2159-07-15 00:00:00 | 2159-07-15 16:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
Right parietal IPH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with a history of T1DM,
HTN, hypothyroidism, chronic thrombocytopenia, who presents with
1 day of headache found to have a right parietal
intraparenchymal
hemorrhage.
She was otherwise in her usual state of health until yesterday
evening, when she noticed a gradual onset, right frontal
headache. She was gardening earlier that day without problems.
She took a Tylenol but did not notice an improvement. She
thought
it might be low blood sugar, so she drank some orange juice;
however, she proceeded to vomit this back up. She went to bed
hoping pain would go away. This morning, however, she woke up
with the same headache, and decided to call EMS. She was taken
to
an OSH where a ___ revealed a right parietal IPH measuring 4.2
x 2.8 x 2.3. She was given 100gm of mannitol as well as 1 gram
of
levetiracetam. Exam was intact, and she was sent to ___ for
further management. Seen by Neurosurgery in ED with no acute
intervention recommended at this time.
Of note, patient reports being compliant with her medications;
finger sticks at home usually range between 100-160. Clinic BP
have been <140 per quick review.
On neuro ROS, the pt loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Adult-onset T1DM
HTN
Hypothyroidism
Thrombocytopenia, thought to be ?ITP vs early MDS per ___ onc
notes
Social History:
___
Family History:
Non-contributory.
Physical Exam:
==============
ADMISSION EXAM
==============
Physical Exam:
Vitals: T98 P81 BP162/70 RR14 O2 99% RA
General: Awake, cooperative, NAD. Falls asleep during exam and
needs constant stimulus.
HEENT: NC/AT, no scleral icterus noted, dry mucus MM, no lesions
noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia.
-Cranial Nerves:
II, III, IV, VI: PERRL 3->2mm. EOMI without nystagmus. Normal
saccades. Left homonymous hemianopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred
==============
DISCHARGE EXAM
==============
Vitals: Tm 98.9 ; Tc 98.4 HR ___ ; BP 145-153/60-68 ; RR 18 ;
O2 96% RA FSBG 283
General: Wide awake, alert, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, no lesions noted in
oropharynx.
Pulmonary: Breathing comfortably.
Cardiac: Well perfused.
Abdomen: NT/ND
Extremities: No C/C/E bilaterally.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Wide awake, alert and oriented x 4. Able to
relate history without difficulty. Language is fluent. Normal
prosody. There were no paraphasic errors. Speech was not
dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
PERRL 3->2mm. EOMI without nystagmus. Normal saccades. No facial
droop, facial musculature symmetric. Palate elevates
symmetrically. Left homonymous hemianopia, but field improved.
-Motor: 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. No extinction to DSS.
-Coordination: No intention tremor. No dysmetria on FNF.
Pertinent Results:
=============
SELECTED LABS
=============
___ 04:10AM BLOOD WBC-5.5 RBC-3.85* Hgb-12.0 Hct-37.5
MCV-97 MCH-31.2 MCHC-32.0 RDW-13.1 RDWSD-46.8* Plt ___
___ 04:10AM BLOOD Neuts-77.8* Lymphs-14.2* Monos-4.9*
Eos-2.0 Baso-0.7 Im ___ AbsNeut-4.28 AbsLymp-0.78*
AbsMono-0.27 AbsEos-0.11 AbsBaso-0.04
___ 04:10AM BLOOD ___ PTT-25.4 ___
___ 04:10AM BLOOD Glucose-305* UreaN-17 Creat-0.6 Na-135
K-4.3 Cl-96 HCO3-25 AnGap-18
___ 04:10AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.8
___ 06:40AM BLOOD %HbA1c-9.6* eAG-229*
___ 06:40AM BLOOD Triglyc-60 HDL-81 CHOL/HD-1.8 LDLcalc-53
___ 06:40AM BLOOD TSH-0.54
___ 09:40AM BLOOD WBC-5.7 RBC-3.70* Hgb-11.5 Hct-35.2
MCV-95 MCH-31.1 MCHC-32.7 RDW-13.2 RDWSD-46.1 Plt ___
___ 06:40AM BLOOD ___ PTT-24.7* ___
___ 09:40AM BLOOD Glucose-190* UreaN-30* Creat-0.7 Na-138
K-3.4 Cl-100 HCO3-25 AnGap-16
___ 05:15PM URINE Color-Yellow Appear-Clear Sp ___
=======
IMAGING
=======
- ___ Non-Contrast CT of ___:
1. 4.2 x 2.8 x 2.3 cm right temporal intraparenchymal hemorrhage
with adjacent vasogenic edema. Associated right lateral
intraventricular hemorrhage. Compared with the study from
___ (Clip ___, no significant change.
2. No new acute hemorrhage detected. No shift of normally
midline structures. Basal cisterns remain patent.
- ___ MR ___
1. Study is moderately degraded by motion and limited by lack of
administration of intravenous contrast.
2. Stable right temporal intraparenchymal hematoma extending
into the lateral ventricles.
3. Within limits of study, no evidence of new hemorrhage or
acute vascular territorial infarction.
4. Evaluation for and underlying mass is limited by lack of
intravenous contrast and presence of acute hemorrhage. Short
interval follow-up with contrast after resolution of the
hematoma is recommended.
- ___ MRI/MRA ___ WWO Contrast
1. No significant change in the size right posterior temporal
parenchymal hematoma with intraventricular extension.
Surrounding vasogenic edema and mild effacement of the atrium
and occipital horn of the right lateral ventricle are stable.
2. Expected evolution of right posterior temporal blood products
is observed, with increased T1 hyperintensity and increased T2
hypointensity. In addition, there are foci of intermediate T2
signal and partial T1 hyperintensity in the posterior aspect of
the hematoma, which are rounded with masslike appearance.
However, no contrast enhancement is seen outside of the T1
hyperintense blood
products to definitively indicate a mass.
3. No evidence for enhancing masses or prior hemorrhages
separate from the current hemorrhage.
4. Right leptomeningeal hyperemia and abnormal signal on FLAIR
images in the right temporal, parietal, and occipital sulci,
which may reflect subarachnoid hemorrhage or reactive
inflammation.
RECOMMENDATION(S): Follow up MRI with and without contrast
after resolution of T1 hyperintense blood products.
Brief Hospital Course:
___ is a ___ year old woman with a history of T1DM,
HTN, hypothyroidism, chronic thrombocytopenia, who presents with
1 day of headache found to have a right parietal
intraparenchymal hemorrhage, likely occurring in the setting of
intense exercise (dragging a barrel up a hill). Only symptom was
left homonymous hemianopia. Regarding risk factors, her lipids
are excellent however her diabetes is poorly controlled (9.6%).
Etiology is most likely hypertensive though given age, history,
and location, there is suspicious for first amyloid bleed as
well. Alternatively may be cavernous angioma, AVM, hemorrhagic
conversion of ischemic stroke. Given minimal deficits, plan for
discharge home with ___ versus a short rehab stay.
Discontinued aspirin indefinitely given hemorrhage. Lisinopril
was increased from 5mg to 20mg daily, but systolic blood
pressures were still elevated 160s-170s, so amlodipine 5mg daily
was added to good effect (SBP 136 on discharge). She is
scheduled for a repeat MRI in ___ weeks, and for follow-up with
stroke neurology in 2 months. She will also transfer her
diabetes management to the ___ on ___.
She was seen by ___ and will be discharged home with services.
Her second-floor apartment has already been arranged to be moved
to the first floor.
========================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Lantus (insulin glargine) 12 units subcutaneous QPM
5. HumaLOG (insulin lispro) ___ units subcutaneous TID
6. FoLIC Acid 1 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
2. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
5. Atorvastatin 80 mg PO QPM
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right posterior parietal hemorrhagic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of headache resulting from
a HEMORRHAGIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain breaks and bleeds. The brain
is the part of your body that controls and directs all the other
parts of your body, so damage to the brain from being deprived
of its blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- Diabetes
- Aspirin use
We are changing your medications as follows:
- STOP aspirin. This medicine is useful in preventing strokes
caused by blockages (clots), but you have had a bleed - making
this medicine a risk for greater bleeds.
- INCREASE lisinopril to 20mg DAILY.
- START amlodipine 5mg DAILY.
- MONITOR your blood pressure. Hold your amlodipine for systolic
BP less than 110. Call your PCP who may ask you to stop or halve
your dose.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Thank You,
Your ___ Neurology Team
Followup Instructions:
___
|
10514375-DS-20 | 10,514,375 | 27,714,376 | DS | 20 | 2175-05-29 00:00:00 | 2175-05-29 23:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female with history of stage IIIB
non-small cell lung cancer s/p treatment with concomitant
chemoradiation and two additional cycles of adjuvant
chemotherapy (completed in ___ now with disease
recurrence with a malignant left pleural
effusion and left hilar mass presents with chest discomfort and
shortness of breath. She notes sudden onset of substernal chest
pain at 11PM, worse when lie flat better when sit forward,
non-radiating, continuous, worse with deep breath, sharp, ___
in severity, associated with dyspnea. Also noticed new cough
this AM, non-productive. The patient went to an outside
hospital, and was evaluated for these symptoms early this
morning. CT imaging of the chest was performed, and the patient
was admitted for rule out MI protocol. She signed out AMA and
drove to the BI for further evaluation. She has had chest pain
for some time in the setting of her cancer diagnosis, however it
has become this is more severe. No history of fever or chills.
.
In the ED initial vitals were: 98.4 113 80/40 22 97% RA. Per
report EKG with "subtle diffuse STE." Bedside U/S did not show
large pericardial effusion. CT from OSH second read by radiology
as no pulmonary embolism although subsegmental vessels limited
by atelectasis, small amount of pericardial fluid without
evidence of tamponade, unchanged LLL mass and pleural fluid, L1
vertebral body metastasis is unchanged. Patient was given
ketorolac, acetaminophen, dilaudid for presumed pericarditis.
Given 2L IVF. 1 18G for access. Vitals on transfer: ___ 18
98%RA.
Past Medical History:
Shortness of breath with right pleural effusion.
Left lower lobe lung adenocarcinoma- still in staging process
awaiting pathology.
T12 sclerotic ___ lesion- awaiting pathology from bone biopsy.
Hypertension
Hypothyroidism
Osteoporosis
Social History:
___
Family History:
Father: lung cancer
___: brother: lung cancer; aunt with lung tumor
Physical Exam:
Admission Exam:
Vitals - T:98.2 118/65 HR:95 RR:16 O2: 99% 3L Pulsus: 6
GENERAL: NAD
HEENT: AT/NC, EOMI anicteric sclera, pink conjunctiva,
oropharynx clear, no JVP
CARDIAC: S1, S2 regular rhythm, II/VI holosystolic murmur LUSB
LUNG: decreased BS left base, mild exp wheeze L side, no
accessory muscle use
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
Discharge Exam:
AVSS
Rest of exam as above
Pertinent Results:
Admission Labs:
___ 06:35PM cTropnT-<0.01
___ 11:50AM cTropnT-<0.01
___ 11:50AM NEUTS-84.8* LYMPHS-10.9* MONOS-4.0 EOS-0.1
BASOS-0.2
___ 11:50AM GLUCOSE-144* UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-13
.
OSH CT Scan
INDICATION: This is a second-read request for a study performed
at ___ on ___ at 7:23 a.m. No report was sent with the
patient upon
transfer to the emergency department.
COMPARISON: ___.
TECHNIQUE: Multidetector CT acquisition of the chest was
performed from the
thoracic outlet to the superior kidneys with intravenous
contrast. Coronal
and sagittal reformations and MIP images are provided for
review.
FINDINGS: No nodules are seen in the thyroid gland. The
thoracic aorta is
normal in caliber without evidence of dissection. Evaluation of
pulmonary
vasculature at the subsegmental level is limited by bibasilar
atelectasis and
a large left lung mass. No filling defect to suggest pulmonary
embolism is
identified in the visualized vasculature. No pathologically
enlarged
axillary, mediastinal or right hilar lymph nodes are identified.
A small
amount of pericardial fluid is increased from ___ without
evidence of
tamponade.
A soft tissue mass at the left hilus and occluding the superior
segment
bronchus to the left lower lobe measures 25 x 40 mm, previously
23 x 37 mm,
unchanged allowing for differences in technique (4:22). Left
pleural fluid is
similar to the prior study. Calcification along the mediastinal
and
diaphragmatic pleural surfaces from prior pleurodesis are again
noted.
Lung volumes are lower than on the prior study and diffuse
ground-glass
opacity in the right lung which is more heterogeneous at the
right lung base
is nonspecific but may represent atelectasis and less likely
aspiration.
Linear scarring or atelectasis at the left lung base is similar
allowing for
lung volumes.
The study is not tailored for subdiaphragmatic evaluation. No
acute
abnormality is identified in the imaged upper abdomen.
BONE WINDOWS: Sclerosis in the L1 vertebral body due to a
metastasis is
unchanged.
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism, although
evaluation of
the subsegmental vessels is limited.
2. Unchanged left hilar mass and left pleural fluid since
___.
3. Lower lung volumes than on the prior study with increased
atelectasis.
More heterogeneous opacity at the lung bases bilaterally may
represent
atelectasis or aspiration.
4. Unchanged L1 vertebral body metastasis.
TTE:
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Very small pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is mildly dilated. 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 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 a very small pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Very small pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ female with history of stage IIIB non-small cell
lung cancer s/p treatment with concomitant chemoradiation and
two additional cycles of adjuvant chemotherapy (completed in
___ now with disease recurrence with a malignant left
pleural effusion and left hilar mass presents with chest
discomfort and dyspnea found to have leukocytosis which resolved
within 24hrs.
#. ACUTE PERICARDITIS: Clinically chest pain appeared most
consistent with pericarditis. Potential etiology was secondary
to malignancy although viral also possible. The pt's most recent
TTE showed small pericardial effusion with "partially echodense
material in the pericardial space which may represent a
pericardial mass." Pulsus WNL and CT chest not concerning for
tamponade at this time. Other etiologies of chest pain were
considered such as pneumonia (given new cough and leukocytosis
but no areas of consolidation on CT), pulmonary embolism (no
evidence to segmental vessels on CT chest). A repeat TTE was
performed (see above) that revealed only a small amount of
pericardial fluid. The pt was given NSAIDs and low dose
oxycodone and her symptoms resolved.
#LEUKOCYTOSIS: UA benign. Improved within 24hrs.
-f/u on blood cultures
.
#NON SMALL CELL LUNG CA: per Dr. ___ as outpatient.
Follow-up end of ___
.
#. HYPOTHYROIDISM
-continue home levothyroxine
#. GERD:
-continue ranitidine
#HYPERTENSION:
-held lisnopril overnight, restarted on discharge.
.
TRANSITIONAL ISSUES:
- Direct verbal sign-out provided to patients PCP and primary
oncologist over phone prior to d/c. Patient asked to follow-up
with her PCP ___ ___ weeks.
Medications on Admission:
. Information was obtained from .
1. Ranitidine 150 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Paroxetine 10 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY (except ___ when
does not take)
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
6. risedronate *NF* 35 mg Oral Qweek
Discharge Medications:
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Paroxetine 10 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Ibuprofen 600 mg PO Q8H:PRN chest pain
RX *ibuprofen [Advil] 200 mg ___ tablet(s) by mouth every 8
hours Disp #*60 Tablet Refills:*0
5. risedronate *NF* 35 mg Oral Qweek
6. Lisinopril 20 mg PO DAILY
7. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
if not relieved by ibuprofen and tylenol
RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6 Disp #*10 Tablet
Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*15 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Pericarditis
- Non-Small Cell Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hosiptal with chest pain. This was
likely due to an episode of pericarditis (inflammation around
the heart). For this you can take advil as needed. Please keep
all of your appointments as listed below.
.
Please take ibuprofen for your pain but for severe pain take
oxycodone and call your doctor. We have also provided you with a
prescription for stool softeners (colace) as needed
Followup Instructions:
___
|
10514375-DS-21 | 10,514,375 | 24,673,565 | DS | 21 | 2175-06-24 00:00:00 | 2175-06-25 22:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine
Attending: ___.
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female with history of stage IIIB
non-small cell lung cancer s/p treatment with concomitant
chemoradiation and two additional cycles of adjuvant
chemotherapy presenting with right sided chest pain and
shortness of breath which started yesterday. It has been
increasing in severity. She denies any cough, fevers or chills,
hemoptysis. No abdominal pain. No fever, chills, nausea,
vomiting. No palpitations.
In the ED, vitals were stable. CXR revealed b/l trace pleural
effusions and LUL opacity representing loculated pleural
effusion.
On the floor, patient endorses ___ right sided chest pain, no
radiation. non-pleuritic. No SOB currently.
ROS: Otherwise negative except as per HOPI.
Past Medical History:
Shortness of breath with right pleural effusion.
Left lower lobe lung adenocarcinoma- still in staging process
awaiting pathology.
T12 sclerotic ___ lesion- awaiting pathology from bone biopsy.
Hypertension
Hypothyroidism
Osteoporosis
Social History:
___
Family History:
Father: lung cancer
___: brother: lung cancer; aunt with lung tumor
Physical Exam:
ADMISSION EXAM:
Vitals - T:98.2 118/67 HR:97 RR:14 O2: 99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI anicteric sclera, pink conjunctiva,
oropharynx clear, no JVP
CARDIAC: S1, S2 regular rhythm, II/VI holosystolic murmur LUSB
LUNG: decreased BS b/l bases and left upper lobe, no accessory
muscle use
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
GENERAL: NAD,
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, +S3, stable pericardial friction rub. No
JVD or peripheral edema.
LUNG: Decreased sounds at bases, dull to percussion at bases. no
w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact
Pertinent Results:
ADMISSION:
___ 10:13PM BLOOD WBC-7.9 RBC-3.47* Hgb-9.9* Hct-29.2*
MCV-84 MCH-28.6 MCHC-33.9 RDW-13.4 Plt ___
___ 10:13PM BLOOD Neuts-67.9 ___ Monos-9.3 Eos-1.2
Baso-0.3
___ 10:13PM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-29 AnGap-10
___ 10:13PM BLOOD CK(CPK)-70
___ 10:13PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:10AM BLOOD Albumin-3.5 Calcium-8.3* Phos-3.8 Mg-2.1
DISCHARGE:
___ 07:55AM BLOOD WBC-4.7 RBC-3.47* Hgb-9.5* Hct-28.4*
MCV-82 MCH-27.4 MCHC-33.4 RDW-14.3 Plt ___
___ 07:55AM BLOOD Glucose-95 UreaN-11 Creat-0.5 Na-139
K-4.1 Cl-104 HCO3-27 AnGap-12
___ 07:55AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9
OTHER RELEVANT:
___ 10:13PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:03AM BLOOD D-Dimer-___*
CXR ___:
FINDINGS: Frontal and lateral views of the chest were obtained.
Again seen is left upper hemithorax/apical opacity, not
significantly changed since the prior study, seen to represent
loculated pleural effusion on prior CT. Left base streaky
opacity radiating from the left hilum is similar in appearance.
Hilar contours are similar. There is blunting of the
costophrenic angles may be due to trace effusions. Otherwise,
the right lung is clear.
CT ___:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Increase in the now moderate size pericardial effusion with
compression
upon the right atrium.
3. Increase in the bilateral pleural effusions, right greater
than left.
Unchanged loculated left pleural effusion at the lung apex.
4. Unchanged large left suprahilar mass causing obstruction of
the left
superior segment bronchus.
ECHO ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
There is abnormal septal motion. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade. Pericardial
constriction cannot be excluded.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion is probably similar.
Brief Hospital Course:
___ female with history of stage IIIB non-small cell
lung cancer s/p treatment with concomitant chemoradiation and
two additional cycles of adjuvant chemotherapy (completed in
___ found recently to have disease recurrence with a
malignant left pleural effusion and left hilar mass presents
again with chest pain and dyspnea found to have worsening
pericardial effusion.
ACUTE ISSUES:
# Chest pain and dyspnea: Improved by the time of discharge.
Chest pain attributed to pericarditis and pericardial effusion
secondary to her malignancy, which improved over the course of
her hospitalization after starting on treatment with ibuprofen
and colchicine. After noting interval increase in pericardial
effusion on her CTA this admission, she was followed closely by
Cardiology with TID pulsus paradoxus checks, which increased
from ___ over the first few days of her admission. Serial
echos were performed which did initially show mild Right Atrial
compression, however this improved by the time of discharge, and
there was never any evidence of right ventricular collapse. She
was not deemed a candidate for pericardiocentesis given the
still small volume of the effusion. She will be followed closely
by Cardiology as an outpatient. Interventional pulmonology also
followed closely given the interval increase in her bilateral
pleural effusion, R>L. Again, she was not deemed a candidate for
pleurocentesis given the small pocket of effusion. She will be
followed by pulmonology as an outpatient. Her shortness of
breath also improved, though the exact etiology was not entirely
clear as to whether related to pericardial effusion vs pleural
effusion vs other etiology. Differential had included pulmonary
embolism given thrombogenic state of malignancy, but ruled out
by CTA. Other etiologies of chest pain considered are pneumonia,
but no areas of consolidation on CXR), and ACS was ruled out by
non-ischemic EKG and negative troponins x 2.
# Tachycardia: In association with her shortness of breath and
chest discomfort, she remained low-grade tachycardic in the high
___ and low 100s for the majority of her hospital stay. In
addition, she frequently experienced spikes into the 140s-160s,
brief and self-resolving on tele lasting generally seconds to
minutes. They were mostly sinus though few short strips appeared
irregular which were not captured on EKG. Her tachycardia
improved towards the end of her hospital stay on treatment for
pericarditis and with IV fluids. She will be followed further by
Cardiology as an outpatient.
CHRONIC ISSUES:
# NON SMALL CELL LUNG CA: Dr. ___ will continue to manage
her carcinoma as an outpatient. Per discussion with him, she
will undergo another trial of Erlotinib with dose-reduction due
to her previous symptoms of nausea, vomiting, and diarrhea.
# HYPOTHYROIDISM: Stable. Continued on home-prescribed dose in
OMR of 112mcg.
# GERD: Stable, continued on ranitidine.
# HYPERTENSION: Lisinopril was temporarily discontinued during
her hospital course due to her intermittent tachycardia and
initial concern over tamponade physiology. Re-starting this
medication can be considered as an outpatient with cardiology.
TRANSITIONAL ISSUES:
# Pericarditis/Pericardial Effusion: Hospital course as above.
She will be followed closely as an outpatient. ___ consider
repeat echo.
# Pleural effusions: Will be followed as outpatient per
pulmonology. CXR or ultrasound may be considered to follow.
# NSCLC: To start Erlotinib as outpatient per Dr. ___.
Script given to patient. As per Dr. ___, start at 25mg po
qd and increase to 50mg if tolerated. Dr. ___ will follow
closely.
# Hypertension: Consider re-starting Lisinopril as an
outpatient. It was held during her hospital course due to her
development of intermittent tachycardia and initial concern over
tamponade physiology, though her BP did remain stable.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Levothyroxine Sodium 150 mcg PO DAILY Start: In am
2. Paroxetine 10 mg PO DAILY Start: In am
3. Ranitidine 150 mg PO DAILY Start: In am
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Lisinopril 20 mg PO DAILY Start: In am
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
if not relieved by ibuprofen and tylenol
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Cyanocobalamin Dose is Unknown PO DAILY
10. Vitamin E Dose is Unknown PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Paroxetine 10 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Erlotinib 25 mg PO DAILY
start with 1 tab qd. If tolerated x 1 week, increase to 2 tabs
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Colchicine 0.6 mg PO BID
notify MD if diarrhea.
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice a day
Disp #*56 Tablet Refills:*0
9. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*84 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Pericarditis
Pericardial Effusion
Non Small Cell Lung Cancer
Secondary Diagnosis
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because you were having chest
pain and shortness of breath. A CT scan showed fluid around the
heart which is called a pericardial effusion. Cardiology was
consulted and they followed you very closely with serial
echocardiograms. Fortunately, the fluid appeared to be getting
better each day and there was no need for any invasive
procedures. You will be followed closely by Dr. ___ Dr.
___ as an outpatient. Please let them know if you have any
more chest pain or shortness of breath. You will start taking
Tarceva again when you get home. You will be provided with a
prescription. You will continue taking colchicine and ibuprofen
as directed for at least 4 weeks. Continuation of these
medications should be discussed with Dr. ___.
You were also evaluated by the interventional pulmonologist due
to fluid around your lungs. They evaluated you and felt that the
fluid was not enough to drain. You have an appintment with Dr.
___ on ___.
Followup Instructions:
___
|
10514375-DS-22 | 10,514,375 | 27,665,572 | DS | 22 | 2178-12-13 00:00:00 | 2178-12-16 22:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ stage IIIB EGFR positive non-small cell lung cancer,
status post definitive chemoradiation, now with recurrent
disease in
mediastinal lymph nodes, mets to the lung and malignant pleural
effusion s/p pleurodesis as well as likely metastatic disease to
bone currently on oral chemo daily, HLD, HTN, hypothyroidism who
presents with chest pain and difficulty breathing 1 day s/p vein
stripping. She had prior b/l vein stripping, including ligation
and stripping of the GSV, and sclerotherapy. She then developed
secondary varicosities most bothersome in the inguinal area. She
underwent left leg vein
stripping (via 24 incisions) with Dr ___ on ___ and the
operation went well. She now returns to the ED with dyspnea and
chest pain described as burning x1 day. When she awoke day of
admission, she felt lightheaded, as though she would faint. She
also feels short of breath and had chest pain that was worse on
deep inspiration.
In the ED, initial vitals were: 99.1 117 136/81 18 94% RA
Patient endorsed dyspnea with exertion, requiring 3L O2 in the
ED to maintain saturations, and she was tachycardic.
Labs: Trop 0.06
Imaging: CTA with multiple PEs in right upper, middle and lower
lobes.
Consults: Vascular, Cardiology
Patient was given: Heparin bolus + drip; dilaudid 0.5; Zofran 4
mg; 2L nS;
Vitals on transfer were: 99.3 ___ 18 98% RA
Decision was made to admit to CCU after patient's blood
pressures softened s/p pain medication administration. BP was
fluid responsive. Pt stable on transfer and admitted to CCU for
close vital sign monitoring and possible catheter directed
thrombolysis.
Past Medical History:
Shortness of breath with right pleural effusion.
Stage IIIB EGFR positive non-small cell lung cancer, status
post definitive chemoradiation now with recurrent metastatic
disease
Hypertension
Hypothyroidism
Hyperlipidemia
Osteoporosis
Varicose Veins
Social History:
___
Family History:
Her father was diagnosed with lung cancer at the
age of ___ and died at the age of ___, and he was a smoker. Prior
to that he was diagnosed with prostate cancer. Her brother was
also a smoker and was diagnosed with lung cancer at the age of
___. However, he was never treated for the lung cancer since
prior to the diagnosis since he had a stroke and he likely died
of starvation. Her maternal aunt had a lung tumor; however, she
never had appropriate workup and diagnosis since that was more
than ___ years ago and probably not in this country. The patient
lives with her husband and the rest of her family, daughter and
___ are around and in fact she takes care of her
grandchildren and was very active until ___ of diagnosis.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.2 106 ___ 95% 3L NC
General Appearance: NAD, resting comfortably
HEENT: MMM, O/P clear, sclera anicteric
Neck: trachea midline, no stridor, supple
Lymphatics: no cervical or supraclavicular lymphadenopathy, no
thyromegaly
Chest: good air entry, mild rales at left base
Cardiovascular: reg rate, nl S1/S2, no MRG
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: no CCE
Neurological: A&O x3, gait WNL
Psychiatric: normal mood, no depression/anxiety
Skin: No rash, skin eruptions, or erythema
DISCHARGE PHYSICAL:
Vitals- Tm 98.9| 121/85 (121-156/73-93)| 94 (85-99)| 20| 96% on
RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, decreased breath sounds at bases. Shallow breathing.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- Alert and oriented, motor function grossly normal, gait
WNL
Pertinent Results:
ADMISSION LABS
___ 03:30PM BLOOD WBC-9.3 RBC-4.55 Hgb-12.5 Hct-37.7 MCV-83
MCH-27.5 MCHC-33.2 RDW-13.7 RDWSD-41.1 Plt ___
___ 03:30PM BLOOD Neuts-71.3* ___ Monos-8.5
Eos-0.4* Baso-0.4 Im ___ AbsNeut-6.65*# AbsLymp-1.78
AbsMono-0.79 AbsEos-0.04 AbsBaso-0.04
___ 03:30PM BLOOD ___ PTT-29.2 ___
___ 03:30PM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-137
K-3.7 Cl-102 HCO3-24 AnGap-15
___ 03:30PM BLOOD cTropnT-0.06*
___ 03:38PM BLOOD Lactate-1.5
___ 02:00AM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:20AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1709*
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-4.6 RBC-3.98 Hgb-11.0* Hct-32.9*
MCV-83 MCH-27.6 MCHC-33.4 RDW-13.2 RDWSD-39.9 Plt ___
___ 07:05AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
___ 07:05AM BLOOD ALT-120* AST-107* AlkPhos-121*
TotBili-0.5
___ 07:05AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
Imaging:
___ CTA Chest:
1. Multiple pulmonary emboli in the right upper, right middle,
and right
lower lobes.
2. Increase in size of irregular infiltrating left hilar mass
since ___.
3. Stable loculated left pleural effusion at the apex.
4. Increase in size of several right pulmonary nodules, as
described above. Attention on follow-up is recommended.
___ TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF = 70%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 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 a small pericardial
effusion. No tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy and
normal left ventricular systolic function. Moderate right
ventricular dilation and moderate systolic dysfunction. Septal
motion suggests RV pressure/volume overload.
___ LENIs:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ DUPLEX ABD/PELVIS
1. No US evidence of portal vein thrombus.
2. 1.3 cm simple cyst in the lower pole of the left kidney, not
significantly
changed compared to the prior CT from ___.
3. No focal hepatic lesions identified.
Brief Hospital Course:
___ w/ stage IIIB EGFR positive non-small cell lung cancer,
status post definitive chemoradiation, now with recurrent
disease in mediastinal lymph nodes, mets to the lung and
malignant pleural effusion s/p pleurodesis as well as likely
metastatic disease to bone currently on oral chemo daily, HLD,
HTN, hypothyroidism who presents with chest pain and difficulty
breathing, found to have submassive pulmonary emboli.
#) SUBMASSIVE PULMONARY EMBOLISM: Patient with NSCLC diagnosed
___, s/p chemoradiation for definitive treatment, and
recurrence with erlotinib treatment for ___ years, presented to
the ED with pleuritic chest pain, SOB and tachycardia. CTA
revealed multiple right sided PEs and patient was started on
heparin drip after bolus. Pt was initially hemodynamically
stable in the ED, but after systolics dropped to ___ in the ED,
it was decided to admit the patient to the CCU. Her pressures
stabilized in the ___ after 2L NS in the ED. TTE showed RV
strain, BNP and troponins both mildly elevated. On the day after
admission, she was transitioned from a heparin drip to
subcutaneous lovenox. Given her active malignancy, she should
continue of LMWH longterm. She was transferred to a medicine
floor and weaned off oxygen.
#)Transaminitis: Rising ALT and AST. ___ be some component of
congestive hepatopathy. Possible drug effect but no new
medications and not taking consistent Tylenol. RUQ US w/ Doppler
was obtained which did not show PVT or other major
abnormalities.
#)Stage IIIb NSCLC: continued home. erlotinib 50 mg daily
#Hypertension: held lisinopril in setting of PEs with
hypotension at first but was able to restart as blood pressures
stabilized with systolic in the 140s-150s.
#Hyperlipidemia: withheld non-formulary WelChol 625 mg 3 tablets
daily
#Hypothyroidism: continued levothyroxine 137 mcg daily
#GERD: continued home ranitidine, omeprazole
Transitional Issues:
-Please follow LFTs and ensure they are downtrending or worked
up further for possible liver metastasis. On discharge AST 107,
ALT 120, T.Bili 0.5, Alk Phos 121.
-Will get outpatient LFTs faxed to PCP ___ ___
-Will likely need indefinite anticoagulation given unprovoked PE
in patient with malignancy. # CODE: Full confirmed
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Denosumab (Prolia) 60 mg SC Q6MONTHS
2. Erlotinib 50 mg PO DAILY
3. WelChol (colesevelam) 1875 mg oral DAILY
4. Levothyroxine Sodium 137 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Paroxetine 10 mg PO DAILY
8. Ranitidine 150 mg PO DAILY
9. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain
10. Cyanocobalamin 1000 mcg PO DAILY
11. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Paroxetine 10 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
6. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain
7. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg SC every 12 hours Disp #*60
Syringe Refills:*0
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Erlotinib 50 mg PO DAILY
10. Denosumab (Prolia) 60 mg SC Q6MONTHS
11. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
12. WelChol (colesevelam) 1875 mg ORAL DAILY
13. Outpatient Lab Work
Please get labs drawn on ___
AST, ALT, T. Bili, Alk Phos
Fax to: ___ MD
Fax: ___
ICD 10: R74.0, C34.90
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Massive Pulmonary Emboli
Secondary:
Stage 4 ___
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ on ___ after being short of
breath. We found that you had pulmonary emboli (blood clots in
your lungs). This caused your blood pressure to be low at first
so you were sent to the cardiac ICU, and then transferred to the
medicine floor for monitoring. We started you on blood thinners
to help keep you from getting more clots and to keep the clots
you already have from getting bigger. During your admission some
abnormal liver function tests were noticed. You got an
ultrasound which was unremarkable. It was a pleasure taking part
in your care. Please get your liver labs checked on ___.
Please attend all of your follow up appointments and take all of
your medications as prescribed.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10514375-DS-25 | 10,514,375 | 25,556,180 | DS | 25 | 2182-01-14 00:00:00 | 2182-01-14 16:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine / Dilaudid
Attending: ___
Chief Complaint:
Diarrhea, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with metastatic NSCLC
previously on erlotinib transitioned to osimertinib due to
progression, PE (on lovenox), who presented with diarrhea with
subsequent hypoxic respiratory failure.
Ms. ___ notes that she has been experiencing diarrhea for the
past ___ days. Has had ___ episodes daily, brown stool without
blood present. No obvious inciting event in the past ___ days,
however her daughter reports she was concerned her mother did
not
look well so they presented to the ED. She notes that she has
experienced diarrhea with osimertinib previously and required IV
fluids.
Ms. ___ reports her breathing had been difficult in the past
24
hours but acutely worsened following the second liter of LR
while
trying to ambulate. Prior to presentation notes increased cough
over the past few days, although chronic at baseline. No sputum
production and no fevers or chills.
She denies recent travel, sick contacts new medications. She
additionally denies any chest pain (past or present)
In the ED,
Initial Vitals: T97.1 HR105 BP137/78 RR 18 100% RA
Exam:
Labs:
UA: Negative
Chemistry: Na 139, K 4.2 Cl107 BUN 21 Sr Cr 0.8
Troponin:
CBC: WBC 4.2 Hgb 9.9, Plt 212, Differential with 59.6%
neutrophils
Imaging:
CXR ___:
PA and lateral views of the chest provided. Left apical fluid
better assessed on prior CT, grossly unchanged. Left lung
volume
loss is similar to prior CT. The right lung remains clear. No
definite acute findings to account for symptoms provided.
Consults: None
Interventions:
-1.5L LR
- 60mg IV Lasix (20, 40)
-Nitroglycerin gtt
VS Prior to Transfer: Afebrile HR 111 BP95/83 RR18 97% Bipap
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- HTN
- Hypothyroidism
- PE on lovenox
- Osteoporosis
- EGFR positive metastatic NSCLC (malignant L pleural effusion
s/p Pleurx and talc pleurodesis in ___ osseous mets)
Current Treatment:
- Erlotinib: started ___ - stopped ___
- Osimertinib: started ___
Oncologic History:
- Presented with back pain ___, referred for physical therapy
- MRI of the back ___ showed left lower lung mass
- ___ Chest CT: mass in superior segment of the left lower
lobe with associated lung collapse
- ___ PET-CT: FDG-positive mass in the left lower lobe
without any uptake in the mediastinum or elsewhere.
- ___ mediastinoscopy with biopsy of mediastinal lymph nodes
at level 4R, 4L and 2R, all positive for adenocarcinoma. Biopsy
from the left lower lobe lesions confirmed adenocarcinoma
- EGFR positive
- ___ bone biopsy negative for malignancy
- ___ CXR showed pleural effusion, no thoracentesis done
- ___: concomitant chemoradiation with cisplatin/etoposide
for 2 cycles
- ___: Cisplatin/Alimta for 2 cycles
- ___: PET scans with decreased FDG-avidity; no
evidence of tumor recurrence
- ___: PET with new left pleural effusion; thoracentesis
shows that cytology is positive for adenocarcinoma.
- ___: took Tarceva 150 mg PO daily; developed
dehydration, extreme fatigue, nausea, diarrhea resulting in a
hospitalization from ___ stopped Tarceva
- ___: talc pleurodesis and pleurex catheter placement for
management of malignant pleural effusion, catheter was pulled
prior to discharge
- ___: resumed Tarceva at a dose of 100 mg daily, developed
intolerable side effects of fatigue, nausea, sweats, and
discontinued it on ___.
- ___: presented with pericarditis and a small pericardial
effusion developed which waxed and waned but was never tapped.
- ___: restarted Tarceva 25 mg daily
- ___: increased Tarceva to 50 mg daily
- ___: CT with overall stable disease, slight enlargement of
the left hilar mass.
- ___: CT with decrease in size of left hilar mass
- ___: CT with stable disease
- ___: CT with stable disease
- ___: CT with stable disease
- ___: CT with stable disease
- ___ CT chest essentially stable disease
- ___: Imaging with essentially stable disease
- ___ - ___: Admitted for submassive PE; placed on
Enoxaparin
- ___: CT scan showed increased in size of tumor
- ___: CT scan showed increased osteoblastic lesions of the
spine and right pelvis
- ___: PET scan shows increased FDG avid disease in the
chest
and left hilum as well as uptake in multiple bony sites in the T
and L spine and the pelvic
-___: Repeat biopsy of lung lesion, sent for T790M mutation
testing
-___: Completed ___ fractions of radiation to L2-R hip
-___: T790M mutation reviewed in clinic - result negative.
Increasing erlotinib to 75mg daily
-___: CT TORSO shows improvement in thoracic disease burden
and stable bony disease
-___: CT TORSO shows stable disease
-___: Interval increase in size of a left lower lobe soft
tissue mass abutting the aorta, now measuring up to 3.9 cm and
previously measuring up to 2.7 cm.
-___ CT shows decrease in size of the previously growing
soft tissue mass next to the thoracic aorta. She has no clear
evidence of progression elsewhere, but 2 tiny nonspecific right
lung nodules. Continued erlotinib at 75mg QD
-___ CT torso with stable disease, progressive
cough/SOB/hemoptysis led to admission from ___ - ___ ___/P negative for PE, ___ embolization failed d/t dissection or
spasm. Restarted on daily therapeutic lovenox prior to discharge
w/o hemoptysis. Started on robitussin DM QD and codeine QHS.
Hypotensive response to dilaudid. IP bx'd LUL mass for
mechanisms
of resistance.
- ___ - Seen in clinic with progressive fatigue, back
pain.
Given concern for progression we send liquid biopsy, which
revealed a 0.73% allele frequency of her initial EGFR mutation,
negative for T790M but not a rule out given allele frequency
<1%.
- ___ - MRI spine with new likely metastatic T4 lesion,
otherwise stable mets; no compression/stenosis
- ___ - started osimertinib 80mg QD, initially very
fatigued/dehydrated so spaced to QOD
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
General: Tired appearing ___ woman resting in bed
Neuro: Cranial nerves: PERRL, Palate elevates symmetrically.
Provides
clear and cogent history.
HEENT: Oropharynx clear without lesions. No
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Decreased breath sounds throughout left lung
fields. No appreciable crackles, ronchi
Abdomen: Soft, nontender, nondistended
Extr/MSK: No peripheral edema, good muscle tone
Skin: No rashes
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1511)
Temp: 98.4 (Tm 98.4), BP: 122/69 (89-122/47-72), HR: 83
(82-93), RR: 18 (___), O2 sat: 100% (96-100)
Fluid Balance (last updated ___ @ 1205)
Last 8 hours No data found
Last 24 hours Total cumulative 275ml
IN: Total 600ml, PO Amt 600ml
OUT: Total 325ml, Urine Amt 325ml
GEN: Well appearing, in no acute distress
NECK: JVP at clavicle at 45 degrees
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
EXTREMITIES: No edema. WWP.
NEURO: AOx3.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:24PM WBC-4.2 RBC-3.47* HGB-9.9* HCT-31.0* MCV-89
MCH-28.5 MCHC-31.9* RDW-14.5 RDWSD-46.8*
___ 05:24PM NEUTS-59.6 ___ MONOS-11.2 EOS-2.2
BASOS-0.7 IM ___ AbsNeut-2.49 AbsLymp-1.09* AbsMono-0.47
AbsEos-0.09 AbsBaso-0.03
___ 05:24PM PLT COUNT-212
___ 05:24PM GLUCOSE-94 UREA N-21* CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-24 ANION GAP-8*
___ 05:24PM CK-MB-5 cTropnT-<0.01 proBNP-1104*
___ 01:09AM ___ PO2-36* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-0
PERTINENT LABS:
===============
___ 05:24PM CK-MB-5 cTropnT-<0.01 proBNP-1104*
___ 05:15AM CK-MB-3 cTropnT-<0.01
___ 09:50AM %HbA1c-5.6 eAG-114
___ 09:50AM TRIGLYCER-76 HDL CHOL-57 CHOL/HDL-3.4
LDL(CALC)-122
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-4.4 RBC-3.69* Hgb-10.4* Hct-32.9*
MCV-89 MCH-28.2 MCHC-31.6* RDW-13.8 RDWSD-44.9 Plt ___
___ 05:40AM BLOOD Glucose-94 UreaN-17 Creat-0.7 Na-141
K-4.8 Cl-106 HCO3-22 AnGap-13
___ 05:40AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1
Imaging/Studies:
================
CXR ___
Similar overall pattern of left apical fluid and left lung
volume loss in this patient with known lung cancer.
CXR ___
1. Mild acute pulmonary edema.
2. Likely small left pleural effusion.
3. Similar appearance of left apical fluid and left lung volume
loss, better assessed on prior CT chest from ___ in
this patient with known
lung cancer.
TTE ___
EF 42%
Borderline dilated left ventricle with septal dyssynchrony and
mild global
hypokinesis. Mildly dilated right ventricle with normal free
wall systolic function. Mildly dilated scending aorta with mild
to moderate aortic regurgitation. Mild mitral regurgitation.
Late ubbles from the right to left heart suggesting pulmonary
AVM.
___ PMIBI
IMPRESSION: 1. No evidence of focal reversible perfusion defect.
2. Decreased
left ventricular ejection fraction. 3. Moderately enlarged left
ventricular
cavity.
IMPRESSION: No anginal type symptoms or interpretable ST
segments.
Nuclear report sent separately.
Microbiology:
=============
___ 12:43 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Brief Hospital Course:
SUMMARY:
==================
Ms. ___ is a ___ woman with metastatic NSCLC
reviously on erlotinib transitioned to osimertinib due to
progression, PE (on lovenox), who presented with diarrhea with
subsequent hypoxemia requiring BIPAP. She was quickly diuresed
in the ICU, taken off BiPAP, and returned to room air. She was
then called out to the hospitalist service, where she was found
to have a new cardiomyopathy with EF of 42% on echocardiogram.
She was then transferred to cardiology service for workup of new
cardiomyopathy. She underwent pharmacologic stress test on ___
which did not demonstrate any perfusion defects.
TRANSITIONAL ISSUES:
===================
Discharge maintenance diuretic: none
Discharge weight: 135.36 lb
Discharge Cr: 0.7
[] New diagnosis of HFmrEF made during this admission. Etiology
of her exacerbation was unclear, felt to be possibly in the
setting of acute volume overload. She was not felt to need
maintenance diuretics at the time of discharge. Please follow-up
volume status as an outpatient and make adjustments as needed.
[] Heart failure regimen at time of discharge included
lisinopril 2.5mg and metoprolol succinate 25mg. Please adjust as
clinically appropriate.
[] Osimertinib was held during this inpatient admission and upon
discharge, with plan for close follow-up in ___ clinic to
discuss when to resume.
[] She presented with diarrhea which seemed to resolve in the
setting of holding osimertinib. If resuming osimertinib, please
monitor for recurrence of diarrhea.
ACUTE ISSUES
===============
# Hypoxic Respiratory Failure:
# Cardiomyopathy (EF 40%)
# Acute Systolic HF Exacerbation
Patient reported some increased dyspnea prior to presentation
but had an acute worsening in the setting of fluid
resuscitation. CXR ___ showed known left apical ffusion but
no evidence of gross volume overload or infiltrates. She briefly
required BIPAP in the ED but then discontinued prior to arrival
to the ICU and after a dose of IV Lasix. Given new LBBB on EKG,
there was a concern for cardiac event as trigger. Although CK MB
and troponin were negative, the patient ultimately did receive
an echo which showed depressed ejection fraction when compared
to prior TTE in ___ with global hypokinesis. She was
transferred to the cardiology service and underwent
pharmacologist stress test to rule out ischemia as a cause of
her new cardiomyopathy. PMIIB on ___ was without evidence of
perfusion defects. Osimertinib as a potential cause of her
cardiomyopathy was discussed with her outpatient oncologists and
was felt to be less likely. Overall it was felt that her mild
global hypokinesis may have been in the setting of volume
overload secondary to aggressive IVF resuscitation. Heart
failure regimen at time of discharge included lisinopril 2.5mg
and metoprolol succinate 25mg.
# Diarrhea: Reports previous bouts of diarrhea, sometimes
related to her immunotherapy. Stool studies including C. diff
were ordered on arrival, although patient did not have any
further diarrhea while in house. Diarrhea was self-limited and
resolved during hospitalization.
# Metastatic NSCLC: Previously on erlotinib, transitioned to
osimertinib ___ in setting of radiographic
progression of disease. Dr. ___ OK to hold osimertinib
while inpatient. She will hold this medication upon discharge
until her next ___ clinic appointment.
CHRONIC ISSUES
===============
# Hx of PE: Continued home lovenox ___ qd.
# Hypothyroidism: Continued home levothyroxine.
# Chronic Normocytic Anemia: H/H at baseline.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 200 mg PO TID cough
2. Cyanocobalamin 1000 mcg PO DAILY
3. Enoxaparin Sodium 100 mg SC DAILY
4. Levothyroxine Sodium 137 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
7. Denosumab (Prolia) 60 mg SC Q6MONTHS
8. Meclizine 12.5 mg PO TID:PRN dizziness
9. Polyethylene Glycol 17 g PO DAILY to keep your stool from
getting hard while taking oxycodone and codeine
10. Senna 8.6 mg PO BID to help prevent constipation
11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Benzonatate 200 mg PO TID cough
5. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Denosumab (Prolia) 60 mg SC Q6MONTHS
8. Enoxaparin Sodium 100 mg SC DAILY
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Meclizine 12.5 mg PO TID:PRN dizziness
11. Omeprazole 20 mg PO DAILY
12. PARoxetine 5 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY to keep your stool from
getting hard while taking oxycodone and codeine
14. Senna 8.6 mg PO BID to help prevent constipation
15. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Acute hypoxemic respiratory failure
Nonischemic cardiomyopathy
Acute systolic heart failure exacerbation
Secondary
Metastatic non-small cell lung cancer
History of pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you developed
shortness of breath after receiving IV fluid.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received medication to help you pee out fluid from your
lungs.
- You had an ultrasound of your heart which showed that your
heart was beating less well than usual. You will follow-up with
a heart doctor after you leave the hospital who will help manage
this.
- You underwent a stress test. This did not show any signs of
blockages in the blood vessels that supply the heart, which is
good news.
- Your home cancer medication (osimertinib/Tagrisso) was held
when you left this hospital. You will follow-up with your
outpatient cancer doctor who will tell you when to restart this
medication.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all your medicines and follow up with
your outpatient doctors as ___ (see below).
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10514375-DS-26 | 10,514,375 | 29,274,123 | DS | 26 | 2182-07-03 00:00:00 | 2182-07-03 16:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine / Dilaudid /
Tagrisso
Attending: ___.
Chief Complaint:
worsening skeletal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a pleasant ___ years old Female who presents to
___ ED for the further evaluation of worsening mid back pain
as
a referral from ___ clinic. Pain has been refractory to
home
tylenol, tramadol, and oxycodone 10mg. Denies any bladder or
bowel incontinence, or issues with ambulation. No recent trauma.
No recent fevers, chest pain, shortness of breath, nausea,
vomiting, diarrhea, abdominal pain, recent prolonged traveling,
or known exposure to sick contacts. Daughter at bedside at time
of exam. She was sent in for appropriate pain control with
eventual plan on undergoin an iliac biopsy to establish
treatment
plan going forward.
In the ED, initial vitals: 98.6 86 120/77 16 98% RA
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
- HTN
- Hypothyroidism
- PE on lovenox
- Osteoporosis
- EGFR positive metastatic NSCLC (malignant L pleural effusion
s/p Pleurx and talc pleurodesis in ___ osseous mets)
Current Treatment:
- Erlotinib: started ___ - stopped ___
- Osimertinib: started ___
Oncologic History:
- Presented with back pain ___, referred for physical therapy
- MRI of the back ___ showed left lower lung mass
- ___ Chest CT: mass in superior segment of the left lower
lobe with associated lung collapse
- ___ PET-CT: FDG-positive mass in the left lower lobe
without any uptake in the mediastinum or elsewhere.
- ___ mediastinoscopy with biopsy of mediastinal lymph nodes
at level 4R, 4L and 2R, all positive for adenocarcinoma. Biopsy
from the left lower lobe lesions confirmed adenocarcinoma
- EGFR positive
- ___ bone biopsy negative for malignancy
- ___ CXR showed pleural effusion, no thoracentesis done
- ___: concomitant chemoradiation with cisplatin/etoposide
for 2 cycles
- ___: Cisplatin/Alimta for 2 cycles
- ___: PET scans with decreased FDG-avidity; no
evidence of tumor recurrence
- ___: PET with new left pleural effusion; thoracentesis
shows that cytology is positive for adenocarcinoma.
- ___: took Tarceva 150 mg PO daily; developed
dehydration, extreme fatigue, nausea, diarrhea resulting in a
hospitalization from ___ stopped Tarceva
- ___: talc pleurodesis and pleurex catheter placement for
management of malignant pleural effusion, catheter was pulled
prior to discharge
- ___: resumed Tarceva at a dose of 100 mg daily, developed
intolerable side effects of fatigue, nausea, sweats, and
discontinued it on ___.
- ___: presented with pericarditis and a small pericardial
effusion developed which waxed and waned but was never tapped.
- ___: restarted Tarceva 25 mg daily
- ___: increased Tarceva to 50 mg daily
- ___: CT with overall stable disease, slight enlargement of
the left hilar mass.
- ___: CT with decrease in size of left hilar mass
- ___: CT with stable disease
- ___: CT with stable disease
- ___: CT with stable disease
- ___: CT with stable disease
- ___ CT chest essentially stable disease
- ___: Imaging with essentially stable disease
- ___ - ___: Admitted for submassive PE; placed on
Enoxaparin
- ___: CT scan showed increased in size of tumor
- ___: CT scan showed increased osteoblastic lesions of the
spine and right pelvis
- ___: PET scan shows increased FDG avid disease in the
chest
and left hilum as well as uptake in multiple bony sites in the T
and L spine and the pelvic
-___: Repeat biopsy of lung lesion, sent for T790M mutation
testing
-___: Completed ___ fractions of radiation to L2-R hip
-___: T790M mutation reviewed in clinic - result negative.
Increasing erlotinib to 75mg daily
-___: CT TORSO shows improvement in thoracic disease burden
and stable bony disease
-___: CT TORSO shows stable disease
-___: Interval increase in size of a left lower lobe soft
tissue mass abutting the aorta, now measuring up to 3.9 cm and
previously measuring up to 2.7 cm.
-___ CT shows decrease in size of the previously growing
soft tissue mass next to the thoracic aorta. She has no clear
evidence of progression elsewhere, but 2 tiny nonspecific right
lung nodules. Continued erlotinib at 75mg QD
-___ CT torso with stable disease, progressive
cough/SOB/hemoptysis led to admission from ___ - ___ ___/P negative for PE, ___ embolization failed d/t dissection or
spasm. Restarted on daily therapeutic lovenox prior to discharge
w/o hemoptysis. Started on robitussin DM QD and codeine QHS.
Hypotensive response to dilaudid. IP bx'd LUL mass for
mechanisms
of resistance.
- ___ - Seen in clinic with progressive fatigue, back
pain.
Given concern for progression we send liquid biopsy, which
revealed a 0.73% allele frequency of her initial EGFR mutation,
negative for T790M but not a rule out given allele frequency
<1%.
- ___ - MRI spine with new likely metastatic T4 lesion,
otherwise stable mets; no compression/stenosis
- ___ - started osimertinib 80mg QD, initially very
fatigued/dehydrated so spaced to QOD
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: ___ Temp: 98.6 PO BP: 120/77 HR: 86 RR: 16 O2
sat: 98% O2 delivery: RA
General appearance: Generally well appearing, in no acute
distress, daughter at bedside
Head, eyes, ears, nose, and throat: Pupils round and equally
reactive to light. Oropharynx clear with moist mucous membranes.
Lymph: No palpable cervical or supraclavicular lymphadenopathy.
Cardiovascular: Regular rate and rhythm, S1, S2, no audible
murmurs.
Respiratory: CTAB
Abdomen: Soft, nontender, nondistended. No palpable
hepatosplenomegaly.
MSK: Lumbar spine tender to palpation
Extremities: Warm, without edema.
Neurologic: Grossly normal strength, coordination and gait.
Skin: No rashes.
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 24 HR Data (last updated ___ @ 426)
Temp: 98.0 (Tm 98.9), BP: 105/54 (105-108/54-68), HR: 76
(74-78), RR: 18, O2 sat: 96% (92-96), O2 delivery: RA
General: well appearing, in no acute distress
Cardiovascular: RRR, S1, S2, no audible murmurs.
Respiratory: CTAB
Abdomen: Soft, nontender, nondistended.
MSK: Lumbar spine tender to palpation around T10
Extremities: Warm, without edema.
Neurologic: Grossly normal strength, coordination and gait.
Skin: No rashes.
ACCESS: PIV
Pertinent Results:
ADMISSION LABS
==============
___ 01:55PM GLUCOSE-102* UREA N-17 CREAT-0.8 SODIUM-135
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-29 ANION GAP-7*
___ 01:55PM ALT(SGPT)-27 AST(SGOT)-33 ALK PHOS-114* TOT
BILI-0.4
___ 01:55PM ALBUMIN-3.9
___ 01:55PM WBC-5.6 RBC-3.60* HGB-10.2* HCT-31.5* MCV-88
MCH-28.3 MCHC-32.4 RDW-14.0 RDWSD-44.9
___ 01:55PM NEUTS-66.9 ___ MONOS-9.5 EOS-1.8
BASOS-0.5 IM ___ AbsNeut-3.72 AbsLymp-1.16* AbsMono-0.53
AbsEos-0.10 AbsBaso-0.03
___ 01:55PM ___ PTT-26.8 ___
DISCHARGE LABS
===============
___ 06:00AM BLOOD WBC-4.9 RBC-3.24* Hgb-9.2* Hct-28.5*
MCV-88 MCH-28.4 MCHC-32.3 RDW-13.3 RDWSD-42.7 Plt ___
___ 05:30AM BLOOD ___
___ 06:00AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-140
K-4.5 Cl-99 HCO3-28 AnGap-13
___ 06:00AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.9
___ 06:00AM BLOOD Cortsol-6.9
IMAGING
=======
___ BIPAT HIPS X-RAY:
Sclerotic bone lesion consistent with metastatic disease at the
right iliac wing similar in overall pattern when compared with
prior CT. No fracture.
___ MRI THORACIC AND LUMBAR SPINE:
1. Significant increase in metastatic osseous involvement of the
spine,
including increasing involvement of the T4 and T12 vertebral
bodies as well as new lesions at C5 through T3, T5, and L5.
2. New epidural extension of tumor at the T12 level resulting in
mild neural foraminal stenosis on the left at T11-T12 and T12-L1
and on the right at T12-L1 without significant spinal canal
stenosis.
3. Right iliac bone and sacrum lesions appear stable.
4. Previously noted large left superior hemithorax loculated
fluid collection is partially imaged on the current study.
PREVALENCE: Prevalence of lumbar degenerative disk disease in
subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal,
height loss, bulge), T2 signal loss 83%, Disk height loss 58%,
Disk protrusion 32%, Annular fissure 38% ___, et al. Spine
___ 26(10):___
Lumbar spinal stenosis prevalence- present in approximately 20%
of
asymptomatic adults over ___ years old. ___, et al, Spine
Journal ___ 9 (7):545-550
___ TTE
Mild symmetric left ventricular hypertrophy with normal cavity
size and
moderate to severe global hypokinesis with visual dyssynchrony.
Normal right ventricular size and systolic function. Moderate
mitral regurgitation. Mild pulmonary artery systolic
hypertension.
Compared with the prior TTE (images reviewed) of ___ ,
the left ventricular systolic function is similar. The severity
of mitral regurgitation is now slightly increased.
PROCEDURES
==========
___ BONE, BIOPSY FOR TUMOR
Multifocal areas of sclerosis within the right iliac bone
corresponding to the FDG avid regions seen on recent PET scan.
Small volume of pelvic free fluid. No lymphadenopathy.
IMPRESSION:
Technically successful right iliac bone CT-guided biopsy.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
#NSCLC
[ ] F/u iliac bone biopsy results
[ ] Erlotinib restarted day after discharge at 100mg.
#Pain control, bony mets
[ ] MS ___ started inpatient for bony pain.
[ ] Prescribed bowel reg at discharge.
#Heart failure w reduced EF
[ ] Entresto reduced dose
[ ] Carvedilol discontinued due to hypotension, started on
metoprolol succinate at 12.5 mg daily.
#HCP/Contact: ___ (daughter) - ___
#Code: Full, presumed
SUMMARY:
========
___ PMH of metastatic NSCLC who presents for eval of worsening
mid back pain as a referral from ___ clinic. She received 5
fractions of radiation to T10-L1 for her bony pain. She
underwent a biopsy of the right iliac bone to determine if there
is a new mechanism of treatment resistance. She was discharged
on long acting MS ___ with oncology follow up.
ACTIVE/ACUTE ISSUES:
====================
# Back pain, hip pain:
Patient had presented to clinic with worsening mid-pack pain and
was admitted for pain control. She was febrile and HD stable, no
leukocytosis to suggest infection. Her pain is likely ___ to
known metastatic osseous sites. Bilateral hip x-rays showed
sclerotic bone lesions consistent with metastatic disease at the
right iliac. MRI showed significant increase in metastatic
involvement of spine, including T4 and T12 vertebral bodies, new
lesions at C5 through T3, T5, and L5. R iliac and sacrum lesions
appear stable. She was started on MS ___ 15mg q12h for
long-acting pain relief. She also received Tylenol ___
TID and oxycodone ___ q6h:PRN. Radiation Oncology met with
the patient for treatment planning and performed palliative
radiation during admission. She received her R iliac biopsy on
___. On discharge, the patient's pain is well-controlled
and she will continue MS ___. She will follow up with her
primary oncologist to review biopsy results.
# Hypotension:
# HFrEF:
HFrEF developed in ___ with sx including SOB, DOE and
worsened to EF 24% on ___ TTE despite optimal medical
management (Entresto, carvedilol). Stress, mibi without e/o
reversible ischemia. cMRI with no fibrosis/inflammation
suggesting osimertinib as the only likely cause. As above, this
is an uncommon complication of osimertinib therapy though
appears more common on this than other TKIs. During admission,
she had 2 episodes of asymptomatic hypotension (BP ___,
where she denied any chest pain/palpitations,
lightheadedness/presyncope, which improved with fluids. Her
Entresto and carvedilol were discontinued and BPs remained
stable afterwards. There was a concern for worsening HF; repeat
TTE showed EF of ___ with slight increase in mitral
regurgitation compared to TTE of ___. Heart
Failure/Cardiology was consulted and recommended restarting
Entresto at 24mg/26mg (lower dose) and metroprolol succinate
12.5mg daily. Upon discharge, the patient's BP is 121/65, she is
asymptomatic, and will begin taking these new medications.
CHRONIC/STABLE ISSUES:
======================
# Metastatic NSCLC:
Patient was diagnosed with EGFR-mutant SIII NSCLC in ___.
Completed two cyclescisplatin/etoposide concurrent radiation
followed by two cyclesof cisplatin/pemetrexed. She recurred in
the pleural fluid in ___ and was initiated on erlotinib at
that time. She remained on erlotinib from ___ - ___, with
eventual dose reduction to 75mg QD for tolerance of AEs; later
transitioned to osimertinib howver discontinued ___ progressive
cardiomyopathy. Per outpatient oncology team, erlotibin to be
restarted at discharge.
# Pulmonary embolism:
- Continued home lovenox ___ daily
# Hypothyroidism
- Continued home synthroid
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. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
2. Meclizine 12.5 mg PO Q8H:PRN dizziness
3. CARVedilol 6.25 mg PO BID
4. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. Atorvastatin 20 mg PO QPM
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
7. Omeprazole 20 mg PO DAILY
8. PARoxetine 10 mg PO DAILY
9. Levothyroxine Sodium 137 mcg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*60 Tablet Refills:*0
3. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
RX *sacubitril-valsartan [Entresto] 24 mg-26 mg 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 8.6 mg by mouth twice a day Disp #*60
Tablet Refills:*0
5. Atorvastatin 20 mg PO QPM
6. Enoxaparin Sodium 100 mg SC DAILY
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Meclizine 12.5 mg PO Q8H:PRN dizziness
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
11. PARoxetine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Pain secondary to bony metastases
EGFR-mutant stage III non-small cell lung cancer
Secondary diagnoses:
Heart failure with reduced ejection fraction
Hypertension
Hypothyroidism
Pulmonary embolism (on lovenox)
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital because you were experiencing severe
back pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your pain was managed with medications.
- You received an MRI of your spine.
- You were evaluated by the Radiation Oncology team and you
received radiation to your spine to help with your pain.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed.
- Please follow up with all the appointments scheduled with your
doctor.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10514375-DS-27 | 10,514,375 | 25,329,373 | DS | 27 | 2182-07-14 00:00:00 | 2182-07-14 16:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine / Dilaudid /
Tagrisso
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
================
___ 02:15PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 01:13PM ___ PO2-41* PCO2-38 PH-7.45 TOTAL CO2-27
BASE XS-2 COMMENTS-GREEN TOP
___ 01:13PM K+-4.1
___ 01:06PM D-DIMER-3991*
___ 01:03PM GLUCOSE-106* UREA N-11 CREAT-0.6 SODIUM-135
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-11
___ 01:03PM estGFR-Using this
___ 01:03PM ALT(SGPT)-21 AST(SGOT)-54* ALK PHOS-147* TOT
BILI-0.5
___ 01:03PM LIPASE-18
___ 01:03PM cTropnT-<0.01
___ 01:03PM proBNP-3955*
___ 01:03PM ALBUMIN-4.0 CALCIUM-9.3 PHOSPHATE-3.9
MAGNESIUM-1.9
___ 01:03PM WBC-5.7 RBC-4.05 HGB-11.4 HCT-35.2 MCV-87
MCH-28.1 MCHC-32.4 RDW-14.2 RDWSD-44.7
___ 01:03PM NEUTS-73.5* LYMPHS-13.3* MONOS-11.6 EOS-0.7*
BASOS-0.5 IM ___ AbsNeut-4.19 AbsLymp-0.76* AbsMono-0.66
AbsEos-0.04 AbsBaso-0.03
___ 01:03PM PLT COUNT-286
DISCHARGE LABS:
================
___ 06:22AM BLOOD WBC-4.5 RBC-3.51* Hgb-10.0* Hct-30.9*
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.6 RDWSD-46.0 Plt ___
___ 06:22AM BLOOD Glucose-87 UreaN-10 Creat-0.6 Na-139
K-4.7 Cl-103 HCO3-24 AnGap-12
___ 06:22AM BLOOD ALT-18 AST-25 AlkPhos-123* TotBili-0.4
___ 06:22AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
MICROBIOLOGY:
==============
- None
IMAGING:
===========
- ___ CXR
Loculated left apical pleural effusion and left lung volume
loss. Right
basilar atelectatic changes. Likely small left pleural effusion
and blunting of the costophrenic angle with underlying
compressive atelectasis. Left perihilar opacities may be
secondary to the mass which was better evaluated on the prior
CT. Increased sclerosis of the lower (T12) thoracic vertebral
body is consistent with known metastatic lesions.
- ___ CTA Chest
1. No evidence of pulmonary embolism.
2. Stable appearance of the left hilar mass with persistent
collapse of the left upper lobe.
3. Stable fibrotic changes in the bilateral paramediastinal
lungs, likely
sequelae of or prior radiation therapy.
4. Stable left apical loculated effusion, unchanged.
5. Bilateral pulmonary nodules perhaps marginally increased in
size though
small changes may be due to differences in technique and
continued follow-up is suggested.
Brief Hospital Course:
___ with history of EGFR positive metastatic NSCLC with mets to
hilum and bone, s/p 2 cycles cis/alimta c/b malignant effusions,
then started on erlotinib (discontinued due to side effects then
re-trialed), followed by osimertinib (___) c/b HFrEF (EF 24%
___ causing cessation in ___, now back on erlotinib, who
presented with dyspnea and weakness presumed secondary to air
hunger, improving with IV opiates.
ACTIVE ISSUES:
=================
# Fatigue
Labs/imaging unrevealing. Felt secondary to erlotinib, MS
contin, and underlying deconditioning in the setting of
malignancy. During admission, home MS contin decreased to ___
and erlotinib held. Outpatient oncologist was alerted of
admission and will manage erlotinib moving forward.
# Dyspnea
Without hypoxia. Imaging without pneumonia, pulmonary edema, or
new PE. Improved with 1mg IV morphine suggesting air hunger.
Discharge with home oxycodone as needed for air hunger.
# Metastatic NSCLC with mets to hilum and bone
EGFR positive. S/p 2 cycles cis/alimta c/b malignant effusions,
then started on erlotinib (discontinued due to side effects then
re-trialed), followed by osimertinib (___) c/b HFrEF (EF 24%
___ causing cessation in ___, recently re-started on
erlotinib. Erlotinib held on discharge. Outpatient oncologist,
Dr. ___ of admission and will manage erlotinib in
outpatient setting.
CHRONIC ISSUES:
=================
# HFrEF
Thought to be secondary to osimertinib. Recent TTE ___ with
stable EF. Continued home ___ and metoprolol.
# Pulmonary Embolism: Continued home lovenox ___ daily
# Hypothyroidism: Continued home Synthroid
TRANSITIONAL ISSUES:
======================
[] Discuss whether erlotinib should be continued at follow-up
with Dr. ___ concern that presentation for fatigue may
have been secondary to this.
CODE: Full, presumed
EMERGENCY CONTACT HCP: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 137 mcg PO DAILY
2. Meclizine 12.5 mg PO Q8H:PRN dizziness
3. Omeprazole 20 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. PARoxetine 10 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
8. Morphine SR (MS ___ 15 mg PO Q12H
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Benzonatate 100 mg PO TID:PRN cough
11. GuaiFENesin-CODEINE Phosphate 5 mL PO ___ cough
12. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: First Routine Administration Time
13. Erlotinib 75 mg PO DAILY
14. Cyanocobalamin 1000 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Morphine SR (MS ___ 15 mg PO ___
2. Benzonatate 100 mg PO TID:PRN cough
3. Cyanocobalamin 1000 mcg PO DAILY
4. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: First Routine Administration Time
5. GuaiFENesin-CODEINE Phosphate 5 mL PO ___ cough
6. Levothyroxine Sodium 137 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Meclizine 12.5 mg PO Q8H:PRN dizziness
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Moderate
Pain, Shortness of Breath
13. PARoxetine 10 mg PO DAILY
14. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
15. Senna 8.6 mg PO BID:PRN constipation
16. HELD- Erlotinib 75 mg PO DAILY This medication was held. Do
not restart Erlotinib until discussing with your oncologist, Dr.
___
___ Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Cancer-associated dyspnea
Deconditioning
SECONDARY DIAGNOSIS:
=====================
EGFR-positive metastatic ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital because you were feeling short
of breath and weak.
In the hospital, you had an X-ray and CT-scan of your lungs that
showed your cancer was stable. You had no evidence of new blood
clots in the lungs, which is great news. You were treated with
pain medication and your breathing improved.
When you leave the hospital, please continue taking all your
medications as prescribed and attend your follow-up appointments
(see below for details). You should also weigh yourself every
morning and call your doctor if your weight goes up by more than
3 pounds.
It was a privilege caring for you, and we wish you well!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10514375-DS-28 | 10,514,375 | 20,808,220 | DS | 28 | 2182-08-27 00:00:00 | 2182-08-27 21:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Adhesive / Tegaderm / morphine / Dilaudid /
Tagrisso
Attending: ___.
Chief Complaint:
PRIMARY ONCOLOGIST: Dr. ___
PRIMARY DIAGNOSIS: Metastatic NSCLC
TREATMENT REGIMEN: Erlotinib
CC: ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with hypertension,
hypothyroidism, osimertinib-induced cardiomyopathy (EF ___ in
___, PE on lovenox and metastatic NSCLC (EGFR positive) on
Erlotinib who presents with dyspnea.
Patient reports several days of worsening dyspnea at both rest
and exertion. Also notes worsening cough with some sputum
production. She notes central chest pain that is worse with deep
breaths, coughing, and exertion. She has been unable to sleep
due to her shortness of ___.
On arrival to the ED, initial vitals were 97.8 94 127/72 26 96%
RA. Exam was notable for diminished ___ sounds at left base.
Labs were notable for WBC 7.1, H/H 11.3/35.5, Plt 354, INR 1.1,
Na 139, K 4.5, BUN/Cr ___, ALT 45, AST 48, ALP 169, Tbili
0.5,
BNP 6181, trop < 0.01, lactate 1.0, VBG 7.37/46/34, and UA
negative. Urine culture was sent. Influenza PCR was negative.
CXR showed stable small bilateral pleural effusions, increased
interstitial edema, and stable opacities within the left upper
and lower lungs. CTA chest showed non-enhancing solid and
ground-glass opacities at the right middle/lower lobe suspicious
for pneumonia, mild volume overload, no PE, and interval disease
progression. EKG with SR at 95 and LBBB. Patient was given Zosyn
4.5g IV, Toradol 30mg IV, and Tylenol 1g PO. Prior to transfer
vitals were 98.5 89 131/81 16 97% 2L.
On arrival to the floor, patient reports headache which is now
improved. Also reports some abdominal cramps and mild diarrhea
in the ED after she was given antibiotics. She denies
fevers/chills, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, hemoptysis, chest
pain, palpitations, nausea/vomiting, hematemesis,
hematochezia/melena, dysuria,
hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Presented with back pain ___, referred for physical therapy
- MRI of the back ___ showed left lower lung mass
- ___: Chest CT: mass in superior segment of the left lower
lobe with associated lung collapse
- ___: PET-CT: FDG-positive mass in the left lower lobe
without any uptake in the mediastinum or elsewhere.
- ___: Mediastinoscopy with biopsy of mediastinal lymph
nodes
at level 4R, 4L and 2R, all positive for adenocarcinoma. Biopsy
from the left lower lobe lesions confirmed adenocarcinoma
- EGFR positive
- ___: Bone biopsy negative for malignancy
- ___: CXR showed pleural effusion, no thoracentesis done
- ___: Concomitant chemoradiation with cisplatin/etoposide
for 2 cycles
- ___: Cisplatin/Alimta for 2 cycles
- ___: PET scans with decreased FDG-avidity; no
evidence of tumor recurrence
- ___: PET with new left pleural effusion; thoracentesis
shows that cytology is positive for adenocarcinoma.
- ___: Took Tarceva 150 mg PO daily; developed
dehydration, extreme fatigue, nausea, diarrhea resulting in a
hospitalization from ___ stopped Tarceva
- ___: Talc pleurodesis and pleurex catheter placement for
management of malignant pleural effusion, catheter was pulled
prior to discharge
- ___: Resumed Tarceva at a dose of 100 mg daily, developed
intolerable side effects of fatigue, nausea, sweats, and
discontinued it on ___.
- ___: Presented with pericarditis and a small pericardial
effusion developed which waxed and waned but was never tapped.
- ___: Restarted Tarceva 25 mg daily
- ___: Increased Tarceva to 50 mg daily
- ___: CT with overall stable disease, slight enlargement of
the left hilar mass.
- ___: CT with decrease in size of left hilar mass
- ___: CT with stable disease
- ___: CT with stable disease
- ___: CT with stable disease
- ___: CT with stable disease
- ___ CT chest essentially stable disease
- ___: Imaging with essentially stable disease
- ___: Admitted for submassive PE; placed on
Enoxaparin
- ___: CT scan showed increased in size of tumor
- ___: CT scan showed increased osteoblastic lesions of the
spine and right pelvis
- ___: PET scan shows increased FDG avid disease in the
chest
and left hilum as well as uptake in multiple bony sites in the T
and L spine and the pelvic
- ___: Repeat biopsy of lung lesion, sent for T790M mutation
testing
- ___: Completed ___ fractions of radiation to L2-R hip
- ___: T790M mutation reviewed in clinic - result negative.
Increasing erlotinib to 75mg daily
- ___: CT TORSO shows improvement in thoracic disease
burden
and stable bony disease
- ___: CT TORSO shows stable disease
- ___: Interval increase in size of a left lower lobe soft
tissue mass abutting the aorta, now measuring up to 3.9 cm and
previously measuring up to 2.7 cm.
- ___: CT shows decrease in size of the previously growing
soft tissue mass next to the thoracic aorta. She has no clear
evidence of progression elsewhere, but 2 tiny nonspecific right
lung nodules. Continued erlotinib at 75mg QD
- ___: CT torso with stable disease, progressive
cough/SOB/hemoptysis led to admission from ___ - ___ ___/P negative for PE, ___ embolization failed d/t dissection or
spasm. Restarted on daily therapeutic lovenox prior to discharge
w/o hemoptysis. Started on robitussin DM QD and codeine QHS.
Hypotensive response to dilaudid. IP bx'd LUL mass for
mechanisms
of resistance.
- ___: Seen in clinic with progressive fatigue, back pain.
Given concern for progression we send liquid biopsy, which
revealed a 0.73% allele frequency of her initial EGFR mutation,
negative for T790M but not a rule out given allele frequency
<1%.
- ___: MRI spine with new likely metastatic T4 lesion,
otherwise stable mets; no compression/stenosis
- ___: Started osimertinib 80mg QD, initially very
fatigued/dehydrated so spaced to QOD
- ___: CT Torso with stable disease
- ___: CT Torso with stable disease
- ___: New SOB, DOE TTE with EF 42% globally depressed;
stress and regadenason mibi with no areas of reversible ischemia
- ___: CT Torso with stable disease
- ___: TTE with EF down to 24%; non dilated, severely
hypokinetic left ventricle. Normal right ventricular size and
systolic function. Mild pulmonary artery systolic hypertension.
- ___: Cardiac MRI with dilated LV with severe global
systolic dysfunction and IV dysynchrony. Normal RV, no late gad
enhancement c/w absence of scar/fibrosis. B/l pleural effusions.
- ___: Called to recommend stopping osimertinib given c/f
drug-induced CMP. Pt held beginning ___.
- ___: CT torso with stable disease
- ___: PET/CT torso with progressive osseous disease with
increased number and extent of metastatic lesions throughout the
axial skeleton; stable innumerable small bilateral pulmonary
lesions; stable L hilar soft tissue mass. Recommended biopsy of
progressing osseous met, but pt delayed procedure given she felt
symptomatically stable.
- ___: Admitted for worsening bone pain. MRI
T/L-spine with significant progression of disease within the
spine, sacral/iliac lesions appeared unchanged. Most concerning
was epidural extension of tumor causing mild neural foraminal
narrowing at T11/12 and T12/L1. On ___ underwent ___ iliac
biopsy
for mechanism of resistance (vertebral biopsy felt too
technically difficult). Foundation Once CDX from ___ iliac
biopsy without identified mechanism of resistance
(redemonstrated
founder EGFRexon 19 deletion (L747_A750>P) and showed BAP1 and
BCOR muts as well as FGF10 and RICTOR amplification); reported
___. She underwent 2000cGy palliative radiation to T10-L1
during that hospitalization.
- ___: Admitted with sudden onset SOB, CTA chest
with no PE nor interval change in findings compared to ___
PET/CT. SOB improved with morphine administration and holding
Tarceva.
PAST MEDICAL HISTORY:
- Osimertinib-Induced Cardiomyopathy (EF ___ in ___
- Hypertension
- Hypothyroidism
- PE on lovenox
- Osteoporosis
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
ADMISSION EXAM
VS: Temp 98.3, BP 132/75, HR 87, RR 18, O2 sat 94% RA.
GENERAL: Pleasant fatigued-appearing woman, in no distress,
lying
in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, R>L bibasilar
crackles,
speaking in full sentences.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, 1+ R>L lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
DISCHARGE EXAM
24 HR Data (last updated ___ @ 743)
Temp: 98.2 (Tm 98.8), BP: 126/72 (91-126/55-76), HR: 103
(86-103), RR: 17 (___), O2 sat: 96% (94-99), O2 delivery: RA,
Wt: 133.9 lb/60.74 kg
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: mild tachy, prominent S2 splitting
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
SKIN: No rashes or ulcerations noted
EXTR: wwp mild bilateral edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS:
___
___ 07:57PM BLOOD WBC-7.1 RBC-3.99 Hgb-11.3 Hct-35.5 MCV-89
MCH-28.3 MCHC-31.8* RDW-15.3 RDWSD-49.6* Plt ___
___ 05:05AM BLOOD WBC-6.9 RBC-3.50* Hgb-9.8* Hct-30.7*
MCV-88 MCH-28.0 MCHC-31.9* RDW-15.3 RDWSD-49.2* Plt ___
___ 05:05AM BLOOD WBC-5.6 RBC-3.68* Hgb-10.2* Hct-32.5*
MCV-88 MCH-27.7 MCHC-31.4* RDW-15.4 RDWSD-50.0* Plt ___
___ 05:05AM BLOOD WBC-6.0 RBC-3.78* Hgb-10.6* Hct-33.5*
MCV-89 MCH-28.0 MCHC-31.6* RDW-15.4 RDWSD-50.0* Plt ___
COAG
___ 07:57PM BLOOD ___ PTT-30.4 ___
BMP
___ 07:57PM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-139
K-4.5 Cl-103 HCO3-24 AnGap-12
___ 05:05AM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-138
K-3.7 Cl-104 HCO3-21* AnGap-13
___ 05:05AM BLOOD Glucose-112* UreaN-12 Creat-0.6 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-11
___ 05:05AM BLOOD Glucose-89 UreaN-12 Creat-0.6 Na-138
K-4.5 Cl-101 HCO3-24 AnGap-13
OTHER CHEM
___ 07:57PM BLOOD ALT-45* AST-48* AlkPhos-169* TotBili-0.5
___ 07:57PM BLOOD proBNP-6181*
___ 07:57PM BLOOD cTropnT-<0.01
___ 07:57PM BLOOD Albumin-3.9 Calcium-8.8 Phos-2.8 Mg-1.9
___ 05:05AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
___ 05:05AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
___ 05:05AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0
___ 07:57PM BLOOD ___ pO2-34* pCO2-46* pH-7.37
calTCO2-28 Base XS-0
MICROBIOLOGY:
___ Influenza A/B PCR - Negative
___ Urine Culture - CONTAMINATED
___ Blood cx x2 - NGTD
___ 3:02 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
IMAGING:
CXR ___
Impression: Similar extent of small bilateral pleural effusions.
Increased interstitial edema. Stable opacities within the left
upper and lower lungs, better assessed on prior CT.
CTA Chest ___
1. No evidence of pulmonary embolism or aortic abnormality.
2. Non-enhancing solid and ground-glass opacities at the right
middle/lower lobe are suspicious for pneumonia in the
appropriate clinical setting. These changes are seen on a
background of mild volume overload.
3. Findings are also consistent with interval disease
progression including the appearance of new pulmonary nodules
and interval enlargement of others. The known left hilar mass
appears similar in size with persistent left upper lobe
collapse.
4. Similar appearance of a loculated left apical pleural
effusion with a new small right pleural effusion.
5. Interval partial height loss of the T4 vertebral body and
increased sclerosis concerning for disease involvement.
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
visual left ventricular dyssnchrony. Overall left ventricular
systolic function is severely depressed. The visually estimated
left ventricular ejection fraction is ___. There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. There is
abnormal septal motion c/w conduction abnormality/paced rhythm.
The aortic sinus diameter is normal for gender with a normal
ascending aorta diameter for gender. The aortic arch diameter is
normal with a normal descending aorta diameter. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is mild [1+] aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is an eccentric jet of mild to moderate [___]
mitral regurgitation. Due to the Coanda effect, the severity of
mitral regurgitation could be UNDERestimated. 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 a trivial pericardial effusion.
IMPRESSION: Severe LV global hypokinesis (LVEF ___ with
visual dyssynchrony. Mild to moderate eccentric MR. ___ AR.
___ with the prior TTE ___ , the LVEF is likely
similar but overestimated on the previous study in the setting
of suboptimal image quality.
Brief Hospital Course:
___ year old woman with HTN, hypothyroidism, metastatic lung
adenocarcinoma (EGFR positive) on Erlotinib, PE on Lovenox,
osimertinib-induced cardiomyopathy (EF ___ in ___, who
presented with dyspnea due to CHF and suspected PNA.
# Shortness of ___, cough
# CAP
# Acute on Chronic HFrEF:
Ms. ___ presented with dyspnea, cough. Exam was notable for
being afebrile, O2 sats 96% on RA. Labs were notable for WBC
7.1, Influenza PCR neg. She clearly appeared dyspneic with
minimal exertion. CTA showed RML/RLL GGO suspicious for PNA (no
PE).
There were also signs of acute on chronic sCHF - which
included elevated BNP 6181 (increased from prior), weight up ___
lbs (139.7 lbs from 134 lbs), ___ edema. It is likely that
the addition of dexamethasone may have contributed to retained
sodium/fluid intake.
She was initially treated for CAP with IV CTX and
azithromycin and then transitioned to cefpodoxime/azithromycin
to complete 5 day course. She was also given IV lasix ___ mg
daily with good response. The goal wt 133-134 lbs. Her
discharge weight was 133.9 lbs. Discharged on Lasix 20 mg
daily (an increase from 10 mg daily - which she reports she
takes). She was counseled on checking daily weights, watching
for edema, and calling her doctors with any significant changes
or concerns.
She had a TTE that was overall similar although EF estimated
as ___ instead of ___ (felt to be more due to poor quality
of prior images than true change). She continued to be treated
with Duonebs PRN, home Entresto and metoprolol, Benzonatate and
guaifenesin PRN. Overall, her breathing improved dramatically
by the time of discharge. She was discharged in good stable
condition.
# Metastatic NSCLC:
# Secondary Neoplasm of Bone:
# Secondary Neoplasm of Lung: Patient with progression while on
erolotinib. Plan was to potentially start Pemetrexed-containing
therapy. Patient initially wished to defer starting chemotherapy
until ___ however is now interested in sooner given
worsening symptoms. Outpt oncology doctor ___ Ms. ___
while in the hospital. She is due for outpatient brain MRI and
PET/CT. She was continued on folate and B12
# Cancer-Related Pain
- Continued MS contin and oxycodone
# Cancer-Related Fatigue
- Continued home dexamethasone
# Pulmonary Embolism
- Continued home lovenox ___ daily
# Hypothyroidism
- Continued home Synthroid
=====================
TRANSITIONAL ISSUES:
- continued titration of lasix as outpatient
- close follow-up with oncology and cardiology
=====================
>30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Morphine SR (MS ___ 15 mg PO Q12H
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
8. PARoxetine 10 mg PO DAILY
9. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Dexamethasone 2 mg PO DAILY
12. Furosemide 10 mg PO DAILY
13. Enoxaparin (Treatment) 100 mg SC Q24H
14. Erlotinib 50 mg PO DAILY
15. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 2 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO BID Duration: 3 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*5
Tablet Refills:*0
[ clarified with pharmacy this was actually 1 tablet twice daily
]
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Benzonatate 100 mg PO TID:PRN cough
5. Cyanocobalamin 1000 mcg PO DAILY
6. Dexamethasone 2 mg PO DAILY
7. Enoxaparin (Treatment) 100 mg SC Q24H
8. Erlotinib 50 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Morphine SR (MS ___ 15 mg PO Q12H
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
16. PARoxetine 10 mg PO DAILY
17. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic systolic heart failure
Pneumonia
Lung cancer
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 looking after you. As you know, you were
admitted with shortness of ___ and a cough. Chest x-ray and
blood tests here revealed that the breathing difficulties were
caused by a combination of congestive heart failure and
pneumonia.
You were treated with diuretics with good response. Your
final weight was approximately 133 lbs... Please follow your
weight and maintain in this range, if possible. It is possible
that the dexamethasone has contributed to some fluid retention.
As a result, your home lasix dose was increased to 20 mg daily.
Weigh yourself every morning, and call your doctor if your
weight goes up more than 3 lbs.
Please complete the short course of oral antibiotics to fully
treat the pneumonia.
Again, it was a pleasure and we wish you quick recovery and
good health.
Your ___ Team
Followup Instructions:
___
|
10514501-DS-7 | 10,514,501 | 21,542,265 | DS | 7 | 2128-06-17 00:00:00 | 2128-06-18 13:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a ___ year old female with PMHx G6PD, HTN, GERD, and
recurrent pneumothoraces ___ endometriosis s/p recent
pleurodesis, who is presenting with lower extremity edema. She
reports that for the past three days, she has noted a change in
her voice while conversing. She believes that this is because
she becomes short of breath while she is talking. She noted
bilateral leg swelling this morning which prompted her to come
into the ED. She also notes PND, denies orthopnea. She snores at
night. Denies any chest pain or palpitations.
Of note, Ms. ___ was transferred to ___ from ___ on
___ for definitive surgical management of her recurrent
right sided pneumothoraces. She was taken to the OR and was
found to have a diaphragm that was covered in tissue consistent
with endometriosis, which was confirmed endometriosis by biopsy.
She underwent pleurodesis at this time.
In the ED, initial vitals were: 97.4 104 164/81 19 100% RA
- Labs were significant for: Na 140 K 4.1 Cl 105 CO2 21 BUN 10
Cr 0.6
- proBNP: 33, D-Dimer: 6245, Trop-T: <0.01
- WBC 7.9 Hgb 10.7 Hct 34.6 Plt 328
- UA with mod leuks, 13 WBCs, few bacteria
- Imaging revealed:
- CTA chest: No pulmonary embolism or acute aortic process.
Mild interval increase in right pleural effusion and compressive
lower lobe atelectasis. Top normal heart size with dilated main
pulmonary artery - please correlate for pulmonary hypertension.
- Bilateral LENIS: No evidence of deep venous thrombosis in the
right or left lower extremity veins.
- CXR: Persistent small right pleural effusion with associated
compress the right lower lung atelectasis, difficult to exclude
a superimposed pneumonia at the right lung base.
- EKG: sinus rhythm, rate 99, normal axis, normal intervals, TWI
avF c/p prior
- The patient was given: Tylenol and Oxycodone
- Vitals prior to transfer were: 75 117/60 20 100% RA
Upon arrival to the floor, patient reports that she feels well
and the swelling in her legs has improved a little.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hypertension
2. G6PD deficiency
3. GERD/gastritis
4. Endometriosis
5. Recurrent right pneumothorax
6. B/L hip brusitis
7. Gastritis (remote)
PSH
1. s/p Partial hysterectomy
2. s/p umbilical hernia repair with mesh
Social History:
___
Family History:
Mother DM, BOOP (alive and well)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.9 116/65 77 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Some flank pain around
prior surgical sites that are c/d/i.
GU: No foley
Ext: Trace pitting edema in bilateral LEs. Warm, well perfused,
2+ pulses, no clubbing, cyanosis
DISCHARGE PHYSICAL EXAM:
Vitals: 98.9, 116/65, 77, 18, 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP at 1inch above clavicle at 45 deg angle
Lungs: decreased breath sounds to ___ of right posterior lung
field, left CTA b/l
CV: RRR, nl S1, prominent S2, no murmurs/rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: WWP, trace ___ edema, symmetric, no tenderness to palpation
Neuro: CN ___ grossly intact
Pertinent Results:
ADMISSION LABS:
___ 04:18PM BLOOD WBC-7.9 RBC-3.44* Hgb-10.7* Hct-34.6
MCV-101* MCH-31.1 MCHC-30.9* RDW-12.5 RDWSD-45.5 Plt ___
___ 04:18PM BLOOD Neuts-74.4* Lymphs-17.8* Monos-6.2
Eos-1.0 Baso-0.3 Im ___ AbsNeut-5.89 AbsLymp-1.41
AbsMono-0.49 AbsEos-0.08 AbsBaso-0.02
___ 04:09PM BLOOD ___ PTT-29.7 ___
___ 04:18PM BLOOD Glucose-103* UreaN-10 Creat-0.6 Na-140
K-4.1 Cl-105 HCO3-21* AnGap-18
___ 07:18AM BLOOD CK(CPK)-59
___ 04:09PM BLOOD cTropnT-<0.01
___ 04:18PM BLOOD proBNP-33
___ 04:09PM BLOOD D-Dimer-6245*
DISCHARGE LABS
___ 07:18AM BLOOD WBC-6.5 RBC-2.98* Hgb-9.2* Hct-29.4*
MCV-99* MCH-30.9 MCHC-31.3* RDW-12.7 RDWSD-45.3 Plt ___
___ 07:18AM BLOOD Glucose-84 UreaN-10 Creat-0.5 Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
___ 07:18AM BLOOD Calcium-8.9 Phos-3.9# Mg-2.4
___ 07:18AM BLOOD CK-MB-<1 cTropnT-<0.01
IMAGING/STUDIES:
CXR ___
Persistent small right pleural effusion with associated compress
the right
lower lung atelectasis, difficult to exclude a superimposed
pneumonia at the right lung base.
___ ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CTA ___
1. No pulmonary embolism or acute aortic process.
2. Mild interval increase in right pleural effusion and
compressive lower lobe atelectasis
3. Top normal heart size with dilated main pulmonary artery -
please correlate for pulmonary hypertension.
MICROBIOLOGY: N/A
Brief Hospital Course:
___ year old female with PMHx G6PD, HTN, GERD, and recurrent
pneumothoraces ___ endometriosis s/p recent pleurodesis, who is
presenting with dyspnea on exertion found to have atelectasis
and possible pulmonary hypertension.
# Dyspnea: Patient presented with 3 days of worsening dyspnea on
exertion. She was evaluated with CXR which showed no evidence of
recurrent pneumothorax. She was evaluated with CTA which showed
compressive atelectasis and slightly increased right sided
pleural effusion as well as some evidence of pulmonary
hypertension. The patient's atelectasis was thought to be due to
splinting from post-operative pain from the patient's recent
pleurodesis. The possible pulmonary hypertension visualized on
CTA may also be contributing to her symptoms (see below). ACS
was thought to be less likely given the absence of ECG changes
and negative troponins x2. CHF was also thought to be less
likely given BNP in ___ on presentation. The patient did not
report cough or fevers/chills to suggest PNA. The patient was
treated with her home pain regimen and with incentive spirometry
with improvement in her symptoms. Pt will f/u with pulmonology
and PCP for consideration of TTE after discharge for further
evaluation of pulmonary HTN (see below). Pt should f/u with
thoracic surgery for further management in post-operative
period. Pt was discharged on her home pain regimen.
# ___ edema: patient reported lower extremity edema on admission.
She was evaluated with b/l ___ US which showed no evidence of
DVT. The patient's ___ edema was thought to be due to poor venous
return in the setting of decreased ambulation post-operatively.
The patient was encouraged to continue pain control regimen and
continue ambulation after discharge.
# Pulmonary HTN: Pt was found to have evidence of pulmonary
hypertension on CTA. This was thought to be caused by the
patient's recurrent pneumothoraces due to thoracic
endometriosis. Though her most recent presentation occurred
relatively recently, per her history she may have had pulmonary
issues for many years as she has previously been evaluated with
TTE at ___ for chest pain and shortness of breath several years
ago. The patient should f/u with PCP and pulmonology for
consideration of repeat outpatient TTE for further work-up of
pulmonary hypertension. ___ also consider further testing for
other autoimmune etiologies of pulmonary HTN, as the patient
noted she does have a family history of rheumatoid arthitis. ___
also consider sleep study as outpatient if concern for OSA.
# Surgical site pain: the patient reported pain at surgical
site. This area was found to be clean and dry without erythema
or purulence. The patient was continued on home oxycdone regimen
as well as ondansetron and scopolamine patch for management on
of nausea associated with oxycodone.
# Hypertension: continued Amlodipine 10 mg PO DAILY
# GERD/gastritis: Continued Pantoprazole 20 mg PO Q24H
# Endometriosis: Continued norethindrone 0.35 mg oral DAILY. The
patient should follow up with ob/gyn as outpatient for further
management of endometriosis. Consider continuing hormonal
suppressive therapy for ___ months given thoracic endometriosis
to decrease risk of recurrence.
# Sciatica: Continue Gabapentin 100 mg PO/NG Q8H:PRN pain
Transitional Issues
- Continue incentive spirometer, goal use 10x/hour
- f/u with pulmonology for further management of thoracic
endometriosis and consideration of TTE as outpatient for w/u of
pulmonary hypertension
- f/u with thoracic surgery for post-operative management
- f/u with ob/gyn for further management of endometriosis,
consider continuation of hormonal suppressive therapy for ___
months following pleurodesis to prevent recurrence of
endometriosis in thoracic cavity
- Please obtain repeat CBC as outpatient as patient was noted to
have macrocytic anemia during hospitalization. Please pursue
anemia workup if found to remain anemic.
- Code Status: Full Code.
- ___ (aunt) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. ___ (norethindrone (contraceptive)) 0.35 mg oral DAILY
3. Gabapentin 100 mg PO Q8H:PRN pain
4. Loratadine 10 mg PO DAILY
5. Pantoprazole 20 mg PO Q24H
6. Acetaminophen 650 mg PO Q6H
7. Docusate Sodium 100 mg PO BID
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Senna 8.6 mg PO BID
10. Scopolamine Patch 1 PTCH TD ONCE
11. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 100 mg PO Q8H:PRN pain
5. Loratadine 10 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Pantoprazole 20 mg PO Q24H
9. Scopolamine Patch 1 PTCH TD ONCE
10. Senna 8.6 mg PO BID
11. ___ (norethindrone (contraceptive)) 0.35 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
- Dyspnea thought to be secondary to atelectasis but possibly
from pulmonary hypertension.
- Lower extremity edema.
- Anemia
SECONDARY DIAGNOSIS
===================
- Thoracic endometriosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital with shortness of breath and
leg swelling. We believe this occurred because you were not able
to take deep breaths after your recent procedure and you were
not able to move around as easily. We evaluated you with a CT
scan of your chest which showed there was some increased
pressure in the blood vessel that connects your heart to your
lungs, called pulmonary hypertension. This may be because of all
the problems you have had with your lungs recently. We also
evaluated you with an ultrasound of your legs which showed no
evidence of blood clot.
After discharge, you should follow up with a pulmonologist for
further evaluation of your possible pulmonary hypertension. You
should follow up with your surgeon who will continue to monitor
you after your procedure. You should follow up with your ob/gyn
for management of your endometriosis. Please continue to use the
incentive spirometer to help improve your breathing.
Please discuss with your primary care physician or your
pulmonologist the need for an ultrasound of your heart
(echocardiogram) to assess for possible pulmonary hypertension.
Please have a repeat blood count checked at your next primary
care appointment for monitoring after your procedure. You were
noted to have anemia during hospitalization.
It was a pleasure taking care of you during your
hospitalization! We wish you all the best!
Sincerely, Your ___ Care Team
Followup Instructions:
___
|
10514512-DS-20 | 10,514,512 | 22,530,895 | DS | 20 | 2169-03-31 00:00:00 | 2169-03-31 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
Left press-fit hemiarthroplasty on ___. (femoral neck
fracture repair)
History of Present Illness:
___ y/o F with anal cancer, stage III (T3 N3 M0) now with
progressive metastatic disease off chemo, recent discharge on
anticoagulation for massive PE in ___ presents after fall.
Pt. lives alone with 24 hour hospice care. Over the past few
weeks, she has had progressive worsening of disease with
significant confusion. Pt. reports that she slipped and feel.
Denies LOC and remembers entire fall. Unwitnessed. (+) head
strike. Unfortunately, unable to obtain further info regarding
nature of fall as pt. does not wish to answer further questions
and brother unavailable for collateral.
In the ED, initial vitals were: 98.9 92 148/98 18 99% RA.
Labs notable for WBC 8.7, H/H 10.2/30.4, nml chem panel and
normal coags.
CT head negative. CT hip/pelvis with fracture of the left
femoral neck.
Given pt's expressed wishes to die at home, she initially
expressed that she would not want surgery and would want to be
kept as comfortable as possible. Her brother (HCP) was involved
in the discussion as well. On review of pt. and imaging, ortho
recommended palliative surgery with pin placement. Family and
ortho together decided for admission for pain control overnight
and if pain control alone insufficient will proceed with
surgery.
Vital signs prior to transfer: 82 106/67 15 97%
On the floor, pt. reports significant left hip pain. She is
tired and does not wish to talk. VSS.
Past Medical History:
Osteoporosis
Normal spontaneous vaginal delivery x 1
Menopause age ___
.
Past Oncologic History:
___ Developed rectal bleeding
___ Colonoscopy showed infiltrative non-obstructive anal
mass with bx c/w papillomatous neoplasm with high ___ dysplasia
___ Re-bx showed moderately differentiated invasive squamous
cell carcinoma
___ PET showed FDG avidity in the anal area at the location
of the primary tumor, uptake in the right inguinal, perirectal
LNs and adjacent fat stranding suggestive of tumor infiltration.
Clinically staged as T3N3 anal cancer.
___: Began concurrent chemorads with mitomycin 10 mg/m2 on
day 1 and 29, and ___ 1000 mg/m2 per day for 4 days on d1-5 and
days ___: Radiation for total dose of 54 Gy
___ PET CT: Significant reduction in size and FDG avidity of
the known anorectal mass. There is persistent moderate
hypermetabolic activity in the distal rectum and anus and may
represent residual tumor or alternatively could be
post-radiation inflammation given that XRT was givne within 12
weeks of this scan. There is interval resolution of presacral
mass and right perirectal LN. The previously described 1.3 cm
right inguinal LN now measures 5 mm and is no longer FDG avid.
There is extensive perirectal inflammatory fat stranding. No
suspicious pelvic LAD on the study. A soft tissue mass in the
right buccal space has decreased in size and metabolic activity,
now measuring 9 mm (1.6 cm previously). There is no abnormal
uptake in the remainder of the neck, chest, abd and pelvis.
___ Pelvic MRI: There is a small 5x4 mm focus at the
anorectal junction on the left at the 3 o'clock position
demonstrating hypointense signal on T2 weighted imaging without
hyperenhancement. It is unclear whether this is representative
of the treated lesion. No other suspicious lesion is visible.
There is diffuse rectal wall thickening and edema as well as
perirectal fat stranding, likely representing post-radiation
changes. The anterior wall of the anus appears deficient or
absent up to the anorectal junction with air and enema meterial
within.
___ Underwent anal biopsies that showed no evidence of
recurrent cancer.
___: POC removed
___: Vulvar lesion removed at ___. Path showed squamous
cell carcinoma, invasive, moderately differentiated. Focal
perineural invasion was noted. The tumor may represent
residual, recurrent or metastatic carcinoma depending on
clinical context. Focal epidermal involvement is appreciated,
however, the bulk of the tumor is present in the deep dermal and
subcutaneous tissues suggesting association with the primary
anal carcinoma.
___: PET showed mild perirectal/perianal wall thickening and
fat stranding may represent post-treatment changes and is
similar to the prior study. There is interval decrease in FDG
uptake at this site suggesting response to therapy. FDG avid
soft tissue lesion in the right back between the scapulas with a
small FDG avid scapular lymph node. Stable non-FDG avid
pulmonary nodules.
___: Excision of subcutaneous, subscapular mass below the
right scapula, anorectal and posterior vaginal exam under
anesthesia, incisional biopsy of vulvar skin as well as biopsy
of deep subcutaneous soft tissues of the vulva, and transanal
biopsy of the anal canal with Dr. ___.
___: excision of perineal nodule with Dr. ___
SCC with LVI
___: PET showed multiple subcentimeter FDG-avid nodules and
lymph nodes in the left inguinal, right axillary, left
subclavian, prevascular mediastinal, and right back areas.
___: L ingunal node + for ___
Social History:
___
Family History:
No family history of cancer
Physical Exam:
ADMIT PHYSICAL EXAM:
Vitals: 99.1, 77, 116/73, 18, 100 on RA
General: A and O x2 (self, place, ___ lethargic but
responsive; chronically ill appearing
HEENT: MMM; PERRL
Neck: supple
Lungs: Clear to auscultation bilaterally in anterior lung fields
CV: Regular rate and rhythm, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Pain on palpation over left lateral hip; distal ___ warm,
well perfused, no edema
Skin: large ulceration above mons pubis extending down towards
perineum; no purluent drainage or expanding erythema; foul odor
DISCHARGE PHYSICAL EXAM:
Vitals: 97.3 114/72 59 18 100%RA
General: A and O x3 in NAD
HEENT: MMM; PERRL
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Pain on palpation over left lateral hip; no pain on flexion
or compression of femur. Pain on valgus stress.
Skin: large ulceration above mons pubis extending down towards
perineum; no purluent drainage or expanding erythema
Pertinent Results:
ADMIT LABS
___ 10:50AM BLOOD WBC-8.7 RBC-3.21* Hgb-10.2* Hct-30.4*
MCV-95 MCH-31.8 MCHC-33.5 RDW-17.5* Plt ___
___ 10:50AM BLOOD Neuts-87.5* Lymphs-8.1* Monos-4.1 Eos-0.3
Baso-0
___ 10:50AM BLOOD ___ PTT-27.0 ___
___ 10:50AM BLOOD Glucose-107* UreaN-20 Creat-0.7 Na-137
K-4.0 Cl-98 HCO3-29 AnGap-14
___ 06:00AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0
CT HEAD: No acute intracranial process.
___ XRAY HIP: AP pelvis and two views left hip were provided.
And IUD is noted in the mid pelvis. The bony pelvic ring
appears intact. There is an acute fracture of the left femoral
neck at the Mid/basicervical level. There is mild varus
angulation of the distal shaft. Right femoral neck appears
intact.
___ HIP XRAY: A left hip hemiarthroplasty appears well seated
and in anatomical alignment. Overlying skin staples are present.
An IUD is partially visualized. Please refer to the operative
note for further details.
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-9.3 RBC-2.69* Hgb-8.3* Hct-25.3*
MCV-94 MCH-30.8 MCHC-32.7 RDW-17.2* Plt ___
Brief Hospital Course:
Ms. ___ is a ___ w/ metastatic anal cancer who presents
from home hospice after mechanical fall found to have left
femoral neck fracture.
# Left femoral neck fracture: patient presented after mechanical
fall resulting in fracture of the left femoral neck. Orthopedics
offered the patient a percutaneous pinning of the fracture to
help relieve pain and possbibly regain functional status. After
an in depth discussion with the patient and the HCP, it was
decided that the benfits of this low-morbidity procedure
outweighed the risks. She underwent the procedure without
complication. Her pain was controlled with her home MS ___
and Oxycodone PRN as well as IV dilaudid for breakthrough.
- WBAT in LLE post op
# Recent massive PE: PE in ___ and on apixiban at home. Was
transitioned to heparin drip and stopped 2 hours before the
operation and restarted 2 hours after. She was restarted on home
apixiban on POD #1 and overlapped with heparin for 2 hours per
pharmacy instruction.
#Anemia: Baseline Hgb of 10 from anemia of chronic inflammation.
Dropped post-op to 8.3 after 3L of NS in the periop setting.
Repeat Hgb showed stable Hgb at 8.9 and next day at 8.3.
Asymptomatic in terms of stable vital signs, dyspnea, chest pain
and presyncope.
# Metastic anal cancer/GOC: Off chemotherapy and previously on
home hospice prior to admission. The team and the patient and
her brother (HCP) discussed the goals of care regarding
disposition after this admission. It was decided that maximizing
comfort and functional status (mobility) were priorities for the
patient and therefore a rehab facility with daily ___ would be
her best option. The goal would then to be to transition to
inpatient hospice or back to home hospice depending how the
acute rehab process played out. It should also be noted that
orthopedics suggested a potential colostomy for the patient as
her fecal incontinence may compromise her surgical wound. After
weighing the pros and cons of this procedure, it was thought
that this was not in line with her goals of care, and that it
would be preferable to focus on hygeine and wound care rather
than undergo another invasive procedure. Her symptom-based
hospice meds were continued on this admission ( dexamethasone
4mg BID, ranitidine, escitalopram, lorazepam, trazodone,
ondansetron, docusate, PEG, senna prn).
# Perineal Wound: On review of chart, wound is likely secondary
to combination of surgical incisions as well as potentially
tumor erosions. Did not appear infected at time of admission.
Wound care was asked to see her daily.
# Orthostasis: continued midodrine 5mg TID and wean as tolerated
Transitional Issues:
====================
[]Oxycodone was uptitrated to 40-60mg q4h for adequate pain
control. This may be adjusted based on patient's pain needs by
palliative care
[]Will need aggressive physical therapy to ensure mobility
[]Aggressive wound care and toileting to prevent infection of
surgical site given fecal incontinence
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN insomnia
3. Morphine SR (MS ___ 100 mg PO Q8H
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. OxycoDONE (Immediate Release) 20 mg PO Q3H:PRN pain
6. Dexamethasone 4 mg PO BID
7. Apixaban 5 mg PO BID
8. Midodrine 5 mg PO TID
9. Senna 8.6 mg PO BID
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Polyethylene Glycol 17 g PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Ranitidine 150 mg PO DAILY
14. OxycoDONE (Concentrated Oral Soln) 20 mg PO Q3H:PRN Pain
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Dexamethasone 4 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 20 mg PO DAILY
5. Lorazepam 0.5 mg PO Q6H:PRN insomnia
6. Midodrine 5 mg PO TID
7. Morphine SR (MS ___ 100 mg PO Q8H
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) 40-60 mg PO Q4H:PRN pain
RX *oxycodone 20 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
11. Ranitidine 150 mg PO DAILY
12. Senna 8.6 mg PO BID
13. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Fracture of the left femoral neck
Secondary:
Metastatic Anal Cancer
Osteoporesis
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 a fractured hip. We
treated you by placing pins in the fracture to stabilize the
bone. You will go to rehab with the goal to work with physical
therapy and regain some mobility.
We wish you the best of luck and it was a pleasure taking care
of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10514517-DS-14 | 10,514,517 | 28,735,695 | DS | 14 | 2189-11-29 00:00:00 | 2189-11-29 13:57:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left thigh abscess
Major Surgical or Invasive Procedure:
___ Beside I&D of left thigh
History of Present Illness:
Mr. ___ is a ___ man with DMII, CHF, and PVD who is s/p
right femoral to below-knee popliteal atery bypass graft using
nonreversed left leg saphenous vein (___), who was admitted
in ___ with an infection in the left graft harvest site. At
that time, he had a 6x4x9cm fluid collection at the left groin
with associated cellulitis. He was taken to the operating room
for incision and drainage, a drain was left in place and he was
kept on antibiotics. He recovered well from that
hospitalization,
however he now returns with similar symptoms. He states that for
the past week he has noted worsening swelling and erythema over
his left groin, which has become increasingly painful and
tender.
He denies drainage, he denies fevers or chills.
Past Medical History:
PMH: CHF, venous insufficiency, PVD, CAD, DM (on insulin),
neuropathy, HTN, HL, renal artery stenosis, CRD stage III, CVA
w/expressive aphasia, chronic lymphangitis RLE, BPH, R foot
ulcer/cellulitis (polymicrobial)
PSH: RLE angiogram (___), R femoral-BK pop artery bypass
graft using nonreversed left leg saphenous vein (___), RLE
angiogram (___), CAD w 3vD s/p CABG (unkown anatomy),
Peripheral arterial disease s/p stenting, RAS s/p stenting,
Carotid artery disease s/p bilateral CEA, s/p cholecystectomy
Social History:
___
Family History:
Positive for premature coronary artery disease. One brother had
laryngeal cancer. Another brother had anal cancer.
Physical Exam:
DISCHARGE PHYSICAL EXAM
VITALS: T 97.5, HR 65, BP 121/74, RR 18 94%RA
GEN: A&ox3, NAD, some word finding difficulty and slurred speech
which he states is his baseline
CV: RRR
PULM: easy WOB
ABD: soft NT ND
EXT: R PICC intact, bilateral lymphedema, venous stasis changes
R > L calf. Left vein harvest incision improving erythema medial
thigh, Left thigh wound non-purulent with clean,dry,intact gauze
dressing
Fem Pop DP ___
R P P D D
L P P D D
Pertinent Results:
ADMISSION LABS:
___ 08:52PM BLOOD WBC-12.9* RBC-3.86* Hgb-13.2* Hct-38.6*
MCV-100* MCH-34.3* MCHC-34.2 RDW-13.9 Plt ___
___ 08:52PM BLOOD ___ PTT-27.6 ___
___ 08:52PM BLOOD Glucose-167* UreaN-50* Creat-2.2* Na-133
K-3.5 Cl-92* HCO3-30 AnGap-15
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-6.8 RBC-3.79* Hgb-12.7* Hct-37.8*
MCV-100* MCH-33.4* MCHC-33.5 RDW-13.9 Plt ___
___ 07:30AM BLOOD Glucose-101* UreaN-49* Creat-1.9* Na-148*
K-4.0 Cl-104 HCO3-29 AnGap-19
___ 07:30AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8
___ US EXTREMITY NONVASCULAR LEFT
FINDINGS:
Focused grayscale and color Doppler ultrasound examination of
the left groin and thigh reveals a 4.1 x 4.0 x 7.2 cm complex
fluid collection with echogenic debris and thick septations, in
a very superficial location. This collection is only 5 mm below
the skin surface. There is no association with any vascular
structures, therefore is not likely to be a pseudoaneurysm.
IMPRESSION:
Complex fluid collection at the location of the patient's
symptoms, without internal vascularity or association with
nearby vessels. Potential etiologies could include hematoma or
abscess.
___ 11:09 am SWAB Source: L thigh.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED
___: PICC ACCESS
IV access: PICC, heparin dependent Location: Right Basilic, Date
inserted: ___
SVC placement confirmed by portable CXR.
Brief Hospital Course:
Mr. ___ was admitted on ___ with recurrence of left groin
fluid collection and cellulitis. An ultrasound revealed a 4.1 x
4.0 x 7.2 cm complex fluid collection. This was drained bedside
and cultures were obtained. It drained purulent material and the
patient felt immediate relief of his pain. He was started on
empiric broad-spectrum antibiotics
(vancomycin/ciprofloxacin/metronidazole) which were tailored
after his wound culture grew Pseudomonas sensitive to
ceftazidime. Infectious Disease was consulted and recommended
2-week course of IV ceftazidime which was started on ___.
On ___ a right basilic heparin-dependent PICC was placed for
administration of IV antitbiotics. Throughout his
hospitalization, he remained afebrile. His initial WBC of 12.9
at admission resolved quickly and he was discharged with WBC
6.8.
At the time of discharge on ___, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. He will be discharged to
rehab to continue IV antibiotics and wound care. He will have
follow-up with Dr. ___ in ___ weeks for evaluation of his
wound. In addition, should it be necessary, he may follow-up
with infectious disease should his wound infection not resolve.
Medications on Admission:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Bumetanide 2 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. CefTAZidime 2 g IV Q12H
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2
gram/50 mL 2 Grams IV twice a day Disp #*25 Bag Refills:*0
7. Citalopram 10 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Gabapentin 100 mg PO TID
11. HydrALAzine 12.5 mg PO QAM
12. HydrALAzine 25 mg PO QPM
13. Glargine 31 Units Breakfast
Glargine 31 Units Dinner
Insulin SC Sliding Scale using REG Insulin
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Bumetanide 2 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. CefTAZidime 2 g IV Q12H
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2
gram/50 mL 2 Grams IV twice a day Disp #*25 Bag Refills:*0
7. Citalopram 10 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Gabapentin 100 mg PO TID
11. HydrALAzine 12.5 mg PO QAM
12. HydrALAzine 25 mg PO QPM
13. Glargine 31 Units Breakfast
Glargine 31 Units Dinner
Insulin SC Sliding Scale using REG Insulin
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left thigh abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted on ___ for a left thigh abscess. This was
drained on ___ and cultures were obtained. You were started
on IV antibiotics to treat the bacteria from that wound. A PICC
was placed so that you can receive IV antibiotics. You will be
discharged to rehab and receive wound care, antibiotics, and
physical therapy. You will have a follow-up appointment with
Dr. ___ in ___ weeks. He may request a
repeat ultrasound to evaluate your left thigh wound. Please
resume all medications.
Followup Instructions:
___
|
10514659-DS-13 | 10,514,659 | 27,133,899 | DS | 13 | 2192-03-28 00:00:00 | 2192-03-29 16:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed woman with a past medical
history of a VP shunt placed on ___ who presents from
___ after a fall two weeks ago and another this
evening with a CT scan showing a left-sided SDH.
The history is obtained partly with help from her husband as she
is having some trouble with language currently. She fell on ___ while in ___, by tripping backwards and hitting
the back of her head. She then was brought to the ED at ___ in ___. There, per report she had an
emergent left craniotomy for a left SDH (though the exact size
of
it is not documented in the ___ notes) and then spent time in
the
ICU. She had some issues with word-finding, and headaches per
her husband and had to "relearn how to do everything - talk,
walk
etc". She had some right-sided deltoid weakness, that was
attributed (per the husband) to pain as that shoulder was hurt
during the fall. She had memory/cognitive issues notes also.
Her
VPS was changed to 2.5 in the setting of needing the emergent
craniotomy and then back to 1.5 at time of discharge. She was
then sent to a SNF for one week and then to a rehabilitation
facility in ___ for 7 weeks.
They transferred her to ___ in ___ next and
she has been there since ___. However, two weeks ago (___), she tripped forwards and fell. She was sent to the ED at
___ where they did a head CT and saw no new
hemorrhages. She was observed in the ED by neurosurgery for
three
days, and then they sent her back to rehab.
She then fell today, likely backwards (where abrasion is), but
she doesn't recall the details. She doesn't think this is
because of loss of consciousness or post-traumatic amnesia
though. She was brought to ___ where a CT head showed an
acute/subacute SDH in the left lateral middle cranial fossa new
since the ___ CT. It was read as stable mass effect from
the old CT with slightly more effacement of the temporal sulci,
but no evidence of midline shift.
There were no ICU beds available at ___, and they felt the
patient would likely need Q1H neuro checks, so sent her to ___
for further evaluation.
In the ED she and her husband reported that her headaches and
language is worse today in comparison to previously. Her
husband
thinks that she would have some word-finding issues previously
but her language is now more hesitant and "confused".
On neuro ROS, the pt reports headaches, right shoulder pain and
weakness and language issues, but denies loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. No new bowel or bladder incontinence or
retention. Denies newdifficulty 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
- RA
- hypothyroidism
- GERD
- HLD
- anxiety
- spinal stenosis
- headaches
- s/p right knee replacement
- s/p colon resection for diverticulitis
- NPH s/p VPS on ___
Social History:
___
Family History:
reviewed and non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: T: 97.8 P: 80 R: 16 BP: 135/68 SaO2: 93% on RA
General: Awake, cooperative, appears mildly frustrated at times.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, VP shunt in place on top of head, depressed
adequately (at 1.5 on testing)
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: venous stasis changes on ankles/calves bilaterally,
no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: She reports that she is in "___" (which is
where SSH is located). She says she is in "rehab" and the year
was ___ and the month ___. She does know that it is
___. She had a hard time with word-finding and would
transpose words, like saying "he or she" for "I". She made
paraphasic errors also "reliculous" rather than ridiculous.
Naming was intact though to high and low frequency objects (got
pen and glasses as well as lenses etc.). Her speech was not
dysarthric. She could ___ backwards to ___, then kept
trying to go forwards and was unable to. She did seem to have a
mild neglect of her right-side.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus, though easier to get her to
follow finger to the left, had to get her to follow my face to
the right. Normal saccades.
V: Facial sensation intact to light touch.
VII: subtle right NLF flattening, but with good activation
bilaterally.
VIII: Hearing intact to finger-rub bilaterally though
diminished.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Right arm starts out
pronated even before I test drift, and then drift upwards
slightly with testing (parietal drift). 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, cold sensation, vibratory
sense, proprioception throughout.
-DTRs: ___ throughout. Toes mute bilaterally
-Coordination: No intention tremor noted. No dysmetria on FNF
bilaterally, but right deltoid weakness/pain limited testing on
the right arm.
-Gait: Deferred
DISCHARGE PHYSICAL EXAM
========================
PHYSICAL EXAM:
Vitals: 97.8 PO 128 / 74 70 18 98 RA
General: NAD. Thin appearing. Appears stated age. Awake.
Cooperative. Pleasant, but frustrated with word finding
difficulties.
HEENT: NC/AT. Abrasion on back of head. No scleral icterus. MMM.
No OP lesions. VP shunt in place on top of head.
Lymph: No cervical or supraclavicular adenopathy.
CV: Normal rate and regular rhythm. S1/S2 audible. No m/r/g.
Lungs: Nonlabored breathing. CTAB. No wheezes/rhonchi/wheezes.
Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly.
No costovertebral tenderness.
GU: No Foley
Ext: Warm and well perfused. No clubbing, cyanosis, or edema.
Skin: erythematous, scaly plaques on ankles and lower legs
bilaterally. No other rashes or bruises.
Neuro: CNII-XII intact, can tract w/ eyes in both directions. No
nystagmus. Strength ___ in upper and lower extremities, except
for R upper extremity at shoulder on flexion/extension.
Sensation intact to light touch throughout. Neg pronator drift.
Neg Babinski. Cerebellar testing intact (FTN and HTS). Gait not
assessed.
Mental status (___): Intermittently attentive and orientation to
first name, but states ___ rather than married last name,
cannot identify that she is in a hospital versus church or
school, and says that the year is 2T4). Repeats "no ifs and or
buts" as "no buts". Says that 6 quarters is 7 dollars. When
asked to ___ backwards, counts backwards from 7 to 1. When
asked to ___ backwards, counts backwards from 12 to 1. Cannot
name "pen, watch, or stethoscope." Cannot remember her husband's
or son's name. No R/L confusion, can raise R or L hand when
asked. Persistent conductive aphasia on ___.
On ___, pt is oriented to first and last name. She is able to
tell me who the current president is. She can spell "WORLD"
forward, but not backwards. She cannot ___ backwards.
Cannot name "pen, clock, or stethoscope."
On ___, pt is able to tell me her full name ___ She
thinks that it is the year ___, but knows that she is in the
"hospital." She is A&Ox2. She can calculate that 7 quarters is
$1.75She is able to name "pen, paper, or stethoscope" and is
able to repeat "No ifs, ands or buts," but is still having a
difficult time finding words (persistent conductive aphasia).
She can spell "WORLD" forward, but not backwards. She cannot do
___ backwards. She can follow commands w/o right-left
confusion. On ___ she doesn't know the date but knows her name
and place.
Pertinent Results:
ADMISSION LABS
================
___ 07:30PM URINE WBCCLUMP-MANY MUCOUS-RARE
___ 07:30PM URINE RBC-20* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-2
___ 07:30PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 07:30PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 07:30PM URINE GR HOLD-HOLD
___ 07:30PM URINE UHOLD-HOLD
___ 07:30PM URINE HOURS-RANDOM
___ 07:30PM URINE HOURS-RANDOM
___ 09:17PM LACTATE-0.8
___ 09:24AM ___ PTT-26.3 ___
___ 09:24AM PLT COUNT-304
___ 09:24AM WBC-13.3* RBC-4.16 HGB-12.5 HCT-39.2 MCV-94
MCH-30.0 MCHC-31.9* RDW-13.7 RDWSD-47.1*
___ 09:24AM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-4.4
MAGNESIUM-1.5*
___ 09:24AM ALT(SGPT)-24 AST(SGOT)-24 LD(LDH)-339* ALK
PHOS-170* TOT BILI-0.3
___ 09:24AM GLUCOSE-56* UREA N-14 CREAT-0.5 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-19* ANION GAP-25*
___ 03:32PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.3*
___ 03:32PM GLUCOSE-224* UREA N-15 CREAT-0.6 SODIUM-129*
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-21* ANION GAP-18
___ 03:54PM LACTATE-2.1*
MICROBIOLOGY
================
URINE CULTURE (Final ___: < 10,000 CFU/mL.
C. difficile DNA amplification assay (___): Negative for
toxigenic C. difficile by the Illumigene DNA amplification
assay.
IMAGING
================
CT Head w/o contrast (___):
FINDINGS:
Postsurgical changes related to prior right frontotemporal
craniotomy are again noted. There is a heterogeneous subdural
extra-axial collection with both hypodense and hypo to isodense
fluid compatible with acute on chronic subdural hematoma. This
measures 14 mm in width from the calvarium. This is minimally
increased from prior exam when it measured 12 mm. There is
subjacent sulcal effacement,
and there is no she significant shift of midline structures.
There is a right frontal ventriculostomy catheter which
terminates in the frontal horn of the left lateral ventricle,
and the ventricles are stable in size and configuration.
Periventricular white matter hypodensities are nonspecific but
likely sequela of chronic small vessel ischemic changes. There
is no new intracranial hemorrhage or vascular territorial
infarction. There is mucosal thickening of the bilateral ethmoid
air cells. There is partial opacification of the right mastoid
air cells. The visualized orbits are unremarkable.
IMPRESSION:
1. Mild increase size of the left lateral convexity acute on
chronic subdural hematoma. No shift of midline structures.
2. Right frontal ventriculostomy catheter terminates in the
frontal horn of the left lateral ventricle.
3. Stable ventricle size and configuration.
CT spine w/o contrast (___):
FINDINGS:
Alignment is normal. No fractures are identified. There is no
prevertebral soft tissue swelling. Patient is status post
vertebroplasty of T12 and L1 with unchanged configuration
compared with prior studies. Posterior osteophytosis at this
level causes at least moderate to severe spinal canal and neural
foraminal stenosis (2:105, 106, 110). Partially imaged portions
of the ventriculoperitoneal shunt appear intact. There is
moderate atherosclerotic disease, including moderate coronary
arterial calcifications. Limited images of the chest and
abdomen are
otherwise unremarkable.
IMPRESSION:
Multilevel degenerative changes with evidence of prior
vertebroplasty with no signs of acute fracture or change in
alignment.
Chest PA & LAT (___):
FINDINGS:
AP upright and lateral views of the chest provided. The tubing
again noted traversing the right hemi thorax consistent with VP
shunt. Lungs are clear. Cardiomediastinal silhouette appears
normal. No acute osseous injury. Vertebroplasty changes are
noted at the thoracolumbar junction and in the mid lumbar spine.
IMPRESSION:
No acute findings.
CT Head w/o contrast (___):
FINDINGS:
Acute on chronic left subdural hematoma measuring approximately
1.3 cm in greatest thickness is similar in size to prior
examination. Mass effect on the adjacent sulci is unchanged.
There is no significant midline shift. A right trans frontal
ventriculostomy catheter with tip abutting the septum pellucidum
near the foramen ___ is similar in appearance to prior
examination. There remains ventriculomegaly, similar in
configuration from prior exam. No new hemorrhage is identified.
There is no acute large territorial infarct. Periventricular
and subcortical white matter hypodensities are nonspecific, but
compatible with chronic microangiopathy in a patient of this
age. A large left parietal scalp 9 mm thick hematoma is similar
in appearance to prior exam. Allowing for left pterional and
parietal craniotomy, no acute osseous abnormalities. The
visualized paranasal sinuses are clear. The orbits are
unremarkable.
IMPRESSION:
1. No interval change in left lateral convexity acute on chronic
subdural hematoma measuring up to 1.3 cm in greatest dimension.
No significant midline shift.
CT spine w/o contrast (___):
FINDINGS:
1. No evidence of acute fracture or malalignment of the thoracic
spine.
2. Status post T12 and L1 vertebroplasty with posterior
osteophytosis/bone fragment causing at least moderate to severe
neural foraminal and spinal canal stenosis, unchanged.
CT Head w/o contrast (___):
IMPRESSION:
1. Since the prior CT the left-sided subdural collection has
evolved and slightly decreased in size.
2. Ventricular size has decreased with consequent small right
frontal subdural effusion.
MR HEAD W/O CONTRAST (___):
IMPRESSION:
1. Unchanged left lateral convexity subdural hematoma measuring
up to 9 mm in maximal thickness with localized mass effect,
without significant midline shift.
2. Small amount of left posterior parietal subarachnoid
hemorrhage.
3. Unchanged position of a right frontal approach VP shunt
catheter with stable ventriculomegaly since ___.
4. Confluent areas of white matter signal changes likely .
5. Otherwise no definite new hemorrhage or acute infarct given
limitations of susceptibility artifact from VP shunt reservoir.
NEUROPHYSIOLOGIC STUDIES
================
Routine EEG (___):
FINDINGS:
Background: The background rhythm over the right hemisphere is
posterior 9.0 Hz alpha activity while over the left hemisphere
the background is slower at the 7.5 - 8.0 Hz theta-alpha range.
There is a breech rhythm over the left hemisphere with
continuous slow ___ Hz delta activity in the keft posterior
centralquadrant superimposed on the background.
Hyperventilation: Hyperventilation was not performed.
Intermittent Photic Stimulation: IPS did not produce a driving
response
Sleep: The patient was drowsy but did not progress beyond that
stage.
Cardiac Monitor: Heart rhythm was sinus throughout.
Impression: This is an abnormal routine EEG. It shows a breech
effect over the left hemisphere along with focal slowing in the
left posterior central quadrant as well as left hemisphere
slowing of the background activity. This is most compatible with
a large left hemisphere structural abnormality and shows the
post-surgical effect on the amplitude of left hemisphere
activity.
No epileptiform abnormalities were seen.
PERTINENT AND DISCHARGE LABS
================
___ 05:30AM BLOOD WBC-9.4 RBC-3.76* Hgb-11.4 Hct-33.8*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 RDWSD-44.7 Plt ___
___ 04:29AM BLOOD WBC-7.5 RBC-3.64* Hgb-10.9* Hct-33.7*
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.6 RDWSD-45.8 Plt ___
___ 05:40AM BLOOD WBC-9.0 RBC-3.70* Hgb-10.9* Hct-34.0
MCV-92 MCH-29.5 MCHC-32.1 RDW-13.8 RDWSD-46.3 Plt ___
___ 04:40AM BLOOD WBC-9.5 RBC-3.69* Hgb-11.1* Hct-33.8*
MCV-92 MCH-30.1 MCHC-32.8 RDW-13.5 RDWSD-45.1 Plt ___
___ 04:25AM BLOOD WBC-9.0 RBC-3.93 Hgb-11.8 Hct-35.4 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.6 RDWSD-45.1 Plt ___
___ 05:30AM BLOOD WBC-8.1 RBC-3.88* Hgb-11.7 Hct-35.8
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.7 RDWSD-46.2 Plt ___
___ 05:30AM BLOOD Plt ___
___ 04:29AM BLOOD Plt ___
___ 05:40AM BLOOD Plt ___
___ 04:40AM BLOOD Plt ___
___ 04:25AM BLOOD Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-101* UreaN-13 Creat-0.5 Na-132*
K-3.8 Cl-97 HCO3-25 AnGap-14
___ 04:29AM BLOOD Glucose-94 UreaN-11 Creat-0.5 Na-132*
K-3.5 Cl-100 HCO3-20* AnGap-16
___ 05:40AM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-134 K-4.7
Cl-102 HCO3-13* AnGap-24*
___ 05:00PM BLOOD Glucose-124* UreaN-8 Creat-0.6 Na-130*
K-4.7 Cl-98 HCO3-24 AnGap-13
___ 04:40AM BLOOD Glucose-104* UreaN-7 Creat-0.5 Na-132*
K-4.1 Cl-99 HCO3-24 AnGap-13
___ 04:25AM BLOOD Glucose-92 UreaN-11 Creat-0.5 Na-132*
K-4.3 Cl-95* HCO3-26 AnGap-15
___ 05:30AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-131*
K-4.9 Cl-93* HCO3-25 AnGap-18
___ 05:30AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.4*
___ 04:29AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.4
___ 05:40AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.7
___ 05:00PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
___ 04:40AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
___ 04:25AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.9
___ 05:30AM BLOOD Calcium-9.8 Phos-5.3* Mg-1.5*
___ 12:12PM BLOOD ___ pO2-50* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 09:30PM BLOOD Lactate-1.3
___ 12:12PM BLOOD Lactate-1.3
___ 07:30PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 07:30PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 07:30PM URINE RBC-20* WBC->182* Bacteri-FEW Yeast-NONE
Epi-2
___ 07:30PM URINE WBC Clm-MANY Mucous-RARE
___ 06:49PM URINE Hours-RANDOM UreaN-876 Creat-97 Na-137
___ 02:14PM URINE Hours-RANDOM UreaN-489 Creat-107 Na-84
___ 06:49PM URINE Osmolal-717
___ 02:14PM URINE Osmolal-482
___ 04:55AM BLOOD WBC-8.5 RBC-3.98 Hgb-11.8 Hct-36.1 MCV-91
MCH-29.6 MCHC-32.7 RDW-13.6 RDWSD-44.9 Plt ___
___ 04:55AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-131*
K-4.5 Cl-93* HCO3-26 AnGap-17
Brief Hospital Course:
Ms. ___ is a ___ lady (R-handed) woman with normal
pressure hydrocephalus characterized by gait difficulty, s/p VP
shunt placed on ___, recent subdural hematoma (___)
with residual word finding difficulty, RA s/p b/l TKR, HTN, HLD,
GERD, hypothyroidism, and anxiety, who presented from ___
___ after a fall with headstrike on ___ w/o acute
CT abnormalities, and another fall on ___, with CT notable
for left lateral convexity acute on chronic SDH.
#Subdural hematoma: Patient, who has NPH (primary gait
abnormalities) w/VP shunt (placed ___, was admitted to ___
s/p fall with headstrike iso attempting to walk w/o walker on
___, with OSH CT on ___ demonstrating acute on chronic SDH in
left lateral convexity (L temporal area) measuring up to 1.3 cm,
w/o midline shift or mass effect. Of note, pt had a recent SDH
resulting from a similar fall while pt was on vacation in
___ on ___, for which she received a craniotomy, and
since when she has had residual word finding difficulty. Pt was
admitted to neurosurgery at which point VP shunt was adjusted to
2.5. She was also started on keppra 500 mg BID for seizure
prophylaxis. Patient had no FNDs on neurologic exam and in the
absence of mass effect/shift, there was no need for
neurosurgical intervention. Repeat CT scans on ___ and ___
demonstrated that acute on chronic SDH was unchanged and
remained w/o midline shift. On ___, patient and family felt that
her word finding difficulty had worsened and that she was
"severely confused." Patient was transferred to medicine for
management of these issues.
On the medicine floor, patient was initially A&Ox1 (only to her
first name) with poor attention on exam, difficulty with
calculation, days of the week backwards, naming, repeating,
following complex left-right commands, and had persistent word
finding difficulties, which frustrated her. She was treated with
nonpharmacologic delirium treatment including frequent
re-orientation, light/day orientation, minimization of
repetitive stimuli (sounds, lights), maximization of cognitive
stimuli (conversation w/family and friends), and placement near
nursing station. In addition, patient's alprazolam and melatonin
were discontinued in order to minimize sedative medications.
Neurology was consulted and they recommended repeat imaging and
EEG. NCHCT on ___ and MRI on ___ show reduction in size of SDH,
and no e/o new infarct or hemorrhage. VP shunt setting
placement/setting were checked by neurosurgery following MRI
(set at 2.5). EEG on ___ was notable for left sided slowing
likely ___ left sided cerebral dysfunction iso patient's acute
on chronic SDH. Given no e/o seizure on EEG, patient should stop
keppra 500 mg BID after finishing 14-day course (___).
At the time of discharge, patient's orientation had improved to
A&Ox2 (thinks it is ___, she was able to calculate that 7
quarters is $1.75, had improvement in naming ("pen, stethoscope,
and cup"), and was able to follow complex left-right commands,
although her word finding difficulties persisted. Patient's
residual word finding difficulty and impaired mental status will
likely improve with continued resolution of the subdural
hematoma and with a combination of physical therapy, occupation
therapy, and speech therapy.
#Hyponatremia: Pt admitted with Na 132, which decreased to 129
on ___, with repeat Na 132 following administration of salt tabs
and IVF on ___. Urine lytes on ___: UreaN:876, Creat:97, Na:137,
Osmolal:717, FeNa 0.5%. SOsm 285. Given improvement in Na with
IVF and FeNa<1%, initially thought that hyponatremia was likely
___ to hypovolemia, although considered an additional component
of SIADH given high UNa and high UOsm, and patient's significant
neurologic disease. Na 132 on ___ and 134 on ___ s/p 1L IVF on
___. Na decreased again to 132 on ___ and ___ with continued
mIFV, with repeat urine lytes on ___: Uosm: 482, UCreat:107,
UNa:84 on ___, FeNa 0.3%, more c/w SIADH. Likely that patient
has SIADH, and was having superimposed hypovolemic hyponatremia
on top of that. Na 131 on ___. Instituted 2L PO fluid
restriction, held mIVF, with Na 131 at time of discharge.
#UTI: Patient had UA on initial workup in ED on ___ notable for
WBC, RBC, bacteria, and large leukocyte esterase. She denied any
dysuria, urinary frequency, and did not have a Foley. Urine cx
obtained, and she was started on empiric ciprofloxacin PO 500 mg
q12hrUrine cx ___ negative. Urine cx resulted negative on ___,
and empiric ciprofloxacin was discontinued.
#HTN: Patient's BPs ranged from ___ throughout
hospitalization. Patient continued on home amlodipine and
atenolol.
#HLD: Patient was continued on home pravastatin.
#RA: Patient is s/p bilateral TKR. She has some slight ulnar
deviation and Swan neck deformities on exam. Says her joints
hurt intermittently, but that this is her b/l right now. Patient
was continued on home prednisone 4 mg QD and home plaquenil.
Patient's home leflunomide was held while receiving empiric
antibiotics for c/f UTI and was started at time of discharge,
per patient's outpatient rheumatologist, Dr. ___,
___.
#Hypothyroidism: Patient was continued on her home
levothyroxine.
#GERD: Patient was continued on her home pantoprazole.
#Lumbar spinal stenosis/back pain: Patient was continued on her
home gabapentin and home lidocaine patch.
#Anxiety/Insomnia: Patient was continued on her home sertraline
and home trazodone.
Her home alprazolam and melatonin were discontinued iso waxing
and waning orientation and not restarted for discharge.
TRANSITIONAL ISSUES:
=======================
#Patient is not on Aspirin/Coumadin/Plavix, but she should not
take these until she is cleared by the neurosurgeon at follow-up
appointment.
#Patient is on keppra 500 mg PO BID for seizure prophylaxis in
the setting of subdural hemorrhage. Given no e/o seizure on EEG,
this can be discontinued upon conclusion of 14-da course (day
___.
#Patient has VP shunt placed ___. Current shunt setting 2.5.
Shunt was checked following MRI on ___ to confirm placement.
#Patient's alprazolam and melatonin were discontinued in the
setting of her waxing and waning orientation, and was not
restarted for discharge. Also recommend that opiates,
benzodiazepines, and anticholinergics are minimized in this
patient.
#Recommend continuation of nonpharmacologic delirium measures
that helped during inpatient hospitalization, including
light/day orientation, frequent re-orientation, minimization of
repetitive stimuli (light/sound), and cognitive stimulation
during the day (placement near nursing station, interaction with
family).
#Patient should call her PCP, ___ (___),
to set up an appointment to be seen within one week of
discharge.
#Patient should call Neurosurgery at ___ to set up a follow-up
appointment with Dr. ___ (___) to be seen
within one week of discharge.
#Patient should call her rheumatologist, Dr. ___,
(___), to schedule an appointment to be seen within two
weeks of discharge.
#Code status: Full code
#HCP: Husband, ___ ___, M: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. PredniSONE 4 mg PO DAILY
6. Acetaminophen 650 mg PO Q8H
7. Modafinil 200 mg PO DAILY
8. Gabapentin 300 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. ALPRAZolam 0.25 mg PO QHS
11. melatonin 5 mg oral QHS
12. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Levothyroxine Sodium 100 mcg PO DAILY
15. Hydroxychloroquine Sulfate 200 mg PO DAILY
16. Sertraline 25 mg PO DAILY
17. TraZODone 25 mg PO QHS:PRN insomnia
18. Pravastatin 40 mg PO QPM
19. leflunomide 20 mg oral DAILY
Discharge Medications:
1. LevETIRAcetam 500 mg PO BID
til ___
2. Multivitamins 1 TAB PO DAILY
3. Acetaminophen 650 mg PO Q8H
4. amLODIPine 10 mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Gabapentin 300 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
10. leflunomide 20 mg oral DAILY
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Modafinil 200 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Pravastatin 40 mg PO QPM
17. PredniSONE 4 mg PO DAILY
18. Sertraline 25 mg PO DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
========================
Left lateral convexity acute on chronic subdural hematoma
Hyponatremia
SECONDARY DIAGNOSES:
========================
Rheumatoid arthritis
Lumbar spinal stenosis
Gastroesophagheal reflux disease
Hypertension
Hyperlipidemia
Hypothyroidism
Anxiety
Insomnia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery service on ___
after a fall from standing. You were found to have a small left
sided head bleed that has been stable on CT scan. You were seen
and evaluated by the neurosurgery team who determined no
surgical intervention was needed, although you continued to have
word finding difficulty which was worse than your baseline and
you were also intermittently confused. You were transferred to
the medicine team for management of these issues that are likely
related to the brain bleed. While on the medicine team, your
confusion and word finding difficulty improved and repeat CT and
MRI imaging showed that your head bleed was reducing in size.
You will likely improve as your bleed continues to resolve, and
you will likely benefit from physical therapy, occupational
therapy, and speech therapy.
Following discharge, please make sure that you:
#Please call your PCP, ___ (___), to set
up an appointment to be seen within one week of discharge.
#Please also call Neurosurgery at ___ to set up a follow-up
appointment with Dr. ___ (___) to be seen
within one week of discharge.
#Please also call your rheumatologist, Dr. ___,
(___), to schedule an appointment to be seen within two
weeks of your discharge.
Followup Instructions:
___
|
10514718-DS-14 | 10,514,718 | 29,172,448 | DS | 14 | 2176-03-23 00:00:00 | 2176-03-23 16:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R arm pain
Major Surgical or Invasive Procedure:
R radial head replacement
History of Present Illness:
The patient is a healthy RHD ___ yo F who presents with R
elbow pain after doing a cartwheel in her back yard. The grass
was wet and her hand slipped on the ground. She heard a pop and
had immediate R elbow pain and swelling. She denies any numbness
or paresthesias in the RUE.
Past Medical History:
depression
adhd
opiod abuse
Social History:
___
Family History:
nc
Physical Exam:
AVSS
NAD, AOx3
RUE skin clean and intact
Tenderness and swelling of R medial and lateral elbow
No forearm tenderenss or wrist tenderness
R arm in posterior spint; wiggles fingers, extends thumb. Fires
EPL/EIP/EDC/VIO/DIO; mildly dc sensation over dorsom of hand and
thumb
M U SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Pertinent Results:
___ 06:00PM GLUCOSE-87 UREA N-11 CREAT-0.7 SODIUM-138
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
___ 06:00PM estGFR-Using this
___ 06:00PM CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-1.9
___ 06:00PM WBC-11.2* RBC-3.65* HGB-11.4* HCT-34.7*
MCV-95 MCH-31.2 MCHC-32.8 RDW-12.6
___ 06:00PM PLT COUNT-274
___ 06:00PM ___ PTT-29.2 ___
___ 04:54AM URINE HOURS-RANDOM
___ 04:54AM URINE UCG-NEGATIVE
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a R radial head fracture. The patient was taken to the
OR and underwent an uncomplicated R radial head replacement. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: NWB R arm.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout, exceptions noted in
physical exam. The patient was discharged in stable condition
with written instructions concerning precautionary instructions
and the appropriate follow-up care. All questions were answered
prior to discharge and the patient expressed readiness for
discharge.
Medications on Admission:
Adderall *NF* (amphetamine-dextroamphetamine) 30 mg Oral tid
Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID dose disscussed
with patients outside addiction md
BuPROPion (Sustained Release) 200 mg PO BID
Fluoxetine 20 mg PO DAILY
Gabapentin 400 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
2. Adderall *NF* (amphetamine-dextroamphetamine) 30 mg Oral tid
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
dose disscussed with patients outside addiction md
4. BuPROPion (Sustained Release) 200 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 20 mg PO DAILY
7. Gabapentin 400 mg PO BID
8. Multivitamins 1 CAP PO DAILY
9. Senna 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
status post R radial head replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
non weight bearing R arm, sling
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
Followup Instructions:
___
|
10514722-DS-8 | 10,514,722 | 22,378,744 | DS | 8 | 2190-04-13 00:00:00 | 2190-04-16 23:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline /
Erythromycin Base / aspirin / Tizanidine
Attending: ___
Chief Complaint:
malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ yo female with a history of hypothyroidism,
hypertension, asthma and depression who presents with three days
of fever, chills, vomiting and diarrhea.
Pt describes generally feeling unwell over the last three days.
She endoreses nonbloody diarrhea, as well as episodes of nausea
and vomiting. She also endorses having fever and chills at home.
She denies any dysuria, chest pain, shortness of breath, cough
or sputum production. She has also not been taking her thyroid
medication for the last five days secondary to her illness.
In the ED her initial vital signs were: 102.4 125 142/77 22 98%
RA.
Labs were notable for a low-grade leukocytosis to 11.8 (81%
PMN's). Chem 7 within normal limits, lactate of 1.6. U/A showed
100 WBC's, large amount of leukocyte esterase and negative
nitrite (2 epi's).
A CXR was obtained and showed a RUL consolidation.
She recieved a dose of IV levofloxacin in the ED and was
admitted to the medicine service.
Past Medical History:
- dense cataracts bilaterally
- chronic HAs
- chronic low back pain
- myofascial pain
- Right hip pain
- "lumbar spinal stenosis" per pt (Hx uncertain)
- "lupus" per pt (follows w/Rheum, no meds for this)
- anxiety no longer taking benzo (stopped recently)
- HTN on meds
- asthma
- hypothyroidism
- vitamin/mineral deficiencies (B12, D, ?Ca, ?Fe)
- Osteoporosis
- Depression (She has no history of hospitalizations
for mental illness or suicide attempts)
- Insomnia
- Degenerative joint disease
- B12 and vitamin D deficiency
- ___'s tenosynovitis s/p left wrist surgery
Social History:
She is not working at present. Reports that she
is on disability/SSI, for unclear indication, believes it is for
knee surgery in the past. She has worked as a ___,
___, ___, and in the ___ clinic.
Her diet is relatively healthy, but does rely on her financial
situation. For exercise she walks, but does not ___ any other
dedicated exercise. Tobacco, she quit only recently. She had
been smoking for about ___ years and quit because of the expense.
Alcohol, she quit because her son was an alcoholic. She does not
have a history of drug use. She is separated and lives with her
daughter and son. She has six sons and one daughter, one son
passed away ___ years ago from cirrhosis secondary to
alcoholism.
She states several family members have this condition.
Family History:
Brother had colon cancer. Mother is living in
___ at age ___, has a history of stroke, heart problems, and
MI. Father died of unknown causes. No additional cancers
identified in the family.
Physical Exam:
ADMISSION:
VS: 98.6 BP 129/81 P 94 RR 18 99% on RA
GEN Alert, oriented, no acute distress
HEENT: NCAT, dry mucous memebranes, EOMI sclera anicteric, OP
clear
NECK supple, no JVD, no LAD
PULM Good aeration, crackles bilaterally at the bases, no
wheezes or rhonchi appreciated
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE - pt left AMA overnight, last exam before AMA
O -VS: 98.7/100.6(4am ___ BP 118/72 HR 114 (100s-110s) 18
99% on RA
GEN: Laying on her right side, quickly acknowledges my presence
and asks questions on her own today, Oriented x 3. Affected
depressed, but does answer questions with more detail today.
Affect constricted; answers were unusually brief, almost
avoidant, unless pressed for relevant details.
HEENT: Dense cataracts. Dry membranes with some white residue on
tongue, Sclera anicteric,
NECK: Tender on direct palpation (chronic), No pain with ROM,
touches chest, left, right without pain.
PULM: Speaking in full sentences, non labored, Good aeration,
crackles bilaterally at the bases, no wheezes or rhonchi
appreciated
CV: RRR normal S1/S2, no mrg
ABD: Tender to palpation diffusely with mild distension. No
rebound.
EXT: No edema of Lower extremeties. WWP 2+ pulses palpable
bilaterally, no c/c/e
NEURO: CNs2-12 grossly intact. Pt walks on her own but has
difficulty with balance. UE and ___ strength ___ and symmetrical.
GAIT: Stands without difficulty. Good initiation. Slightly wide,
very hesistant steps. Minimal arm swing. No ataxic quality to
her gait. She occasionally seems prone to sway in any direction
and stops herself. Turns quickly. Poor balance.
Pertinent Results:
ADMISSION:
___ 04:45PM BLOOD WBC-11.8*# RBC-4.69 Hgb-12.2 Hct-37.0
MCV-79* MCH-26.1* MCHC-33.0 RDW-15.3 Plt ___
___ 04:45PM BLOOD Neuts-81.2* Lymphs-12.9* Monos-4.9
Eos-0.7 Baso-0.3
___ 04:45PM BLOOD Glucose-120* UreaN-15 Creat-1.1 Na-130*
K-6.8* Cl-94* HCO3-25 AnGap-18
___ 04:45PM BLOOD TSH-0.10*
___ 04:55PM BLOOD Lactate-1.6 K-4.4
STUDIES:
CXR: Right upper lobe consolidation compatible with pneumonia in
the
proper clinical history. Recommend repeat exam after treatment
to document
resolution. Trace right pleural effusion.
MICRO:
CDiff neg
BCx neg
UCx neg
DAY OF AMA:
___ 07:40AM BLOOD WBC-6.7 RBC-4.47 Hgb-11.6* Hct-36.2
MCV-81* MCH-25.9* MCHC-32.0 RDW-15.2 Plt ___
___ 07:40AM BLOOD Neuts-63 Bands-0 ___ Monos-7 Eos-0
Baso-1 ___ Myelos-0
Brief Hospital Course:
Pt is a ___ yo female with a history of hypothyroidism,
hypertension, and asthma who presents with malaise x 5 days,
with fevers and chills, several episodes of diarrhea, found to
have a consolidation on CXR and possible urinary tract
infection. Pt left on ___ ___ AMA after complaining
about not receiving Nortriptyline.
.
## FEVERS/CHILLS/DIARRHEA: Last fever at ___ 100.6. Likely
infectious etiology: most likely PNA of RUL. DDX: Infection of
GI (diarrhea), vs GU (UA with WBC) vs. Encephalitis (somnolence,
malaise). She certainly has an infection with a leukocytosis
and left-shift, as well as fevers as high as 102.4 on admission.
Pt denies dysuria so UTI less likely. . Encephalitis can be
considered, however, per chart analysis pt has long history of
Gait abnormalities, HA, and neck soreness. Pt was started and
then continued on Levofloxacin (IV initially then PO). WBC and
Fever curve trending down before AMA. Blood cx were negative,
Ucx grew skin flora.
.
## DIARRHEA - 5 episodes overnight per patient on ___. Episodes
started prior to hospital admission, could be related to a vrial
process. Cdiff was negative.
## DEPRESSED AFFECT/AMS - Improving significantly on ___. More
interactive and talkitive. Could be ___ PNA, resopnding to ABX.
- Will confirm with family that patient is improving
- Cont Levofloxacin
.
## GAIT - no evidence ___ weakness, no sensory deficit, no
sensory loss, can navigate the room. Of note, the patient gives
a history of lumbar "spinal stenosis". Moving bowels and
urinating appropriately. No concern for cord compression. Will
need further f/u in outpatient setting
.
--------
CHRONIC
--------
# LOW BACK PAIN - chronic with DJD, we continued tylenol ___
QID and Lidocaine patch
.
# HTN: we continued nifedipine . SBPs ranged 110s-140s
.
# Asmtha: cont advair, albuterol-ipratropium nebs q6h prn
.
# Depression/Insomnia: cont duloxetine 40 mg daily, ativan 0.5
mg qhs
.
# Hypothyroidism: TSH was 0.10 on admission , we continued
levothyroxine 88 mcg daily
.
# Osteoporosis: cont fosamax 70 mg daily
.
# VIT B12 DEFICIENT - cont supplements
.
## TRANSITIONAL
- pt left AMA to another hospital
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen w/Codeine 1 TAB PO DAILY:PRN headache
please hold for rr<12 or increased somnolence
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Alendronate Sodium 70 mg PO QWED
4. Cyanocobalamin 1000 mcg PO DAILY
5. Duloxetine 40 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Gabapentin 400 mg PO QID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Lorazepam 0.5 mg PO HS:PRN insomnia
11. NIFEdipine CR 30 mg PO DAILY
please hold for sbp<100
12. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN back pain
please hold for rr<12 or increased somnolence
14. Calcium Carbonate 1500 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
LEFT AMA
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Alendronate Sodium 70 mg PO QWED
3. Calcium Carbonate 1500 mg PO BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Duloxetine 40 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Gabapentin 400 mg PO QID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. NIFEdipine CR 30 mg PO DAILY
please hold for sbp<100
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN back pain
please hold for rr<12 or increased somnolence
12. Vitamin D 1000 UNIT PO DAILY
13. Levofloxacin 750 mg PO Q24H
until ___
RX *levofloxacin 750 mg one tablet(s) by mouth once per day Disp
#*5 Tablet Refills:*0
14. Lorazepam 0.5 mg PO HS:PRN insomnia
15. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent. Oriented.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
Thank you for chosing ___. You were admitted for weakness and
fever. A chest xray showed pneumonia of your right lung. We
started an oral antibiotic which you should continue until
___. You decided to leave AGAINST medical advice on ___ around midnight. At this time, you were eating, drinking,
and using the bathroom without problems. You were walking in the
hallways well. Your blood pressure and heart rate were stable.
You have not had a fever since yesterday.
Please continue to take your levofloxacin, which was started in
the hospital. This is an antibiotic to treat your pneumonia.
Please take Levofloxacin 750 mg by mouth once per day until
___.
Please make sure to call your PCP at the number below to set up
a close follow up appointment.
**MEDICATIONS:**
START Levofloxacin 750mg by mouth once a day until ___
Followup Instructions:
___
|
10515141-DS-3 | 10,515,141 | 26,282,235 | DS | 3 | 2133-09-15 00:00:00 | 2133-09-15 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
.
CC: ___
.
HISTORY OF PRESENT ILLNESS: ___ y/o woman with PMHx HTN, LVH and
mild AS (mean gradient 12mm Hg) presenting to the ED with HA.
She states the HA is dull and posterior - does not typically
have headaches. She thinks the HA was associated with blurry
vision. She subsequently took her BP, and noted it was 200s
systolic. She states she took her Lisinopril this morning as
prescribed, but thinks she has been eating more salt that usual
recently. She denies CP/SOB/N/V/D. Denies HA or blurry vision
currently.
Past Medical History:
PAST MEDICAL HISTORY:
-Left Ventricular Hypertrophy on echocardiogram
-Mild Pulmonary Hypertension
-Borderline RV Enlargement
-Mild Aortic Stenosis
-Hypertension dx ___
Social History:
___
Family History:
Family History:
Mother: ___ Infarction: late ___, early ___ yo,
history of hypertension
Siblings: healthy
No family history sudden cardiac death/valve disease/premature
coronary artery disease
Physical Exam:
PHYSICAL EXAM:
T 97.4 BP 179/107 HR 67 RR 18 O2 Sat 96% RA
GENERAL: well appearing, NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, II/VI systolic murmur best heard at the RUSB, nl
S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp. the R knee has a
moderate effusion, full ROM bilaterally, no erythema or warmth.
NEURO: awake, A&Ox3, CNs II-XII grossly intact, non focal.
patienn admitted same day as d/c her d/c BP was 142/98
Pertinent Results:
___ 06:45PM BLOOD WBC-3.6* RBC-4.03* Hgb-12.3 Hct-38.5
MCV-96 MCH-30.6 MCHC-32.0 RDW-13.5 Plt ___
___ 06:53AM BLOOD WBC-2.8* RBC-3.78* Hgb-11.6* Hct-35.5*
MCV-94 MCH-30.6 MCHC-32.6 RDW-13.1 Plt ___
___ 06:45PM BLOOD Neuts-62.4 ___ Monos-7.1 Eos-1.1
Baso-0.9
___ 06:45PM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
___ 06:53AM BLOOD Glucose-84 UreaN-16 Creat-0.7 Na-137
K-3.6 Cl-102 HCO3-25 AnGap-14
___ 06:53AM BLOOD CK(CPK)-53
___ 06:53AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0
CXR
Mildly dilated, tortuous aorta. Moderate cardiomegaly. No
acute
cardiopulmonary abnormality
Brief Hospital Course:
**consider repeat outpt TTE for eval of AS and LVH**
___ y/o woman with PMHx HTN, LVH and mild AS (mean gradient 12mm
Hg) presenting to the ED with hypertensive emergency.
.
# Hypertensive Emergency: Likely related to increased NaCl
intake and undertreated HTN given LVH. Given blurry vision,
concern for end organ damage. When I saw patient she no longer
had headaches. We continued home lisinopril 40 and started
amlodipine 5 and was given IV labetalol (while in ER) and when
on the floors was given PO 100TID. Cardiac enzymes checked adn
were negative. Nutrition consulted to educate patietn about low
salt diet. She is discharged on lisinopril and amlodipine and
will check her BPs at home regularly and follow up with her PCP.
# Aortic Stenosis: Last echo ___. Patient has a cardiologist
who she sees as follow up . Recent echo from ___ showing
Aortic Valve - Peak Velocity: *2.5 m/sec Aortic Valve - Peak
Gradient: *25 mm Hg Mild to moderate (___) aortic
regurgitation was also seen. She also has LVH. Patient will
follow up with her cardiologist, and should have echo done
___.
.
# Positive UA: Given she was asymptomatic, no indication to
treat so we did not start antibiotics.
.
# R Knee Effusion: Likely related to miniscal tear, as patient
endorses swelling after skiing assocaited with "clicking" and
decreased ROM. No erythema or warmth to suggest infection or
crystal arthropathy. ROM is currently back to baseline.
Patient will follow up with ortho
TRANSITIONAL ISSUES
#R knee effusion: patient should follow up with ortho
#HTN: should be followed and amlodipinen should be increased as
needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: hypertension
secondary: left ventricular hypertrophy and aortic stenosis
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 your during your stay here at
___.
You came to the hospital because of a headache and high blood
pressure. You were found to have a blood pressure in theh
200s/100s. We gave you medication to lower your blood pressure
which worked. We started you on a new medication which we would
like for you to take every day and follow up with your primary
care doctor about your blood pressure. It is also very important
that you avoid salty foods such as ___ sausage etc.
Please check your blood pressures while at home in the morning.
If the top number is above 180 please call your primary care
doctor.
The following changes have been made to your medication regimen:
START amlodipine
Followup Instructions:
___
|
10515313-DS-16 | 10,515,313 | 27,824,879 | DS | 16 | 2128-10-10 00:00:00 | 2128-10-10 16:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine / Epinephrine / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Fluorescein
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, reduction of closed loop
obstruction, and resection of small intestine about 121 cm with
application of ABThera VAC in open abdomen
___: Small bowel resection with primary anastomosis
History of Present Illness:
___ F w/ COPD, Sjogren's, HTN p/w severe abdominal pain,
nausea and vomiting. Reports pain started suddenly this AM and
was associated with ~ 5 episodes of bilious, non-bloody emesis.
No BM or flatus since early AM. Reports subjective fevers and
chills since the pain started. No diarrhea or BRBPR. Has never
had this pain before. CT scan in ED demonstrates closed loop
SBO. Surgery was emergently consulted.
Past Medical History:
- COPD
- Hypertension
- Hypercholesterolemia
- Hypothyroidism
- Sjogren's syndrome
- Squamous cell skin cancers
- Multiple GI issues: GERD, IBS, duodenitis, gastritis,
hemorrhoids, colonic polyps
- Tobacco use and past bronchitis
Social History:
___
Family History:
Non-contributory.
Physical Exam:
PE ON ADMISSION:
VS: ___ 48 147/45 19 96% RA
Gen: NAD, AOx3
___: reg
Pulm: no resp distress
Abd: soft but significantly distended, TTP throughout mainly
lower abdomen with rebound and guarding.
___: no LLE
Physical Exam on Discharge:
VS: 97.7 61 150/56 18 96% 2L
Gen: NAD, AOx3
___: reg
Pulm: no resp distress
Abd: soft but significantly distended, TTP throughout mainly
lower abdomen with rebound and guarding. Vertical midline
incision, stapled, lower ___ of incision open with wtd packing,
no drainage, no signs of infection.
___: no LLE
Pertinent Results:
___ 04:48AM BLOOD WBC-14.4*
___ 05:32AM BLOOD WBC-13.1* RBC-2.86* Hgb-9.1* Hct-26.5*
MCV-93 MCH-31.8 MCHC-34.3 RDW-14.8 Plt ___
___ 10:11AM BLOOD WBC-14.2* RBC-2.96* Hgb-9.3* Hct-26.9*
MCV-91 MCH-31.5 MCHC-34.7 RDW-14.6 Plt ___
___ 05:07AM BLOOD WBC-12.8* RBC-2.95* Hgb-9.5* Hct-27.6*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.8 Plt ___
___ 06:30PM BLOOD WBC-24.1*# RBC-4.72 Hgb-15.1 Hct-43.6
MCV-92 MCH-32.0 MCHC-34.6 RDW-14.3 Plt ___
___ 05:32AM BLOOD Neuts-76* Bands-1 Lymphs-14* Monos-8
Eos-1 Baso-0 ___ Myelos-0
___ 05:32AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
___ 05:32AM BLOOD Plt Smr-NORMAL Plt ___
___ 01:51AM BLOOD ___ PTT-29.0 ___
___ 05:32AM BLOOD Glucose-98 UreaN-6 Creat-0.4 Na-139 K-3.6
Cl-104 HCO3-30 AnGap-9
___ 10:13AM BLOOD CK(CPK)-449*
___ 12:16PM BLOOD ALT-15 AST-19 AlkPhos-88 TotBili-0.4
___ 05:27PM BLOOD CK-MB-4 cTropnT-0.01
___ 01:42AM BLOOD CK-MB-11* cTropnT-0.04*
___ 10:13AM BLOOD CK-MB-15* MB Indx-3.3 cTropnT-0.03*
___ 01:55AM BLOOD CK-MB-9 cTropnT-0.02*
___ 05:32AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.7
___ 09:33PM BLOOD freeCa-1.16
*IMAGING*
___ CT abd:
Closed loop small bowel obstruction (mid and distal, part of
jejunum and ileum) with transition points centered in the lower
mid abdomen. Area of indistinctness and hypoenhancement
involving
a short segment of the involved small bowel is concerning for
ischemia. No wall thickening or pneumatosis. No pneumoperitoneum
or portal venous gas. Adjacent free fluid.
___ CXR:
New left lower lobe aspiration or atelectasis.
Nasogastric tube terminates in stomach.
___: chest x-ray:
ReportInterval resolution of left perihilar and basilar
consolidation compared to 22
Preliminary ___, but with development of new right
base consolidation a concerning
Preliminary Reportfor an infectious process.
Brief Hospital Course:
The patient was taken to the surgical ICU after an ex-lap and
small bowel resection (approximately 140cm) for closed loop SBO.
The abdomen was left open with a vac in place. She was extubated
after the case. Of note, during the case, the patient had some
ST depressions and a very labile blood pressure. She had no EKG
changes post-op, but CKMB and troponins were mildly elevated
with peak troponin 0.04. Cardiology evaluated the patient's
post-op EKG, which was unremarkable. She denied chest pain. The
cadiology team advised that she be started on a baby aspirin,
that her lipitor be increased to 40 daily, and that she follow
up as an outpatient.
On HD2, she was given 250mL of 5% albumin for a decreased urine
output. She was restarted on beta blockade with IV lopressor.
She remained on cipro/flagyl for 24 hours post-op.
On HD3, she returned to the operating room. An additional 35cm
of bowel was removed prior to reanastomosis, and the abdomen was
closed. She was extubated post-op and epidural was placed. She
had some hypotension with initiation of the epidural which
resolved with fluid resuscitation.
On HD4, CXR showed increasing left pleural effusion. Lopressor
was increased to 10mg Q6 for tachycardia and hypertension. She
began to get out of the bed.
On HD5, she was started on home levothyroxine, atenolol and
HCTZ.
On HD6, pain remained well controlled with epidural. Her
atenolol was increased to 25 BID for hypertension. NGT clamp
trial had 25ml residual, and thus the NGT was d/c'd. Her
epidural was also removed. Her BP remained elevated, likely due
to poor absorbtion of atenolol. She was thus started again on
metop 10 IV Q6H and atenolol was held.
On HD7, the patient remained on a clear liquid diet due to
ongoing abdominal distention. On HD8, WBC was slightly elevated
to 14.8, and the inferior aspect of her midline incision was
opened and a seroma was drained. The incision was packed with a
wet to dry dressing and the wound appeared clean.
On HD9, the patient was endorsing flatus, and abdomen was soft.
Pain was well controlled. Diet was advanced as tolerated to a
regular diet with good tolerability. The patient voided without
problem. During this hospitalization, the patient was adherent
with respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. Physical Therapy was working with the patient, and
recommended she be discharged to rehab. She still continued to
have a congested cough, and remained on all her inhalers. A
chest x-ray was done on ___ which showed a new right base
consolidation. She was started on a 1 week course of
levofloxacin.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding, and pain was well
controlled. The patient was discharged to rehab. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan
Medications on Admission:
___: Advair Diskus 250 mcg-50 mcg inh', Alphagan P 0.1 % eye
drops
1 drop both eyes'', Ativan 0.5 mg'' prn anxiety, B Complex
tablet extended release', Estrace 1 mg', Fiber Laxative 48.57 %
Oral Powder
7 teaspoons by mouth at bedtime, Lipitor 10 mg', Pepto-Bismol
262
mg/15 mL oral suspension prn nausea, acitretin 10 mg', atenolol
12.5 mg'', vit D3) 1,000 unit capsule', colace 100 mg'',
glucosamine sulfate dipotassium chloride 1,000 mg', HCTZ 12.5
mg', latanoprost 0.005 % eye drops1 gtt ___, levothyroxine 75
mcg', oxycodone-acetaminophen 5 mg-325 mg ___ tab BID prn pain,
potassium chloride ER 10 mEq tablet,extended release 1 tab',
tobramycin 0.3 % eye drops ? dose
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO BID
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
5. Docusate Sodium 100 mg PO BID
6. Estradiol 1 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
12. Levofloxacin 750 mg PO DAILY
1 week course, last dose ___. Atorvastatin 10 mg PO ___
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
15. Potassium Chloride 10 mEq PO DAILY
16. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth twice a day Disp #*15
Tablet Refills:*0
17. Psyllium Powder 1 PKT PO QHS
18. Vitamin B Complex 1 CAP PO DAILY
19. Nicotine Patch 21 mg TD DAILY
20. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES
DAILY:PRN as instructed
21. Heparin 5000 UNIT SC TID
22. Bismuth Subsalicylate 15 mL PO DAILY:PRN nausea
23. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
sob/wheeze
24. Glucosamine Relief (glucosamine sulfate 2KCl) 1,000 mg oral
DAILY
25. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
hold for increased sedation, resp rate <8
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intestinal necrosis due to internal hernia
Closed loop small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ with abdominla pain and were found to
have a closed loop bowel obstruction with ischemic bowel. You
were taken urgently to the operating room for an exploratory
laparotomy, reduction of closed loop obstruction, and resection
of small bowel. Your abdomen was left open, and you were
monitored closely in the intensive care unit, and were taken
back to the operating room a day later to have the intestines
washed out and closed. You tolerated the procedure well and are
now being discharged to rehab to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10515366-DS-13 | 10,515,366 | 26,739,112 | DS | 13 | 2133-12-20 00:00:00 | 2133-12-20 23:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and SOB
Major Surgical or Invasive Procedure:
Radial ABG ___
History of Present Illness:
This is a ___ year old male w/PMH of relapsed CLL (on ibrutinib
with recent CT scan and WBC improvement) and prior pulmonary
embolism who presents w/fever and shortness of breath. ___ he
had a temperature to 101 and took tylenol which helped but the
fever came back after about 6 hours. He otherwise felt well but
___ was febrile again. Then today he noted some shortness of
breath when walking around and spoke with his oncologist who
referred him to the ED. He states he has also had a
nonproductive mild cough for the past two days. He has two
neighbors with upper respiratory tract illnesses and they share
doorways and keypads of joint apartment. Denies nausea,vomiting,
diarrhea, abdominal pain, headache, or dysuria.
ED course:
Triage v/s: + Triage 15:29 0 100.4 151 141/96 18 95% RA
Note that in the ED BP dipped as low as 89/61 but with IVF went
back up to 113/66. Satting 100% on ___ NC in ED per record.
-labs: UA unremarkable, lactate 2.2
chem: 140/3.5; 97/30; ___ <95
LFTs WNL.
CBC: 13.5 > 43.0 < 124. 70% PMNs 26% lymphs. INR 1.2.
- imaging: CTA chest showed no PE but RUL and RML consolidations
c/f pneumonia.
-interventions: Pt received 2L IVF (NS), 1g CTX IV, 500mg IV
azithro, and 5 mg morphine IV. He was also given 100mg IV
hydrocortisone.
On the floor, pt feels comfortable. He is satting 92% on RA and
96% on 2L. He has no dyspnea on exertion. He reports not feeling
as feverish at this time. No dysuria or cough or nasal
congestion
at this point.
REVIEW OF SYSTEMS:
GENERAL: No night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: Mild cough only as per HPI but no hemoptysis or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, 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.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
SAPHO syndrome
Significant ankylosing spondylitis since ___
Gastric ulcer
Kidney stones about ___ years ago
CLL since ___
His treatment history is as follows:
___: 6 cycles R-CVP
___: 6 cycles FCR
___: 3 cycles Bendamustine/Rituximab
___: 4 cycles Bendamustine/Rituximab
Social History:
___
Family History:
Mother deceased from lung cancer ___.
Father deceased from a brain aneurysm. He had a sister who is
deceased from ovarian cancer. Six other siblings. He has a
maternal uncle with leukemia and maternal aunt with lung cancer
Physical Exam:
ADMISSION EXAM
T 98.2 BP 100/68 HR 100 RR 20 98% on 4L, 96% on 2L, 92% on
RA.
General: NAD, resting calmly in bed watching tv
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly.
Protuberant abdomen, obesity.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy. Left ankle swollen but not erythematous or painful
to
palpation or full range of motion.
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+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; coordination is intact.
DISCHARGE EXAM
Vitals: 98.3, 136/82, 107, 18, 98% sitting on 0.5-1 L
GENERAL: NAD, obese body habitus
SKIN: warm and well perfused, no excoriations or lesions, facial
rash/erythema present
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no labored breathing, right breath sounds less than
left
ABDOMEN: protuberant, +BS, nontender in all quadrants, no
rebound/guarding, mildly enlarged spleen with just palpable tip,
no hepatomegaly
PULSES: 2+ DP pulses bilaterally, pitting edema 1+ b/l ___
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact
Pertinent Results:
ADMISSION LABS
___ 02:10PM BLOOD WBC-14.3* RBC-4.18* Hgb-13.6* Hct-41.4
MCV-99* MCH-32.4* MCHC-32.7 RDW-13.0 Plt ___
___ 02:10PM BLOOD Neuts-68.3 ___ Monos-2.1 Eos-0.8
Baso-0.4
___ 04:10PM BLOOD ___ PTT-28.8 ___
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-95 UreaN-6 Creat-0.7 Na-140 K-3.5
Cl-97 HCO3-30 AnGap-17
___ 02:10PM BLOOD ALT-31 AST-22 LD(LDH)-215 AlkPhos-64
TotBili-1.2
___ 02:10PM BLOOD TotProt-5.6* Albumin-3.9 Globuln-1.7*
Calcium-9.3 Phos-3.3 Mg-2.0 UricAcd-4.6
___ 04:18PM BLOOD Lactate-2.2*
DISCHARGE LABS
___ 06:35AM BLOOD WBC-10.3 RBC-3.63* Hgb-11.5* Hct-36.5*
MCV-101* MCH-31.6 MCHC-31.4 RDW-13.6 Plt ___
___ 06:35AM BLOOD Neuts-43* Bands-0 Lymphs-51* Monos-1*
Eos-0 Baso-0 Atyps-5* ___ Myelos-0
___ 06:35AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD ___ PTT-29.9 ___
___ 06:35AM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-139
K-4.1 Cl-99 HCO3-34* AnGap-10
___ 06:35AM BLOOD ALT-19 AST-19 LD(LDH)-189 AlkPhos-63
TotBili-0.3
___ 06:35AM BLOOD Albumin-3.4* Calcium-8.9 Phos-4.4 Mg-2.1
PERTINENT LABS
___ 07:00AM BLOOD proBNP-122
___ 06:15AM BLOOD IgG-277*
___ 06:17PM BLOOD Type-ART pO2-76* pCO2-42 pH-7.46*
calTCO2-31* Base XS-5
___ 04:18PM BLOOD Lactate-2.2*
___ 07:01AM BLOOD Lactate-1.9
IMAGING
Imaging:
CXR ___
Increased opacity concerning for right mid and lower lobe PNA.
CTA chest ___
No evidence of PE or acute aortic syndrome.
Right upper lobe and right middle lobe consolidations are
concerning for PNA.
Stable widespread lymphadenopathy
Lower extremity non-invasive imaging ___
FINDINGS:
There is normal compressibility, flow and augmentation of the
bilateral common
femoral, superficial femoral, and popliteal veins. Normal color
flow and
compressibility are demonstrated in the right posterior tibial
and peroneal
veins. The left posterior tibial vein show normal
compressibility color flow.
The left perineal veins are not visualized.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Left peroneal veins not visualized. Otherwise, no evidence of
deep venous
thrombosis in the bilateral lower extremity veins.
TTE ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. The aortic root is mildly dilated at
the sinus level. The aortic valve is not well seen. There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
no clear change.
MICROBIOLOGY
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
*FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ y/o M with CLL on ibrutinib since ___ and history of prior
PE presented with fever and dyspnea and CT imaging c/w
pneumonia.
# PNA - He was afebrile throughout course of hospital stay but
had shortness of breath along with findings on CT suggestive of
pneumonia. This would be community acquired given no recent
hospitalizations though does have risk factors for atypical
organisms given underlying immunocompromise of CLL and on
ibrutinib along with a steroid (though only on very low dose
prednisone). Pt is not neutropenic and symptoms such as cough
and shortness of breath improved during hospitalization. He
received IV antibiotics for CAP for 2 days and was transitioned
to levofloxacin for a 5 day course that he completed on the day
of discharge. He also received 30g of IVIg while inpatient due
to low level of immunoglobulin determined as inpatient. All
tests performed other the initial scan were negative for
specific etiology of PNA including legionella/strep urine
antigen along with a RVP screen. Blood and urine cultures were
negative as well. Patient was unable to completely wean from
oxygen, requiring 0.5 to 2 L oxygen for minimal exertion to
maintain oxygen saturation. The pulmonary team saw him while
inpatient and recommended small dosage of Lasix one time along
with an ABG and follow up outpatient for further investigation
of lung status.
# HA - Never had HA problems in past, no focal deficits,
received oxycodone at night which he usually does at home for
back pain, it helped. HA most likely secondary to caffeine
withdrawal and changes in consumption food/drink along with lack
of oxycodone/acetaminophen dosing inpatient that he receives
nightly at home. We encouraged mild caffeine consumption along
with adequate fluid intake and the usage of nighttime oxycodone
5 mg as needed for pain or discomfort.
# Sinus tachycardia - HR up to 120 for most of the admission
most likely due to compensatory tachycardia along with holding
of home atenolol due to concerns for hypotension. Improved with
atenolol and gentle fluid boluses. He was never symptomatic from
the tachycardia. TTE was essentially unchanged since ___.
# Pitting edema b/l - Became pronounced ___ AM, last
echocardiogram was ___ with LVEF > 55% and ___
echocardiogram was essentially the same. Decreased with modest
dosages of Lasix over two days.
# Back pain - Chronic issue with active concerns at night for
which we provided oxycodone 5 mg QHSPRN:pain q6h.
# CLL - Patient doing well with WBC down and reduced
lymphadenopathy when last seen in clinic in ___. He is on
ibrutinib 420mg po daily started ___. WBC decreased
during admission from 13.5 to 10 to 4 to 5 range, which could be
suppressed in setting of infection, percentage of lymphocytes
stable in mid 20 range. As noted above, patient was provided
with IVIg while inpatient.
# SAPHO syndrome - He is on prednisone 2.5 mg BID for control of
acne eruptions associated with condition and we continued this
while inpatient. Diagnosed with syndrome based on constellation
of clinical findings, history, and imaging.
# Coping - Pt has very little family involvement, although his
sister currently lives with him. He needs to identify a HCP soon
and is amenable to consideration.
# HTN - History of HTN, held atenolol due to original
hypotension but started again on ___ due to persistent sinus
tachycardia.
Transitional:
- He will need PFTs, full set including lung volumes.
- He should get a sleep study.
- Provided O2 as outpatient to maintain saturation above 92%
- Pulmonology outpatient appointment to be determined. Patient
will be contacted with date and time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. ibrutinib 140 mg oral daily
4. oxyCODONE-acetaminophen 7.5-325 mg oral four times a day prn
pain
5. PredniSONE 2.5 mg PO BID
Discharge Medications:
1. oxygen
2 L via NC with ambulation only for sats of 88%
Pulse dose for portability
Dx Pneumonia
2. Allopurinol ___ mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. ibrutinib 140 mg oral daily
5. PredniSONE 2.5 mg PO BID
6. oxyCODONE-acetaminophen 7.5-325 mg oral four times a day prn
pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1). Pneumonia, improved
2). Restrictive chest wall physiology, stable
3). Chronic lymphocytic leukemia, managed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent with O2
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your time as an
inpatient at ___. You were diagnosed with pneumonia based on
the images taken of your lungs. Your breathing improved and your
cough decreased while inpatient on a course of antibiotics and
intravenous immunoglobulin which have completed. We were able to
decrease the amount of oxygen used, but you were still becoming
hypoxic without oxygen at the end of your time at ___. We
therefore discharged you on home oxygen. You will follow up with
pulmonology doctors at ___ as an outpatient to evaluate your
lung function.
Based on the ultrasound of your heart, there were no changes
from ___ and essentially normal function. Please monitor for
any weight gain greater than 3 lbs especially in the context of
increased swelling in your feet, ankles, and lower legs.
For your CLL, please continue to take the ibrutinib medication
and make sure to attend outpatient follow up appointments as
described below.
You may continue to take the oxycodone for back pain before bed
as per home routine.
Followup Instructions:
___
|
10515638-DS-21 | 10,515,638 | 24,976,128 | DS | 21 | 2149-10-24 00:00:00 | 2149-10-24 11:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
TBI
Major Surgical or Invasive Procedure:
___: Right Burr hole for ___ evacuation
___: Right MMA embolization
___: PEG placement
History of Present Illness:
___ male who presents to ___ on ___ with a
moderate TBI. Patient intubated and sedated on arrival. History
obtained from medflight, and OSH records.
Patient was reportedly on his bicycle this afternoon,
un-helmeted and un-witnessed, unknown LOC. The patient was able
to get himself to his sister's house, and was there for a half
an hour, before his family realized he was acting "off", with
altered mental status. Family reportedly took the patient to ___
(___, where upon arrival, he had a decline
in his mental status. Per report the patient was not following
commands, but verbalizing, saying "help me" and moving all
extremities antigravity. Patient intubated for airway protection
and NCHCT was obtained which demonstrated multiple areas of IPH,
SDH along the falx and multiple facial, skull fractures. Patient
was transferred via medflight to ___ for further evaluation.
Per medflight report, patient went into afib during transport,
then to ___. He was shocked and converted back to afib.
Patient was HTN in the 180s/120s, which came down to 120s/80s
after receiving fentanyl. Patient was given a 250cc Bolus of 3%
during medflight.
Neurosurgery was consulted for further evaluation on arrival to
___. Sedation could not be fully held for examination
as patient was not able to tolerate it, bucking at ET tube and
biting down on it.
Mechanism of trauma: Fall off bicycle
Past Medical History:
- CAD, MI, stent x 3
- HTN
- Dyslipidemia
- Hep C
- Chronic back pain
- NIDDM, controlled with diet
- Tonsillectomy
- Prior surgery to left shoulder
- h/p Spinal surgery
- Plate in skull
- Anxiety
- Depression
- Panic attacks
- PTSD
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
************
Physical Exam:
***Sedation could not be fully held for examination as patient
was not able to tolerate it, bucking at ET tube and biting down
on it. Exam below is under light sedation***
GCS at the scene: Unknown
GCS upon Neurosurgery Evaluation: 7T
Time of evaluation: 1:30AM
Airway: [x]Intubated [ ]Not intubated
Eye Opening:
[x]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
Exam:
Gen: Patient intubated, sedation
HEENT: Bleeding from the left ear. Right periorbital edema.
Neck: supple
Extrem: warm and well perfused
Neuro:
Mental Status: Intubated, sedated.
Orientation: Intubated and sedated, not oriented.
Language: Unable to assess
If Intubated:
[x]Cough [x]Gag
*Patient bucking and biting on the tube while on light sedation
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5mm to
2mm bilaterally.
III, IV, VI: Unable to assess
V, VII: Unable to assess
VIII: Unable to assess
IX, X: Not tested
XI: Unable to assess
XII: Unable to assess
Motor:
Unable to complete a formal motor exam, but on light sedation
patient localizes antigravity with good strength in bilateral
uppers. He attempts to reach for the ET tube. He withdraws
briskly in bilateral lower extremities
Sensation: Intact to light touch
------
Off Sedation, he EO to light noxious but does not sustain.
PERRL.
No commands. Moves BUE spontaneously and purposefully full
strength, antigravity. Patient wild, trying to pull off clothes,
grabbing at things. Moves RLE spontaneously. Withdraws localizes
but less than the right, yet withdraws briskly to noxious.
Repeat Exam GCS: 8T.
ON DISCHARGE:
*************
Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Seated in the chair at nursing station, alert and conversant.
Orientation: Alert and oriented to name, ___, ___,
and ___.
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3->2mm, bilaterally
EOM: [x]Full [ ]Restricted
Face Symmetric: [ ]Yes [x]No - mild left facial
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x] No
Speech Fluent: [x]Yes [ ]No
Comprehension intact: [x]Yes [ ]No
Motor:
Trap Delt Bi Tri Grip IP Quad Ham AT ___
L 5 5 5 5 5 4 4 4 ___
Wound:
Right sided incision area of granulation tissue, no drainage or
surrounding erythema.
Pertinent Results:
Please refer to OMR for pertinent imaging and lab results.
___ 07:57AM BLOOD WBC-4.1 RBC-4.12* Hgb-12.6* Hct-39.5*
MCV-96 MCH-30.6 MCHC-31.9* RDW-14.6 RDWSD-50.6* Plt ___
___ 06:55AM BLOOD Neuts-63.6 ___ Monos-11.1 Eos-3.6
Baso-0.3 Im ___ AbsNeut-4.98 AbsLymp-1.64 AbsMono-0.87*
AbsEos-0.28 AbsBaso-0.02
___ 07:57AM BLOOD Plt ___
___ 07:57AM BLOOD Glucose-121* UreaN-17 Creat-0.7 Na-144
K-4.2 Cl-106 HCO3-27 AnGap-11
___ 07:57AM BLOOD ALT-85* AST-57*
___ 04:40AM BLOOD ALT-76* AST-50*
___ 05:10AM BLOOD ALT-72* AST-46* AlkPhos-113 TotBili-<0.2
___ 05:15AM BLOOD ALT-77* AST-55*
___ 06:18AM BLOOD ALT-63* AST-43* LD(LDH)-245 AlkPhos-130
TotBili-0.2
___ 07:40PM BLOOD ALT-62* AST-39 LD(LDH)-179 AlkPhos-124
TotBili-0.3
___ 07:57AM BLOOD Calcium-9.8 Phos-4.1 Mg-1.8
Brief Hospital Course:
Patient was admitted to neurosurgery on ___ s/p fall off
bicycle while intoxicated with TBI, bifrontal, bitemporal IPH
and SDH along falx. He was transferred to the Neuro ICU for
atrial fibrillation/tachycardia. Following improvement in the
NICU, she was transferred to the step down unit, and eventually
the floor where his neurologic exam remained stable.
#TBI
Patient was admitted to neurosurgery to the ICU. He was started
on Keppra and hypertonic saline for Na control. Repeat NCHCT was
obtained 6 hours from prior which remained stable. The patient
remained in the TSICU intubated and sedated. He was extubated on
___. Repeat CTs on ___ and ___ were stable. Patient was
reintubated on ___ for respiratory issues. Patient self
extubated from a forceful cough and maintained his respiratory
status on shovel mask. His pupils were dilated by ophthalmology
on ___. He was reintubated on ___ and later extubated on
___. MRI of the brain on ___ showed no evidence of stroke.
He was restrated on gabapentin and Seroquel was decreased. His
salt tabs were eventually weaned to off for normal sodium
levels. Guardianship paperwork was started on ___, as the
patient's ex-wife no longer wished to fulfill that role, however
on ___, she agreed to continue being his HCP. On ___, he was
unable to move his left upper extremity, and would only
minimally withdraw to noxious stimuli. Head CT revealed a large
chronic right sided subdural hematoma. The patient was taken to
the OR urgently for right burr hole for evacuation. The OR was
uncomplicated. Please see OMR for further intraoperative
details. Postoperative imaging showed improvement and remained
stable. The patient remained intubated postoperatively and was
taken for a right MMA embolization the next day, on ___. This
procedure was also uncomplicated. Please see OMR for further
intraoperative details. The patient was extubated on ___. He
remained neurologically stable and was transferred to the ___
on ___. The patient's neurological status improved while in
___, and he was noted to be more alert and conversant. The
patient's neurological status continued to improve in the NIMU
as sedating medications were weaned off. The patient was
transferred to the floor for further care awaiting disposition.
On the floor, he had intermittent episodes of agitation and
repeatedly tried to get out of bed. On ___, he fell onto the
ground while trying to get out of bed, however, HCT was stable
following the incident. He was re-evaluated by psychiatry who
recommended increasing Depakote for agitation. On Depakote, LFTs
became elevated. Depakote stopped on ___ per hepatology
recommendations. Due to continued pain, gabapentin was titrated
up as tolerated with a goal of
returning the patient to his home dose of gabapentin. He was
found to be picking at his incision, and this was closely
monitored. Incision remained dry with granulation tissue. The
patient was occasionally felt to be depressed, and when
psychiatry was consulted they recommended outpatient follow up
once patient is in rehab. Follow up will also be arranged with
Dr. ___ in neurosurgery in approximately 4 weeks. He will
return and a repeat HCT will be performed to assess for
resolution of the SDH. At the time of discharge, he was
ambulating with assistance using the walker, pain was adequately
controlled on an oral regimen and his neurologic exam remained
stable.
#Decreased Left Lower Extremity Movement
The patient had an MRI of the total spine in the setting of
continued decreased movement of his left lower extremity, which
was notable for syringohydromyelia and old blood products within
the thoracic spine. Per patient's family, the patient was also
ambulating previously with a cane. This is likely traumatic
syringomyelia vs chronic arachnoiditis leading to syringomyelia.
On ___, the patient was not moving his left lower extremity as
well as the prior day and a CT head was ordered which revealed
stable HCT. The change in mental status was likely due to opioid
medications for PEG placement. Patient's LLE improved over the
course of his hospital stay. However, the patient will need
continued intensive physical therapy to increase mobility and
strength, and to increase function in the left lower extremity.
He is at significant risk for falls and should be maintained on
fall precautions, with additional fall precautions such as a low
bed at nighttime.
#Fevers
On ___ the patient spiked fever and was started on vanc/zosyn.
He was pan cultured. Due to persistent tachycardia, blood
cultures were obtained on ___ that showed staphylococcus,
however this was likely a contaminate as blood cultures x3 were
negative thereafter. The patient was treated for an aspiration
pneumonia with ceftriaxone. A CXR obtained on ___,
demonstrated no focal consolidation or concern for pneumonia.
Ceftriaxone was discontinued ___. The patient remained afebrile
for the remainder of his hospitalization.
#Transaminitis
On ___, patient was noted to have elevated LFT's. Hepatology
was consulted who recommended discontinuing Depakote in the
setting of hepatitis C and elevated LFT's. Repeat LFT's were
trended, hepatitis panel was sent. Liver U/S was performed which
revealed mild splenomegaly and normal morphology of liver
without lesions noted. LFTs were checked daily while in hospital
and were down trending since cessation of Depakote, however on
monitoring on ___ they increased and were closely monitored
for the remainder of his hospitalization. LFTs were also checked
on ___ and showed slightly elevated AST and ALT. LFTs should
be continued to be followed with his PCP to assess for rapid
elevation. Caution should be used when using Depakote for mood
stabilization as this previously resulted in significant LFT
elevation.
#ETOH withdrawal/agitation
The patient developed ETOH withdrawal and agitation while in the
TSICU. He was started on Seroquel and Precedex drip. He was
given small phenobarbital bolus x1, and was later started on a
phenobarbital taper. The patient then continued on Seroquel and
Clonidine with PRN Haldol IV. Psych was consulted on ___ for
further recommendations. He was started on Depakote QHS on
___, this dose was titrated per psychology recommendations
according to patients response and agitation. Patient was
discharged on Depakote 250mg Q12hrs, 25mg Seroquel PRN HS. On
___, clonidine was titrated down to 0.1mg q8hrs per cardiology
recs. On ___, the clonidine was further titrated down.
Agitation improved over the course of his hospitalization. He is
no longer requiring Seroquel, deptakote, or restraints.
#Orbital roof fracture
Orbital roof fracture was noted on CT, ophthalmology and plastic
surgery were consulted. Lateral canthotomy was lengthened. No
globe injury was identified. No urgent surgical intervention
was recommended. His pupils were dilated by ophthalmology on
___ after extubation. Optho re-evaluated the patient on ___
to measure ocular pressures and findings were likely normal.
Ophthalmology unable to fully assess visual acuity due to
patient's metal status. They recommend follow up outpatient for
a routine exam and patient as discharged with information to
make this appointment. (See discharge info for phone number of
clinic).
#Left parietal bone fracture
ENT was consulted for recommendations on management of fracture.
No acute intervention was recommended. He completed a course of
Neomycin-Polymyxin-HC otic drops. There was no facial paralysis
noted upon extubation. Patient needs follow-up with ENT for his
Ossicular chain discontinuity.
#New onset Afib
The patient developed new onset Atrial Fibrillation while in the
TSICU. He was not a candidate for anticoagulation in the setting
of recent TBI with contusions. On ___, due to persistent
hypertension and tachycardia not controlled by IV
Metoprolol, and he was transferred to the NICU where he briefly
required a Nicardipine, Diltiazem drip and Precedex. He later
improved and was able to tolerate PO medications. On ___, the
patient's HR dipped down into the 30's, but he remained
asymptomatic. His PO Diltiazem was held. Overnight on the ___,
he went back into atrial fibrillation and his PO Diltiazem was
resumed at 30mg Q6hrs. Patient also on PO metoprolol tartrate,
which was increased on ___ to 50mg q6hrs due to persistent
afib with RVR. Based on cardiolgy recommendations, Metoprolol
was further increased to 75 mg q6 hr. Patient to discuss
anticoagulation options for Afib at outpatient follow up. On
___, patient's HR's transiently down to ___ while sleeping,
while awake HR 40-50s. Metoprolol decreased to 37.5mg q6h.
Based on cardiology recommendations, the patient was then
transitioned to Digoxin 0.25, long acting digoxin 240 mg, and
Metoprolol succinate 200 mg. Due to episodes of bradycardia the
patient was then transitioned back to q6 dosing of metoprolol
and diltiazem to prevent prolonged bradycardic episodes. Patient
should follow up with a PCP to adjust these medications as
needed. Patient will also need cardiology follow-up given
persistent afib, and to titrate medications as needed. The
patient should not be started on systemic anti-coagulation until
cleared by neurosurgery.
#Nutrition
The patient was evaluated by SLP, who recommended that he be
NPO. An NG tube was placed, which the patient pulled out.
Attempts were made to replace it x7, without success. GI was
consulted and attempted to replace it, but was unsuccessful. It
will be replaced under visualization on ___. Formal speech
trials were attempted again however patient did not do well
given oral secretions and altered mentation. After multiple
failed attempts to replace NGT, the patient was brought to
endoscopy suite with GI to place NJ tube. He was started on tube
feedings with recommendations for nutrition. On the morning of
___, the patient became acutely agitated and self-discontinued
NJ tube despite restraints. However, he was then able to eat his
meals with 1:1 RN supervision. SLP re-evaluated the patient on
___, and continued to recommend NPO with trials under RN
supervision. Due to acute decompensation from worsening ___
patient was again unable to safely intake PO. An NG tube was
placed successfully post-operatively. Speech evaluated patient
again post-operatively on ___ and recommended patient be NPO
and PEG placement for continued nutritional support. ACS was
consulted for PEG placement. Nutrition consult recommended
temporary PPN until PEG placed. PEG was placed on ___ without
issues. When CXR was obtained and showed increased air under the
right hemi diaphragm, ACS evaluated the patient and felt that
findings were not concerning. On ___ the patient was more
awake, and SLP cleared for sips of water. Over the subsequent
few days, this swallowing improved, and he was cleared for a
ground diet. Tubefeeds were changed to being cycled overnight.
Cleared for regular diet and thin liquids with supervision on
___. Tolerating diet with 1:1 supervision, PEG remains in
place but not currently receiving tube feedings. Patient's PEG
site looked red and the bumper was not visible on ___. ACS was
paged who pulled back the bumper and removed the T bumper and
replaced it with a star bumper on ___. ACS did not
recommend prophylactic abx at this time as WBC low and no signs
of infection. Patient will continue with PEG placement for at
least ___ weeks post placement, then may be removed. Nursing
performed PEG tube checks every shift during hospitalization.
The patient will need to seen by ___ at ___ in ___ weeks for
PEG removal. Please call to schedule outpatient appointment.
AHA/ASA Core Measures for SAH/ ICH:
1. Dysphagia screening before any PO intake? [x]Yes []No
2. DVT prophylaxis administered? [x]Yes []No
3. Smoking cessation counseling given? [x]Yes []No [Reason:
()non-smoker ()unable to participate]
4. Stroke Education given in written form? [x]Yes []No
5. Assessment for rehabilitation and/or rehab services
considered? [x]Yes []No
Stroke Measures:
1.Was ___ performed within 6hrs of arrival? []Yes [x]No -
not SAH
2.Was a Procoagulant Reversal agent given? []Yes [x]No [Reason:
Not anticoagulated
3.Was Nimodipine given? []Yes [x]No [Reason: not SAH]
Medications on Admission:
1. Gabapentin 1200 mg PO TID
2. Pravastatin 40 mg PO QPM
3. Metoprolol Tartrate 25 mg PO BID
4. Pantoprazole 20 mg PO Q24H
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Aspirin 81 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
Discharge Medications:
1. Artificial Tears GEL 1% 2 DROP RIGHT EYE Q6H
RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1
%-0.3 % 2 drops PF Every 6 hours Disp #*1 Bottle Refills:*2
2. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
3. Digoxin 0.25 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*2
4. Diltiazem 60 mg PO Q6H
RX *diltiazem HCl 60 mg 1 tablet(s) by mouth Every 6 hours Disp
#*60 Tablet Refills:*2
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily Disp
#*60 Tablet Refills:*2
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
7. Heparin 5000 UNIT SC BID
RX *heparin (porcine) in 0.9% NaCl 5,000 unit/5 mL (1,000
unit/mL) 5000 Units SC Twice daily Disp #*60 Syringe Refills:*2
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*2
9. Lidocaine 5% Patch 1 PTCH TD QPM back pain
RX *lidocaine [Lidocaine Pain Relief] 4 % Apply a new patch to
the lower back Every night Disp #*60 Patch Refills:*2
10. Multivitamins W/minerals Chewable 1 TAB PO DAILY
RX *pediatric multivit-iron-min [Multi-Vitamins with Iron] 1
tablet(s) by mouth Daily Disp #*60 Tablet Refills:*2
RX *pediatric multivit-iron-min [Multi-Vitamins with Iron] 1
tablet(s) by mouth Daily Disp #*60 Tablet Refills:*2
11. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine 14 mg/24 hour Apply a new patch directly onto the
skin Daily Disp #*42 Patch Refills:*0
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #*42
Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g powder(s) by
mouth Daily Refills:*1
14. Ramelteon 8 mg PO QHS Insomnia (pill needs to be given
whole!)
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Ever night
Disp #*60 Tablet Refills:*2
15. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice daily Disp
#*30 Tablet Refills:*2
16. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily
Disp #*60 Tablet Refills:*2
17. Zonisamide 100 mg PO DAILY
RX *zonisamide 100 mg 1 capsule(s) by mouth Daily Disp #*60
Capsule Refills:*2
18. Gabapentin 1200 mg PO BID
19. Gabapentin 300 mg PO QHS
20. Metoprolol Tartrate 37.5 mg PO Q6H
21. Aspirin 81 mg PO DAILY
22. Mirtazapine 15 mg PO QHS
23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
24. Pravastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
TBI, bifrontal IPH, SDH, Orbital roof fracture with R globe
proptosis, right superior orbital rim fx, Left parietal bone fx,
extends to temporal and mastoid bone, thoracic syrinx,
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:
Traumatic Brain Injury
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage from the incision.
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.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any other blood thinning medication other
than Aspirin (Ibuprofen, Plavix, Coumadin) until cleared by the
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
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.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
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:
___
|
10516213-DS-20 | 10,516,213 | 22,054,181 | DS | 20 | 2171-09-17 00:00:00 | 2171-09-17 11:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
adhesive bandage / Tramadol / Percocet / Zestril / morphine /
codeine / Hydromorphone
Attending: ___.
Chief Complaint:
progressive back pain and worsening ___ symptoms
Major Surgical or Invasive Procedure:
1. Removal of L2, L3 hardware.
2. Incision and debridement to bone with biopsy and
culture.
3. Revision T12-L1 partial corpectomy.
History of Present Illness:
___ underwent a L1-S1 decompression and fusion with hardware
instrumentation on ___. Post op she had progressively worse
back pain w/o neurologic deficit along with nausea/vomiting but
denied fevers/chills/sweats. Labs showed no leukocytosis but
high inflammatory markers with ESR >130 and CRP
___ of spine showed T12-L1 discitis osteomyelitis with 2.5 x
2 cm peripheral enhancing fluid collection centered in the
anterior aspect of the disc. Phlegmon was seen in the
prevertebral space as well as the central canal surrounding the
thecal sac and compressing the central cord.
Past Medical History:
PMH: DMII, HTN, DVT and back pain s/p multiple spinal
surgeries
PSH: Multiple spine surgeries. Knee arthroscopy x3 one of which
was in ___.
Social History:
___
Family History:
She reports a family history of endometrial cancer, one of which
was in her mother at age ___. She also has a brother who had age
___ had lymphoma and a father who had lung cancer at age ___.
Physical Exam:
Physical ___
AFVSS
General-ill appearing, older than stated age. mild to moderate
distress w/ movement r/t recent surgery.
Heart-RRR
Lungs-CTAB
Abd-soft,ntnd,+bs's
Extremties-wwp,1+rad/1+dp pulses
Strength-BLE ___ ___
+SILT bilaterally
Pertinent Results:
___ 08:30AM BLOOD WBC-7.4 RBC-3.37* Hgb-9.8* Hct-29.8*
MCV-89 MCH-28.9 MCHC-32.7 RDW-15.5 Plt ___
___ 08:30AM BLOOD Plt ___
___ 08:30AM BLOOD ___
___ 08:30AM BLOOD Glucose-87 UreaN-8 Creat-0.5 Na-136 K-3.9
Cl-100 HCO3-22 AnGap-18
___ 08:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.1*
___ 12:52PM BLOOD Calcium-8.3* Phos-4.4 Mg-1.6
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots/SCH/Coumadin Bridge were
used for postoperative DVT prophylaxis. Intravenous antibiotics
were continued per ID recommendations based on intraop cultures.
IV antibiotics is recommended for at least ___ weeks or until
___ per ID recommendations. PICC line was placed on ___.
Initial postop pain was controlled with a fentanyl PCA. Diet was
advanced as tolerated. Chronic pain service was consulted for
her post-op pain mgmt due to her many narcotic allergies. Pain
Service attempted IV dilaudid but was discontinued due to N/V.
Fentanyl pca was discontinued and eventually transitioned to
vicodin. Pain service does not recommend increasing her current
pain regimen or adding any long acting. Physical therapy was
consulted for mobilization OOB to ambulate. She is deconditioned
and requires maximum assistance to chair with TLSO in place. On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet and on IV antibiotic therapy for her spinal infection.
Medications on Admission:
Brimonidine Tartrate Ophth
Dorzolamide Ophth
Latanoprost Ophth
Colace
Nortriptyline
Omeprazole
Zofran
Tizanidine
Vicodin
Coumadin
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. CefTAZidime 2 g IV Q8H
___
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2
gram/50 mL 2 Grams IV every eight (8) hours Disp #*50
Intravenous Bag Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
6. Heparin 5000 UNIT SC TID DVT prophylaxis
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Lorazepam 1 mg PO Q8H:PRN anxiety
11. Nortriptyline 10 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. Ondansetron 4 mg IV Q6H:PRN N/V
14. Senna 8.6 mg PO QHS
15. Tizanidine 2 mg PO BID
16. Warfarin 5 mg PO DAILY16 DVT/PE Prophylaxis
17. Duloxetine 60 mg PO BID pain
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. Cyclobenzaprine 10 mg PO TID:PRN spasm
20. Pregabalin 75 mg PO QHS pain
21. VICOdin (HYDROcodone-acetaminophen) 7.5mg-3 mg ORAL ___
Q3H PRN pain
RX *hydrocodone-acetaminophen 7.5 mg-300 mg ___ tablet(s) by
mouth Q3H Disp #*100 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. T12-L1 osteomyelitis.
2. Pseudoarthrosis L1, L2.
3. Status post L1-S1 fusion.
4. Previous splenectomy, removal of hardware, and incision
and debridement.
5. Pseudomonas 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:
Removal of Hardware
You have undergone the following operation: Removal of Spinal
Hardware
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
-___ times a day you should be out of bed into a chair as part
of your recovery and work up to going for a walk ___ times a day
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
-Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery. You have been given medication
to help with this issue.
Brace: You have been given a brace. This brace
is to be worn when you are out of bed at all times. You may take
it off when lying in bed.
Wound Care: If the incision is draining cover
it with a new sterile dressing. If it is dry then you can leave
the incision open to the air. Once the incision is completely
dry (usually ___ days after the operation) you may take a
shower. Do not soak the incision in a bath or pool. If the
incision starts draining at anytime after surgery, do not get
the incision wet. Cover it with a sterile dressing and call the
office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in or fax
narcotic prescriptions (oxycontin, oxycodone, percocet) to your
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your discharge if this has not been
done so already. At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. Please
call the office if you have a fever>101.5 degrees Fahrenheit
and/or drainage from your wound.
Physical Therapy:
-Weight bearing as tolerated
-Gait, balance training
-No lifting >10 lbs
-No significant bending/twisting
-TLSO on at all times when out of bed
Treatments Frequency:
If the incision is draining cover it with a new sterile
dressing. If it is dry then you can leave the incision open to
the air. Once the incision is completely dry (usually ___ days
after the operation) you may take a shower. Do not soak the
incision in a bath or pool. If the incision starts draining at
anytime after surgery, do not get the incision wet. Cover it
with a sterile dressing and call the office.
Followup Instructions:
___
|
10516278-DS-17 | 10,516,278 | 29,695,500 | DS | 17 | 2165-03-30 00:00:00 | 2165-04-04 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
headache, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with a history of EBV-associated gamma-delta
cytotoxic T cell lymphoma, NK cell deficiency, ESRD due to
glomerulonephritis, who was recently admitted for neutropenic
fever from ___ to ___, with course complicated by
seizures and transaminitis, recently found to have
leptomeningeal involvement of disease s/p intrathecal
cytarabine, presenting one day after discharge with nausea,
vomiting, and headache.
Patient was recently treated in the second half of ___
for febrile neutropenia; infectious work-up negative, presumed
to be due to virus. He was supported with filgrastim and
antibiotics, which were discontinued prior to discharge as
patient remained afebrile. His hospital course was complicated
by non-convulsive status epilepticus, and was started on Keppra.
LP demonstrated CD4/CD8 double negative CD3+ T cells in the
CSF, possibly related to patient's underlying lymphoma.
Over the last ___ weeks, he has been having fatigue, decreased
appetite, increased sleep, and frequent headaches.
He notes that he had headaches before his recent LP, and was
having headache at the time of discharge one day prior to
re-admission. Headache mainly in mid-frontal area, radiating to
the neck and shoulders, decreased to ___ by admission, with
pressure-like quality. It is worse with standing and improves
with lying down. He had emesis x2 after eating on the morning
of admission prior to dialysis. Reports headache initially ___
but improved to ___ after second episode of emesis. By the the
time he arrived on the floor his headache had resolved. Denies
photophobia, visual changes, fevers, chills, CP/SOB, urinary
symptoms, or abdominal pain.
Past Medical History:
Mr ___ was diagnosed with infectious mononucleosis in
the ___ in the setting of flu-like symptoms,
adenitis, positive Monospot and mild splenomegaly. In the
ensuing months, the patient continued to have waxing and waning
constitutional symptoms and in ___ he was hospitalized for
progressive impaired renal function secondary to
glomerulonephritis. At the same time he was found to have
persistently elevated EBV viral loads, consistent with chronic
EBV infection. Further immunologic work up was notable for a
profound NK cell deficiency, but he tested negative for XLP1 and
ALPS syndromes. Although he did have a population of DN T cells
by FC in the peripheral blood and BM at that time, the PCR for
TCR rearrangement was negative and there was no definitive
evidence of lymphoma. Subsequently, Mr ___ received a
course of steroids for his glomerulonephritis with initial
improvement of his kidney function, but this was complicated by
bilateral serous retinal detachments and the prednisone was
gradually tapered over a period of 4 months, with subsequent
deterioration of his renal function. A repeat kidney biopsy in
___ showed progressive glomerulonephritis and he was started
on hemodialysis on ___. With regards to his EBV viremia, he has
been on Valgancyclovir since ___ with inadequate response.
It was subsequently discontinued.
Mr ___ was again hospitalized in ___ with malaise,
night sweats and cough. CT torso was notable for a new LUL
nodule. He underwent wedge resection and the pathology was
consistent with an EBV-associated cytotoxic gamma-delta T cell
lymphoma. Staging BM biopsy showed no definitive evidence of
lymphoma involvement, but FC was positive for a population of DN
T cells. PCR for TRC rearrangement was negative in the marrow.
The patient also had an LP that did not show elevated lymphocyte
counts, but PCR on CSF was positive for EBV DNA. Finally,
staging PET/CT on ___ showed scattered bilateral FDG-avid
nodules in the lungs, single FDG-avid lesion in the R lobe of
the liver, and moderate non-avid splenomegaly.
Mr ___ commenced cycle 1 of R-CHOEP on ___ and he
as also been evaluated at ___ for consideration of combined
kidney/bone
marrow transplant, assuming that he achieves a durable remission
with chemotherapy.
TREATMENT HISTORY:
- ___ C1D1 R-CHOEP (Cyclophosphamide and Etoposide 50%
dose reduced). Patient remained hospitalized till ___ for
febrile neutropenia, abdominal pain, otalgia and mucositis.
- ___ C2D1 R-CHOEP (Cyclophosphamide and Etoposide dose
reduced 58% and 55% respectively)
- ___ Hospitalization for fever and abdominal pain.
Patient empiriaclly covered with cipro/flagyl for possible
abdominal source, however his ID work-up was negative, he
remained afebrile and antibiotics were discontinued once
neutropenia recovered. Fever could have been due to Neupogen
injections. For his chornic abdominal discomfort, the patient
underwent EGD on ___ that was concerning for esophageal
candidiasis, although stains were negative. Patient received
brief course of fluconazole. Patient also received one dose of
ivermectin on ___ for his history of strongyloides. For his
cytopenias, he required 2 units of pRBCs and 3 units of PLTs.
- ___: C3 Rituximab. PET/CT with marked response.
- ___: PET/CT with no evidence of FDG avid disease.
- ___: Started on Rituximab post-HD ___.
- ___: Rituximab #5
- ___: CHOEP (full dose vincristine, 20% dose reduction of
doxorubicin, 66% dose reduction of cyclophosphamide, 68% dose
reduction of etoposide)
- ___: Rituximab #6
- ___: Rituximab #7
PAST MEDICAL/SURGICAL HISTORY:
- Infectious mononucleosis in ___
- NK cell deficiency
- High grade chronic EBV viremia
- Strongyloiadiasis-treated with 3 doses ivermectin ___
- Latent TB infection treated with 9 months INH, finished ___
- ESRD secondary to glomerulonephritis
- Mild gastritis
- Cervical LAD s/p non-diagnostic biopsy ___ years ago
Social History:
___
Family History:
His parents are alive, father is ___ and mother is ___ years old.
They do not have any major health issues. His grandmother died
from lung cancer. One brother died in his sleep at the age of
___, possibly due to seizure disorder. The patient also states
that his brother had a swollen leg right before the event,
raising the possibility of VTE as the cause of death. There is
no history of frequent infections in any family members. No
family history of hematologic disorders or malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: T 98.4, BP 140/99, HR 77, RR 18, SPO2 98RA
General: no acute distress, appears tired, AOX3
HEENT: PERRLA, EOMI, MMM, oropharynx clear
Neck: supple, full ROM, no meningismus, no LAD
CV: RRR, normal S1/S2, ___ SEM appreciated at apex
Lungs: CTAB, no W/R/R
Abdomen: soft, bowel sounds normoactive, nondistended, non TTP
GU: deferred
Ext: warm, well-perfused, no edema in feet
Neuro: CN2-12 intact. ___ strength in BUE/BLE. Sensation intact
to light touch in face and all extremities.
DISCHARGE PHYSICAL EXAM:
============================
Vitals: T 97.8, BP 142/80, HR 80, RR 18, SPO2 100RA
General: no acute distress, appears more energetic compared to
admission, AOx3
HEENT: PERRLA, EOMI, MMM, oropharynx clear
Neck: no JVD
CV: RRR, normal s1/s2, ___ SEM appreciated at apex
Lungs: CTAB, no w/r/r
Abdomen: soft, bowel sounds normoactive, nondistended, non ttp
GU: deferred
Ext: warm, well-perfused, no edema in feet
Neuro: ___ strength in BUE/BLE, trace numbness in L face, but
sensation otherwise intact and CN ___ otherwise intact.
Tenderness Mild tenderness and reproduction of neck pain with
palpation of lower midline C-spine and trapezii L>R. Gait
intact.
Pertinent Results:
ADMISSION LABS:
=======================
___ 05:30AM BLOOD WBC-1.2* RBC-2.36* Hgb-7.9* Hct-22.4*
MCV-95 MCH-33.3* MCHC-35.1* RDW-18.1* Plt Ct-48*
___ 05:30AM BLOOD Neuts-10* Bands-2 Lymphs-72* Monos-14*
Eos-0 Baso-2 ___ Myelos-0
___ 05:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+ Tear
Dr-1+
___ 05:30AM BLOOD Glucose-79 UreaN-14 Creat-3.5*# Na-134
K-3.9 Cl-97 HCO3-32 AnGap-9
___ 05:30AM BLOOD ALT-20 AST-36 LD(LDH)-311* AlkPhos-196*
TotBili-0.5
___ 05:30AM BLOOD Calcium-7.5* Phos-3.3# Mg-1.9
MICROBIOLOGY:
=======================
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
PERTINENT RESULTS:
=======================
___ 05:00PM BLOOD WBC-0.9* RBC-2.68* Hgb-9.0* Hct-25.4*
MCV-95 MCH-33.6* MCHC-35.4* RDW-17.8* Plt Ct-42*
___ 06:50AM BLOOD WBC-1.2* RBC-2.84* Hgb-9.5* Hct-27.0*
MCV-95 MCH-33.2* MCHC-35.0 RDW-18.2* Plt Ct-38*
___ 06:10AM BLOOD WBC-1.2* RBC-2.53* Hgb-8.7* Hct-24.0*
MCV-95 MCH-34.4* MCHC-36.3* RDW-18.9* Plt Ct-22*
___ 05:00PM BLOOD Neuts-11* Bands-0 Lymphs-67* Monos-17*
Eos-3 Baso-1 Atyps-1* ___ Myelos-0
___ 06:50AM BLOOD Neuts-4* Bands-0 Lymphs-66* Monos-27*
Eos-3 Baso-0 ___ Myelos-0
___ 06:10AM BLOOD Neuts-7* Bands-0 Lymphs-50* Monos-41*
Eos-0 Baso-0 ___ Metas-1* Myelos-1*
___ 05:00PM BLOOD Glucose-94 UreaN-28* Creat-6.1*# Na-134
K-4.1 Cl-95* HCO3-25 AnGap-18
___ 06:50AM BLOOD Glucose-112* UreaN-21* Creat-5.1*# Na-136
K-4.5 Cl-99 HCO3-27 AnGap-15
___ 06:10AM BLOOD Glucose-93 UreaN-22* Creat-4.2*# Na-139
K-3.9 Cl-101 HCO3-29 AnGap-13
___ 06:26AM BLOOD ALT-22 AST-36 LD(LDH)-308* AlkPhos-186*
TotBili-0.4
___ 06:10AM BLOOD ALT-17 AST-20 LD(LDH)-203 AlkPhos-160*
TotBili-0.3
___ 06:26AM BLOOD Calcium-7.8* Phos-6.1*# Mg-1.9
___ 06:10AM BLOOD Calcium-7.8* Phos-2.1*# Mg-1.8
___ 02:40PM BLOOD PTH-154*
___ 05:15PM BLOOD Lactate-1.1
DISCHARGE LABS:
====================
___ 06:15AM BLOOD WBC-4.6# RBC-2.66* Hgb-9.1* Hct-26.2*
MCV-98 MCH-34.1* MCHC-34.6 RDW-19.4* Plt Ct-32*
___ 06:15AM BLOOD Glucose-89 UreaN-35* Creat-5.7*# Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
___ 06:15AM BLOOD ALT-17 AST-17 LD(LDH)-228 AlkPhos-157*
TotBili-0.4
___ 06:15AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.7
IMAGING:
=====================
#CT HEAD:
There is no acute large territorial infarct, hemorrhage, edema,
or mass
effect. There is no obvious mass or fluid collection. The
ventricles and
sulci are normal in size and configuration. The basal cisterns
are patent and
there is preservation of gray-white matter differentiation.
There is no acute fracture. The visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear.
Brief Hospital Course:
___ year old man with EBV-associated gamma-delta T cell lymphoma
(recently found to have leptomeningeal involvement and CN
deficits), NK cell deficiency, ESRD ___ glomerulonephritis, who
presented with headaches, nausea, vomiting after receiving
intrathecal chemotherapy.
#HEADACHE/VOMITING:
Patient's headache began shortly after receiving intrathecal
chemotherapy. There was concern that headache and vomiting may
be related to increased intracranial pressure due to CNS
involvement of his lymphoma. Arachnoiditis following intrathecal
cytarabine was also a possibility. Blood pressure, while
elevated on admission, was not high enough to concern for
hypertensive emergency. Patient also noted muscle tightness in
his neck and forehead, which may indicate tension headache. Low
concern for meningitis/encephalitis given he was afebrile and
relatively well-appearing. There were no focal neurological
signs. He was started on intravenous dexamethasone with
improvement in his headaches and nausea, and was discharged on
oral dexamethasone.
# EBV-associated gamma-delta T cell lymphoma c/b leptomeningeal
involvement and CN deficits. LP was performed on recent
admission and was significant for presence of EBV in the CSF as
well as 9% other cells, likely representing lymphoma based on
morphology. Will likely need combination of IT chemotherapy as
well as XRT to base of skull, although discussion of radiation
deferred to outpatient setting.
#NEUTROPENIA:
Patient presented with ANC 90, decreased to 24 on ___.
Patient without overt signs of infection or fevers, but degree
of neutropenia was concerning for risk of infection. He was
treated with filgrastim 300mcg SC daily and ANC was 1840 on day
of discharge.
# Seizure disorder: during last hospitalization, seen to have
AMS/disorientation and twitching. EEG was obtained and showed
non-convulsive status epilepticus; broke with ativan, and later
controlled on keppra. He was continued on Keppra this admission,
with no episodes of seizure or altered mental status.
# ESRD:
Secondary to FSGS. On HD MWF. He received dialysis while
hospitalized.
# Depression/Anxiety: stable this admission. Continued home
ativan and sertraline
# Neuropathy: stable
- continued home gabapentin 100mg PO daily
TRANSITIONAL ISSUES:
=================================
#Dexamethasone: Patient started on dexamethasone for concern
that headaches/nausea were due to increased intracranial
pressure. Fortunately, his headaches were not typical for this
etiology, and improved rapidly. However he was started on a
taper of dexamethasone, and will take 4mg PO BID on ___,
then PO daily for 3 days. Further course to be determined in
follow-up with his oncologist.
#Lymphoma: further treatments for lyphoma with possible CNS
involvement to be determined in follow-up with his oncologist.
While inpatient, discussed the possibility of whole-body PET/CT.
Has already been simulated to receive skull/brain radiation if
needed.
#Neutropenia: ANC low at 24 this admission, increased to 1800
with several days of Neupogen. Neupogen discontinued on day of
discharge for complaint of bone pain and adequate ANC. Should
have CBC checked within one week of discharge to monitor WBC
count and ANC.
#PCP ___: patient started on atovaqone this admission
for PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Ranitidine 300 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Lactulose 30 mL PO BID:PRN constipation
5. LeVETiracetam 500 mg PO DAILY
6. LeVETiracetam 250 mg PO 3X/WEEK (___)
7. Pantoprazole 40 mg PO Q12H
8. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID
11. Sertraline 25 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. ethyl chloride 100 % topical before dialysis every other day
14. Gabapentin 100 mg PO DAILY
15. Nephrocaps 1 CAP PO DAILY
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Acyclovir 400 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. ethyl chloride 100 % topical before dialysis every other day
5. Gabapentin 100 mg PO DAILY
6. Lactulose 30 mL PO BID:PRN constipation
7. LeVETiracetam 500 mg PO DAILY
8. LeVETiracetam 250 mg PO 3X/WEEK (___)
9. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
10. Nephrocaps 1 CAP PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Ranitidine 300 mg PO DAILY
14. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
15. Sertraline 25 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
17. Ondansetron 8 mg PO Q8H:PRN nausea
18. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth daily Disp #*420
Milliliter Milliliter Refills:*0
19. Dexamethasone 4 mg PO Q12H Duration: 2 Days
RX *dexamethasone 4 mg 1 tablet(s) by mouth Q12 Disp #*2 Tablet
Refills:*0
20. Dexamethasone 4 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-EBV-associated gamma-delta cytotoxic T cell lymphoma
SECONDARY DIAGNOSIS:
-NK cell deficiency
-End-stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure meeting you and taking care of you during your
hospitalization at ___. You
were hospitalized after having headaches and vomiting, shortly
after being discharged after having chemotherapy in the spinal
cord and brain. There was concern that lymphoma may be causing
the headaches and vomiting, and so you were treated with
steroids to reduce inflammation. You will continue this medicine
until you are seen in follow-up with an oncologist later this
week.
Fortunately your headaches improved and you were able to
tolerate a regular diet. You were also treated with several
doses of Neupogen to increase the white blood cell in your
immune system.
Followup Instructions:
___
|
10516278-DS-24 | 10,516,278 | 23,645,520 | DS | 24 | 2165-07-06 00:00:00 | 2165-07-08 18:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
cough, fevers
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ yo man with a PMHx of EBV associated
T-Cell lymphoma and ESRD on dialysis (___) completed C6 of
CHOEP (___) and recently hospitalized at ___ ___ w/
fever, headache, and thrombocytopenia. He was found to have
preseptal cellulitis and sinusitis and discharged on ___. He was
admitted again on ___ with fever and malaise which was
attributed to his ongoing EBV viremia. He was treated with
steroids and discharged with a dexamethasone taper on ___.
Last night (___) he developed a cough with some mild
hemoptysis. His hemoptysis this morning was worse. He had some
dsypnea and soreness in his chest and throat. He had a
temperature this morning of greater than ___ and presented to
___. There, his vitals were 101.6, BP 165/110,
P ___, 99% on RA. He had witnessed hemoptysis. A CXR showed
diffuse bilateral airspace disease, and a CTA of the chest
showed multifocal diffuse opacities concerning for infection or
inflammation, but no PE. He was bolused 1L NS and given
vancomycin 1g IV, cefepime 2g IV, and azithromycin 500 mg IV.
Given concern for pneumocystis pneumonia, he was given one
tablet of Bactrim DS. He got dexamethasone 10 mg IV. He was
transferred to ___ for further care.
In the ED here, his initial vitals were: T 99.5, P ___, BP
140/88, RR 19, 100%/RA. He was given another dose of Bactrim DS
and admitted to the ___ service.
On arrival to the floor, he is well appearing and not in any
acute distress. He is breathing comfortably on room air.
Review of Systems:
(+) Per HPI. Also has sore throat and chest especially with
coughing. Denies abdominal pain, vomiting, diarrhea, dysuria.
Past Medical History:
- Infectious mononucleosis in ___
- NK cell deficiency
- High grade chronic EBV viremia
- Strongyloiadiasis-treated with 3 doses ivermectin ___
- Latent TB infection treated with 9 months INH, finished ___
- ESRD secondary to glomerulonephritis (FSGS from EBV viremia)
- Mild gastritis
- Cervical LAD s/p non-diagnostic biopsy ___ years ago
- Sinusitis and multifocal PNA (___)
PAST ONCOLOGIC HISTORY (per OMR):
Mr. ___ was diagnosed with infectious mononucleosis in
the ___ in the setting of flu-like symptoms,
adenitis, positive Monospot and mild splenomegaly. In the
ensuing months, the patient continued to have waxing and waning
constitutional symptoms and in ___ he was hospitalized for
progressive impaired renal function secondary to
glomerulonephritis. At the same time he was found to have
persistently elevated EBV viral loads, consistent with chronic
EBV infection. Further immunologic work up was notable for a
profound NK cell deficiency, but he tested negative for XLP1 and
ALPS syndromes. Although he did have a population of DN T cells
by FC in the peripheral blood and BM at that time, the PCR for
TCR rearrangement was negative and there was no definitive
evidence of lymphoma. Subsequently, Mr ___ received a
course of steroids for his glomerulonephritis with initial
improvement of his kidney function, but this was complicated by
bilateral serous retinal detachments and the prednisone was
gradually tapered over a period of 4 months, with subsequent
deterioration of his renal function. A repeat kidney biopsy in
___ showed progressive glomerulonephritis and he was started
on hemodialysis on ___. With regards to his EBV viremia, he has
been on Valgancyclovir since ___ with inadequate response.
It was subsequently discontinued.
Mr. ___ was again hospitalized in ___ with malaise,
night sweats and cough. CT torso was notable for a new LUL
nodule. He underwent wedge resection and the pathology was
consistent with an EBV-associated cytotoxic gamma-delta T cell
lymphoma. Staging BM biopsy showed no definitive evidence of
lymphoma involvement, but FC was positive for a population of DN
T cells. PCR for TRC rearrangement was negative in the marrow.
The patient also had an LP that did not show elevated lymphocyte
counts, but PCR on CSF was positive for EBV DNA. Finally,
staging PET/CT on ___ showed scattered bilateral FDG-avid
nodules in the lungs, single FDG-avid lesion in the R lobe of
the liver, and moderate non-avid splenomegaly.
Mr. ___ commenced cycle 1 of R-CHOEP on ___ and he
as also been evaluated at ___ for consideration of combined
kidney/bone marrow transplant, assuming that he achieves a
durable remission with chemotherapy.
TREATMENT HISTORY:
- ___ C1D1 R-CHOEP (Cyclophosphamide and Etoposide 50%
dose reduced). Patient remained hospitalized till ___ for
febrile neutropenia, abdominal pain, otalgia and mucositis.
- ___ C2D1 R-CHOEP (Cyclophosphamide and Etoposide dose
reduced 58% and 55% respectively)
- ___ Hospitalization for fever and abdominal pain.
Patient empiriaclly covered with cipro/flagyl for possible
abdominal source, however his ID work-up was negative, he
remained afebrile and antibiotics were discontinued once
neutropenia recovered. Fever could have been due to Neupogen
injections. For his chornic abdominal discomfort, the patient
underwent EGD on ___ that was concerning for esophageal
candidiasis, although stains were negative. Patient received
brief course of fluconazole. Patient also received one dose of
ivermectin on ___ for his history of strongyloides. For his
cytopenias, he required 2 units of pRBCs and 3 units of PLTs.
- ___: C3 Rituximab. PET/CT with marked response.
- ___: PET/CT with no evidence of FDG avid disease.
- ___: Started on Rituximab post-HD ___.
- ___: Rituximab #5
- ___: CHOEP (full dose vincristine, 20% dose reduction of
doxorubicin, 66% dose reduction of cyclophosphamide, 68% dose
reduction of etoposide)
- ___: Rituximab #6
- ___: Rituximab #7
- ___ CHOEP # 4 Modified: Cyclophosphamide 300 mg/m2,
DOXOrubicin 50 mg/m2, VinCRIStine 2 mg IV, Etoposide IV Days 1,
2 and 3. 20 mg/m2
- ___ NCSE: antiepileptics initiated
- ___ IT Cytarabine
- ___ CHOEP #5 Modified: Cyclophosphamide 300 mg/m2,
DOXOrubicin 50 mg/m2, VinCRIStine 2 mg IV, Etoposide IV Days 1,
2 and 3. 20 mg/m2
- ___ CHOEP #6 Cyclophosphamide 750 mg/m2 - dose reduced by
50% to 375 mg/m2, DOXOrubicin 50 mg/m2 - dose reduced by 50% to
25 mg/m2, VinCRIStine 2 mg - dose reduced by 50% to 1 mg,
Etoposide 100 mg/m2 - dose reduced by 50% to 50 mg/m2
Social History:
___
Family History:
His parents are alive, father is ___ and mother is ___ years old.
They do not have any major health issues. His grandmother died
from lung cancer. One brother died in his sleep at the age of
___, possibly due to seizure disorder. The patient also states
that his brother had a swollen leg right before the event,
raising the possibility of VTE as the cause of death. There is
no history of frequent infections in any family members. No
family history of hematologic disorders or malignancies.
Physical Exam:
ADMISSION PHYSICAL:
=============================
Vitals: T 98.6, BP 164/82, HR 111, RR 22, O2 94/RA
Gen: Pleasant, calm, NAD
HEENT: Anicteric sclera, no conjunctival injection, EOMI. MMM.
OP clear.
CV: RRR. Normal S1, S2. No M/R/G
LUNGS: No incr WOB. Mildly coarse breath sounds throughout.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema. LUE AVF with palpable thrill
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: Alert and oriented, non-focal
LINES: PIV
DISCHARGE PHYSICAL:
=============================
Vitals: T 98.5 (98.7), BP 144/98, HR 93, RR 18, O2 99/RA
Gen: Pleasant, calm, NAD
HEENT: Anicteric sclera, no conjunctival injection, EOMI. MMM.
OP clear.
CV: RRR. Normal S1, S2. No M/R/G
LUNGS: No incr WOB. Lungs CTA bilaterally.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema. LUE AVF with palpable thrill
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: Alert and oriented, non-focal
LINES: PIV
Pertinent Results:
ADMISSION LABS:
===========================
___ 10:45AM BLOOD WBC-27.0*# RBC-2.84* Hgb-9.4* Hct-27.4*
MCV-97 MCH-33.2* MCHC-34.4 RDW-19.2* Plt Ct-59*
___ 10:45AM BLOOD Neuts-88.9* Lymphs-4.2* Monos-6.5 Eos-0.3
Baso-0.1
___ 10:45AM BLOOD ___ PTT-32.4 ___
___ 10:45AM BLOOD Glucose-110* UreaN-42* Creat-7.7*#
Na-131* K-5.7* Cl-93* HCO3-20* AnGap-24*
___ 10:45AM BLOOD ALT-73* AST-37 LD(LDH)-394* AlkPhos-291*
TotBili-0.5
___ 10:45AM BLOOD Albumin-3.2*
___ 05:55AM BLOOD Calcium-8.2* Phos-5.5*# Mg-2.1
___ 11:00AM BLOOD Lactate-0.9
DISCHARGE LABS:
===========================
___ 09:35AM BLOOD WBC-5.4 RBC-2.32* Hgb-7.7* Hct-22.7*
MCV-98 MCH-33.0* MCHC-33.8 RDW-18.1* Plt Ct-71*
___ 06:10AM BLOOD Neuts-79.4* Lymphs-16.1* Monos-4.0
Eos-0.5 Baso-0.1
___ 06:10AM BLOOD ___ PTT-30.6 ___
___ 09:35AM BLOOD Glucose-141* UreaN-45* Creat-7.0* Na-136
K-3.7 Cl-95* HCO3-23 AnGap-22*
___ 06:10AM BLOOD ALT-42* AST-32 AlkPhos-204* TotBili-0.3
___ 09:35AM BLOOD Calcium-7.7* Phos-5.5* Mg-1.9
MICROBIOLOGY:
===========================
BETA-GLUCAN and GALACTOMANNAN NEGATIVE
___ 03:16PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
BLOOD and URINE CULTURES NEGATIVE
NASOPHARYNGEAL VIRAL SWAB NEGATIVE
INDUCED SPUTUM NEGATIVE FOR PJP
STUDIES:
===========================
___: CT SINUS W/OUT CONTRAST:
IMPRESSION:
1. Interval improvement of aeration of the right maxillary
sinus, now with residual chronic mucous retention cyst.
2. Interval resolution of right periorbital soft tissue
swelling.
___: CT CHEST W/OUT CONTRAST:
IMPRESSION:
Decrease in extent and severity of the pre-existing bilateral
upper lobe
predominant ground-glass opacities. Decrease in extent and
severity of the pre-existing right lower lobe consolidation. A
left lower lobe consolidation and the scars in the lingular are
unchanged. Unchanged small bilateral pleural effusions.
Today's examination shows signs of mild airway wall thickening,
potentially infectious in origin.
Brief Hospital Course:
___ yo man with a PMHx of EBV associated T-Cell lymphoma and ESRD
on dialysis (___) with recent admissions for fevers,
presenting with fever, cough, and hemoptysis.
# Pneumonia: Possibly atypical bacterial versus viral given CT
findings. PJP ruled out with negative induced sputum and
negative beta-glucan. Repeat CT showed marked improvement. Also
checked CT sinus which showed improvement in prior sinusitis.
S/p 5 days of azithromycin. Treated initially with vancomycin
and Zosyn, transitioned to Augmentin to complete a 10 day course
(last day ___. Also initially treated with treatment dose
Bactrim (DS TID), which was transitioned to ppx dosing. Started
on prednisone 40 mg BID for PJP treatment but decreased to
resume prior taper once PJP was negative. B-glucan negative,
galactomannan pending.
# EBV ssociated gamma-delta T cell lymphoma: Patient recently
s/p cycle 6 of R-CHOEP. Patient will f/u with Dr. ___
further management. Continued Acyclovir 400 mg PO/NG Q24H ppx.
Batrim ppx for PJP.
# ESRD on HD (___): This is likely secondary to FSGS from
chronic EBV viremia. Has been on dialysis since ___. Patient
was recently set up with new dialysis unit and had first session
on ___. Continued HD while in house. Continued nephrocaps.
Started PhosLo.
# Seizure disorder: continued LeVETiracetam 500 mg PO DAILY,
LeVETiracetam 250 mg PO 3X/WEEK (___)
# HTN: continued home labetolol
# Depression: continued home sertraline
# GERD: continued home ranitidine
TRANSITIONAL ISSUES:
[ ] f/u with Dr. ___ on ___
[ ] continue ___ HD
[ ] complete course of Augmentin (last day ___
[ ] complete prednisone taper (40 mg daily x 3 days, 30 mg, 20
mg, 10 mg x 4 days each, then stop)
# CODE: Full
# EMERGENCY CONTACT: ___ (brother), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Gabapentin 100 mg PO DAILY
6. Labetalol 100 mg PO BID
7. Lactulose 30 mL PO BID:PRN constipation
8. LeVETiracetam 500 mg PO DAILY
9. LeVETiracetam 250 mg PO 3X/WEEK (___)
10. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
11. Nephrocaps 1 CAP PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Ranitidine 300 mg PO DAILY
16. Senna 8.6 mg PO BID
17. Sertraline 25 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Atovaquone Suspension 1500 mg PO DAILY
20. Dexamethasone 6 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Gabapentin 100 mg PO DAILY
5. Labetalol 100 mg PO BID
6. Lactulose 30 mL PO BID:PRN constipation
7. LeVETiracetam 500 mg PO DAILY
8. LeVETiracetam 250 mg PO 3X/WEEK (___)
9. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
10. Nephrocaps 1 CAP PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Pantoprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Ranitidine 300 mg PO DAILY
15. Senna 8.6 mg PO BID
16. Sertraline 25 mg PO DAILY
17. Vitamin D ___ UNIT PO DAILY
18. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth Daily Disp #*4 Tablet Refills:*0
19. Calcium Acetate 1334 mg PO TID W/MEALS
RX *calcium acetate 667 mg 2 capsule(s) by mouth three times a
day Disp #*90 Capsule Refills:*0
20. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 1 spry in each nostril daily
Disp #*1 Spray Refills:*0
21. Guaifenesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
22. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*36 Tablet
Refills:*0
23. Sulfameth/Trimethoprim SS 1 TAB PO POST HD (___)
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth ___ after dialysis Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: pneumonia likely from an atypical bacteria or virus
SECONDARY: end stage renal disease on hemodialysis, ___
virus driven T cell lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a pneumonia. We initially
treated you with IV antibiotics and then transitioned you to
oral antibiotics. Your symptoms improved and a repeat CT scan of
your chest showed that the pneumonia was resolving. We also did
a CT of your sinuses which showed that your sinus disease was
improving.
Any medication changes are detailed in your discharge medication
list. You should review this carefully and bring it with you to
any follow up appointments. Your follow up appointments are
detailed below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10516481-DS-21 | 10,516,481 | 21,323,452 | DS | 21 | 2189-05-21 00:00:00 | 2189-05-23 09:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet / morphine / iodine
Attending: ___.
Chief Complaint:
fevers and chills at
home, vomiting, and abdominal pain
Major Surgical or Invasive Procedure:
___ ___ drainage catheter placed within the
collection
History of Present Illness:
___ with h/o chronic abdominal pain as well as multiple
intraabdominal hemangiomas s/p total abdominal colectomy with
end
ileostomy and subsequent takedown with j-pouch in ___ most
recently s/p segmental hepatectomy for symptomatic hepatic
sclerosing hemangiomas on ___ who was discharged on ___
and now presents with a multiple day history of fevers/chills,
nausea, vomiting and worsening RUQ pain. She reports that she
has
been unable to tolerate any food or water and has not peen able
to take her medication. Her hospital course was complicated by
fevers of unknown origin and multiple urine and blood cultures
were negative. CT of the abdomen and pelvis on ___ was notable
for a 8.5 x 5.7 x 5.1 cm fluid collection in the segment ___
resection bed as well as a 7.3 x 4.1 x 4.9 cm collection along
the inferior aspect of the right hepatic lobe. Both were thought
to represent hematoma. She was discharged to home on a 10 day
course of cipro/flagyl (which she has not been able to take due
to emesis) and her WBC count at that time was 8.
ROS:
(+) per HPI
(-) Denies night sweats, unexplained weight loss, trouble with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest
pain, shortness of breath, cough, edema, urinary frequency,
urgency
Past Medical History:
PMH: asthma, colonic AVM, hepatic hemangiomas
PSH: ex lap total abdominal colectomy for AVMs with end
ileostomy ___ CHB ___, ostomy takedown with ileal anal
anastamosis ___, ex lap loa B hydro-salphingectomy ___, biopsy
liver hemangioma c/b bleeding, chest tube
Social History:
___
Family History:
mother is alive at age ___ with sarcoid. Two maternal aunts had
breast cancer and one cousin had breast cancer. Maternal
grandfather had stomach
cancer. Maternal grandfather had a segmental colonic resection
for polyps. Father is alive at age ___ and has diabetes.
Physical Exam:
Vitals: 99 88 137/76 18 100 RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, TTP diffusely but mainly in RUQ, no
rebound or guarding, surgical incision well healed
Ext: No ___ edema, ___ warm and well perfused
Laboratory:
140 103 6 < 89
3.5 ___ > 26.6 < 573
ALT 22
AST 20
AlkPhos 90
Tbili 0.2
Lipase 111
Imaging:
CT A/P ___
IMPRESSION:
1. 8.5 x 5.7 x 5.1 cm fluid collection in the segment ___
resection bed with internal foci of gas is consistent in
appearance with a hematoma containing surgical packing material.
Additional 7.3 x 4.1 x 4.9 cm collection along inferior aspect
of
right hepatic lobe also likely represents hematoma.
Superinfection cannot be excluded in the appropriate context. No
extravasation of enteric contrast.
2. Mild diffuse distension of bowel is most suggestive of
adynamic ileus. Prior total colectomy with J-pouch and ileoanal
anastomosis.
3. Ill-defined soft tissue lesion with calcifications
demonstrated inferior to the pancreatic body was previously
characterized on MRI as a probable mesenteric hemangioma.
4. Hepatic hemangiomas as characterized on prior exams not well
visualized on this noncontrast CT.
5. Bilateral adnexal cysts may reflect follicular activity in
this patient with history of prior bilateral salpingectomies,
although CT is limited in its assessment of adnexal cysts.
RUQ/Liver US ___
IMPRESSION:
1. Stable if not minimally smaller complex heterogeneous lesion
within the left lobe of the liver. Differential includes
abscess,
hematoma and less likely a biloma. Normal Dopplers.
2. 2 stable hemangiomas.
Pertinent Results:
___ 04:10PM BLOOD WBC-12.8*# RBC-3.00* Hgb-8.3* Hct-26.6*
MCV-89 MCH-27.8 MCHC-31.4 RDW-14.3 Plt ___
___ 06:10AM BLOOD WBC-8.1 RBC-2.65* Hgb-7.3* Hct-24.0*
MCV-91 MCH-27.7 MCHC-30.4* RDW-14.5 Plt ___
___ 08:10AM BLOOD ___ PTT-31.2 ___
___ 04:10PM BLOOD ALT-22 AST-20 AlkPhos-90 TotBili-0.2
___ 06:10AM BLOOD ALT-14 AST-19 AlkPhos-73 TotBili-0.1
___ 06:10AM BLOOD Glucose-97 UreaN-5* Creat-0.8 Na-143
K-3.8 Cl-106 HCO3-29 AnGap-12
___ Blood cultures: pending
___ 1:45 pm ABSCESS Source: Resection bed.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
She presented again to the ED on ___ with fevers and chills at
home, vomiting, and abdominal pain. WBC count was 12.8. She was
started on Unasyn. CT abdomen and pelvis revealed a collection
(.5 x 7.6 cm) at resection site, not significantly changed from
prior, aside from decreased gas content. She underwent ___ drain
placement, with Gram staining revealing 1+ PMNs and no
organisms, fluid culture with no growth, and anaerobic culture
with no growth to date. Blood cultures from ___ were still
pending. The drain was removed (minimal drainage) and
antibiotics discontinued prior to discharge. Pain management was
difficult and chronic pain service consulted. Recommendations
were made which included increasing Neurontin to TID. However,
the patient declined this. IV Dilaudid was the most helpful
relieving her pain. Hyoscyamine 0.125 QID was started which
seemed to help. She did continue to have c/o stomach pain after
eating. Pain was "all over", but more localized to LUQ (ABD was
soft, non-distended and negative for rebound)PPI was increased
to bid.
Vital signs were stable and she requested to go home. She will
f/u with ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
6. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H pain
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
4. Senna 8.6 mg PO BID
5. Hyoscyamine 0.125 mg SL QID
RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) sublingually four
times a day Disp #*28 Tablet Refills:*0
6. Gabapentin 300 mg PO DAILY
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
7. Pantoprazole 40 mg PO Q12H pain/fullness after eating
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
segmental liver resectio ___
resection bed collection s/p drainage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ office if you develop any of the
following:
fever (temperature of 101 or greater), shaking chills, nausea,
vomiting, increased abdominal pain, jaundice, abdominal
distension/bloating, incision redness/bleeding/drainage,
diarrhea, constipation or any questions.
You may shower with soap and water, rinse, pat dry. No tub baths
or swimming until healed
Do not apply powder, lotion or ointment to your incision.
Do not lift anything heavier than 10 pounds or strain.
No driving while taking narcotic pain medication.
Followup Instructions:
___
|
10516930-DS-4 | 10,516,930 | 23,436,374 | DS | 4 | 2127-06-15 00:00:00 | 2127-06-15 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ polysubstance abuse (IV heroin, cocaine), tobacco use,
HCV, HTN, who p/w weakness, dyspnea, and vomiting.
The patient is a vague historian. He lives alone in a room above
the ___. He says he eats badly and sometimes go a
long time between meals, largely owing to poor food access. He
says he has money for food, but cannot be bothered to go out in
the setting of escalating fatigue/weakness/unintentional weight
loss. Just stays home and does drugs instead.
Regarding his drug use, he is a longstanding cocaine user and
continues to use this actively. He has recently stopped taking
Suboxone (unclear why) and has instead "reintroduced heroin to
my
regimen." He has only injected a couple times since making the
decision to relapse. Although he appears to be possibly
intoxicated with some deliriant at the time of my interview, he
denies any intentional use of any other drugs.
He had several episodes of vomiting, and also subjective
shortness of breath in the early morning hours of ___. He
walked to the store but then felt too fatigued and ill to walk
back. He requested a ride home from a nearby EMS crew (who had
showed up in his immediate area to assess a different patient).
EMS did not feel that he was in any distress, noted that his
vitals were stable (HR 72, BP 118/82, not hypoxic), but they
brought him to the ED for evaluation given his reported
symptoms.
In the ED, vitals remained stable, but labs showed numerous
abnormalities:
WBC 10.3 (78% polys)
Bicarb 47 (AG 17, lactate 2.2)
VBG w/ pH 7.48, pCO2 74 (which is appropriate compensation, per
Winter's formula)
K 2.4
Cr 1.3, BUN 39
EKG with QTc >580.
Although he seemed superficially oriented, he was unable to
report the year accurately. Exam otherwise unremarkable. He was
given 1L NS w/ 40 mEq KCl and 40 more mEq of PO KCl. Admitted to
medicine.
ROS
Patient is a vague historian and ROS is unreliable, but
positive
as per HPI.
Past Medical History:
PAST MEDICAL HISTORY:
-IV drug abuse
-hepatitis C
-hypertension
-diverticulitis
-bipolar disorder
-chronic pain
-erectile dysfunction
PAST SURGICAL HISTORY:
-colostomy procedure (___?) for perforated diverticulitis
___
-colostomy reversal ___
-appendectomy
Social History:
___
Family History:
Uncle had prostate cancer
Physical Exam:
ADMISSION EXAM:
CONSTITUTIONAL: cachectic man in NAD
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear
LYMPHATIC: No LAD
CARDIAC: RRR, no M/R/G, JVP not elevated, no edema
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS. Laparotomy scar
GU: no CVA tenderness, suprapubic region soft and nontender
MSK: no visible joint effusions or acute deformities.
DERM: no visible rash. No jaundice.
NEURO/PSYCH: AAOx2-3. Abnormal interaction. He speaks in a
rambling, vague and tangential way. Picking at things. No
facial
droop, moving all extremities.
PSYCH: Full range of affect
==============
DISCHARGE EXAM:
VITALS: ___ 1121 Temp: 98.4 PO BP: 151/97 L Lying HR: 83
RR: 18 O2 sat: 98% O2 delivery: RA
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses
bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No GU catheter present
MSK: Moves all extremities, no edema or swelling
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to person, place, month, year; face
symmetric, speech fluent, moves all limbs, no asterixis
PSYCH: Calm, partially cooperative
Pertinent Results:
ADMISSION RESULTS:
___ 03:30AM BLOOD WBC-10.3* RBC-5.09 Hgb-15.0 Hct-45.1
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.1 RDWSD-46.1 Plt Ct-UNABLE TO
___ 03:30AM BLOOD Neuts-78.1* Lymphs-13.9* Monos-7.5
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.06* AbsLymp-1.43
AbsMono-0.77 AbsEos-0.00* AbsBaso-0.02
___ 05:53AM BLOOD ___ PTT-23.1* ___
___ 05:53AM BLOOD Glucose-127* UreaN-39* Creat-1.3* Na-138
K-2.4* Cl-74* HCO3-47* AnGap-17
___ 05:53AM BLOOD ALT-7 AST-17 AlkPhos-66 TotBili-1.1
___ 05:53AM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.3 Mg-2.7*
___ 12:05PM BLOOD ___ pO2-39* pCO2-74* pH-7.48*
calTCO2-57* Base XS-25
___ 06:22PM BLOOD pH-7.39 Comment-GREEN TOP
___ 03:38AM BLOOD Glucose-134* Lactate-2.2* Creat-1.3*
Na-140 K-2.8* Cl-73* calHCO3-54*
=============
PERTINENT INTERVAL RESULTS
___ 08:56PM BLOOD Glucose-124* UreaN-19 Creat-1.0 Na-146
K-3.0* Cl-99 HCO3-38* AnGap-9*
___ 12:00PM BLOOD Calcium-7.8* Phos-1.1* Mg-2.3
___ 12:00PM BLOOD VitB12-1385*
___ 11:56AM BLOOD TSH-0.22*
___ 05:00PM BLOOD T3-60*
___ 11:56AM BLOOD Free T4-1.4
___ 12:00PM BLOOD Trep Ab-NEG
___ 12:00PM BLOOD HIV Ab-NEG
___ 11:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:13PM BLOOD ___ pO2-49* pCO2-66* pH-7.41
calTCO2-43* Base XS-13 Comment-GREEN TOP
___ 06:22PM BLOOD freeCa-1.01*
___ 09:18AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.5* Leuks-NEG
___ 09:18AM URINE RBC-<1 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 09:18AM URINE CastGr-2* CastHy-10*
=================
DISCHARGE LABS:
___ 09:02AM BLOOD WBC-8.2 RBC-4.06* Hgb-12.0* Hct-36.2*
MCV-89 MCH-29.6 MCHC-33.1 RDW-14.8 RDWSD-47.8* Plt ___
___ 09:23AM BLOOD ___ PTT-25.6 ___
___ 09:02AM BLOOD Glucose-142* UreaN-11 Creat-0.9 Na-147
K-3.1* Cl-97 HCO3-38* AnGap-12
___ 09:02AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.2
=================
___ 9:18 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 3:30 am BLOOD CULTURE # 2.
Blood Culture, Routine (Pending): No growth to date.
___ 3:20 am BLOOD CULTURE # 1.
Blood Culture, Routine (Pending): No growth to date.
=================
CXR ___:
Lungs are hyperinflated. No focal consolidation is seen. No
pleural effusion or pneumothorax. The descending aorta appears
tortuous. No cardiomegaly.
.
CT HEAD WITHOUT CONTRAST ___:
Atrophy. No evidence of mass, hemorrhage or infarction.
.
RUQ ULTRASOUND ___:
1. Echogenic renal cortex, suggestive of chronic medical renal
disease.
2. No sonographic evidence of cirrhosis, splenomegaly, ascites
or
hydronephrosis.
3. Borderline echogenic liver no focal liver lesion.
.
EKG ___:
Sinus rhythm with premature atrial depolarizations with aberrant
conduction
Left axis deviation
Nonspecific ST and T wave abnormality
Prolonged QT interval
Abnormal ECG
When compared with ECG of ___ 13:47,
Infero-lateral T wave changes have improved.
HR is faster
Brief Hospital Course:
Mr. ___ is a ___ yo man with polysubstance abuse (IV heroin and
cocaine), hepatitis C, HTN, who presented with weakness, dyspnea
and vomiting. He was found to have severe metabolic alkalosis,
hypokalemia, hypophosphatemia, hypermagnesemia, acute kidney
injury, and acute encephalopathy. His renal function has
normalized and electrolyte abnormalities have improved. His
mental status improved and he was
AOx3.
ACUTE/ACTIVE PROBLEMS:
# Acute toxic metabolic encephalopathy: On admission, he was
oriented x2-3. He does have history of hepatitis C and was
noted to have asterixis initially, which raised question of
hepatic encephalopathy, so he was empirically started on
lactulose.
However, RUQ ultrasound on ___ showed no evidence of
cirrhosis, so discontinued scheduled lactulose TID. Other
possibility is that his mental status changes were related to
___ and metabolic abnormalities. Hyperthyroidism could also be a
possibility, since TSH was suppressed but with normal free T4,
though no intervention regarding this suppressed TSH. He had no
focal neurologic deficits and CT head without contrast on ___
showed no acute abnormalities, only atrophy. He had negative
serum and urine tox screen. He had negative HIV antibody,
Treponemal antibody, and B12 was not low. VBG showed
hypercapnia but normal pH so this is probably chronic. He is
AOx3 and I do not really know how far this is from his baseline,
but I suspect this is very close. Unfortunately had to use
Lorazepam PRN for nausea since QTc was prolonged, but he was not
using frequently and last dose was on ___. His psychiatrist
at ___ said at baseline he has been AOx3 and not exhibiting
cognitive problems. He was evaluated by physical therapy and
had no need for home ___ or SNF.
# Nausea/vomiting: Unclear etiology, but likely caused his
metabolic alkalosis, which was improved since admission. His
frequent bowel movements were probably worsened by lactulose,
which was continued. Closer to discharge, his episodes of
vomiting did not appear to be true emesis, but rather spitting
up of saliva. He was given PRN Ativan 0.5mg Q6H, but he was not
using >24 hours prior to discharge, so not prescribed on
discharge. Unable to use other agents due to prolonged QTc of
598 on ___ and 572 on ___. Ordered to get KUB on ___ for
further evaluation (though benign abdominal exam) but patient
refused.
# Acute kidney injury: Initial creatinine was elevated to
1.3-1.4, though no recent baseline available. Back in ___
creatinine was 0.7. Suspect he had acute kidney injury
secondary to hypovolemia due to nausea and vomiting, as
creatinine has improved to 0.9 after IV fluids. He was
tolerating oral intake and creatinine was 0.9 on discharge.
# Hypokalemia:
# Hypophosphatemia: Resolved
# Hypochloremia: Resolved
He was given IV and oral repletion for low potassium and
phosphorus. He had normal phosphorus of 2.9 on discharge, but
since this was while on oral repletion QID, he was discharged
with BID Neutra-Phos to maintain normal level. His K was 3.1
and he was given 60meq the day of discharge and prescribed 40meq
daily on discharge, since needing nearly daily repletion. He
should have BMP, calcium, magnesium, phosphorus checked as an
outpatient within the next 5 days, as he may be able to stop the
potassium and phosphorus supplements.
# Metabolic alkalosis
# Respiratory acidosis: Most likely his electrolyte deficiencies
and alkalosis are primarily related to volume depletion and
vomiting, as both are improving. Unclear why he has respiratory
acidosis (pCO2 74-->60s) but pH is normal, which is more
suspicious for chronic issue. CXR showed hyperinflated lungs
and he is a smoker, so may have undiagnosed COPD.
# Leukocytosis: Mild, with WBC ___, without fevers. Urine
culture contaminated on ___. Resolved. Blood cultures from
___ had no growth to date.
# Normocytic anemia: Hb was 15 on admission and decreased to
___, but all counts decreased and he'd gotten IV fluids in
setting of repeated vomiting, so probably hemoconcentrated
initially. He denies blood in emesis and has not had blood in
stool. Hb was 12 on discharge.
# HTN: SBP mostly in 120s-130s, but up to 160s at times. He is
not on anti-hypertensive medication at baseline and was not
started as inpatient.
# Polysubstance abuse: He recently relapsed on heroin and
stopped his Suboxone and also admits to frequent cocaine use.
His suboxone was held in setting of acute metabolic issues. He
was unclear about when he'd stopped taking his Suboxone - on
admission he'd said that he had already stopped (unclear why),
but prior to discharge, he said that he'd been on it until he
came to the hospital. Social work was following. Addiction
psychiatry was consulted for assistance with restarting
Suboxone. His psychiatrist is Dr. ___, who
prescribes his suboxone. I spoke with her by phone at
___. He last saw her on ___, and sees every 4
weeks. Urine screen back then was clean and has been clean for
years, except intermittently positive for cocaine, which he does
admit to using sometimes. He will need close follow up with Dr.
___ addiction psychiatry gave him a prescription for 8mg
suboxone to bridge until he can see Dr. ___.
# QTc prolongation: QTc 572 on ___ and should be monitored with
serial EKGs as outpatient.
# Severe malnutrition:
# Weight loss, abnormal, unintentional: Unclear etiology, may be
related to above acute issues but need to keep in mind other
more sinister etiologies. Never had colonoscopy, no TB contacts,
no symptoms of TB. Negative HIV test. Nutrition was consulted.
He was eating while hospitalized and tolerating most oral
intake. He was given daily multivitamin and thiamine
supplement. He needs age appropriate cancer screening, including
colonoscopy, but can be done as outpatient.
# Hepatitis C: Will need referral to GI doctor for outpatient
follow up
# Tobacco use: Daily nicotine patch
TRANSITION OF CARE ISSUES:
- I personally called his psychiatrist and PCP's offices to make
follow up appointments and the soonest appointments were in
___, so booked those appointments but trying to see if he can
get sooner appointment. If so, please call him directly to let
him know. I gave him a prescription for CBC, BMP, Ca, Mg, Phos
that he could take to a lab near him and have results be faxed
to his PCP.
- Recheck CBC, BMP, Ca, Mg, Phos within 5 days of discharge
- If he has persistent abdominal pain and vomiting, may need
further imaging and workup, but the patient declined while here
- Outpatient workup for possible COPD given respiratory acidosis
and is a smoker
- Follow up blood cultures from ___ - no growth to date
- Will need referral to GI doctor for outpatient follow up for
hepatitis C that is untreated
- He will need repeat EKG to monitor prolonged QTc. Avoid QTc
prolonging medications
- He needs age appropriate cancer screening, including
colonoscopy, but can be
done as outpatient
====================
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Neutra-Phos 1 PKT PO DAILY
RX *potassium, sodium phosphates 280 mg-160 mg-250 mg 1
packet(s) by mouth once a day Disp #*14 Packet Refills:*0
4. Nicotine Patch 14 mg TD DAILY:PRN Tobacco withdrawal
RX *nicotine 14 mg/24 hour 1 patch once a day Disp #*30 Patch
Refills:*0
5. Potassium Chloride 40 mEq PO DAILY
Hold for K >
RX *potassium chloride 20 mEq 2 tab by mouth once a day Disp
#*14 Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID
8.Outpatient Lab Work
CBC, BMP, magnesium, phosphorus, calcium to be drawn on/after
___
ICD-9 code: ___, ___, ___, ___.___
FAX: Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute kidney injury
Encephalopathy
Hypokalemia
Metabolic alkalosis
Hypophosphatemia
Prolonged QTc
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you.
You were admitted for nausea and were found to have acute kidney
injury. We think this was due to a combination of dehydration,
poor oral intake, and drug use. You got better with IV fluids
and monitoring and repletion of your electrolytes. Your kidney
function is back to normal. It's important to stay well
hydrated. If you're having worsening nausea and vomiting and
cannot keep fluids down, then call your doctor or go to the
emergency department if severe. Your potassium and phosphorus
have been low, so you have been started on a potassium and
phosphorus supplement. You have a prescription to have lab work
done, which you can take to any lab near you, and have the
results faxed to your primary doctor.
We recommend you not use cocaine or heroin and continue to
follow up with a primary care doctor and psychiatrists, as you
have appointments scheduled with both. Recommend having kidney
function and electrolytes checked with your primary doctor to
make sure these are normal. You will need a referral to a
gastroenterologist (GI doctor) for your hepatitis C and your
primary care doctor can help set this up.
Followup Instructions:
___
|
10517005-DS-17 | 10,517,005 | 24,485,157 | DS | 17 | 2170-01-12 00:00:00 | 2170-01-12 19:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
penicillin
Attending: ___.
Chief Complaint:
? seizure episodes x3
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with no significant PMH presenting as transfer from OSH for
evaluation s/p possible syncopal episodes. Pt has had three
episodes so far. The first two episodes occurred while she was
sitting and watching TV at home 1 week ago. She felt a sensation
like she was "coming up in an elevator" and then felt like she
was going to pass out, but didn't. She remained seated in her
chair with a feeling like something was wrong. She wanted to
call out or call someone for help on the phone but couldn't. The
symptoms resolved on their own. SHe was still sitting in her
chair and was unsure how much time had passed. The third and
most recent episode happened today at her friend's house. She
says she remembers feeling like the sensation was coming on
again, and then doesn't remember anything until it ended. Her
friend witnessed the event and told her that she clutched the
arm rests and looked up at the ceiling. The friend asked if she
was OK. The patient responded with "I don't know, I don't know"
and shifted her upper body side to side slightly in the chair
like she was trying to move. It lasted about 5 minutes. Patient
went home and told her husband who suggested calling her PCP.
She remembers having difficulty/confusion trying to figure out
how to call the PCP. She denies weakness, numbness, or tingling
in any of her extremities or face. No incontinence of bowel or
bladder. No falls. No vision changes. She never had episodes
like this until 1 week ago. She does say that in the past, she
has had experiences where she was told she had been looking
directly at people who were talking to her, but not responding.
When her husband asked why she wasn't answering, said she "did
not notice that they were talking." This has happened a few
times over the past few weeks. No history of seizures.
Went to OSH where CT head was negative. CTA chest was normal
after elevated D-dimer. EKG with PVCs and fusion complexes, no
ischemia. Trop negative x 1. Other labs significant for CK 476,
K 3.5, Cr 1.1, LFTs WNL, CBC WNL, U/A neg. Sent to ED for
further eval given dysrythmia and suspicion for syncope.
In the ED, VS 98.4 85 144/92 16 99%. EKG showed SR 74, NA/NI, no
STE. Labs significant for CHEM-7 WNL, CBC WNL. Trop < 0.01. ED
requested ___ read on CTA which was also neg on prelim. VS on
transfer 72, RR: 18, BP: 134/62, Rhythm: sr, O2Sat: 99, O2Flow:
(Room Air).
On arrival to the floor, VS 98.4, 144/97, 78, 20, 98% RA. Pt
comfortable and pleasant. Curious about possible seizures. Has a
facial twitch on right corner of mouth but when asked pt has not
noticed this.
Past Medical History:
- diverticulosis
- no history of seizures
- possible concussion about ___ years ago when tripped and hit
head against wall, lacerating scalp, requiring sutures.
Developed nausea. Not sure if she had concussion diagnosis but
CT head otherwise NL.
Social History:
___
Family History:
All men on her fathers side of the family with MIs before the
age of ___. Brother with seizure disorder s/p head trauma as a
child. No other family history of seizure or migraine.
Physical Exam:
ADMISSION EXAM
VITALS: Tc 98.7, Tm 98.7, BP 123/78 (120s-140s/70s-90s), HR 71
(70s), RR 20, 99% RA
ORTHOSTATICS: laying (BP 123/78 HR 71), sitting (BP 139/89 HR
81), standing (BP 142/87, HR 78)
GENERAL: NAD, walking easily out of bathroom
HEENT: PERRL, EOMI, MMM, no tongue lacerations
NECK: supple, no signs of meningismus, no carotid bruits, no JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: CN2-12 intact, possible bitemporal hemianopsia,
strength ___ in UE and ___. No pronator drift. Sensation intact
to light touch throughout. Finger-nose-finger and heel-to-shin
intact b/l. Rhomberg absent.
DISCHARGE EXAM
VS: Tc 97.6 Tm 98.1 BP 120-149/81-90 HR ___ RR 20 O2 99%RA
GENERAL: NAD
HEENT: PERRL, EOMI
NECK: supple, no carotid bruits, no JVD
LUNGS: CTAB
HEART: RRR, normal S1 and S2, no m/r/g
ABDOMEN: Soft, nontender, normal bowel sounds
EXTREMITIES: No c/c/e
Pertinent Results:
ADMISSION LABS
___ 08:45PM BLOOD WBC-5.6 RBC-4.64 Hgb-13.6 Hct-40.8 MCV-88
MCH-29.4 MCHC-33.4 RDW-13.4 Plt ___
___ 08:45PM BLOOD Neuts-62.5 ___ Monos-4.4 Eos-3.0
Baso-1.0
___ 08:45PM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-14
___ 09:02PM BLOOD CK(CPK)-385*
CARDIAC ENZYMES
___ 09:02PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:00AM BLOOD CK-MB-6 cTropnT-<0.01
DISCHARGE LABS
___ 06:25AM BLOOD WBC-4.9 RBC-4.30 Hgb-12.8 Hct-38.0 MCV-89
MCH-29.9 MCHC-33.7 RDW-13.3 Plt ___
___ 06:25AM BLOOD Glucose-102* UreaN-23* Creat-0.9 Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
___ 06:25AM BLOOD CK(CPK)-127
EKG ___
Sinus rhythm. Normal ECG. No previous tracing available for
comparison.
IntervalsAxes
___
IMAGING
CTA CHEST ___, NON-CORONARY ___ 9:40 ___
IMPRESSION: No pulmonary embolism.
CT HEAD W/O CONTRAST ___ 3:28 ___
IMPRESSION: No acute intracranial process.
MRI HEAD ___ CONTRAST ___
1. No intracranial mass.
2. Multifocal areas of punctate FLAIR signal hyperintensity as
described
above. These likely represent areas of chronic microvascular
disease, though
the appearance is nonspecific and can also be seen less commonly
with migraine
headaches, amongst other possibilities
EEG ___
This is a normal routine EEG in the waking state. No focal
abnormalities or epileptiform discharges are present. If
clinically indicated, repeat EEG with sleep recording may
provide additional information.
Carotid Series ___
Impression: Right ICA with no stenosis. Left ICA with no
stenosis.
Brief Hospital Course:
___ with no significant PMH presenting as transfer from OSH for
evaluation 3 episodes concerning for seizure vs. syncope.
# Seizure vs. syncope episodes: Given her continued
responsiveness to her neighbor, these episodes sounded most like
atypical seizure (perhaps frontal or abscense). This is further
supported by her elevated CK on admission. A primary seizure
disorder was thought unlikely at her age, although the patient
did report h/o remote head trauma. However, a non-contrast head
CT and MRI was negative for any intracranial process that might
secodarily cause seizures. An EEG revealed no seizure activity.
TIA was also considered, but thought less likely given her
nonfocal neuro exam and more generalized deficits during these
episodes. She had no bruits on exam to suggest carotid
dissection and no prior history of vascular disease.
Furthermore, MRI/MRA revealed no evidence of stroke and carotid
ultrasounds revealed no stenosis. Although her neighbor's
description of the episode did not suggest syncope, a syncope
differential of neurocardiogenic, cardiogenic, or orthostatic
was considered. She did not describe prodromal symptoms or
visual changes to suggest neurocardiogenic syncope. She has no
history of arrhythmias or family history of sudden cardiac
death, but the abrupt onset and offset of her episodes was
concerning for cardiogenic syncope. She was monitored on
telemetry, which showed no evidence of arrhythmia. Suspicion was
not high for a cardiac structural abnormality given normal
cardiac exam, so a TTE was not done. Cardiac enzymes were
negative for ischemia. Orthostatic vital signs were
unremarkable. Given that 10% of PEs present as syncope, a CTA
was done which was negative for PE. No definitive etiology of
symptoms was ultimately identified. Patient was discharged with
PCP and neurology follow up for further investigation.
# Headache: On the evening of hospital day 1, the patient
developed a sudden onset throbbing ___ headache behind her eyes
and posteriorly, similar to previous sinus headaches. She
concurrently had a single episode of NBNB emesis. In the setting
of new neurological complaints, there was concern for increased
ICP, but she had no papiledema on exam and no evidence of an
intracranial process on non-contrast head CT or subsequent MRI.
Her headached and nausea improved with naproxen and zofran with
no recurrence throughout the remainder of her course.
Transitional issues
-Code status: full code
-Patient will follow up with PCP and neurology.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Multivitamins 1 TAB PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Multivitamins 1 TAB PO DAILY
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:
Dear Ms ___,
You were admitted to the hospital for evaluation of syncope. We
were concerned that you may have had a seizure or a mini-stroke.
We did some tests which showed no evidence of seizures or
stroke. We also monitored your heart to evaluate for an abnormal
heart rhythm as a possible cause, but we found no abnormality.
While you were here, you remained stable with no reccurrent
episodes. We were unable to find a definitive reason for your
episode of possible syncope. Please follow up with your primary
care doctor and with neurology for further evaluation. You
should also avoid driving until your doctor tells you it is safe
to do so. If you have any recurrent episodes please seek
immediate medical attention.
No changes were made to your medications. It was a pleasure
taking care of you.
Followup Instructions:
___
|
10517359-DS-6 | 10,517,359 | 25,894,740 | DS | 6 | 2182-04-12 00:00:00 | 2182-04-13 15:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
severe anemia
Major Surgical or Invasive Procedure:
blood transfusion
upper endoscopy
colonoscopy
History of Present Illness:
___ w/ PMH of prostate CA in remission, colon CA in remission, L
MCA stroke in ___ with residual mild right-sided deficits,
and afib/aflutter on dabigatran (recently increased), who is
admitted from clinic after being found to have Hct 16.8 and
guaiac positive stool. Pt states that he has been feeling
completely well. No fatigue, no dyspena on exertion, no chest
pain. No lightheadedness or fainting. No fevers, chills, night
sweats, or weight loss. No nausea or vomiting. No abdominal
pain. No diarrhea, no hematochezia, no melena, no bright red
blood per rectum. Pt apparently went for routine clinic visits
to his PCP, who ordered labs including Hct, and
urology-oncologist, who performed a rectal exam and found brown
stool that was guaiac positive. Pt was then sent to the ED after
Hct returned 16.8.
.
In the ED, Pt's vitals were 98.4F 102 129/36 16 100%. Pt was
started on 1 x pRBC transfusion and admitted to medicine for GI
bleed. Pt was completely comfortable and mentating well.
.
Upon transfer, vitals were 97.4 po, 47, 126/60, 18, 100% RA
.
On arrival to the floor, vitals were 98.1F, 124/71, HR 48, RR
16, Sat 100% RA.
.
ROS: 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:
-Cerebrovascular disease: s/p left MCA in ___
-Atypical Atrial Flutter/fibrillation, s/p partial ablation
(previously not on Warfarin), now on dabigatran 150mg po bid per
Dr. ___ s/p XRT- ___ in remission, followed by Dr. ___ colorectal CA, s/p surgery and chemo. In remission.
-s/p Right Inguinal Hernia repair
-s/p "knee surgery"
-h/o renal stones- ___
Social History:
___
Family History:
Father (___.)- stroke, MI.
Mother (___.)- no known problems
Physical Exam:
Physical Exam on admission:
VS - 98.1F, 124/71, HR 48, RR 16, Sat 100% RA.
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, pale
conjunctiva
NECK - supple, no thyromegaly, JVP ~8cm
LUNGS - fine bilateral inspiratory crackles, winged scapula on R
HEART - irreg irreg rhythm, brady rate, nl S1-S2, no MRG
ABDOMEN - normal bowel sounds, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ peripheral pulses (radials, DPs), 2+ lower
extremity edema up to knees
SKIN - no rashes or lesions
RECTAL - deferred
NEURO - A&Ox3, CNs II-XII grossly intact, mild slowing of
speech, but fully interactive, making jokes, ___ strength in
LUE, ___ strength in proximal RUE, ___ strength in bilateral
lower extremities, sensation grossly intact throughout.
Physical Exam:
Gen: pale appearing elderly man in no acute distress, alert and
interactive.
VITALS: Tm 98.8, Tc 98.1, BP 116-142/66-71, HR 37-50, RR 16, Sat
98% RA.
HEENT: PERRL, normal oropharynx
Lungs: bibasilar mild inspiratory crackles
CV: irreg irreg rhythm, brady rate, nl s1, s2, no m/r/g
Abd: normal bowel sounds, soft, non-tender, no masses
Ext: 2+ pulses in bilat radial and dp, 2+ edema in bilateral
lower extremities, compression hose on.
Pertinent Results:
Admission labs:
___ 01:40PM BLOOD WBC-5.5 RBC-2.63* Hgb-5.0*# Hct-16.8*
MCV-64*# MCH-19.0*# MCHC-29.8* RDW-17.7* Plt ___
___ 01:40PM BLOOD Neuts-70.5* ___ Monos-8.7 Eos-1.9
Baso-0.4
___ 01:40PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-OCCASIONAL
Acantho-OCCASIONAL
___ 05:40AM BLOOD Ret Man-1.9*
___ 01:40PM BLOOD UreaN-18 Creat-0.8
___ 01:40PM BLOOD ALT-17 AST-22 LD(LDH)-173 AlkPhos-67
TotBili-0.4
___ 01:40PM BLOOD proBNP-1155*
___ 01:40PM BLOOD Iron-12*
___ 01:40PM BLOOD calTIBC-534* ___ Ferritn-4.0*
TRF-411*
___ 01:40PM BLOOD Testost-306
___ 01:40PM BLOOD CEA-1.6 PSA-0.3
___ 05:40AM BLOOD WBC-6.6 RBC-3.21* Hgb-6.8*# Hct-21.9*#
MCV-68* MCH-21.1*# MCHC-30.9* RDW-18.7* Plt ___
___ 06:20AM BLOOD WBC-6.8 RBC-3.07* Hgb-6.2* Hct-20.9*
MCV-68* MCH-20.0* MCHC-29.4* RDW-19.4* Plt ___
___ 06:22AM BLOOD WBC-6.9 RBC-2.90* Hgb-6.0* Hct-20.1*
MCV-69* MCH-20.6* MCHC-29.7* RDW-21.0* Plt ___
___ 05:45AM BLOOD WBC-6.3 RBC-3.37* Hgb-7.4* Hct-24.0*
MCV-71* MCH-21.8* MCHC-30.7* RDW-22.2* Plt ___
___ Colonoscopy
Large non-bleeding internal hemorrhoids were noted. Excavated
Lesions Upon reaching the ileocolonic anastamosis, it was noted
that there were ulcerations and surrounding friability on both
sides of the anastamosis. There was bright red blood oozing from
the borders of the ulcers. BI-CAP Electrocautery was applied for
hemostasis successfully. Cold forceps biopsies were performed
for histology at the ileocolonoic anastamosis. Impression:
Internal hemorrhoids Ulcers at the ileocolonic anastamosis
(thermal therapy, biopsy) Otherwise normal colonoscopy to
ileocolonic anastamosis
___ Upper endoscopy
Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
___ Echo
The left atrium is moderately dilated. The left atrial volume is
mildly increased. The right atrium is moderately dilated. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with normal free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION: Mild
symmetric left ventricular hypertrophy with preserved regional
and global systolic function. Moderate right ventricular
dilation with preserved function. Moderate-to-severe tricuspid
regurgitation. Moderate mitral regurgitation. Moderate to severe
pulmonary artery systolic hypertension.
Upper endoscopy ___
Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Colonoscopy ___
Protruding Lesions Large non-bleeding internal hemorrhoids were
noted.
Excavated Lesions Upon reaching the ileocolonic anastamosis, it
was noted that there were ulcerations and surrounding friability
on both sides of the anastamosis. There was bright red blood
oozing from the borders of the ulcers. BI-CAP Electrocautery was
applied for hemostasis successfully. Cold forceps biopsies were
performed for histology at the ileocolonoic anastamosis.
Impression: Internal hemorrhoids
Ulcers at the ileocolonic anastamosis (thermal therapy, biopsy)
Otherwise normal colonoscopy to ileocolonic anastamosis.
Recommendations: The patient will be notified of biopsy results
in ___ weeks. Further treatment plans will depend on the biopsy
results.
Brief Hospital Course:
___ w/ PMH of prostate CA in remission, colon CA in remission, L
MCA stroke in ___ with residual mild right-sided deficits,
and afib/aflutter on dabigatran (recently increased), who is
admitted from clinic after being found to have Hct 16.8 and
guaiac positive stool.
.
# severe anemia: due to Pt's anticoagulation with dabigatran and
guaiac positive stool, suspect GI source. Pt has a history of
prostate and colon cancer, both in remission. Given absence of
constitutional symptoms, suspect more benign cause of GI bleed.
Suspect lower GI bleed given absence of upper GI (or lower GI)
symptoms, but cannot rule out upper GI bleed. No evidence of
hemolysis; normal T bili, normal LDH, normal haptoglobin, no
schistocytes on smear. Pt is very microcytic but was previously
normal, suspect that this is a long, slow process, which has
made him extremely iron deficient. Iron studies showed serum
iron 12 (last 18 in ___, Ferritin 4.0 (last 57 in ___, TIBC
534, transferrin 411. Pt last took dabigatran ___ morning and
appears to be very stable clinically. Conferred with GI fellow,
who wanted to wait and scope Pt on ___ after dabigatran has
washed out. Pt received 2 x PRBCs on the evening of admission
with appropriate increase in Hct from 16 to 22. Hct remained
stable and increase throught his admission to 24 on ___. Pt
was started on ferric gluconate 125mg iv daily x 4 days (D1 =
___ for his severe iron deficiency anemia. Pt was also treated
with pantoprazole 40mg iv bid given unclear source of GI bleed,
though suspected lower GI. Pt's Hct remained stable throughout
hospitalization, 24.0 on discharge.
Pt's upper endoscopy on ___ was normal. His colonoscopy
showed large non-bleeding internal hemorrhoids, and ulcerations
and surrounding friability on both sides of the ileo-colonic
anastamosis. There was bright red blood oozing from the borders
of the ulcers. BI-CAP Electrocautery was applied for hemostasis
successfully. Cold forceps biopsies were performed for histology
at the ileocolonoic anastamosis. Per the GI service, these
lesions did not look cancerous, but the biopsies will provide
more definitive information. Their etiology remains unclear and
they may continue to bleed despite coagulation. The situation
was discussed with Dr. ___ Dr. ___ it was decided
that Pt should remain off anticoagulation for now and will be
discharged on aspirin 81mg po daily pending further discussion
w/ his doctors next week.
.
# bradycardia: chronic. Physiologic vs AV nodal disease. Pt was
noted to have several pauses in the 1.6 to 1.8 second range
overnight when sleeping. No acute interventions, Pt was
scheduled for follow-up w/ his outpatient cardiologist.
.
# atrial fibrillation / atrial flutter: chronic, s/p
unsuccessful ablation procedure. Had a large MCA stroke off
medication. Started on dabigatran afterwards w/ dose recently
increased from 75mg po bid to ___ po bid. Repeat ECG showed
sinus bradycardia with irregularly irregular rhythm. His
dagibatran was stopped given his GI bleed, and Pt was started on
aspirin 81mg po daily. CHADS2 score of 3 = 5.9% annual risk of
stroke (for age and stroke). The issue of resuming
anticoagulation will be determined by his PCP and neurologist.
.
# inspiratory crackles, pedal edema: seems to be new per Pt's
daughter, likely over at least 2 weeks. Pt denies any dyspnea or
weakness. BNP elevated at 1155, but no prior for comparison. Pt
had inspiratory crackles and pedal edema. Given his severe
anemia, Pt had an ECG, which showed no evidence of ischemia, and
a repeat echo, which showed no focal motion abnormalities. Pt
had moderately dilated left and right atria, LVEF > 55%,
moderately dilated RV w/ preserved function. Pt also had
moderate-severe TR, moderate MR, and severe pulmonary artery
systolic hypertension. Pt has an appointment with his
cardiologist to address these findings.
.
TRANSITIONAL ISSUES:
-have Hct check to assess for continued bleeding
-follow up endoscopy and colonoscopy biopsies
-address the issue of anticoagulation and stroke prevention
-address bradycardia, severe pulmonary artery systolic
hypertension
Medications on Admission:
dabigatran 150mg po bid (recently increased from 75mg po bid)
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
severe microcytic anemia
iron deficiency
bradycardia
ulcerations near the ileo-colonic anastamosis
severe pulmonary hypertension
Secondary:
atrial fibrillation / atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were sent to the hospital because you had very low levels of
red blood cells (severe anemia). You likely have had a chronic
slow bleed from your gastrointestinal tract. You received blood
transfusions, and your blood levels remained stable. You were
also treated with IV iron because your body iron levels were
very low. You had two studies to find the location of this
bleed, which showed that you had ulcers near the part of your
colon that was operated on previously. There was some blood
oozing from these ulcers, which were cauterized to stop the
bleeding. After you had your studies, your condition was
discussed by Dr. ___ Dr. ___ felt that you should
go home on a baby aspirin daily and re-address your need for
blood thinners at you appointment with them next ___.
We have made the following changes to your medications:
Please STOP taking dabigatran (Pradaxa). Do not restart this
medication until instructed by your doctor.
Please START taking aspirin 81 mg tabs (enteric coated), 1 tab
by mouth daily.
Followup Instructions:
___
|
10517613-DS-19 | 10,517,613 | 26,330,491 | DS | 19 | 2176-12-01 00:00:00 | 2176-12-02 11:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP:
Name: ___ MD
Location: ___
Address: ___, ___
Phone: ___
Fax: ___
HOSPITALIST ADMISSION NOTE
HPI:
Mr. ___ is a ___ yo M with poorly controlled DM2, HTN, HL,
with CKD who presents with headache, mild confusion,
uncontrolled HTN, and hyperglycemia. He states that for various
work reasons he has not taken his medications or his blood sugar
for the past ___ months. Over the last week, he has felt
fatigued, "woozy", confused, and has had an intermittent frontal
HA with blurriness of vision. He went to work yesterday and was
not even able to ___ to his computer. He felt confused and
his coworkers took him into the hospital. In addition to the
above, he reports urinary frequency. He denies F/C, double
vision, sore throat, CP, SOB, cough, n/v/d, bloody/black stool,
leg pain or swelling. He reports good appetite. He reports
numbness in his feet, but otherwise denies any focal weakness.
In the ED, SBP 200s requiring labetalol, FSBG 500s. Labs, CXR,
and CT head performed. ___ was consulted and patient was
initiated on glargine and Humalog insulin.
PCP is ___ ___
10 point review of systems reviewed, otherwise negative except
as listed above
Past Medical History:
type 2 diabetes mellitus, last A1C ___ 8.9%
HTN
HL
CKD stage II-III
Social History:
___
Family History:
___. Mother with diabetes
Physical Exam:
VS: T 98.7, BP 157/81, HR 85, RR 18, 100%RA
GEN: well appearing talkative in NAD
HEENT: MMM, OP clear, anicteric sclera, poor dentition
NECK: supple no LAD
HEART: RRR no mrg
LUNG: CTAB no wheezes or crackles
ABD: sfot NT/ND +BS no rebound or guarding
EXT: warm well perfused no pitting edema, skin dry and cracked
SKIN: skin dry and cracked over feet no bruising
NEURO: CNII-XII intact. strength ___ symmetric. gross
sensation intact. no dysmetria. ? mild R pronator drift.
Proprioception intact bilateral ___ toe
Pertinent Results:
___ 07:37PM GLUCOSE-286* UREA N-27* CREAT-1.9* SODIUM-135
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 07:37PM cTropnT-0.02*
___ 11:19AM ___ PO2-40* PCO2-42 PH-7.38 TOTAL CO2-26
BASE XS-0
___ 11:00AM GLUCOSE-510* UREA N-27* CREAT-2.0*
SODIUM-129* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-22 ANION GAP-19
___ 11:00AM estGFR-Using this
___ 11:00AM CK(CPK)-231
___ 11:00AM cTropnT-0.02*
___ 11:00AM CK-MB-4
___ 11:00AM URINE HOURS-RANDOM
___ 11:00AM URINE HOURS-RANDOM
___ 11:00AM URINE UHOLD-HOLD
___ 11:00AM URINE GR HOLD-HOLD
___ 11:00AM WBC-11.2* RBC-4.07* HGB-12.1* HCT-35.9*
MCV-88 MCH-29.7 MCHC-33.7 RDW-11.7 RDWSD-37.5
___ 11:00AM NEUTS-92.1* LYMPHS-6.1* MONOS-1.0* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-10.35* AbsLymp-0.68* AbsMono-0.11*
AbsEos-0.01* AbsBaso-0.03
___ 11:00AM PLT COUNT-220
___ 11:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:00AM URINE RBC-10* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
EKG, my review: NSR, LAD, LVH with repolarization changes.
Similar to prior EKG reviewed.
CXR, my review: No infiltrate or edema or acute processes
CT head x2: negative
DC LABS:
___ 08:00AM BLOOD WBC-6.3 RBC-3.86* Hgb-11.6* Hct-38.0*
MCV-98# MCH-30.1 MCHC-30.5* RDW-11.9 RDWSD-42.9 Plt ___
___ 08:00AM BLOOD Glucose-321* UreaN-35* Creat-2.1* Na-136
K-4.1 Cl-100 HCO3-23 AnGap-17
___ 09:23AM BLOOD %HbA1c-13.4* eAG-338*
Brief Hospital Course:
___ yo M with poorly controlled DM2, HTN, HL, presents with
subacute fatigue, lethargy/confusion, and HA, found to have
hypertensive urgency, ARF, and hyperglycemia.
Lethargy/Encephalopathy
Poorly controlled DM2 with nephropathy/neuropathy
Hypertensive urgency/Malignancy hypertension
The patient' symptoms were consistent with uncontrolled DM2 and
HTN causing hypertensive urgency and encephalopathy. He also
had ARF. There was no evidence of infection, cardiac ischemia,
or acute stroke. The above were likely exacerbated by poor
adherence to his medication for the last year. Clinically he
improved with blood pressure and FSBG control. ___ was
involved. He was placed on Lantus monotherapy at 25 units qHS
as well as Glipizide 10mg BID. Metformin was held due to his
renal failure. His A1c was found to be >13. He will follow up
with ___ for his diabetes.
Hi blood pressure improved markedly with initiation of his
amlodipine. His HCTZ and ACEi were not restarted due to his
renal failure. Further titration will be necessary.
- of note he had microscopic hematuria on UA. This requires
follow up
HL:
Resumed statin. LFTs normal.
Medications on Admission:
HAS NOT TAKEN IN LAST 10 MONTHS:
amlodipine 5 qd
atrova 10 qhs
glipizide 5 qd
hctz 50 qd
lisinopril 40 qd
metformin 500 BID
ASA 81mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Glargine 25 Units Bedtime
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
25 Units before BED; Disp #*3 Syringe Refills:*0
4. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. GlipiZIDE 10 mg PO BID
RX *glipizide 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Type 2 diabetes mellitus with nephropathy
Acute kidney injury
CKD stage III
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with very high blood pressure and high blood
sugars causing headache and fatigue. This improved with
medication and IV fluids. It is very important that you take
your medications every day and as prescribed. Please also check
your blood sugars ___ times per day and keep a log for when you
see your diabetes doctor.
Followup Instructions:
___
|
10517746-DS-18 | 10,517,746 | 27,124,674 | DS | 18 | 2130-02-05 00:00:00 | 2130-02-05 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
penicillin V
Attending: ___.
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o F s/p mechanical fall in Back ___, during which time she
tripped on a sidewalk, and landed on her left hip and knee. She
also hit her right forehead on the cement. She was walking with
her son, who partially caught her, so her head had minimal
impact. She denied loss of consciousness, but had a right
forehead abrasion, for which wound care done.
In the ED, initial VS were 99.0, HR 61, BP 145/94, RR 16.
Labs showed H/H of 9.3/30.4. BMP WNL. Troponin negative x 1.
CT Head negative. CT Cspine negative.
CT lower extremity negative for acute fracture.
CXR significant for ventral venous congestion, possible early
pulmonary edema, and patchy airspace opacities at the lung bases
suggestive of superimposed infection/aspiration.
She was given CTX and azithromycin for possible pneumonia.
Upon arrival to the floor, the patient is very hard of hearing
so
the history is slightly limited. She reports she has not seen a
doctor in years. She has no medical problems that she knows
about. She reports she was walking with her son in Back ___ when
she tripped on uneven sidewalk and fell and hit the cement. She
denies loss of consciousness or headstrike. She denies feeling
dizzy, or having chest pain. She reports that she has
longstanding shortness of breath with exertion, but states this
occurs after walking half a mile. She otherwise denies fevers,
chills, diarrhea, dysuria. She endorses post nasal drip and a
dry
cough. She endorses left leg numbness and pain. It is difficult
to pinpoint the pain in her left leg. She describes it as
"vague."
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Hypothyroidism
- HLD
- Hearing loss
- HTN
- H pylori
- Iron deficiency
- Paroxysmal atrial fibrillation
Social History:
___
Family History:
Denies FH of cardiac problems.
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress, very hard of hearing
EYES: Anicteric, pupils equally round
ENT: Abrasion over right lip and near R eyebrow
Mucous membranes moist
CV: Heart irregular, + systolic ejection murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
BACK: No spinal tenderness
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: grip strength ___ bilaterally, plantar/dorsiflexion ___
bilaterally, initially, very limited motion of R knee, however,
on revaluation, will bend knee against gravity and with some
resistance, will flex hip slightly
SKIN: facial abrasions as described above
EXT: + DP pulses of both foot equal
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS:
___ 05:03PM BLOOD WBC-7.1 RBC-3.96 Hgb-9.3* Hct-30.4*
MCV-77* MCH-23.5* MCHC-30.6* RDW-18.6* RDWSD-50.8* Plt ___
___ 07:06AM BLOOD WBC-7.9 RBC-4.03 Hgb-9.6* Hct-31.2*
MCV-77* MCH-23.8* MCHC-30.8* RDW-18.7* RDWSD-52.1* Plt ___
___ 05:03PM BLOOD Neuts-76.8* Lymphs-12.6* Monos-6.8
Eos-2.8 Baso-0.4 Im ___ AbsNeut-5.43 AbsLymp-0.89*
AbsMono-0.48 AbsEos-0.20 AbsBaso-0.03
___ 07:00AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-144
K-3.6 Cl-103 HCO3-26 AnGap-15
___ 05:03PM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-140
K-4.2 Cl-102 HCO3-25 AnGap-13
___ 05:03PM BLOOD ALT-7 AST-13 LD(LDH)-158 CK(CPK)-43
AlkPhos-88 TotBili-0.3
___ 05:03PM BLOOD cTropnT-<0.01
___ 05:03PM BLOOD proBNP-1092*
___ 07:00AM BLOOD calTIBC-445 Ferritn-12* TRF-342
___ 07:00AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0 Iron-58
IMAGING:
Left Femur 4 views ___
Although there is no convincing fracture, there is a small to
moderate-sized joint effusion, sometimes may be associated with
occult fracture or quadriceps injury.
CXR ___
Suspected early pulmonary edema. Patchy airspace opacities at
the lung bases, although may represent alveolar edema, are
suspicious for superimposed infection/aspiration, for clinical
correlation.
CT CSPINE ___
1. No acute fracture or traumatic malalignment.
2. Benign-appearing fatty lucency within the left lateral mass
of
the C2 vertebra, may represent area of fatty marrow adjacent to
the venous plexus, small hemangioma or less likely intraosseous
lipoma.
3. Given presence chondrocalcinosis in the cervical spine, lower
extremity involving the pubic symphysis and knee, patient may
have CPPD.
CT Lower Extremity ___
1. No acute fracture or dislocation.
2. There is no joint effusion or lipohemarthrosis. Apparent
density over the suprapatellar recess, likely artifactual and
due
to confluent shadow on recent radiograph.
3. No large retracted quadriceps or patellar tendon tear,
although there is likely remote injury to the rectus femoris on
the basis of chronic appearing dystrophic calcifications.
CT HEAD ___
No acute intracranial posttraumatic sequela.
L ANKLE ___
Diffusely osteopenic bones. No acute displaced fractures or
dislocations.
Brief Hospital Course:
___ year old woman with history of anemia (Hb ___ and HTN (not
on medication) admitted after a mechanical fall. Trauma survey
including CT head/C-spine and L knee x-ray notable only for
moderate knee effusion. Incidentally found to be in AFib on
routine EKG. Patient declined anticoagulation or further
evaluation with TTE. CXR on admission abnormal (edema vs
infection vs inflammation) however patient asymptomatic so did
not receive treatment. ___ evaluated and recommended rehab
however patient declined, and was discharged home (she lives
with children) with ___ and home ___. After thorough discussion,
patient signed MOLST form changing code status to DNR/DNI.
TRANSITIONAL ISSUES:
- Newly diagnosed atrial fibrillation, patient declined further
evaluation with TTE and anticoagulation; daughter/patient
open/amenable to discussion of aspirin and were made aware of
its limited efficacy in this scenario
- Abnormal CXR of unclear clinical relevance, can consider
further evaluation with repeat CXR and possible chest CT if
patient desires
- Signed MOLST indicating DNR/DNI
ACUTE ISSUES:
#L knee effusion
#Fall: Mechanical, witnessed fall with headstrike onto L knee.
CT head/neck without bleed or fracture. L knee plain film with
moderate effusion, no major fracture, unable to rule out smaller
fracture. AROM and PROM limited by joint effusion. Ligaments
intact on exam. Evaluated by ___ who recommended rehab however
patient declined, arranged home ___ and ___. Pain control with
tylenol, ice, NSAIDs after ~72 hours due to possible
hemarthrosis.
# Atrial fibrillation: Newly diagnosed, rates well controlled.
CHADSVASC at least 3 (age, sex). Patient declined
anticoagulation and understood risks of stroke. Also declined
TTE. Prior to discharge, the patient's daughter inquired about
taking aspirin for stroke prevention. I informed her that
aspirin is not typically recommended given the efficacy of
anticoagulants; I suggested that the data for aspirin is weak,
suggesting a possibly a 20% reduction in stroke risk, however,
also an increase in bleeding risk, similar to that of the
anticoagulants. I have encouraged her to continue to discuss
this with her outpatient providers.
#Abnormal CXR
#Elevated BNP: Patient declines significant respiratory
symptoms. Did not want further evaluation with TTE given would
not take any recommended medications or have any procedures.
Received one dose of CTX/azithromycin in ED, no further
antibiotics.
#GOC: After thorough code status discussion, given preferences
for avoiding medical care, patient signed MOLST changing code
status to DNR/DNI
CHRONIC ISSUES:
#Hearing loss: Patient has declined hearing aides, however
concern her deafness will contribute to cognitive decline
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Mechanical fall
Atrial fibrillation
Knee effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after you fell on your knee.
The physical therapists thought you would benefit from rehab,
but you preferred to return home. We discussed your abnormal
heart rhythm, atrial fibrillation, which is where the top
portions of the heart quiver. This heart rhythm increases your
risk for stroke and the risk of stroke can be decreased by
taking a blood thinner medication. We spoke about aspirin as a
possible alternative. The research suggests that there is some,
but not a strong benefit of taking aspirin for this reason. I
encourage you to continue to discuss blood thinners with your
primary care doctor.
You should take acetaminophen (tylenol) to treat your pain.
Taking Tylenol three times a day can really improve pain so that
you can participate in physical therapy. You should avoid NSAIDs
(i.e. ibuprofen, naproxen) for the next 2 days as they might
worsen your knee swelling, but then can start ibuprofen to help
with pain.
During this hospital stay, we also signed a MOLST form which you
should put on your refrigerator. We've scheduled a follow up
appointment for you and hope that you keep it!
It was a pleasure participating in your care,
Your ___ Team
Followup Instructions:
___
|
10517939-DS-6 | 10,517,939 | 24,242,134 | DS | 6 | 2182-12-25 00:00:00 | 2182-12-27 07:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
This is a ___ year-old genteman with h/o aortic stenosis s/p
bovine valve replacement in ___ presenting with fever to 38.7 C
and leg pain. Patient states he had neck pain about 1 week ago
for which he went to a ___ who improved his symptoms.
About 3 days prior he began having fevers up to 101 (per son).
He would take tylenol during the fevers. He denied focal
symptoms including cough, shortness of breath, dysuria,
abdominal pain, diarrhea, constipation. Patient is outdoors much
of the time and gardens frequently. Son states he rarely puts on
bug spray and is careless with protecting his skin etc. He does
not have any recent travel nor has he been in any lakes or other
bodies of water. Denies IV drug use, recent dental work as well.
No recent antibiotic exposure or sick contacts.
Patient also states that he has had bilateral leg pain that
began after the fevers as well. It was hard to describe the
pain, but he says it is mild, ___ which starts at both of his
feet and goes up to his knee. It is not worse or better at any
particular time.
In the ED, initial vital signs were 98.2 99 137/92 18 100%. Pt
then spiked to 102.5. CXR did not show evidence of pneumonia.
Patient was given acetaminophen 1000 mg x1. Labs were
significant for a normal WBC of 5, UA with tr blood and protein,
Cr 1.7 (last one in ___ 1.1). Blood cultures x 3, urine
culture, and anaplasmosis serologies were sent off. CXR was
unremarkable.
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Hypertension,
-hypercholesterolemia
-aortic stenosis
-depression
-prior hernia repair
Social History:
___
Family History:
Mother died of complications following hernia repair. Father
died of heart failure at ___.
Physical Exam:
Admission Exam
Vitals- 99.5 93 123/76 16 99%
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, loud S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. old scratches seen on posterior left calf
Neuro- CNs2-12 intact, motor function grossly normal
Discharge Exam:
Vitals: 98, 100, 115/75, 88, 22, 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, loud S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. old scratches seen on posterior left calf, ecchymosis on
right upper arm.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs
___ 12:24PM WBC-5.0 RBC-6.10 HGB-15.6 HCT-48.1 MCV-79*
MCH-25.5* MCHC-32.4 RDW-13.7
___ 12:24PM NEUTS-83.3* LYMPHS-11.0* MONOS-4.8 EOS-0.2
BASOS-0.7
___ 12:24PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:24PM PLT COUNT-120*#
___ 12:24PM ALT(SGPT)-41* AST(SGOT)-56* ALK PHOS-99 TOT
BILI-0.2
___ 12:24PM estGFR-Using this
___ 12:24PM GLUCOSE-126* UREA N-29* CREAT-1.7* SODIUM-139
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 02:26PM URINE MUCOUS-FEW
___ 02:26PM URINE HYALINE-4*
___ 02:26PM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
Discharge Labs
___ 07:40AM BLOOD WBC-5.7 RBC-5.01 Hgb-12.9* Hct-38.6*
MCV-77* MCH-25.8* MCHC-33.5 RDW-13.5 Plt Ct-95*
___ 07:40AM BLOOD Glucose-102* UreaN-24* Creat-1.3* Na-136
K-3.5 Cl-101 HCO3-22 AnGap-17
Parasite smear: INTRACELLULAR ORGANISMS SUSPICIOUS FOR ANAPLASMA
Micro:
___ 07:15 LYME DISEASE ANTIBODY, IMMUNOBLOT PND
___ 21:30 SPOROTHRIX (SPOROTRICHOSIS) ANTIBODY PND
___ 07:15 ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) PND
___ 07:15 ARBOVIRUS ANTIBODY IGM AND IGG PND
___ 13:46 ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) PND
Reports
ECHO:
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF 70%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No vegetations seen
Neck CT:
IMPRESSION:
1. No fluid collection, inflammatory change or lymphadenopathy.
2. Dilated distal ascending aorta, 4.3 cm; aortic arch not
imaged. Recommend CTA chest to evaluate, if not already
performed elsewhere.
3. Atherosclerosis at left ICA origin with possible moderate
stenosis, not adequately quantified as this is not a CTA. If
clinically indicated, this could be assessed by carotid
sonography.
4. Multilevel cervical spondylosis; please correlate whether
this may be the source of the patient's pain.
Brief Hospital Course:
___ year-old genteman with h/o aortic stenosis s/p bovine valve
replacement in ___ presenting with fever to 38.7 C and
generalized myalgias x4 days. During hospitalization, patient
was found to have parasite smear for anaplasma. Patient was
discharged home on 14 day course of doxycycline to treat both
anaplasma and empirically for lyme disease as coinfection is
common.
ACTIVE ISSUES:
#Fevers: Given h/o aortic valve replacement endocarditis was
considered as a possibility, but TTE did not show this.
Serologies were sent for tick borne illness as pt spent
significant time outdoors. Cultures did not reveal infection.
No evidence of pneumonia on CXR. Pt had neck CT to evaluate for
abscess/neck infection given his neck mucsle pain (no meningeal
signs), but this did not show signs of infection. Patient's
parasite smear showed anaplasma and he was discharged on 14 day
course of doxycycline to treat both anaplasma and empirically
for lyme disease as coinfection is common.
___: Cr is 1.7 up from 1.3 in ___. Likely prerenal in the
setting of fevers (insensible losses). On admission patient
received 1L IVF bolus and creatinine improved to baseline.
#Thrombocytopenia- 120 from 185. Decreased to ___ at discharge.
Likely secondary to anaplasma infection. Recommended patient
have CBC rechecked at PCP's office this week.
INACTIVE ISSUES:
#Aortic Stenosis: Stable.
#Hypertension: Continued verapamil, aspirin 162 mg daily,
doxazosin 1 mg daily
#Hyperlipidemia: Continued statin
#Depression: Continued effexor
#Insomnia: Continued ambien
TRANSITIONAL ISSUES:
- Pt with CT scan showing dilated ascending aorta. Consider CTA
as outpatiet to further evaluate. This was communicated with
the patient and his son and they will follow-up with his
PCP/cardiologist to discuss further. (ECHO showed mild
dilitation of aortic root).
- Pt needs CBC rechecked at PCP's office this week.
- Lyme, sporothrix, anaplasma, arbovirus serologies pending at
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. verapamil *NF* 240 mg Oral daily
2. Zolpidem Tartrate 5 mg PO HS
3. Donepezil 10 mg PO HS
4. Lorazepam 0.5 mg PO DAILY anxiety
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Potassium Chloride 10 mg PO DAILY
Hold for K >
7. Doxazosin 1 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Aspirin 162 mg PO DAILY
10. Simvastatin 40 mg PO DAILY
11. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Doxazosin 1 mg PO DAILY
4. Lorazepam 0.5 mg PO DAILY anxiety
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Venlafaxine XR 150 mg PO DAILY
8. Zolpidem Tartrate 5 mg PO HS
9. Doxycycline Hyclate 100 mg PO Q12H Duration: 10 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*27 Capsule Refills:*0
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Potassium Chloride 10 mg PO DAILY
12. Verapamil *NF* 240 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-Erlichiosis/Anaplasmosis
Secondary
-Aortic stenosis status post valve replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for fevers, leg pain, and neck pain. We
obtained an extensive infectious workup which revealed
erlichiosis or anaplasmosis, an infection of the blood cells.
Please take 2 weeks of antibiotics as prescribed.
Followup Instructions:
___
|
10517964-DS-11 | 10,517,964 | 28,459,645 | DS | 11 | 2172-08-30 00:00:00 | 2172-08-30 12:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___
Total intrapleural pneumolysis with video- assisted thoracic
surgery decortication
___
Left basilic PICC line placement
History of Present Illness:
___ gentleman with no past medical history presents for
evaluation of dyspnea and pleuritic chest pain. Pt. reports
symptoms began about two weeks prior. He had mild associated
cough with possible pink-tinged sputum. He took about a one week
course of unknown antibiotic given by his wife with some
improvement. Over the weekend, however, the pain and dyspnea
worsened. He was seen by his PCP who obtained an CXR that per
report showed what sound like patchy opacities. He was given
NSAIDs and oxy-acetaminophen for pain and sent home. His
symptoms persisted and he began to develop hot flashes and
sweats, and so he presented to the ED.
___ the ED, initial vitals were 97.6 65 177/83 16 96% RA. CXR was
notable for RML and RLL consolidation with pleural effusion. Pt.
initiated on ceftriaxone and azithromycin and admitted to the
floor for presumed CAP.
On the floor, initial vitals were: T 100, 86, 174/88, 28, 93 on
RA. Pt. continued to report significant dyspnea
Past Medical History:
None.
No hx lung disease.
Social History:
___
Family History:
NC
Physical Exam:
VS: 100, 86, 174/88, 28, 93 on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
LUNGS: Decreased breath sounds ___ RLL, RML; no crackles or
wheezes
CV: Regular rate and rhythm, 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 edema
SKIN: warm, mildly diaphoretic
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
___ 09:00 9.0 3.95* 11.8* 37.5* 95 30.0 31.6 13.2
616*
___ 08:00 7.9 3.80* 11.5* 36.2* 95 30.2 31.7 12.9
445*
___ 06:22 8.5 3.89* 11.7* 37.3* 96 30.2 31.5 12.8 422
___ 06:55 12.6* 4.10* 12.6* 39.0* 95 30.7 32.3 12.7
435
___ 23:12 12.0* 4.06* 12.4* 38.6* 95 30.5 32.1 12.7
378
___ 07:15 13.0* 4.07* 12.6* 38.6* 95 31.1 32.7 12.7
381
___ 07:00 12.7* 4.14* 13.0* 39.5* 96 31.5 33.0 12.7
352
___ 12:20 12.0* 4.66 14.1 44.8 96 30.3 31.5 12.6
362
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 09:00 147*1 9 0.8 138 3.9 92* 34* 16
ADDED
___ 08:00 ___ 4.1 100 26 14
___ 06:22 116*1 15 0.8 138 3.8 ___
TROUGH/VANCO
___ 06:55 122*1 13 0.8 134 3.7 93* 29 16
___ 23:12 164*1 14 0.9 136 3.7 97 30 13
___ 07:15 109*1 11 0.9 137 3.8 97 29 15
ADDED CA,MG,P 10:55AM
___ 07:00 120*1 11 0.9 140 3.5 100 29 15
ADDED CHEM 8:29AM
___ 12:20 150*1 14 0.9 136 3.6 97 30 13
___ 3:16 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 4:35 pm PLEURAL FLUID PLEURAL FLUID .
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___ @ ___ ON
___ - ___.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Final ___:
THIS IS A CORRECTED REPORT ___ 14:49.
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN <= 0.12 MCG/ML.
PREVIOUSLY REPORTED AS (ON ___ AT 14:40).
CLINDAMYCIN <= .012 MCG/ML.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- 4 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 5:10 pm TISSUE PLEURAL TISSUE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH
___ 5:37 pm TISSUE PLEURA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ ___ AT 1320.
STAPH AUREUS COAG +. RARE 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.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ CTA Chest :
1. Larger opacifications ___ the right middle and to a greater
extent right
lower lobe with air bronchograms and areas of hypoperfusion at
the periphery
are concerning for pneumonia. Associated large locules of
pleural fluid with a
thickened rim. Pleural rim can be explained by chronicity of
collection though
cannot exclude superimposed infection suggest empyema.
2. No pulmonary embolism or aortic pathology.
___ CXR :
Two chest tubes remain ___ place ___ the right hemithorax, with a
moderate, partially loculated right pleural effusion, that has
slightly
increased ___ size since the previous radiograph with adjacent
parenchymal
opacities ___ the right mid and lower lung. There is no visible
pneumothorax
___ CXR :
As compared to the previous radiograph, the right chest tube has
been removed.
There is a minimal lateral pneumothorax with some apical lateral
air
inclusions. There is no evidence of tension. Intrafissural
effusion is
unchanged ___ extent.
The appearance of the cardiac silhouette and of the left lung
are constant.
___ Cardiac echo:
No echocardiographic evidence of endocarditis ___ a good quality
study. Normal biventricular cavity size and regional/global
systolic function.
Brief Hospital Course:
___ gentleman with no PMH presents with dyspnea and chest pain.
# Pneumonia: Pt. admitted with constilation of symptoms
including fevers, dyspnea, chest pain, leukocytosis with 84%
PMNs, and CXR with RML/RLL consolidations all concerning for
pneumonia. CT Chest with evidence of loculated empyema
concerning for more virulent infection such as MRSA,
pseudomonas, or anaerobes. Pt. initiated on
vanc/cefepime/metronidazole. He underwent thoracentesis with
chest tube placement with serosanguinous and frank pus drained.
Unfortunately, the effusion failed to resolve even with TPA and
DNAase. Pt. then underwent VATS by thoracic surgery on ___.
# Chest pain: Pleuritic chest pain ___ setting of prominent
RLL/RML pneumonia is suggestive of pleural irritation as source.
ACS less likely ___ setting of unconcerning EKG, pleuritic
nature of pain, and lack of cardiac risk factors other than age
and male gender. No suggestion of hepatobiliary dysfunction ___
setting of normal LFTs. Pt. was maintained on acetaminophen,
ketorolac and dilaudid.
# HTN: No hx of known HTN. Most likely ___ setting of pain and
acute illness as pt. reports he regularly checks his BP and it
is usually ___ the 130s. Currently asymptomatic and no
indications for acute lowering of BP.
This portion of the summary relates to his surgical procedure
and post op recovery:
He was taken to the Operating Room on ___ where he
underwent a total intrapleural pneumolysis with video- assisted
thoracic surgery decortication. He tolerated it well and
returned to the PACU ___ stable condition. He had adequate pain
control with Dilaudid PCA and both chest tubes were patent and
draining minimal serosanguinous fluid. He maintained stable
hemodynamics and returned to the Surgical floor later ___ the
day. He used his incentive spirometer effectively and was
maintained on IV antibiotics of Vanco and Cefapime pending intra
op cultures. The Infectious Disease service followed him
closely. His intra op pleural fluid cultures grew MSSA and his
antibiotics were changed to Nafcillin 2 Gm IV Q 4 hrs.
Traetment of at least ___ weeks was recommended and that will be
based on chest xray findings, fevers or leukocytosis. His chest
tubes were removed and his port sites remained dry. He was up
and walking independently and had adequate pain relief with
Oxycodone. A PICC line was placed on ___ for home IV
therapy and he was discharged on that day with follow up ___ the
Thoracic and ID Clinics ___ 2 weeks.
# Transitional issues:
- repeat CT chest once recovered to assess for resolutinon of
right hilar lymphadenopathy
- thyroid u/s to assess for exophytic thyroid nodule, f/up C
level
- hypodensity ___ liver could use further eval with RUS U/S
- CODE: FULL
- CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
3. Nafcillin 2 g IV Q4H
RX *nafcillin ___ dextrose iso-osm 2 gram/100 mL 2 Gms every four
(4) hours Disp #*126 Intravenous Bag Refills:*1
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
5. Senna 8.6 mg PO BID constipation
6. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
7. Outpatient Lab Work
Weekly labs on ___:
CBC, chem 7, LFT's
Please FAX results to ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Empyema.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with pleuritic chest pain
and possible pneumonia. Lung surgery was necessary to remove the
infection and help reinflate your lung. You've recovered well.
You will need to be on antibiotics at home for at least a few
weeks and a PICC line was placed for that purpose. You are now
ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed ___ 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 8 hours ___ between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
10518021-DS-19 | 10,518,021 | 26,804,746 | DS | 19 | 2174-03-31 00:00:00 | 2174-03-31 13:43:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: History per report as pt is unable
to provide coherent story. ___ with h/o colonic mass vs perf
appendicitis treated conservatively ___ mos ago, has been on
linezolid for enterococcus UTI via ___ line, has had vomiting
and diarrhea since, started on po flagyl and had neg C diff cx's
few days ago. Now no BM since ___. Still unable to tolerate po's
until today. Today at nursing facility BP and O2 sat low, so
sent to ED for eval. Stomach was noted to be distended today as
well.
In ED pt was found to UTI, PNA and bowel obstruction on imaging
and physical exam. Surgery evaluated pt and recommended medical
management. NGT was placed and pt was given Vanco, CTX and levo.
On floor VSS, pt AO x1 unable to provide hx but appears
comfortable in bed.
REVIEW OF SYSTEMS:
unable to perform
Past Medical History:
- Abdominal Mass identified ___ uncertain if a perforated
appendix vs colonic mass
- Recurrent UTI
- Dementia
- COPD
- Hypertension
- Urinary Incontinence.
- Osteoporosis
- Anemia
- Gastroesophageal reflux
- Chronic renal insufficiency
- Vitamin D deficiency
- h/o L breast ca (___) s/p lumpectomy/chemo/rads
- h/o cataracts, ___
- h/o duodenal ulcer s/p repair ___
Social History:
___
Family History:
+ Family Hx of breast cancer.
Elder sister with ___ Disease.
Physical Exam:
admission:
VS: 98.3, 95, 118/56, 20 96% 2L
GENERAL: NAD, frail appearing, comfortable in bed
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, NGT
NECK: supple
LUNGS: HEART: RRR, no MRG, nl S1-S2
ABDOMEN: distended, hypoactive BS, not TTP
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: AO x1, confused
discharge
VS: 98. 96 130/57 22 94%2L
GENERAL: elderly female, sleeping in bed but arouseable
HEENT: EOMI, sclerae anicteric, MM dry
LUNGS: Tachypneic, CTA bilat anteriorly, no w/r/r
HEART: RRR, no MRG
ABDOMEN: normal bowel sounds, soft, non-tender but distended
EXTREMITIES: wwp
NEURO: A&Ox0, follows commands, CNs II-XII grossly intact,
moving all extremities
Pertinent Results:
admission:
___ 12:40PM BLOOD WBC-12.4* RBC-3.48* Hgb-9.8* Hct-32.3*
MCV-93 MCH-28.3 MCHC-30.4* RDW-14.5 Plt ___
___ 12:40PM BLOOD Glucose-101* UreaN-26* Creat-1.3* Na-140
K-4.4 Cl-110* HCO3-19* AnGap-15
___ 12:40PM BLOOD ALT-6 AST-19 AlkPhos-46 TotBili-0.1
___ 05:06AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
___ 12:40PM BLOOD Albumin-2.8*
___ 12:46PM BLOOD Lactate-1.8
Cdiff per ___ ___:
NEGATIVE (conversation with nurse on ___
CXR ___
In comparison with study of ___, there has been placement of a
nasogastric tube that extends to the body of the stomach. The
side hole is at about the esophagogastric junction, so that the
tube should be pushed forward at least several centimeters. The
central catheter extends to mid-to-lower portion of the SVC.
Otherwise, little overall change in the appearance of the heart
and lungs.
CT ABD ___
The visualized lung bases demonstrate interval increase in size
of small to moderate right pleural effusion and associated
compressive atelectasis of the right lower lobe. There is
interval development of a small left pleural effusion with
associated compressive atelectasis of the left lower lobe. The
subpleural left lower lobe lung mass is unchanged in size
measuring approximately 30 x 23 mm (2: 9). Nodular ground-glass
opacities are noted along the fissure in the right lung base (2:
1), which may represent additional pulmonary lesions not seen
on the most recent prior CT. An enlarged pericardial lymph node
is present and there is a conglomerate of lymphadenopathy along
the right diaphragmatic border.
There is a new fluid collection with a simple internal fluid
density of 14 Hounsfield U between the right hepatic dome and
the diaphragm (2: 10). Infection cannot be excluded. New
moderate ___ hepatic and ___ splenic ascites is present. 2
new ill-defined hypodensities in the right and left lobe of the
liver measuring 11 mm (2: 31) and 14 mm (2: 28), respectively,
are incompletely evaluated on this single phase examination but
concerning for new hepatic metastases. The common bile duct is
prominent proximally and tapers within the head of the pancreas.
The gallbladder is prominent but folded on itself without wall
thickening but surrounded by ascitic fluid. The pancreatic duct
is visualized throughout the pancreas but not pathologically
dilated. No enhancing or hypodense pancreatic mass is detected.
The spleen contains an 8 mm hypodensity superiorly, similar to
the prior study. The left adrenal gland is ___ thickened.
The right adrenal gland is within normal limits. Both kidneys
enhance symmetrically and excrete contrast normally without
hydronephrosis. Tiny cortical hypodensities are too small to
fully characterize but likely represent renal cysts. No
suspicious renal lesion is identified.
The stomach is relatively collapsed. Multiple dilated
fluid-filled loops of small bowel are noted with a prominent
transition point in the right lower quadrant at the level of an
enhancing cecal mass. The mass is again noted to contain air
within the extent of which has decreased since the prior study,
likely suggesting necrosis, without free intraperitoneal air.
The large bowel is relatively collapsed. The appendix is not
definitively visualized; however, the fluid filled tubular
structure likely reflecting the appendix seen on the most recent
prior CT is no longer identified in the right lower quadrant.
There is marked and severe progression of diffuse
intra-abdominal peritoneal carcinomatosis from the most recent
prior study.
There is dense calcified atherosclerotic disease throughout the
abdominal aorta extending into the iliac arteries without
aneurysmal dilatation.
The urinary bladder is decompressed by a Foley catheter in place
with air in the nondependent portion of the bladder, likely
related to catheter placement. The rectum and sigmoid colon are
relatively collapsed. Ascitic fluid extends into the pelvis.
The uterus is not seen.
OSSEOUS STRUCTURES: Multilevel degenerative changes are noted
throughout the spine. There is unchanged grade 1
anterolisthesis of L4 on L5 and L5 on S1. No bony lesions
concerning for malignancy are identified.
IMPRESSION:
1. Small bowel obstruction with multiple loops of dilated
fluid-filled small bowel and primary transition point in the
right lower quadrant that the level of the cecal mass.
2. Appendix is difficult to discern but no fluid-filled
structure is identified in the region of the appendix as seen on
the prior study of ___.
3. Marked severe progression of disease from ___
with new moderate ascites, peritoneal carcinomatosis,
diaphragmatic and pericardial lymphadenopathy, and new hepatic
hypodensities and pulmonary lesions concerning for widespread
metastatic disease.
KUB ___
Findings concerning for early or partial small bowel
obstruction.Please refer to subsequent CT for further details.
CXR ___
Ground-glass opacities in the mid to lower lungs bilaterally,
most likely representing pneumonia.
CXR ___
In comparison with study of ___, there has been placement of a
nasogastric tube that extends to the body of the stomach. The
side hole is at about the esophagogastric junction, so that the
tube should be pushed forward at least several centimeters. The
central catheter extends to mid-to-lower portion of the SVC.
Otherwise, little overall change in the appearance of the heart
and lungs.
discharge:
none
Brief Hospital Course:
___ year old woman with hx of L breast cancer s/p lumpectomy &
chemorad tx in ___, duodenal ulcer s/p repair in ___ with recently
diagnosed cecal mass and pulmonary nodule admitted with
intractable vomting, found to have small bowel obstruction at
the level of cecal mass and marked progression of disease from
last month with peritoneal carcinomatosis, hepatic lesions and
known pulmonary lesions concerning for widespread metastatic
disease.
.
# Metastatic cancer: Unclear primary, likely colorectal given
cecal mass. Team discussed ___, patient's legal
guardian and social worker a ___. Given rapid progression of
disease and poor prognosis, patient was made DNR/DNI and CMO.
Palliative care was consulted with a plan for hospice care.
Antibiotics, labs were discontinued as well. Vital signs were
continued for purposes of guiding dispo, and remained stable.
Patient will be discharged to ___ with hospice capabilities.
.
# SBO: Pt presented with several days without bowel movements,
not able to tolerate POs. Imaging showed obstruction at level of
cecal mass. CT abd/pelvis showed evidence of widespread
malignancy. Initially treated with NG tube for decompression
with bowel rest. However, once ___ care initiated, NG
tube was discontinued and diet was advanced to patient
preference. Palliative surgery was initially considered, but
patient with clinical improvement, leading to a decision not to
pursue this route a this time.
.
# Hypoxia: No longer trending vitals. Was hypoxic with concern
for ?HCAP. However, no clinical signs or symptoms, so
discontinued antibiotics. Oxygen was continued for comfort.
.
# Toxic/metabolic encephalopathy: Most likely delirium from SBO,
?infection with baseline dementia. On discharge, patient
improved as compared to reports from ___ as well as
in comparison to admission exam.
.
# UTI: Last admission pt presented with AMS and positive urine
analysis and culture from ___ showing VRE. Completed
a course of linezolid for her infection. U/A in ED dirty, likely
colonization. No longer on antibiotics.
.
PENDING LABS:
-NONE
.
TRANSITIONAL ISSUES
-Patient DNR/DNI as well as CMO during this admission after
finding diffusely metastatic disease with peritoneal
carcinomatosis, hepatic lesions, and pulmonary lesions
suggestive of aggressive disease.
-Please note several special circumstances for this patient's
CMO care:
--Patient should be allowed to take several small spoonfuls of
food for taste (e.g. pudding, apple sauce). However, please
avoid too much more oral intake given her bowel obstruction
--Patient on standing morphine oral concentrate because of
inability to reliably ask for pain medicine. Hold for
oversedation
--Patient receives 1L NS at 50 cc/hr daily in order to keep her
alert and interactive especially during the day. This can be
discontinued if she is no longer interactive. Please evaluate
patient daily for signs of volume overload before ordering (e.g.
respiratory distress, worsening peripheral edema, JVD)
--Patient is currently receiving 2L oxygen by nasal cannula for
comfort
--If patient does not have bowel movement for 3 days, consider
suppository regimen (e.g. dulcolax) for her
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Ranitidine 150 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Simvastatin 10 mg PO DAILY
12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
13. Risperidone 0.25 mg PO HS
14. Senna 2 TAB PO HS:PRN constipation
15. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
4. Lorazepam 0.5-2 mg PO Q2H:PRN anxiety/distress
RX *lorazepam 0.5 mg ___ pills by mouth Q2H:PRN Disp #*120
Tablet Refills:*0
5. Prochlorperazine 25 mg PR Q12H:PRN nausea, vomiting
6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
Pain or respiratory
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
Q1H:PRN Disp ___ Milliliter Refills:*0
7. OLANZapine (Disintegrating Tablet) 2.5-5.0 mg PO Q4H:PRN
delirium/restlessness, nausea
8. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
RX *lidocaine 5 % (700 mg/patch) apply 1 patch to back daily
Disp #*30 Unit Refills:*0
9. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q8H
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth
every eight (8) hours Disp ___ Milliliter Refills:*0
10. Oxygen
2L nasal cannula for patient comfort
11. Intravenous Normal Saline
Please order patient for 1L NS running at 50 cc/hr on a daily
basis given her very poor PO intake. Reassess daily for signs of
volume overload (e.g. respiratory distress, worsening peripheral
edema) before ordering.
12. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth Q8H:prn Disp #*90
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Diffusely metastatic cancer, unknown primary
Small bowel obstruction
Hypoxia
Toxic metabolic encephalopathy
Secondary diagnoses:
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___:
It was a pleasure to take care of you. You were admitted to the
___ with a small bowel obstruction. We performed imaging of
your abdomen, which showed evidence of widely metastatic disease
due to cancer, likely colorectal cancer. After extensive
discussion with ___, your legal guardian, we determined
that we would best respect your wishes by focusing on comfort.
You were being discharged home with medications focused on
comfort.
Please review your medication list closely.
Followup Instructions:
___
|
10518881-DS-10 | 10,518,881 | 27,572,571 | DS | 10 | 2191-05-01 00:00:00 | 2191-05-01 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture
Intubation
R craniotomy for wash out ___
History of Present Illness:
Mr. ___ is a ___ with history of HCV cirrhosis, c/b hepatic
encephalophaty, transferred from ___ for AMS and CT findings
concerning for a Potts Puffy tumor. History is obtained through
pt's fiancee, as pt is on mechanical ventilation.
About 10 days ago, pt complained of headache and was evaluated
at ___. He underwent CT and MRI of head, and was
discharged home with flonase for presumed sinusitis. There was
also a concern that his right eye swell with blue color by his
fiancee. In the past two days, pt was found lethargic and
confused, frequently moaning for pain during the day and at
night. He had green-yellow sputum dripping from nose. He
complained of headache, but there were no reports of fever,
chill, neck stiffness or pain.
Pt presented to ___ last night. VS initially were:
100.3, 98, 162/80, 98% on RA. His lab was notable for WBC of
19.3, normal H/H, and CHEM7. CT scan of head showed
pan-sinusitis "the worst I've ever seen" by radiologist there,
and CT evidence of frontal bone osteomyelitis, concernign for
Potts Puffy tumor. Pt was given vancomycin 1 g and ceftriaxone 2
g for meningitis dosing.
Pt was subsequently transferred to ___ for neurosurgery
evaluation. At ___, initial VS was: 101.6 93 143/84 16 98%.
The neurosurgery team felt that there is no need for immediate
surgical intervention, and recommended an MRI with contrast. Pt
became agitated when pursuing the imaging study. He was
subsequently intubated in the ED, and sedated with midazolam,
fentanyl and propofol.
Past Medical History:
HCV cirrhosis
history of elevated AFP
history of varices
Social History:
___
Family History:
the patient denies any known family history of liver disease or
liver cancer. His mom had heart issues, but he does not know
the details of this. His father had congestive heart failure.
He has one brother who was diagnosed with colon cancer at age
___. There is no other significant family history
Physical Exam:
ADMISSION EXAM
Vitals- T 101.5: BP:110/56 P: 74 R: 18 O2: 99% on PSV
General- intubated and sedated, RASS -2
HEENT- Pupil minimally reactive to light
Neck- supple
CV- bradycardic, no m/r/g
Lungs- bilateral breath sound, no wheeze, rales, rhonchi on
anterior auscultation
Abdomen- soft, nondistended, +BS
Ext- no pitting edema, 2+ ___
DISCHARGE EXAM
VSS, NAD, A+Ox3
HEENT: PERRLA
Neck- supple
CV: RRR, nls1/s2
Lungs: CTAB
Abd: S, NT, ND
Neuro: CN III-XII intact, strength ___ throughout, sensation and
proprioception intact, no pronator drift, neg ___, toes
downgoiong.
Pertinent Results:
ADMISSION LABS
___ 10:55PM BLOOD WBC-20.5*# RBC-4.79 Hgb-15.9 Hct-46.0
MCV-96 MCH-33.2* MCHC-34.6 RDW-14.7 Plt ___
___ 10:55PM BLOOD Neuts-86.4* Lymphs-7.2* Monos-6.2 Eos-0.1
Baso-0.2
___ 04:44AM BLOOD ___ PTT-30.7 ___
___ 10:55PM BLOOD Glucose-147* UreaN-20 Creat-0.9 Na-129*
K-9.7* Cl-94* HCO3-21* AnGap-24*
___ 10:55PM BLOOD ALT-31 AST-129* AlkPhos-74 TotBili-1.1
___ 10:55PM BLOOD Albumin-3.4* Calcium-9.1 Phos-3.3 Mg-1.7
___ 11:06PM BLOOD Lactate-2.2* K-4.3
___ 03:39AM BLOOD Type-ART Temp-37.0 Tidal V-500 PEEP-5
FiO2-100 pO2-433* pCO2-58* pH-7.28* calTCO2-28 Base XS-0
AADO2-222 REQ O2-45 Intubat-INTUBATED
___ 10:55PM BLOOD ASA-NEG* Ethanol-NEG* Acetmnp-NEG*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT LABS
DISCHARGE LABS
PERTINENT STUDIES
CXR ___
FINDINGS: An ET tube terminates approximately 5 cm from the
carina in correct positioning. The lungs are clear. Cardiac
apex is unremarkable. There is no pleural effusion, pneumonia
or pneumothorax.
___ MRI
IMPRESSION:
1. Pansinusitis.
2. Right frontal subdural empyema. Adjacent right frontal
leptomeningeal
enhancement could be reactive but meningitis cannot be excluded.
No cerebral edema to suggest cerebritis.
3. Cellulitis in the superior extraconal right orbit without
evidence for an abscess.
4. Osseous defect in the posterolateral wall of the right
frontal sinus,
resulting in communication of sinus with the right orbit and the
intracranial
compartment, better seen on the preceding CT. These findings
suggest
osteomyelitis.
___ Non Contrast Head CT
IMPRESSION:
1. Status post right craniotomy with new right subdural
hemorrhage and
postoperative pneumocephalus.
2. Continued extensive opacification of the sinuses.
___ Non contrast head CT
IMPRESSION:
1. Unchanged appearance of right subdural hematoma, with stable
very minimal shift of midline structures to the left.
2. Continued extensive opacification of the sinuses.
___ Non contrast head CT
IMPRESSION: Unchanged right subdural hematoma. No new areas of
hemorrhage or mass effect.
___ CXR
FINDINGS: Feeding tube terminates within the proximal stomach.
Cardiomediastinal contours are stable in appearance. Worsening
patchy
atelectasis is present in the medial right lung base with
otherwise no
relevant short interval changes since the recent radiograph.
Brief Hospital Course:
Mr. ___ is a ___ with history of HCV cirrhosis, c/b hepatic
encephalophaty, transferred from ___ for AMS and CT findings
concerning for a Potts Puffy tumor.
ACTIVE ISSUES
# Altered mental status: the CT findings is concerning for Potts
Puffy tumor and intracranial infection secondary to his
sinusitis. Hepatic encephalopathy is also possible. Will rule
out other systemic infectious causes are on the ddx.
- lumbar puncture
- c/w Vancomycin/CTX for meningitis coverage
- MRI head +/- contrast
- c/w lactulose 30 mg tid and rifaximin 550 bid
- followup blood cx and urine cx
- appreciate neurosurgery rec
- consult ENT
# Hypotension: This is likely in the setting of sedation and
mechanical ventilation.
- bolus 1000 cc NS
- hold lasix and spironolactone
- hold nadolol
# Mechanical ventilation: pt was intubated in the setting of
agitation while purusing imaging studies.
- will wean sedation and extubate after MRI
CHRONIC ISSUES
# Cirrhosis: no evidence of acute decompensation. No evidence of
ascites.
# Narcotic dependence:
- hold methadone during sedation
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: Subcutaneous heparin
# Access: PIVs
# Restraints: YES - while intubated to protect patient from
accidental removal of tubes/lines/drains and will be reassessed
at regular intervals per hospital policy
# Communication: Patient (H ___, ___
___ (c)
# Code: Full
# Disposition: ICU pending clinical improvement
NEUROSURGERY COURSE:
On ___ neurosurgery was consulted for evaluation for possible
surgery given the question of intracranial extension of
sinusitis on CT scan. MRI was obtained to further evaluate the
area in question. The MRI showed concern for subdural empyema in
the right frontal region and as such the patient was emergently
taken to the OR. The patient underwent a right frontal
craniotomy for washout of the collection with palcement of
subgaleal drain and was subsequently taken to the intensive care
unit. Post-operative head CT showed a right sided subdural
collection. Repeat CT scan showed stable right SDH.
Patient's WBC came down on antibiotics on ___ and he was
afebrile, taken off Vacomycin by ID. He went into Afib with RVR
and was placed on a amiodrone drip.
Exam improved markidly on ___ and patient was alert and
oriented x 3. On ___ he was started on PO feedings. On ___ the
patient continued to improve. He was oob to chair with physical
therapy.He remained on Ceftriaxone and Flagyl. On ___ he was
transferred to SDU. ID recommended MRV to rule out venous sinus
thrombosis. MRV was obtained that was negative for venous sinus
thrombosis. HIV was negative. Consent was obtained prior to
testing.
On ___, Mr. ___ remained stable. ENT is not recommending
surgery; continue with antibiotics. On ___, ID gave final
recommendations on antibiotics. He is to continue antibiotics
for 4 weeks. PICC was placed and he was screened for rehab. He
was placed on a regular diet with TFs. On ___, his pain regemin
was switched to ultram. On ___, nutrition was consulted for
calorie counts to help determine if dophoff could be
discontinued. His staples were removed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 20 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Methadone 60 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Nadolol 20 mg PO DAILY
6. Simethicone 40-80 mg PO BID
7. Spironolactone 100 mg PO DAILY
8. Vitamin D Dose is Unknown PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Methadone 60 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Spironolactone 100 mg PO DAILY
6. Nadolol 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pott's Puffy Tumor
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:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10518881-DS-11 | 10,518,881 | 27,235,023 | DS | 11 | 2191-05-11 00:00:00 | 2191-05-11 11:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old gentleman with PMHx significant for
Hepatitis C with hepatic encephalopathy who had presented to
___ with acute mental status change and found to have
significant sinusitis with subdural empyema which was evacuated
via right frontal craniotomy on ___. He did well
post-operatively and was discharged to rehab. He remained stable
and was doing well at rehab and then today he was talking with a
friend that was visiting him when he began to experience per
report slurred speech and bilateral upper extremity shaking
which
lasted less than 1 minute. There may have been right leg
involvement but it is unclear. He was transported to ___ for
assessment and given his recent surgery neurosurgery was
consulted. He currently denies headache, nausea, vomiting,
dizziness, changes in vision, hearing, or speech.
Past Medical History:
HCV cirrhosis
history of elevated AFP
history of varices
Social History:
___
Family History:
the patient denies any known family history of liver disease or
liver cancer. His mom had heart issues, but he does not know
the details of this. His father had congestive heart failure.
He has one brother who was diagnosed with colon cancer at age
___. There is no other significant family history
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch and proprioception bilaterally
Coordination: normal on finger-nose-finger
On Discharge:
A&O x3
PERRL
EOMs intact
Face symmetrical
tongue midline
Motor: ___
No pronator drift
Incision is c/d/i and healing appropriately
Pertinent Results:
MRI Brain ___:
Right subdural collection is stable in size and now is T1
hyperintense, which likely represents subacute blood products.
There is stable small enhancing loculated subdural collection in
the right
anteriorly when compared to the preoperative MRI, which likely
represents infection.
T2 hyperintensity in the right frontal lobe anteriorly adjacent
to the the
subdural collection which could be edema or cerebritis.
No acute infarct.
Evolving hematoma in the right temporal soft tissues.
CXR ___:
No acute cardiopulmonary process.
___: ECHO
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild mitral
regurgitation
___ Head CT:
Stable extra-axial collection adjacent to the right cerebral
hemisphere,
consistent with evolving subdural hemorrhage.
CHEST (SINGLE VIEW) ___
In comparison with study of ___, the patient has taken a much
better inspiration. There is a streak of atelectasis running
obliquely in the right mid zone. Otherwise, no pneumonia,
vascular congestion, or pleural effusion.
Brief Hospital Course:
Patient presented to the emergency department after a seizure at
rehab that self resolved in less than 1 minute. he was seen by
neuromedicine in the ED who felt he did not require admission
from their perspective. He then got a MRI brain during which he
had another self resolving seizure. He was admitted to ___ Floor
for observation and titration of anti-epileptic medication. On
___ he was seizure free and had no complaints. On ___ he had a
seizure involving his left upper arm with left facial twitching.
He was given ativan and also ntoed to have slurred speech. He
recieved a bolus of Keppra. His heart rate was found to be in
170's and he received lopressor 5mg x 2 and was transferred to
the ICU. He was placed on EEG and neurology was ___
sgiven his seizure activity. He markedly improved overnight and
on ___ was back to his baseline. He remained stable and on EEG
into ___ and was deemed fit for trasnfer to the floor.
On ___, patient remained stable on examination. Repeat labs
showed a decrease in NA but was hemolyzed and labs were resent.
Neurology recommended changed IV meds to PO and checking a free
and total dilantin trough due to frequent discharges seen on EEG
on ___. On ___, patient remained stable. He was discharged to
rehab in stable condition.
Medications on Admission:
colace, lasix, labetalol, lactulose, keppra, methadone, nadolol,
rifacimin, simethicone, spirinolactone, flagyl
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Heparin 5000 UNIT SC TID
3. LeVETiracetam 1500 mg PO BID
4. Methadone 60 mg PO DAILY
5. Lactulose 20 mL PO TID
6. Simethicone 40-80 mg PO QID:PRN indigestion
7. Rifaximin 550 mg PO BID
8. Phenytoin Sodium Extended 100 mg PO TID
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
10. Nadolol 20 mg PO DAILY
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
12. Furosemide 10 mg IV DAILY
13. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
14. CeftriaXONE 2 gm IV Q12H
15. Outpatient Lab Work
Weekly CBC w/ diff, Chem 7, and LFTs
16. Spironolactone 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
sinusitis
subdural empyema
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:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10518993-DS-21 | 10,518,993 | 20,831,773 | DS | 21 | 2187-11-02 00:00:00 | 2187-11-02 17:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
The patient is ___ year-old Male with a PMH significant for
frequent falls, ESRD (on HD), DM2, HTN, paroxysmal atrial
fibrillation (not on anticoagulation), PAD, and prior CVA who
presents with syncope.
.
He reports that he was lying on the couch and tried to stand up
in order to have dinner the evening prior to admission. His son
was helping him stand up. As he was standing, he felt weak and
lightheaded, and then passed out. He was unconscious for about
20-seconds. During that time, he had about 10 seconds of head
and eye shaking without full body shaking. He had a small amount
of urinary incontinence. He woke up after about 20-seconds and
was largely back to baseline, but still feeling somewhat weak.
He did not fall to the ground or strike his head since his son
was holding him. He has been on a 1.5 L fluid restriction given
his HD status, and has felt dizzy on several occasions recently.
He has had significant weight loss since starting dialysis. He
has otherwise been well without any recent complaints besides a
mild, minimally productive cough over the last few weeks.
.
Initial vitals in the ED were T 96.7, HR 58, BP 110/54, RR 16,
and SpO2 98% on 2L. Orthostatics were positive with vitals
lying: HR 60, BP 104/50, SpO2 95%; sitting: HR 65 HR, BP 89/45,
SpO2 95%, dizzy; and standing: HR 64, BP 70/43, SpO2 98%, dizzy.
Labs showed HCT 34.6% above recent baseline, WBC 8.5 with 13.5%
eosinophiila, chem panel consistent with ESRD, and glucose of
284. EKG showed sinus rhythm at ___, NA, no acute
ischemic changes, similar to prior. CXR showed low lung volumes
with bibasilar atelectasis. CT head showed no acute intracranial
process. He was given a 250 mL normal saline bolus in the ED,
with improvement in his BP and dizziness.
.
He was admitted to Medicine for evaluation of syncope. Vitals
prior to floor transfer were T 97 PO, HR 60, BP 109/49, RR 14,
and SpO2 96% on RA. On reaching the floor, he reported feeling
much better. He denied any current complaints.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. End-stage renal disease (on hemodialysis - regimen M, W, F) -
status-post tunneled HD line (___) R-IJ which was
self-discontinued the evening of ___ (initial placement
___
2. Type 2, diabetes ___ (on insulin)
3. Hypertension
4. Hypercholesterolemia (unable to tolerate statins)
5. Paroxysmal atrial fibrillation (no longer on Coumadin given
frequent falls)
6. Patent Foramen Ovale
7. Chronic deep venous thrombosus (diagnosed ___, appeared
chronic - IVC filter placed ___, no anticoagulation given
falls)
8. COPD (mild emphysema from chronic smoking)
9. Pleural plaques (likely asbestos exposure)
10. Latent tuberculosis (noted on PPD for dialysis) - started on
Isoniazid ___ - developed hallucinations and was switched to
Rifampin ___, completing ___
11. Right thalamic and left pontine stroke (___)
12. Peripheral vascular disease (multiple bypass surgeries); s/p
aortobifemoral bypass graft (___), Right femoral to AT bypass
with PTFE (___), Right femoral to AT bypass with in situ
saphenous vein and angioscopy (___)
13. Endovascular AAA repair ___ at ___
14. Right first toe amputation (___), for gangrene
15. Right second toe amputation (___)
16. Compression fractures (___)
17. Peripheral neuropathy
18. Colonic polyps
19. Anemia of chronic disease (related to CKD)
20. Rhabdomyolysis (___) - incited by falls, medication
related
21. Bilateral cataract surgeries and laser treatments
22. s/p open Appendectomy (___) - mucinous adenoma,
complicated by wound dehiscence
23. s/p umbilical hernia repair
25. Diverticulosis - noted on CT ___
26. Cholelithiasis - noted on CT ___
Social History:
___
Family History:
Multiple family members with diabetes ___.
Physical Exam:
PHYSICAL EXAM:
.
VITALS: 97.___.0 160/72 54 18 98%RA
I/Os: 1240 / - | 250 + HD
ORTHOSTATICS (___): 122/57 (51) / 122/65 (52) / 76/48 (51)
ORTHOSTATICS (___): 171/131 (54) / 136/74 (60) / 99/64 (72)
GENERAL: Elderly male in NAD. Oriented x 3. Pleasant and
appropriate.
HEENT: NCAT. Sclera anicteric. Left pupil slightly larger than
right, but both reactive. EOMI. Dry mucous membranes. OP benign.
NECK: Supple. JVP not elevated. No cervical lymphadenopathy.
___: Distant heart sounds. RRR with normal S1, S2. No murmur,
rub or gallop.
CHEST: Respiration unlabored. Scattered fine crackles
throughout. Decreased breath sounds at bases. No wheezes or
rhonchi. Tunneled dialysis catheter on right chest without
tenderness or bleeding.
ABDOMEN: Normal bowel sounds. Soft, obese, NT. No organomegaly
or masses.
EXTR: WWP. Digital cap refill < 2 sec. No cyanosis, clubbing or
edema. Distal pulses intact radial 2+, DP palp, ___ palp.
Amputation of right first and second toes.
NEURO: CN II-XII grossly intact. Hearing slightly impaired
grossly. Strength ___ in all extremities. Normal gait. Normal
speech. AAO x 3 this AM.
Pertinent Results:
___ 06:05AM BLOOD WBC-7.9 RBC-3.27* Hgb-10.5* Hct-30.2*
MCV-92 MCH-32.2* MCHC-34.8 RDW-14.1 Plt ___
.
___ 08:20PM BLOOD Neuts-53.9 ___ Monos-4.7
Eos-13.5* Baso-0.5
.
___ 08:20PM BLOOD ___ PTT-21.7* ___
.
___ 06:05AM BLOOD Glucose-181* UreaN-46* Creat-5.7* Na-132*
K-4.3 Cl-95* HCO3-28 AnGap-13
.
___ 07:50AM BLOOD CK(CPK)-38*
.
___ 07:50AM BLOOD CK-MB-2 cTropnT-0.03*
.
___ 08:20PM BLOOD CK-MB-2 cTropnT-0.03*
.
___ 06:05AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.2
.
___ 07:30AM BLOOD Cortsol-35.9*
___ 07:00AM BLOOD Cortsol-31.5*
___ 06:05AM BLOOD Cortsol-15.0
.
MICROBIOLOGY DATA: None
.
IMAGING:
___ CHEST (PA & LAT) - Similar to multiple prior exams,
lung volumes are profoundly diminished. Hazy opacity at both
lung bases is likely atelectasis. A large bore dual-lumen
dialysis catheter is again noted in a stable course and position
from a right subclavian approach. Mild aortic tortuosity is
again noted. The cardiac silhouette size is stable. No definite
effusion or pneumothorax is noted. Degenerative changes are
noted throughout the thoracic
spine. Degenerative changes are again present in bilateral
shoulder joints as well. Right humeral head is suggestive of
chronic rotator cuff injury.
.
___ CT HEAD W/O CONTRAST - No acute intracranial process.
Stable prior lacunar infarcts and small vessel ischemic changes.
Brief Hospital Course:
___ with a PMH significant for frequent falls, ESRD (on HD),
DM2, HTN, paroxysmal atrial fibrillation (not on
anticoagulation), PAD, and prior CVA who presents with syncope
.
PLAN:
# SYNCOPE - The patient presented with historical evidence of
pre-syncopal lightheadedness and dizziness and documented
orthostatic vitals with resulting symptoms noted in the ED. His
exam demonstrated some volume depletion - recently started
hemodialysis several months ago with 1.5L fluid restriction
initiated at that time. He received 250 mL NS bolus x 1 in the
ED with improvement in BP and symptoms. Possible etiologies
included: postural hypotension or orthostatics vs. cardiac
(ACS/MI vs. arrhythmia - prolonged PR interval that is stable,
known A.fib vs. valvular disease) vs. neurogenic (seizure - some
stable urinary continence vs. CVA/stroke - strong history, but
no focal deficits, CT head negative) vs. hypoglycemia (elevated
glucose on admission) vs. polypharmacy or AV-nodal agents (on
beta-blocker) vs. autonomic dysregulation leading to postural
hypotension. In the ED, his EKG showed a sinus rhythm @ ___, NA, no acute ischemic changes, similar as compared
to prior. He had a stress 2D-Echo (___) showing
non-diagnostic ST changes with normal blood pressure and heart
rate responses to stress; normal regional and global LV systolic
function. No aortic stenosis, aortic regurgitation or
significant mitral regurgitation was noted on that study. A
previous MRA head & neck (___) showed no flow-limiting
stenosis in either the cranial or cervical arterial vessels. His
orthostatic hypotension was thus attributed to neuropathy or
dysautonomia. We did check an AM cortisol with cosyntropin
stimulation test ___ which was normal and reassuring. We thus
tapered his blood pressure medication regimen, we discontinued
his Amlodipine and Ethacrynic acid. We continued his
hemodialysis with careful fluid balances, aiming for even -
likely a strong contributor to his postural hypotension. We
encouraged PO hydration and judicious PRN fluid challenge for
tenuous blood pressures and discontinued his fluid restriction.
His daily orthostatics improved and his symptoms resolved. His
Tropinin was negative for two sets and his CK-MB was flat. He
was monitored via telemetry and was stable prior to discharge.
He worked with physical therapy and was noted to have no
lightheadedness or dizziness, but only minimal weakness.
.
# END-STAGE RENAL DISEASE, REQUIRING HEMODIALYSIS - He started
dialysis a few months ago and is on a M, W, F schedule -
attributed to diabetic nephropathy. He currently uses a tunneled
right IJ HD line. There are plans for fistula formation.
Notably, he removed the HD line himself overnight shortly after
its initial placement, but has not had further issues since
replacement. He has had uneventful dialysis sessions with last
session ___ prior to admission. We continued his outpatient
regimen here and continued Nephrocaps and Sevelamer dosing. We
avoided nephrotoxins and renally dosed all medications.
.
# PAROXYSMAL ATRIAL FIBRILLATION - He has a history of PAF and
was previously on Warfarin, but it was stopped due to his
frequent falls. He is currently on only Aspirin 81 mg PO daily
despite his CHADS-2 score of 4. He presented in sinus rhythm
with adequate rate control. We continued his Metoprolol
succinate 150 mg PO daily given his rate control needs. His
rhythm remained controlled. We continued only the Aspirin for
A.fib without anticoagulation. We monitored him via telemetry
and optimized his electrolytes.
.
# HYPERTENSION - Presented with orthostatic hypotension on
arrival to the ED, but has had SBPs in the 140s on several
recent ___ clinic visits. He had SBP in the 130s on arrival to
the floor. We ended up discontinuing his Amlodipine 10 mg PO
daily and continued his Metoprolol succinate 150 mg PO daily for
rate control (as noted above). We discontinued his Ethacrynic
acid 25 mg PO BID given the orthostatic hypotension issues. We
also maintained his clonidine patch (0.2 mg) TP weekly on
___.
.
# DIABETES ___, TYPE 2 - His last HgbA1c was 5.3% on
___, but this was prior to starting HD. Initial labs here
showed a glucose 284 - with evidence of ESRD from presumed
diabetic nephropathy. We maintained him on a sliding scale with
Q6 hour glucose monitoring without issues. He will return to an
insulin sliding scale on discharge.
.
# LATENT TUBERCULOSIS INFECTION - He was found to have a
positive PPD on testing for outpatient dialysis previously. He
was initially started on Isoniazid, but could not tolerate it
due to hallucinations. He was recently switched to Rifampin
(started ___, completing ___. Pyridoxine appears to
have been started when on Isoniazid, but he has continued taking
this. We discontinued Pyridoxine. We changed his Rifampin dosing
from 150 mg 3-times weekly to Rifampin 300 mg PO daily per
Pharmacy recommendations.
.
# PRIOR CVA/STROKE, DEMENTIA - The patient reportedly has mild
dementia and minimal focal neurologic deficits from his prior
CVA, but remained alert and oriented x 3 on admission with
minimal sundowning in the evenings. He was fully conversant, and
appropriate on arrival. He does have a history of frequent
falls. He is at high stroke risk given his PFO (chronic VTE with
IVC filter), A.fib off of Warfarin, and peripheral vascular
disease. No new focal deficits were concerning for
neurogenic-induced syncope and this was attributed to
orthostatic hypotension. We continued his Aspirin 81 mg PO daily
and performed serial neurologic exams.
.
# ANEMIA OF CHRONIC DISEASE - He has chronic anemia related to
his renal disease with some history of bleeding in the past
while anticoagulated. His HCT was near baseline at 34.6% (MCV
94, normocytic) on arrival. Iron studies from ___ showed a
ferritin of 539 with normal TIBC, TRF. He is no longer on
anticoagulation, except Aspirin 81 mg PO daily. His hematocrit
remained stable this admission.
.
# CHRONIC PAIN, DEPRESSION - He has a history of compression
fractures (___) and peripheral neuropathy that appear stable.
We continued his outpatient regimen of Acetaminophen ___ mg
PO Q6H PRN pain, Citalopram 10 mg PO daily, Nortriptyline 50 mg
PO QHS. We changed his Gabapentin dosing to non-dialysis days to
avoid toxicity.
.
TRANSITION OF CARE ISSUES:
1. The patient was worked-up for syncope and postural
hypotension due to orthostatics and neuropathic dysautonomia was
established as the likely diagnosis. We decreased his Amlodipine
and Ethacrynic acid with some effect. We also lifted his fluid
restriction and stopped removing fluid at dialysis. This will
need to be monitored closely, but likely the issue will persist.
Encourage PO hydration.
2. Continue to check orthostatics.
3. Continue Rifampin at new dosing of 300 mg PO daily until
___ to complete latent tuberculosis treatment.
4. No pending laboratory studies, radiologic studies or
microbiologic data at the time of discharge.
5. Home safety evaluations.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Rifampin 150 mg PO 3-times a week (___)
2. Aspirin 81 mg PO daily
3. Amlodipine 10 mg PO daily
4. Metoprolol succinate 150 mg PO daily
5. Ethacrynic acid 25 mg PO BID
6. Clonidine Patch (0.2 mg/24 hr) TP weekly (every ___
7. Humalog sliding scale QACHS
8. Nephrocaps 1 cap PO daily
9. Sevelamer carbonate 1600 mg PO TID with meals
10. Docusate sodium 100 mg PO BID
11. Senna 8.6 mg PO BID PRN constipation
12. Citalopram 10 mg PO daily
13. Nortriptyline 50 mg PO QHS
14. Gabapentin 200 mg PO BID
15. Percocet ___ mg ___ tabs PO Q6H PRN pain
16. Omega-3 / Fish oil (360 mg-1,200 mg) 1 cap PO BID
17. Pyridoxine 50 mg PO daily
Discharge Medications:
1. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
Disp:*30 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
4. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every ___.
5. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous see insulin sliding scale: see insulin
sliding scale for Humalog administration QACHS.
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO 4X/WEEK
(___): on non-dialysis days.
Disp:*120 Capsule(s)* Refills:*0*
13. omega-3 fatty acids-fish oil 360-1,200 mg Capsule Sig: One
(1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Neuropathic dysautonomia
2. Orthostatic hypotension (postural hypotension)
3. Syncope
.
Secondary Diagnoses:
1. End-stage renal disease on hemodialysis
2. Paroxysmal atrial fibrillation
3. Diabetes ___, type 2
4. Latent tuberculosis infection
5. Anemia of chronic 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:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your orthostatic hypotension with syncope. You were treated with
IV fluids, maintained on hemodialysis and we decreased and
removed some of your antihypertensive medications to increase
your blood pressure. We also checked your cortisol level which
was normal. You were feeling improved prior to discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
.
We INCREASED: your Rifampin from 150 mg by mouth three times
weekly to 300 mg by mouth daily
We CHANGED: Gabapentin from 200 mg by mouth twice daily to 300
mg by mouth four times a week (on non-dialysis days)
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Amlodipine
DISCONTINUE: Ethacrynic acid
DISCONTINUE: Pyridoxine
DISCONTINUE: Percocet
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
___
|
10518993-DS-23 | 10,518,993 | 26,503,051 | DS | 23 | 2187-12-09 00:00:00 | 2187-12-11 19:27:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Pulled HD line
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with end-stage renal disease on hemodialysis MWF
presented from home after he was found with his dialysis
catheter out. He'd apparently accidentally pulled it out
overnight though does not remember the incident. No bleeding
noted, denies any pain, fevers, chills, confusion. Left upper
arm arteriovenous graft placed on ___, not currently being
used. Currently complaining of dizziness with standing, which
started this morning and has persisted. Noted to have a HR in
the ___.
.
In ED VS were 97 45 177/60 18 100%. Labs were remarkable for Cr
of 4.4, WBC 8.3 with eos of 13.6%. Hct 33.8 (at baseline). ECG
showed SB at 49, QTc 473, TWF aVL, NO stemi, na/ni, cw prior.
CXR showed no evidence of PNA. Chest US showed no evidence of
pneumothorax, per ED. Transplant surgery came to see him in the
ED and will formally evaluate fistula to assess if it can be
used for dialysis. Vitals on transfer were 97.5, 63, 15, 163/66,
99%RA.
.
On arrival to the floor, vitals were 97.1, 186/76, 50, 20,
97%RA. Patient feels well and is without any complaints.
.
Review of systems:
(+) Per HPI. Only urinating a small amount daily.
(-) Denies fever, chills, night sweats. Denies headache, URI
sypmtoms. Denies 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. No dysuria.
Past Medical History:
1.End-stage renal disease (on hemodialysis - regimen M, W, F) -
not currently with catheter access and fistula placed on ___
(no currently being used)
2. Type 2, diabetes ___ (on insulin)
3. Hypertension
4. Hypercholesterolemia (unable to tolerate statins)
5. Paroxysmal atrial fibrillation (no longer on Coumadin given
frequent falls)
6. Patent Foramen Ovale
7. Chronic deep venous thrombosus (diagnosed ___, appeared
chronic - IVC filter placed ___, no anticoagulation given
falls)
8. COPD (mild emphysema from chronic smoking)
10. Latent tuberculosis (noted on PPD for dialysis) - started on
Isoniazid ___ - developed hallucinations and was switched to
Rifampin ___, completing ___
11. Right thalamic and left pontine stroke (___)
12. Peripheral vascular disease (multiple bypass surgeries); s/p
aortobifemoral bypass graft (___), Right femoral to AT bypass
with PTFE (___), Right femoral to AT bypass with in situ
saphenous vein and angioscopy (___)
13. Endovascular AAA repair ___ at ___
Social History:
___
Family History:
Multiple family members with diabetes ___.
Physical Exam:
Admission Exam:
VS: 97.1, 186/76, 50, 20, 97%RA
GA: AOx3, elderly obese man in NAD
HEENT: PERRLA minimally, with cataracts present. MMM. poor
dentition, no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg ___ sign.
Extremities: wwp, no edema. DPs, PTs palpable. ___ finger of
left hand with distal phalanx missing, ___ and ___ toes with
distal phalanx missing. ___ right toes with necrotic area.
Skin: dried blood at his HD insertion site
Neuro/Psych: A&Ox3. CNs II-XII grossly intact. ___ strength in
U/L extremities. sensation intact to LT, decreased in lower
extremities
Discharge Exam:
VS: 97.9, 168/64 (136-168/60-70), 60 (60-70), 20, 98%RA
GA: AOx3, elderly obese man in NAD
HEENT: PERRLA minimally. MMM. poor dentition, no LAD. no JVD.
neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: obese, soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs palpable. graft in left
forearm. ___ finger of left hand with distal phalanx missing,
___ and ___ toes with distal phalanx missing. ___ right toes
with necrotic area.
Skin: some dried blood on chin. dried blood at his HD insertion
site in right chest
Neuro/Psych: A&Ox3. CNs II-XII grossly intact. ___ strength in
U/L extremities. sensation intact to LT, decreased in lower
extremities
Pertinent Results:
Admission Labs:
___ 09:30AM BLOOD WBC-8.3 RBC-3.56* Hgb-11.1* Hct-33.8*
MCV-95 MCH-31.2 MCHC-32.8 RDW-14.2 Plt ___
___ 09:30AM BLOOD Neuts-51.4 ___ Monos-7.4
Eos-13.6* Baso-0.8
___ 09:30AM BLOOD ___ PTT-28.3 ___
___ 09:30AM BLOOD Glucose-143* UreaN-28* Creat-4.4*# Na-134
K-4.7 Cl-95* HCO3-28 AnGap-16
___ 09:30AM BLOOD CK-MB-2
___ 09:30AM BLOOD cTropnT-0.02*
___ 07:15AM BLOOD cTropnT-0.03*
___ 09:41AM BLOOD K-4.5
Discharge Labs:
___ 07:15AM BLOOD WBC-7.0 RBC-3.19* Hgb-10.1* Hct-29.7*
MCV-93 MCH-31.6 MCHC-33.9 RDW-14.4 Plt ___
___ 07:15AM BLOOD ___ PTT-25.6 ___
___ 07:15AM BLOOD Glucose-132* UreaN-40* Creat-5.3* Na-134
K-5.3* Cl-96 HCO3-29 AnGap-14
___ 07:15AM BLOOD Calcium-8.8 Phos-4.2# Mg-2.0
___ 07:15AM BLOOD %HbA1c-7.2** eAG-160**
Imaging:
___ ECG: Afib with slow ventricular response, rate 49,
nonspecific twave changes, prolonged QTc 473, No stemi, na/ni,
cw prior
___ CXR: No evidence of pneumonia.
Brief Hospital Course:
___ gentleman with end-stage renal disease on
hemodialysis ___ admitted for lack of HD access (HD catheter
came out overnight).
.
Active Issue:
# ESRD and access: Patient gets HD on ___ with HD catheter.
Patient was last dialyzed on ___, the day prior to
admission. Had left arm graft placed on ___, which has not
yet been used as it typically requires 6 weeks to mature.
Transplant surgery, who placed the graft, saw patient in the ED
and felt it was ready for dialysis use. Renal was aditionally
consulted and agreed that the graft could be accessed. Patient
received dialysis via his graft on Fridamy morning, without
complication. He was continued on nephrocaps, renvela, edecrin
and discharged home shortly after his dialysis session.
.
Chronic Issues:
# Type 2, diabetes ___ (on insulin): Patient was
maintained on 25units glargine and covered with HISS.
.
# Hypertension: BP was 136-168/60-70, however no additional
anti-hypertensives were given as patient was scheduled to
receive dialysis later in the day. Patient was normotensive
prior to discharge. Clonidine 0.2 mg/24 hr Weekly (change on
___ was continued. Metoprolol was held given initial
bradycardia, but restarted on discharge.
.
# Paroxysmal atrial fibrillation: no longer on Coumadin given
frequent falls. Initially held metoprolol, but restarted on
discharge.
.
# Latent tuberculosis - started on Isoniazid ___, but
developed hallucinations and was switched to Rifampin ___,
completing ___. Continued on rifampin 150mg ___,
___.
.
# PAD: Patient with some necrotic area of his ___ right toe. ASA
was continued and vascular surgery was consulted and recommended
outpatient NIAS (noninvasive arterial study) and follow-up,
which was scheduled.
.
# Chronic pain: continued home regimen of gabapentin, percocet,
nortriptyline.
.
Transitional Issues:
Patient has Vascular follow up and will continue to get dialysis
at his outpatient dialysis center.
Medications on Admission:
- Renvela 800 mg Tab Oral 2 Tablet(s) Three times daily
- ___ Caps 1 mg Cap Oral 1 Capsule(s) Once Daily
- *ez lax stool softener 1 Twice Daily
- Vitamin B-6 50 mg Tab Oral 1 Tablet(s) Once Daily
- gabapentin 100 mg Tab Oral 3 Tablet(s) Once Daily on ___,
___, and ___
- metoprolol tartrate 100 mg Tab Oral 1.5 Tablet(s) Once Daily
(not since ___ per pharmacy)
- Fish Oil 1,000 mg Cap Oral 1 Capsule(s) Twice Daily
- aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily
- citalopram 20 mg Tab Oral 1 Tablet(s) Once Daily (not since
___ per pharmacy)
- rifampin 150 mg Cap Oral 1 Capsule(s) Once Daily ___,
___ per pharmacy)
- nortriptyline 50 mg Cap Oral 1 Capsule(s) Once Daily
- Percocet 5 mg-325 mg Tab Oral 1 Tablet(s), as needed ___
q6, per pharmacy)
- clonidine 0.2 mg/24 hr Weekly Transderm Patch Transdermal 1
Patch Weekly(s) Changed every ___
- Humalog 100 unit/mL SubQ Cartridge Subcutaneous 1 Cartridge(s)
per sliding scale
- Humulin N 100 unit/mL Susp, Sub-Q Inj Subcutaneous 1
Suspension(s) per sliding
- edecrin 25mg BID
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Ex-Lax (sennosides) 15 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO 4X/WEEK
(___).
6. metoprolol tartrate 100 mg Tablet Sig: 1.5 Tablets PO once a
day.
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. rifampin 150 mg Capsule Sig: One (1) Capsule PO QTUTHSA
(___).
11. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
12. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q6H (every 6 hours) as needed for pain.
13. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSUN (every ___.
14. ethacrynic acid 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: 4 times daily (meals and bedtime)
as per home sliding scale.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: pulled hemodialysis catheter
Secondary Diagnosis: end stage renal disease on hemodialysis
___.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted because your hemodialysis
catheter came out. The vascular surgery team felt your newly
placed graft could be used so you had a successful dialysis
session with the graft. You are safe for discharge home and can
begin using your graft for all future dialysis session. You have
been scheduled for an outpatient appointment with the Vascular
Specialists because we noted some unhealthy tissue on your right
toe and left finger.
No changes have been made to your medications. Continue all
medications as prescribed.
Followup Instructions:
___
|
10518993-DS-25 | 10,518,993 | 29,871,969 | DS | 25 | 2188-11-12 00:00:00 | 2188-11-12 23:10:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old gentleman with history of dementia, ESRD, DM2, HTN,
paroxysmal AF, and COPD presenting with altered mental status at
hemodialysis. At this nursing home (___) this morning, he
was given Haldol and Percocet, per normal dosing. He tends to be
aggressive and assault nursing when in pain. He will typically
receive these meds prior to dialysis. He refused vitals and was
"fighting off the nurses" this AM, per usual. Upon arrival to
HD, he was reportedly more altered than usual and minimally
responsive at dialysis. He does not usually have this reaction
to these meds, and is often redirectable. He is able to vocalize
pain at baseline, but did not report any new symptoms recently,
such as dysuria. He needs to be accompanied to HD given his
combativeness. He was given 1 mg of Narcan at HD, which
reportedly resolved him to his baseline confusional and agitated
state, only receiving 45 minutes of a prescribed ___ hour course
of HD (___ Dialysis), without any ultrafiltration.
He is not able to give any significant history at this time, but
is arousable. At baseline, he is reportedly able to follow
simple commands. All history provided is from a nurse at the
nursing home.
In the ED, initial VS were: 66 145/46 17 92%. Urinalysis was
grossly positive for bacteriuria and pyuria, so he was covered
with IV ciprofloxacin. He was given 2 dose of Haldol for
agitation and has not required additional Narcan. Per nursing,
he did not follow commands, somnolent/combative at times. He
pulled out his IV and Foley. He is being admitted for altered
mental status secondary to presumed opiate overdose and UTI.
On arrival to the floor, he is in 2-point restraints and
arousable to voice, but unable to sensically answer questions.
REVIEW OF SYSTEMS: unable to perform due to mental status.
Past Medical History:
1.End-stage renal disease (on hemodialysis - regimen M, W, F) -
not currently with catheter access and fistula placed on ___
(no currently being used)
2. Type 2, diabetes ___ (on insulin)
3. Hypertension
4. Hypercholesterolemia (unable to tolerate statins)
5. Paroxysmal atrial fibrillation (no longer on warfarin given
frequent falls)
6. Patent Foramen Ovale
7. Chronic deep venous thrombosus (diagnosed ___, appeared
chronic - IVC filter placed ___, no anticoagulation given
falls)
8. COPD (mild emphysema from chronic smoking)
10. Latent tuberculosis (noted on PPD for dialysis) - started on
Isoniazid ___ - developed hallucinations and was switched to
Rifampin ___, completing ___
11. Right thalamic and left pontine stroke (___)
12. Peripheral vascular disease (multiple bypass surgeries); s/p
aortobifemoral bypass graft (___), Right femoral to AT bypass
with PTFE (___), Right femoral to AT bypass with in situ
saphenous vein and angioscopy (___)
13. Endovascular AAA repair ___ at ___
Social History:
___
Family History:
Multiple family members with diabetes ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.9F, BP 137/50, HR 64, RR 20, O2-sat 98% RA
GENERAL - elderly man in mild distress and asking to be
unrestrained, unable to answer questions, but arousable
HEENT - NC/AT, pupils mild reactive but pinpoint, EOMI, sclerae
anicteric, MMM; whitish growth along tongue and ?oropharynx
NECK - supple, no JVD, no LAD
LUNGS - CTA bilat to anterior and lateral lung fields, no
r/rh/wh, good air movement, resp unlabored, no accessory muscle
use
HEART - RRR, soft II/VI systolic murmur (?transmitted AV
fistula) heard best over LUSB, 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), left upper arm AV fistula with good thrill
GU - foley in place, with drain holding frankly purulent output,
turning into small amount of hematuria
SKIN - no rashes or lesions
NEURO - arousable, AAOx0, rest of neuro exam unable to be
completed secondary to mental status, but is moving all
extremities with CN II-XIIs grossly intact.
.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS
___ 04:20PM BLOOD WBC-13.4*# RBC-2.99* Hgb-9.8* Hct-29.5*
MCV-99* MCH-32.8* MCHC-33.3 RDW-13.9 Plt ___
___ 04:20PM BLOOD Neuts-73.6* ___ Monos-4.2 Eos-3.7
Baso-0.4
___ 04:20PM BLOOD ___ PTT-29.2 ___
___ 04:20PM BLOOD Glucose-161* UreaN-35* Creat-6.2* Na-145
K-4.1 Cl-99 HCO3-33* AnGap-17
___ 06:00AM BLOOD ALT-14 AST-25 LD(LDH)-169 AlkPhos-70
TotBili-0.2
___ 04:20PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
___ 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:42PM BLOOD Lactate-1.9
___ 09:00AM BLOOD Type-MIX Temp-36.8 FiO2-21 pO2-112*
pCO2-42 pH-7.52* calTCO2-35* Base XS-10 Intubat-NOT INTUBA
.
OTHER PERTINENT LABS
___ 06:00AM BLOOD Albumin-3.1*
___ 06:00AM BLOOD VitB12-1101*
___ 06:00AM BLOOD TSH-2.9
___ 06:00AM BLOOD Vanco-8.8*
___ 12:14PM BLOOD Vanco-4.2*
.
DISCHARGE LABS
??????
.
URINE STUDIES
___ 05:00PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 05:00PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 05:00PM URINE RBC-7* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0 TransE-<1
___ 05:00PM URINE WBC Clm-MOD
.
MICROBIOLOGY
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ RAPID PLASMA REAGIN TEST-FINAL, NEGATIVE
___ URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
.
___ Blood Culture, Routine-FINAL, NEGATIVE
___ Blood Culture, Routine-FINAL, NEGATIVE.
.
EKG ___
Sinus rhythm. Normal tracing. No major change from previous
tracing.
___
___
.
CHEST ___
IMPRESSION:
Low lung volumes. Patchy bibasilar airspace opacities could
reflect
atelectasis but infection is not excluded. Ill-defined nodular
opacity in the right upper lung field may also represent a site
of infection but is
nonspecific.
.
CT HEAD WITHOUT CONTRAST ___
1. No acute intracranial abnormality.
2. Disproportionate prominence of ventricles in comparison to
sulci, for which normal pressure hydrocephalus can not be
excluded.
Brief Hospital Course:
>> BRIEF HOSPITAL COURSE
___ year old gentleman with history of dementia, ESRD on HD, DM,
HTN, paroxysmal AF, presenting with altered mental status and
found to have significant bacteriuria and pyuria. AMS seems to
be improving though seems to have been on top of pre-existing
baseline dementia.
.
# Altered mental status: Possibly secondary to infections (HCAP,
UTI) vs medications (narcotics, haldol). Per nursing home he is
combative at baseline. Some concern for NPH, however Neuro does
not think large volume tap appropriate at this time. His
haloperidol was discontinued, and he was treated for UTI and
HCAP. However his mental status has not improved despite maximal
treatment.
.
# UTI: He was found to have a positive UA on admission, cultures
showed enterococcus sensitive to vanc. He was treated with
vancomycin per hemodialysis protocol.
.
# HA-PNEUMONIA: He presented with leukocytosis, productive
cough, concerning CXR and is on chronic dialysis. attempts to
obtain sputum not successful. Total duration is 8 days (started
___, last day ___. He was treated with vancomycin 1g per HD
protocol and cefepime 1gm q24hr. At the time of discharge he did
not have dyspnea or cough.
.
# ESRD on HD: He has received hemodialysis ___, and ___
while in the hospital. Goals of care discussion with family was
held on ___, and a decision was made to discontinue
hemodialysis. His sevelamer and nephrocaps were discontinued at
discharge.
.
# Diabetes ___: He received Lantus + ISS while in house,
which were discontinued at the time of discharge for comfort
care measures.
.
# Hypertension/hyperlipidemia: Stable. He was treated with his
home amlodipine, clonidine, and metoprolol. These were
discontinued at the time of discharge for comfort care.
.
# Paroxysmal atrial fibrillation: Bradycardic. He did not
receive anticoagulation in the setting of frequent falls.
.
>> TRANSITIONAL ISSUES
- Emergency contact: son, ___ ___ (cell phone #
in webomr not in use)
- He was prescribed oral liquid dilaudid as needed for pain or
shortness of breath.
- Most of his medications were discontinued at the time of
discharge for a focus on comfort care. Please see discharge
medications for full list.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. sevelamer CARBONATE 800 mg PO TID W/MEALS
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES 6X/DAY
5. Nephrocaps 1 CAP PO DAILY
6. Aspirin 81 mg PO DAILY
7. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD WEEKLY
8. Gabapentin 200 mg PO DAILY
9. Polyethylene Glycol 17 g PO TUES, THURS, ___
10. Docusate Sodium 100 mg PO DAILY
11. Glargine 6 Units Bedtime
12. Divalproex (DELayed Release) 250 mg PO BID
13. Amlodipine 10 mg PO DAILY
14. Metoprolol Succinate XL 150 mg PO DAILY
15. Heparin 5000 UNIT SC TID
16. Haloperidol 1 mg PO BID
17. Acetaminophen 650 mg PO Q4H:PRN pain
Discharge Medications:
1. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
RX *erythromycin 5 mg/gram (0.5 %) small amount both eyes twice
a day Disp #*1 Each Refills:*2
2. Gabapentin 200 mg PO Q48H
RX *gabapentin 250 mg/5 mL (5 mL) 1 Solution(s) by mouth every
48 hours Disp #*5 Each Refills:*2
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain, dyspnea
RX *hydromorphone 1 mg/mL ___ Liquid(s) by mouth every 3 hours
Disp #*15 Each Refills:*2
4. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO BID:PRN
agitation
RX *olanzapine 5 mg 0.5 - 1 tablet(s) by mouth twice a day Disp
#*15 Tablet Refills:*2
5. Docusate Sodium 100 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*16
Tablet Refills:*1
7. Divalproex (DELayed Release) 250 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Dementia
- Pneumonia
- Urinary tract infection
Secondary
- End stage kidney disease
- Hypertension
- Diabetes ___
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted to the ___ for altered mental status, and were found
to have pneumonia and urinary tract infection. You were treated
with IV antibiotics, and your fever and high white blood count
improved. You received dialysis for your end stage kidney
disease. After a discussion with your family, a decision was
collectively made to stop hemodialysis. We then focused on care
that made you more comfortable. At the time of discharge, you
did not have significant discomfort, and you were going home
with hospice services.
Please start the following medications:
1. Dilaudid ___ mg oral liquid every 3 hours as needed for pain
or shortness of breath
2. Olanzipine (Disintegrating Tablet) 2.5-5 mg twice a day as
needed for agitation
3. Tramadol 50 mg oral every 6 hours as needed for pain
Please change the following medications:
1. Erythromycin 0.5% Apply small amount to both eyes twice a day
2. Gabapentin 200 mg by mouth every 48 hours
Please stop the following medications:
1. Amlodipine 10 mg
2. Aspirin 81 mg
3. Clonidine Patch 0.2 mg/24
4. Haloperidol 1 mg
5. Heparin 5000 UNIT
6. Glargine 6 Units Insulin Bedtime
7. Metoprolol Succinate XL 150 mg
8. Nephrocaps 1 CAP
9. Oxycodone-Acetaminophen (5mg-325mg)
10. Polyethylene Glycol 17 g
11. sevelamer CARBONATE 800 mg
Please continue to take you other medications
Followup Instructions:
___
|
10519529-DS-15 | 10,519,529 | 20,715,392 | DS | 15 | 2177-01-29 00:00:00 | 2177-01-29 20:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Biopsy of lymph node
History of Present Illness:
This is a ___ with PMH of HTN who presented to ___
with dyspnea x3 weeks and pain and swelling in her right leg and
was subsequently found to have massive bilateral PEs.
She reports starting in ___ she ahd pain around the inside
of her right ankle associated with a deep purple bruise. She
denied any known trauma to the area or history of travel or long
immobilization. Because of the discomfort, she started limping
and felt as if she couldn't walk normally. She also noted that
the ankle was more pink and swollen, and thatthis spread up her
leg up to the mid thigh. It had been very tender although she
feels this has improved recently.
She also notes that starting in mid ___ she would get
'hitches' in her breath. She noted that after climbing stairs
she required ___ min to recover and catch her breath. On the
morning of presentation, she rose from bed and on taking a few
steps felt immediately out of breath. Because she was barely
exerting herself, she went to ___ ED.
Of note, back in ___ she had a couple episodes of cellulitis of
her right arm. She had an ultrasound at that time and was told
that she had a tiny blood clot. She has never had any history of
blood clots previously nor does she have any family history of
bleeding disorders. She has regular mammograms, pelvic exams and
she is up to date with her colonoscopy.
On arrival to the OSH ED, her vitals were T 97.6 BP 177/104, HR
103, RR 16, and O2 Sat 95% on RA. Her exam was noteworthy for 2+
RLE pitting edema. She had a DDimer > 32.5, NT proBNP of 704 ,
troponin 0.334 and CK-MB 1.9 with CBC noteable for WBC of 14.6
(77.5PMN) She began to complain of chest discomfort in her left
chest that was worse with inspiration. She then had a CT PE
protocol that showed massive bilateral PE. Doppler ultrasounds
reportedly showed DVT in right leg (full report not available).
She was started on a heparin gtt and transferred to ___.
In the ED, her initial vitals were: 98.5 ___ 22 96% 2L
A bedside echo showed no right heart strain or pericardial
effusion.
On arrival to the MICU, she complained of a headache that began
in the ambulance ride over. She still has chest discomfort with
deep inspiration. Denies any difficulty breathing.
Past Medical History:
HTN
sinus infection
cellulitis
Social History:
___
Family History:
Parents lived to the ___, died of heart related issues. Sister
has HTN and DM, brother has HLD, glaucoma, diabetes. No FH of
blood clots or cancer
Physical Exam:
=============================
ADMISSION EXAM
=============================
VS: 36.6 ___ ___ 95%2L
___- Lying in the dark, mildly uncomfortable appearing but
in no acute distress. Pleasant and conversant.
HEENT- Sclera anicteric, Dry mucous membranes, oropharynx clear
Lungs- Clear to auscultation, mildly decreased on the left
compared to the right.
CV- Tachycardic but regular rhythm, normal S1 + S2, no prominent
RV heave, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- Pitting edema of RLE, mild tenderness with palpation
Neuro- CNs2-12 intact, motor function grossly normal
.
=============================
DISCHARGE EXAM
=============================
VS: 36.6 138/74 ___ 18 98% RA
___- Lying in the dark, comfortable
HEENT- Sclera anicteric, Dry mucous membranes, oropharynx clear
Lungs- Clear to auscultation
CV- RRR, normal S1 + S2, no prominent RV heave, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- no edema ___
Pertinent Results:
Prelim path report of lymph node biopsy - Adenocarcinoma
___ 06:30AM BLOOD WBC-10.8 RBC-4.20 Hgb-12.2 Hct-37.8
MCV-90 MCH-29.0 MCHC-32.2 RDW-13.4 Plt ___
___ 02:00PM BLOOD LD(LDH)-299*
___ 03:30PM BLOOD CEA-1.4 ___*
=============================
IMAGING:
=============================
TTE (Complete) Done ___ at 10:40:49 AM
Suboptimal image quality.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 is top
normal with mild global free wall hypokinesis. There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. 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. The tricuspid
valve leaflets are mildly thickened with at least mild to
moderate regurgitation (not well characterized due to poor image
quality).
.
.
BILAT LOWER EXT VEINS Study Date of ___ 7:26 AM
FINDINGS:
There is normal respiratory variation in the bilateral common
femoral veins. The right common, proximal, mid, and distal
femoral veins, as well as the popliteal, posterior tibial, and
peroneal veins are distended with echogenic contents, not
compressible with transducer pressure, and without flow detected
on color and spectral Doppler. On the left, one of the
posterior tibial veins as well as both peroneal veins are
distended with echogenic contents, not compressible with
transducer pressure, and without flow detected on color Doppler.
The left common, proximal, mid, and distal femoral, as well as
the popliteal vein demonstrate normal compressibility and flow.
The greater saphenous veins are patent bilaterally.
IMPRESSION:
Deep vein thromboses extending throughout the entire right lower
extremity, as well as deep vein thromboses involving the left
calf deep veins.
CT abdomen
1. Prominent retroperitoneal and mesenteric lymph nodes
surround the mid to upper abdominal aorta and infiltrate along
the porta hepatis, encasing the celiac trunk and common hepatic
artery. Findings are most compatible with lymphoma.
2. Cholelithiasis without cholecystitis.
3. Fatty liver.
Brief Hospital Course:
# Sub-massive pulmonary embolism & DVT: The patient presented
from OSH with bilateral submassive. She was hemodynamically
stable on arrival and therefore did not require thrombolytic
therapy. Echo did show some rt heart strain. LENIs here showed
DVTs extending throughout the entire right lower extremity, as
well as deep vein thromboses involving the left calf deep veins.
We chose not to give thrombolytic therapy because she was doing
well clinically and risks outweighed benefits.
She improved rapidly. At discharge she was off O2 and able to
ambulate around the halls without difficulty. She surprisingly
had no edema in her legs. She did have some rt sided pleuritic
pain when she ambulated or took a deep breath but this was quite
mild.
We chose to send her home on just lovenox (vs coumadin) because
of better efficacy in more DVT
# Metastatic Adenocarcinoma: Abd CT revealed diffuse ___. Bx
showed adenocarcinoma. cA-125. Primary remains unclear at d/c.
mammogram normal, colonoscopy ___ yrs ago normal.
Oncology fellow will call patient and pending test results will
set up follow-up with patient.
=============================
CHRONIC ISSUES
=============================
# Hypertension: The patient is on HCTZ and metoprolol at
baseline for HTN. Currently holding these in the setting of her
PE
# Diarrhea: The patient reports a history of intermittent
diarrhea x ___ months despite keeping to a BRAT diet. C diff was
negative.
=============================
TRANSITIONAL ISSUES
=============================
- She will be discharged on anticoagulation for anticoagulation
- Test results pending include urine cytology and several tumor
markers
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*60
Syringe Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pulmonary embolus, DVT, metastatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please follow-up with your PCP and oncologist here at ___. The
oncologist will be contacting you with an appointment.
Followup Instructions:
___
|
10519585-DS-24 | 10,519,585 | 29,175,939 | DS | 24 | 2139-08-26 00:00:00 | 2139-08-26 06:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R leg pain and deformity
Major Surgical or Invasive Procedure:
R tibial IMN, ___
History of Present Illness:
HPI: ___ with a history of syncope, osteoporosis, HTN, s/p ORIF
of bilateral femurs who presents after a fall. Daughter was not
available at the time of my interview and this was obtained via
the ED staff. Per daughter the patient was feeling unwell today.
Daughter briefly left the room and found her on the floor when
she came back. At her baseline mental status but has significant
pain and a deformity of the RLE.
Past Medical History:
-s/p ORIF of bilateral proximal femur
-osteoporosis
-depression
-pernicious anemia/malnutrition
-anemia
-chronic constipation
-HTN
-h/o syncope
Social History:
___
Family History:
Father with MI in ___.
Physical Exam:
Vitals: AFVSS
General: Well-appearing, breathing comfortably
MSK: leg soft and compressible with mild pain, wiggle toes, WWP
Pertinent Results:
___ 05:50AM BLOOD WBC-6.5 RBC-3.37* Hgb-8.9* Hct-28.3*
MCV-84 MCH-26.4 MCHC-31.4* RDW-15.9* RDWSD-47.5* Plt ___
___ 05:50AM BLOOD Glucose-96 UreaN-15 Creat-0.6 Na-140
K-4.2 Cl-102 HCO3-26 AnGap-12
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a closed right tibia/fibula fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for intramedullary nailing of the right
femur, which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the right lower extremity, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. TraMADol 50 mg PO TID
4. Donepezil 5 mg PO QHS
5. Mirtazapine 15 mg PO QHS
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. brimonidine 0.2 % ophthalmic (eye) BID
3. Calcium Carbonate 500 mg PO TID
4. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (MO) Duration: 4 Weeks
5. Docusate Sodium 100 mg PO BID
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Enoxaparin Sodium 40 mg SC Q24H VTE Prophylaxis -> Trauma
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Metoprolol Tartrate 12.5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Senna 17.2 mg PO HS
12. TraZODone 25 mg PO HS:PRN insomnia
13. Vitamin D 800 UNIT PO DAILY
14. Aspirin 81 mg PO DAILY
15. Calcitriol 0.25 mcg PO DAILY
16. Donepezil 5 mg PO QHS
17. Fish Oil (Omega 3) 1000 mg PO DAILY
18. FoLIC Acid 1 mg PO DAILY
19. Mirtazapine 15 mg PO QHS
20. Pantoprazole 40 mg PO Q24H
21. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until discharge from rehab (replace Metoprolol tartrate)
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
R tibia/fibula fracture, closed
Discharge Condition:
AVSS
NAD, A&Ox3
RLE: Incision well approximated. Dressing clean and dry. Fires
FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP
pulse, wwp distally.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT RLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take ASA 325 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10519585-DS-25 | 10,519,585 | 26,608,894 | DS | 25 | 2139-10-05 00:00:00 | 2139-10-05 11:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by Dr. ___ in note dated ___:
___ yo woman w/ history of recurrent syncope, HTN,
osteoporosis, s/p ORIF of bilateral femurs (most recently
hospitalized in ___ ___/b R tib/fib fracture and
underwent intramedullary nailing of R femur on ___ presenting
with fall, found to have hypoglycemia.
History obtained from pt's daughter ___ given her significant
dementia at baseline.
Daughter states she was in her OSH until 3 days prior to
admission when she c/o feeling "hot" and flushed. She denied
any
fevers/chills, urinary symptoms, cough, SOB, or abdominal pain.
Recently was discharged from ___ and had good PO
intake at home. Daughter states she was recently given
glucometer to test her mother's BG but was unable to get test
strips as these were not covered by her insurance.
At 3AM the morning of presentation, ___ states that she heard a
thud from her mother's room, and found her on the floor in a
puddle of water. Her mother's mental status was "off" and she
was c/o some R shoulder pain. As her MS did not clear for
several hours, EMS was called. When EMS arrived, they found
that
she was confused with FSBG of 56. She received glucose with
return to baseline MS.
___ note, pt was found to be quite hypoglycemic to the 20___-30___
during her last hospitalization. Seen by the Med Consult team
who felt that her hypoglycemia was likely due to poor PO intake
and decreased gluconeogenesis. Metoprolol was held for
hypotension and hypoglycemia. Both issues had resolved on
discharge.
On arrival to the ED, pt afebrile and VSS.
Her FSBG was initially 94 on arrival but then decreased to 36
over 2 hours. D50 was administered again with improvement of
FSBG's to 178.
Labs otherwise notable for largely baseline CBC and wnl CMP.
Trauma w/u revealed R clavicle fracture with some anterior
displacement of the proximal segment.
Pt admitted to medicine for further w/u and management of
persistent hypoglycemia.
ROS: Rest of 10-point ROS reviewed and is negative except as
noted above."
Past Medical History:
-s/p ORIF of bilateral proximal femur
-osteoporosis
-depression
-pernicious anemia/malnutrition
-anemia
-chronic constipation
-HTN
-h/o syncope
-hx of prior surgery for gastric ulcers
Social History:
___
Family History:
Father with MI in ___.
Physical Exam:
Admission Exam:
VITALS: 97.7PO 136 / 76L Lying 78 22 96 RA
GENERAL: elderly F, laying in bed, in NAD
EYES: no scleral icterus, no conjunctival injection
ENT: MMM, clear OP, hard of hearing
NECK: Supple, no appreciable LAD
RESP: Diminished breath sounds b/l, no w/r/r, pursed lip
breathing (chronic per daughter)
CV: ___, no m/r/g
GI: Soft, NT/ND, normoactive BS
GU: no foley
EXT: R leg with more edema than L leg, chronic per daughter.
WWP
MSK: TTP over R clavicle, R arm in sling, moving bilateral
fingers and arm.
SKIN: hypopigmented abrasion over R anterior shin, some
hyperpigmentation over b/l ___
NEURO: AOx1.5 (does not know name of hospital, reason for
hospitalization or date), moving all extremities purposefully
PSYCH: pleasant, normal mood and affect
Discharge Exam:
***
Pertinent Results:
ADMISSION LABS:
___ 07:55AM BLOOD WBC-9.3 RBC-4.10 Hgb-10.5* Hct-35.3
MCV-86 MCH-25.6* MCHC-29.7* RDW-15.3 RDWSD-48.3* Plt ___
___ 07:55AM BLOOD Glucose-83 UreaN-17 Creat-0.5 Na-143
K-3.9 Cl-104 HCO3-27 AnGap-12
___ 06:18PM BLOOD Albumin-3.5 Calcium-9.0 Mg-1.9
___ 07:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
TSH 0.72
AM cortisol 23.9
MICRO:
Blood culture ___: pending
Urine culture ___:
CITROBACTER AMALONATICUS
|
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 8 R
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
IMAGING:
CXR ___:
1. Limited exam due to patient position. Similar bibasilar
opacities as on prior studies likely representing atelectasis.
Underlying infection is difficult to exclude.
2. Distal right clavicle fracture with the proximal fragment
displaced and angulated superiorly. The right AC joint appears
intact.
Glenohumeral ___:
1. Distal right clavicle fracture with the proximal fragment
slightly angulated and displaced superiorly. Intact right AC
joint.
2. Right hemithorax is evaluated separately.
CT C-spine ___:
1. No acute fracture or traumatic malalignment.
2. Bilateral edematous sternocleidomastoid muscles with soft
tissue stranding more severe on the right could be related to
trauma.
3. Multilevel degenerative changes are most severe C4-5, C5-6,
and C6-7.
CT head w/out Contrast ___:
1. No acute intracranial abnormalities.
2. No calvarial fractures.
DISCHARGE LABS:
***
Brief Hospital Course:
___ yo woman w/ history of recurrent syncope, HTN, osteoporosis,
s/p ORIF of bilateral femurs, presenting after a fall, found to
have recurrent hypoglycemia.
# Hypoglycemia
The patient has a history of recurrent hypoglycemia. She was
seen by Med Consult last admission who felt that her
hypoglycemia may be due to poor PO intake and low glycogen
reserves/impaired gluconeogenesis. Pt does not have hx of DM
and does not take any hypoglycemic. Spoke with daughter ___
who said family friend
at ___ who is an Endocrinologist felt hypoglycemia may be
due to prior gastric resection for PUD. On review of
literature, there appears to be a condition called noninsulinoma
pancreatogenous hypoglycemia syndrome which sometimes occurs
after gastric surgery (d/t beta cell hypertrophy) but is
apparently rarer than insulinoma.
Endocrinology was consulted. The differential for her
hypoglycemia included endogenous vs. exogenous insulin-driven
process, insufficient substrate (starvation, liver disease),
accelerated utilization (tumor, sepsis), adrenal insufficiency
(essentially ruled out by am cortisol of 24). Other
considerations in the setting of her prior gastric surgery and
described hot flushes include dumping syndrome and
neuroendocrine tumor.
She had a 72 hour fast, and her CBG did not drop below 50 for
the entire fast. Thus, most likely she does not have an
insulinoma or other insulin-hypersecretion state. Given the
history of episodic hypoglycemia after boluses of
carbohydrate-heavy foods (like ___ sweets), her presentation
was most consistent with reactive
hypoglycemia. Nutrition was consulted to educate the patient and
her daughter re: dietary strategies to treat reactive
hypoglycemia - small frequent meals throughout the day, mixed
meals (avoiding carb loads), avoiding foods with high glycemic
index. The full panel of hypoglycemic labs are still pending.
There is no need to check blood sugars routinely unless she has
symptoms suggestive of hypoglycemia. Even if BG is low,
drinking juice would cause a rapid rise which would then result
in a rebound decrease. A1C done in ___ was normal, so no
need for Metformin.
# Citrobacter UTI
Pt denied urinary complaints initially. She had >100K CFUs of
Citrobacter amalonaticus growing in urine culture. She has a
history of pan-sensitive E.coli UTI in ___. Despite lack of
symptoms will treat given her recent possible syncope/fall,
which could be due to hypoglycemia but there may be some
component from
infection. She was initially treated with ceftriaxone, however
sensitivities
showed that Citrobacter was resistant to CTX so she was switched
to nitrofurantoin to complete a 5 day course.
# Fall from Standing
# Possible Syncope
Pt found down near her bed after having presumed syncopal event.
Most likely trigger was hypoglycemic episode. However, pt with
long history of syncopal events with prodromal symptoms that
sound very vasovagal in nature. UTI may be contributing (in ___
she had a fall/syncopal episode and was found to have an E.coli
UTI). Telemetry for >48 hours has been unremarkable.
Orthostatics vital signs were normal. ___ was consulted and
recommended rehab.
# R Clavicle Fracture
Pt with minimally displaced clavicular fracture found on x-ray.
This was discussed with orthopedics. She should follow up in
their clinic ___ weeks after discharge. They recommended that
she keep the RUE in sling for comfort only - otherwise she is
able to participate in any & all weight-bearing activities as
tolerated. Her pain was consulted with Tylenol, tramadol prn
pain.
Chronic Problems:
# Osteoporosis: continued home calcium, calcitriol, vitamins.
She may benefit from a DEXA scan as an outpatient, but her PCP
can discuss this with her and her family.
# Dementia: ___ protocol, continued home Donepezil, remeron,
trazodone prn
# Hx of gastric ulcer: continued PPI
# HTN: hold homed metoprolol
# Glaucoma: continued home eye gtts
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Donepezil 5 mg PO QHS
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Pantoprazole 40 mg PO Q24H
8. Acetaminophen 650 mg PO TID
9. brimonidine 0.2 % ophthalmic (eye) BID
10. Calcium Carbonate 500 mg PO TID
11. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (MO)
12. Docusate Sodium 100 mg PO BID
13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
14. Enoxaparin Sodium 40 mg SC Q24H VTE Prophylaxis -> Trauma
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Metoprolol Tartrate 12.5 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Senna 17.2 mg PO HS
19. TraZODone 25 mg PO HS:PRN insomnia
20. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. TraMADol 25 mg PO Q4H:PRN BREAKTHROUGH PAIN
2. Acetaminophen 650 mg PO TID
3. Aspirin 81 mg PO DAILY
4. brimonidine 0.2 % ophthalmic (eye) BID
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Carbonate 500 mg PO TID
7. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (MO)
8. Docusate Sodium 100 mg PO BID
9. Donepezil 5 mg PO QHS
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. Enoxaparin Sodium 40 mg SC Q24H VTE Prophylaxis -> Trauma
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. Metoprolol Tartrate 12.5 mg PO BID
16. Mirtazapine 15 mg PO QHS
17. Multivitamins 1 TAB PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Senna 17.2 mg PO HS
20. TraZODone 25 mg PO HS:PRN insomnia
21. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Reactive hypoglycemia
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:
You were admitted to the hospital with low blood sugar
(hypoglycemia). This was a reaction to your body responding
strongly to carbohydrates and sugars and having a rebound low
blood sugar as a result. This can be prevented by having low
carb, frequent meals.
We wish you the best in your recovery,
Your ___ team
Followup Instructions:
___
|
10519667-DS-6 | 10,519,667 | 28,214,158 | DS | 6 | 2169-12-29 00:00:00 | 2170-01-01 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Keflex / Erythromycin Base
Attending: ___.
Chief Complaint:
Chest pain with exercise
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
___ yr old man with HTN and HLD who presents with ___ months of
R-sided chest, shoulder, and neck pain after eating and physical
activity. The patient noted in ___ of last year he would
experience predominantly R-sided chest pain accompanied by R
shoulder and, occasionally, R neck pain after physical activity
and after eating. This pain is relieved with rest, resolving
after ___ after cessation of the inciting activity. He was
evaluated by his PCP in ___ but due to the atypical
presentation and his current work up for GERD (diagnosed with a
hiatal hernia approximately 1 mo ago), further evaluation was
not pursued until he saw his PCP in ___ approximately one
week ago. He does report his GERD-like symptoms are different
from his R-sided chest pain following exertion. Since his first
evaluation in ___, his chest pain episodes have been
increasing in frequency, although not in severity. Since his
symptoms had persisted he was sent for Stress ECHO on ___
for evaluation. During these episodes, he denies any concerning
symptoms such as SOB, palpitations, dizziness, nausea/vomiting,
or diaphoresis. He does endorse DOE after climbing stairs but
notes no appreciable ___ edema. Of note, he does report having a
Stress ECHO last year after an anxiety/panic-like episode during
which he had a fast heart rate.
On ___, his Stress test showed the following:
His EKG at baseline was sinus rhythm at 98 beats per minute
with
___epressions in the inferolateral leads. He assured
us
that these were known abnormalities. He had no chest pain to
start the test. During exercise at about 3 minutes of exercise,
he developed right arm to upper chest discomfort, this
increased
to ___ in severity during exercise. His EKG while generally
uninterpretable at baseline had changes of an additional 2 mm
of
flat to downsloping ST depressions in the inferolateral leads
and
additional 1-2 mm of elevation in AVR. He completed 7 minutes
of
the protocol. He stopped secondary to overall leg fatigue. His
echocardiographic images showed normal functional pre and
post-exercise.
After the test, he continued to have these persistent ST
depressions and his jaw and shoulder pain while lessened had
not
disappeared. He received two nitroglycerin sublingually and at
25 minutes post-exercise, he had ___ discomfort in his jaw and
his EKG was almost back to baseline. In this setting, his
Troponin was <0.01
Given these results and his history of present illness, he was
referred to ___ for immediate cardiac catheterization.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, HLD
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- four teeth removed in ___, replaced with implants
- Polymyalgia Rheumatica
- Hiatal hernia
- sleep apnea
- bilateral hearing loss ___ presbycusis
- pre-glaucoma
- Low testosterone
- BPH
- Recent Decompression at the L3, L4 and L5 level and L4-L5
instrumented fusion here at ___ in ___
- septoplasty for deviated septum
- L submandibular gland excision
- internal fixation of L elbow, after fracture
Social History:
___
Family History:
Father with angina, although no MIs per patient. Paternal
uncles with heart disease. Mother with colon cancer. Brother
and sister healthy. No other cardiac hx or hx of spontaneous
death.
Physical Exam:
Physical Exam at Admission:
===========================
VS: T=97.9 BP=116-135/60s ___ RR=16 O2 sat=98RA
8Hr I/Os: 240/325
24hrs I/Os: 120/258
Telemetry: no events
Admission weight: not recorded
GENERAL: Pt in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm. L neck scar appreciated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Physical Exam at Discharge:
===========================
GENERAL: Pt in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm. L neck scar appreciated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
Admission labs, imaging, and micro data:
========================================
___ 07:20PM BLOOD WBC-9.8 RBC-4.27* Hgb-12.9* Hct-38.7*
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.5 RDWSD-44.2 Plt ___
___ 07:20PM BLOOD ___
___ 07:20PM BLOOD Plt ___
___ 07:20PM BLOOD Glucose-121* UreaN-11 Creat-0.9 Na-138
K-3.5 Cl-104 HCO3-24 AnGap-14
___ 07:20PM BLOOD ALT-41* AST-28 CK(CPK)-226 AlkPhos-60
Amylase-75 TotBili-0.3
___ 07:20PM BLOOD %HbA1c-5.7 eAG-117
___ 07:20PM BLOOD Albumin-3.8
Cardiac Cath ___:
LAD: The proximal-mid LAD was heavily calcified. There was a 25%
ostial stenosis. The proximal-mid LAD had a tubular 40% stenosis
before S1 and D1. There was an eccentric 75% stenosis after D1
and
S1, before D2. There was a bifurcation lesion in the mid LAD
involving the origin of the large D2 to 40% with a 60% stenosis
in the LAD immediately after D2. The mid LAD after D2 may have
been
intramyocardial. Flow in the LAD was TIMI 2.
Ramus intermedius: There was a modest caliber ramus intermedius
of modest length with mild ostial plaquing.
LCX: The proximal CX had focal heavy calcification and a
retroflexed origin. The curved proximal CX had an 80% stenosis
after a small OM1 (with the lesion extending into the proximal
OM1). There was
TIMI 1 delayed flow into the distal OM2 with a larger lower
pole and a smaller upper pole with a proximal 50% bifurcation
lesion.
RCA: The RCA had was very angulated proximally with mild
diffuse plaquing throughout (especially to 30% proximal-mid
vessel and distally before the RPDA in another angulated
segment). The RPDA was
tortuous. RPL1 was small with moderate diffuse disease
throughout. RPL2 was short. The distal AV groove RCA extended
well up the LV and supplied an atrial branch (? SA nodal
branch).
___ 05:10AM BLOOD cTropnT-0.02* after cath
Discharge labs, imaging, and micro data:
========================================
___ 04:55AM BLOOD WBC-9.2 RBC-4.71 Hgb-14.2 Hct-43.6 MCV-93
MCH-30.1 MCHC-32.6 RDW-13.2 RDWSD-45.1 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD ___ PTT-29.6 ___
___ 04:55AM BLOOD Glucose-91 UreaN-11 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-26 AnGap-15
___ 05:10AM BLOOD ALT-52* AST-38 LD(LDH)-207 AlkPhos-62
TotBili-0.5
___ 04:55AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ male with history of HTN and HLD
who presents with ___ of exercise-induced R-sided chest pain
with ST changes on stress ECHO (EF of 60%) and now confirmed 3VD
by cardiac cath who was admitted for Cardiac surgery evaluation.
# Stable Angina/Coronary Artery Disease
The patient presented with stable angina (no angina symptoms at
rest). He underwent Stress ECHO at an outside clinic which
showed ST elevations during the study, and the patient reported
angina symptoms. He was then transferred to ___ for cardiac
catheterization which showed 3 vessel disease, best treated by
cardiac surgery. The cardiac surgery team evaluated the patient
obtained relevant preoperative labs and studies (CXR, UA/UCx,
MRSA swab). The patient was also started on Atorvastatin 80mg
Daily and Metoprolol 25mg daily. The patient was initially
placed on a heparin drip, however, given the patient's
presentation is most consistent with stable angina, this was
stopped shortly after its initiation. The patient remained
symptom-free throughout his admission. He was discharged with
plans to arrange for elective CABG with Cardiac surgery.
# Polymyalgia Rheumatica: The patient's usual symptoms
(joint/muscle aches) appeared stable. He was continued on his
daily prednisone.
# HTN: The patient was given his home dose of Losartan
(100mg). He remained normotensive throughout his admission.
#BPH: The patient was given his daily tamsulosin.
#Transitional Issues:
=================
*The patient was started on Metoprolol Succinate 25mg daily.
*The patient was started on Atorvastatin 80mg daily.
*The patient will need to continue taking his 81mg ASA and
Losartan 100mg daily.
*The Cardiac Surgery clinic will call the patient on ___ to set
up a follow up appointment with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 3 mg PO QPM
2. Tamsulosin 0.4 mg PO EVERY OTHER DAY
3. testosterone propionate 50 mg transdermal DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. PredniSONE 3 mg PO QPM
4. Tamsulosin 0.4 mg PO EVERY OTHER DAY
5. Vitamin D 1000 UNIT PO DAILY
6. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
7. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
8. testosterone propionate 50 mg transdermal DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
You underwent cardiac catheterization on ___ which revealed
coronary artery disease. You did not have any stents placed
because it was thought your disease would be best treated with
surgery. You were seen by our cardiac surgery team in
preparation for coronary heart surgery.
It is very important to take all of your heart healthy
medications.
You are now on aspirin. You need to take aspirin everyday. Do
not stop taking aspirin unless you are told by your
cardiologist. You also need to continue taking Atorvastatin,
Losartan, and Metoprolol.
We wish you all the best,
Your ___ Cardiology team
Followup Instructions:
___
|
10519676-DS-11 | 10,519,676 | 27,682,904 | DS | 11 | 2138-02-05 00:00:00 | 2138-02-06 13:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
penicillin
Attending: ___
Chief Complaint:
abdominal swelling and pain
Major Surgical or Invasive Procedure:
___ guided para on ___ removed
History of Present Illness:
___ with h/o T2DM, cryptogenic cirrhosis c/b non-occlusive PVT,
esophageal varices (___) s/p banding, and portal hypertension
presents to the emergency department with abdominal distention.
He was seen today by Dr. ___ in ___ clinic with
worsening abdominal distention. Per the hepatology outpatient
note: "He has been stable in term of fluid overload over past
year and he has been evaluated for umbilical hernia repair. He
underwent cardiac evaluation with echocardiogram showing severe
AS but still was cleared for surgery due to lack of symptoms."
1 month ago, he started having increase in abdominal girth and
discomfort with increase in weight going up to 247. He doubled
the dose of spironolactone 1 week ago from 100mg daily to 200mg
daily. He lost almost 13 pounds. 3 days ago, he felt chills
without documented fever, No URT symptoms, no vomiting, no SOB
or
chest pain. No diarrhea, melena or rectal bleeding. Today he
reports abdominal distention, and pain. Denies confusion or
recent falls.
Regarding his cirrhosis history, his cryptogenic cirrhosis was
previously decompensated by a variceal bleed in ___ and
subsequent eradication with banding. He has been intolerant of
beta blockade in the past and also has iron deficiency anemia
for
which he is on ferrous gluconate.
On evaluation on the floor, the patient states that he still has
diffuse abdominal pain. He states that, 2 months ago, he
weighed
234 pounds. On arrival to the floor, he weighs 238 pounds. He
endorses a chronic cough, but no worsening of his cough. No one
sick at home. He denies dysuria, or urinary frequency.
Of note, he has insulin-dependent diabetes. He was taking 24
units of ___ daily. His most recent hemoglobin A1c was 5.1%,
so his PCP decrease his ___ to 18 units daily. The patient
states that he has not had any ___ in 4 days, and his blood
sugars have been in the ___ to low 100s.
In the ED, initial VS were: 96.6 76 115/72 18 100% RA
Exam notable for:
EXAM: alert, oriented,
___: Murmur. clear lungs
ABD: mod amount ascites, tender
EXT: + 2 EDEMA
Labs showed:
White blood cell count 3, hemoglobin 11.9, platelet 68, INR 1.5,
AST 48, ALT 28, albumin 2.8, lactate 2.9. UA notable for
positive nitrites, large leuks, 49 WBCs, moderate bacteria.
Imaging showed:
CXR:
Heart size is normal. The mediastinal and hilar contours are
normal. Thepulmonary vasculature is normal. Lungs are clear. No
pleural effusion orpneumothorax is seen. There are no acute
osseous abnormalities.
Abdominal Ultrasound:
Targeted grayscale ultrasound images were obtained of the 4
quadrants of the abdomen, revealing moderate ascites. The
largest pocket is in the right lower quadrant. The amount of
ascites appears larger when compared to prior CT.
Hepatology was consulted, who recommended UA/Ucx, albumin, and
admission to hepatology with therapeutic paracentesis in the AM.
Patient received: 2g ceftriaxone
Past Medical History:
HTN
Gout
Cirrosis
Esophageal Varices
Social History:
___
Family History:
No known family history of cirrosis, GI issues. Father had CAD
and died of MI. Mother had macular degeneration.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98.2PO ___ 18 96 RA
GENERAL: NAD, alert and oriented x3
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: 4 out of 6 crescendo decrescendo murmur best auscultated at
the base of the heart, radiates to the carotids
PULM: CTAB
GI: Distended, reducible umbilical hernia, positive fluid wave,
diffusely mildly tender to palpation, no rebound tenderness
EXTREMITIES: no cyanosis, clubbing, or edema, no asterixis
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes no palmar erythema or spider angiomata
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1518)
Temp: 98.2 (Tm 98.2), BP: 95/61, HR: 79, RR: 18, O2 sat:
98%, O2 delivery: RA
GENERAL: NAD, alert and oriented x3
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, ___ systolic murmur
PULM: CTAB
ABD: Distended, reducible umbilical hernia, positive fluid wave,
diffusely mildly tender to palpation, no rebound tenderness
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DERM: warm and well perfused, no excoriations or lesions, no
rashes no palmar erythema or spider angiomata
Pertinent Results:
ADMISSION LABS:
===============
___ 02:52PM BLOOD WBC-3.0* RBC-3.61* Hgb-11.9* Hct-36.6*
MCV-101* MCH-33.0* MCHC-32.5 RDW-14.6 RDWSD-54.9* Plt Ct-68*
___ 02:52PM BLOOD Neuts-64.0 ___ Monos-9.2 Eos-3.1
Baso-1.0 Im ___ AbsNeut-1.89 AbsLymp-0.64* AbsMono-0.27
AbsEos-0.09 AbsBaso-0.03
___ 02:52PM BLOOD ___ PTT-30.4 ___
___ 06:20AM BLOOD ___
___ 02:52PM BLOOD Glucose-168* UreaN-20 Creat-1.1 Na-137
K-4.3 Cl-103 HCO3-23 AnGap-11
___ 02:52PM BLOOD ALT-28 AST-48* AlkPhos-121 TotBili-1.5
___ 06:20AM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.1 Mg-1.6
___ 03:02PM BLOOD Lactate-2.9*
IMAGING:
========
Abdominal ultrasound (___)
Moderate ascites. Largest pocket in the right lower quadrant.
DISCHARGE LABS:
===============
___ 07:21AM BLOOD WBC-2.7* RBC-3.31* Hgb-11.3* Hct-32.6*
MCV-99* MCH-34.1* MCHC-34.7 RDW-14.4 RDWSD-51.9* Plt Ct-52*
___ 07:21AM BLOOD ___ PTT-32.0 ___
___ 07:21AM BLOOD Glucose-97 UreaN-21* Creat-1.2 Na-136
K-4.4 Cl-103 HCO3-24 AnGap-9*
___ 07:21AM BLOOD ALT-21 AST-34 AlkPhos-96 TotBili-1.8*
___ 07:21AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6
___ 06:46AM BLOOD Lactate-1.0
Brief Hospital Course:
SUMMARY STATEMENT:
==================
___ with h/o T2DM, cryptogenic cirrhosis c/b non-occlusive PVT,
esophageal varices (___) s/p banding, and portal
hypertension,
who was admitted for abdominal distention.
ACUTE ISSUES:
=============
#Decompensated cirrhosis
Upon admission, MELD-Na 15, Child class B. The patient presented
with 1 month of
worsening abdominal distention, and 3 days of worsening
abdominal pain. He had no asterixis and no history of hepatic
encephalopathy. Of note, the patient weighed 245 pounds at an
outpatient visit in ___. On this admission, he weighed 238
pounds. Ascites fluid studies were negative for SBP. The patient
did receive 2 g of ceftriaxone in the ED for initial concern of
SBP. His hernia was reducible on physical exam, so this was
likely not contributing to his pain. His lactate was slightly
elevated at 2.9 on admission, but downtrended to 1.0 on repeat
labs. His abdominal pain was deemed likely secondary to
worsening of his ascites from his decompensated cirrhosis, and
he underwent ___ guided therapeutic paracentesis with 4.25L
removed on ___, which was followed by 8g/kg albumin repletion.
Additionally he was actively diuresed with IV lasix 20mg on ___
and spironolactone 200mg. He was started on midodrine 5mg TID on
___ for low SBPs ___. He was discharged with lasix 20mg
and spironolactone 150mg. His discharge weight was: 103.06 kg
(227.2 lb). His Cr on discharge was 1.2.
#Pancytopenia
#Coagulopathy
#Iron deficiency anemia
Patient presented with a hemoglobin of 11.9, macrocytosis, white
count of 3, platelets of 68, INR 1.5. This is all likely
secondary to his liver disease. There were no active signs of
bleeding and his hemoglobin stayed stable during hospital stay.
Discharge hemoglobin 11.3.
#Asymptomatic bacteriuria
The patient's UA is notable for positive nitrites, positive leuk
esterases, positive bacteria. The patient denied any urinary
symptoms. He had no CVA tenderness on exam. He did receive 2 g
of ceftriaxone in the ED. Urine cultures were pending on
discharge.
CHRONIC ISSUES:
===============
#T2DM
Patient with a history of type 2 diabetes, but his most recent
outpatient hemoglobin A1c was 5.1. This suggests that his
diabetes was over-treated with the 24 units of glargine that he
was taking. Patient's glargine was heled on admission and he was
kept on Humalog ISS. His FSBS ranged from 114 to maximum 166 and
only required a one time 2u Humalog while admitted. His home
glargine was held on discharge and he was instructed to record
FSBS at home.
#Esophageal varices status post banding
The patient had esophageal varices and banding in ___. There
was no active evidence of bleeding. He denied melena and guaiac
was negative on admission. He has been unable to tolerate
beta-blockers in the past for bleeding prophylaxis.
#Gout
Continued on home allopurinol
#Chronic Bilateral leg cramping for which he is prescribed 5 mg
oxycodone as needed by his PCP, which was verified and continued
during hospital stay.
#GERD
Continued home pantoprazole
TRANSITIONAL ISSUES:
=====================
Discharge weight: 103.06 kg (227.2 lb)
Discharge hemoglobin: 11.3
Discharge MELD-Na score: 19
[] Diuretic regimen on discharge: 20mg lasix, 150mg
spironolactone. Please follow up BMP, weight and volume status
at follow up exam and adjust diuretic regimen as needed.
[] Please follow up CMP - patient discharged with lab script for
CMP to be collected on ___, requested to be faxed to both Dr.
___ and Dr. ___
[] Started on midodrine 5mg TID for low SBPs 90-100s while
admitted, please titrate as appropriate
[] Instructed to hold home nightly glargine on admission as
recent outpatient A1c 5.1 and FSBS while admitted ranging
114-166. Was instructed record FSBS at home with plan to follow
up with PCP to adjust his insulin regimen as needed.
[] Removed 4.25L by ___ guided paracentesis on ___, received
37.5g albumin afterwards
#CODE: Full (presumed)
#CONTACT: ___ (wife) Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Spironolactone 100 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Glargine 18 Units Bedtime
5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN leg cramps
6. Ferrous GLUCONATE 324 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*0
3. Spironolactone 150 mg PO DAILY
RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Ferrous GLUCONATE 324 mg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO BID:PRN leg cramps
7. Pantoprazole 40 mg PO Q24H
8. HELD- Glargine 18 Units Bedtime This medication was held. Do
not restart Insulin until your doctor tells you to
9.Outpatient Lab Work
please collect CMP on ___ for ICD 9 code 78___.59
Please fax to: Dr. ___ at ___ and ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Decompensated cirrhosis
SECONDARY DIAGNOSIS:
====================
cryptogenic cirrhosis c/b nonocclusive PVT, esophageal varices
s/p banding, and portal hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had worsening
abdominal swelling and pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had an ___ guided paracentesis with drainage of >4L of
fluid and were given albumin afterwards.
- We adjusted your home diuretic medications to include: lasix
20mg daily, and spironolactone 150mg daily. You will need to
follow closely with your PCP as well as Dr. ___ as an
outpatient to ensure that this is an appropriate dose of
diuretics.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
or you develop worsening abdominal swelling and pain, fever,
chills, black or bloody stools, or any other symptoms that
concern you.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10519706-DS-19 | 10,519,706 | 27,874,926 | DS | 19 | 2184-08-25 00:00:00 | 2184-08-25 18:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L face weakness, eye opening, L arm
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ F hepatic adenoma, ADPKD, chronic
migraines, RLE DVT/PE, PCOS, endometriosis s/p ex lap ___,
chronic pain, anxiety, nutrition intolerance s/p NGT
She was admitted to ___ from ___ to ___, ___ summary
reviewed.
She had initially presented that admission at ___ for acute
exacerbation of chronic right abdominal pain and headache, she
had liver lesions which appear to have expanded on ultrasound.
Her hospital course is briefly summarized from the discharge
summary. MRI of hepatic lesions concerning for HCC/metastases
versus adenomas. She had declined hepatology consult due to
anxiety about the lesions. Eventually liver biopsy was done and
were consistent with hepatic adenoma. She did have a mild
transaminitis max 90/127 at one-point which was thought to be
due
to venlafaxine, there is no plans to discontinue venlafaxine and
the enzymes had normalized. She developed a right leg DVT and
was started on Lovenox on ___. ___ was discussed with
her however he declined due to lack of a reversal agent. She did
refuse lovenox at some points in the hospitalization.
Thrombophilia workup was unremarkable. Lovenox teaching was
performed. She experienced intermittent episodes of chest pain
that was pleuritic, tachycardia, tachypnea that self resolved
after ___ minutes without hypotension or hypoxia while she was
on therapeutic anticoagulation. Throughout her hospital stay
her
functional status declined and she became bedbound by mid
___ despite ___ and OT. Neurology saw her in mid ___ it
was thought that her decrease in movement was functional due to
positive Hoover sign sensory symptoms without any clear
distribution, being seen moving legs when in pain or distracted.
Lumbar MRI was performed due to her polycystic kidney disease
and
its association with hemangiomas. This was normal. She had
poor
p.o. intake during her hospitalization with ketonuria noted at
any time. NG tube placed for feeds and encouraged to feed as
tolerated. She intermittently refused NG feeds and water NG
tube
supplies and feeds were provided prior to discharge. Her final
tube feed regimen was 55 mils per hour of vital 1.5 continuous.
She was followed closely by psychiatry throughout her
hospitalization.
It is noted in psychiatry note from ___ (one day prior to her
discharge that hospitalization) that "Per medical team, 1:1 care
companion for ___ roommate in bedspace A observed ___
lower herself from bed to floor and then position herself under
the bed. Upon discovery, ___ reported to nursing staff that
she fell." This was felt by the psychiatry/psychology team to be
potentially concerning for malingering or factitious disorder.
She has undergo MRI L spine in ___, MRI brain ___, MRI
brain and T/L spine ___, all at ___, without abnormalities
noted.
She was admitted to ___ last ___, after she had presented
at
recommendation of her ___ for increased vaginal bleeding, mild
pleuritic chest pain and acute on chronic abd pain. Hgb nl. CTA
showed r segmental PE. She had endorsed nonadherence to her
lovenox. She was observed by nursing to be moving legs in bed,
despite no movement on direct exam. No signs of R heart strain.
Lovenox was continued. Tizanidine uptitrated. She was seen by
neurology this admission and there was observation of functional
overlay of exam including hoovers sign. She was discharged
___. Her exam on ___ was notable for right hemisensory
decreased sensation. In addition to little to no movement for
additionally of the legs
She returns to the ED today reporting several symptoms. She
states that starting at 6 AM today she began having severe
substernal left-sided chest pain she states this was worse than
her usual chest pain she does note she had an episode of chest
pain for 30 minutes yesterday. This was accompanied by left arm
numbness and tingling in the whole arm she also felt the arm was
not moving properly and it felt like it was not her arm. She
was
able to lift it off the bed still. She also states she noticed
her left eye would not open and that she could only squint. She
tried for ___ minutes to open her eyes but is not working. She
also noticed in the mirror that her left mouth was drooping.
She
felt that she was slurring words. She noted that the tongue and
bottom of her jaw felt numb and tingling. She states she cool
for signs of stroke. She had her godmother to a stroke
assessment and they also called ED nursing who recommended they
call ___. She also states she had a hard time breathing and
thought she might be having a stroke. She says she feels
slightly better than when the symptoms initially started. She
states that her headache is slight today compared to normal. It
is 5 out of 10. She states she has had more severe headaches in
the past. She states she has chronic migraines 4 times a day.
She also notes that the left chin and upper lip and forehead are
all tingling she feels that her nose is okay however. She
states
that she had 1 hour numbness in the left leg too. She also
notes
that her left hand became stuck in a fist and that she had to
open up her fingers with the other hand. She states she began
to
have numbness and tingling in her left foot that spread up to
her
mid calf over 45 minutes. She states that the symptoms seem
worse than her chronic right-sided symptoms sensory symptoms.
She
states that she had otherwise been in her USOH.
On neurologic review of systems, the patient denies,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, or dysphagia.
Denies bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Polycystic Kidney Disease (ADPKD)
Enlarging hepatic adenomas (Bx confirmed s/p prolonged admission
to ___)
Acute on chronic right sided abd pain
Nutrition intolerance s/p NG tube
DVT/PE, stopped taking lovenox 3 days PTA
Depression/Anxiety
Headaches
Nonambulatory s/p normal Lspine MRI, functional exam
Endometriosis
Social History:
___
Family History:
multiple with polycystic kidney disese on mother's side
HTN
Physical Exam:
Admission Exam:
Vitals: 97.8 116 ___ 99% RA
General: sitting up in bed wearing sunglasses, talking on the
phone at times on a phone call during interview, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x self, date, location. Able to
relate history without difficulty. Attentive, able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without
nystagmus.
V: increased vibration over L forehead. decreased to all
modalities v1-v3
VII: facial musculature symmetric at rest. when smiles, R side
elevates slowly, L side does not move at all, her mouth appears
to depress slightly however. Forehead raise equal initially, but
then the left depresses, she asks if it was moving stating it
was
not moving earlier. Her L eye closure is easily overcome. when
her eye closure is overcome, bell's phenomenon is not observed
as
expected, her eyes are midline and in center position.
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 atrophy. No pronator
drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Strength testing:
strength basically full in R arm
L arm with fluctuating giveway weakness, able to provide some
resistance briefly in all muscle groups in the L arm
Slight movement of toes to command. some proximal leg movements
seen when patient shifting in bed.
-Sensory: patchy sensory loss over L arm, L leg, more
pronounced/denser in hands and feet. Decreased to all modalities
over R hemibody, less so than over L.
-DTRs:
Bi Tri ___ Pat Ach
L 1 ___ 1
R 1 ___ 1
Plantar response was flexor bilaterally. No ankle clonus
-Coordination: FNF accurate
-Gait: unable to perform
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Discharge exam:
General: lying in bed, wearing sunglasses
HEENT: NC/AT, no scleral icterus noted
Neck: moving neck in all directions
Pulmonary: breathing comfortably in room air
Cardiac: well perfused, no edema
Abdomen: non-distended
Extremities: well perfused
Skin: no rashes or lesions in the exposed skin
Neurologic:
-Mental Status: Alert, able to relate history without
difficulty. Upset about not receiving triptan, withdrawn during
the meeting about disposition. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric.
-Cranial Nerves:
tracking well on limited view when wearing glasses, EOMI appears
grossly normal. facial musculature symmetric at rest. Activating
bilateral facial muscles when talking. Hearing intact
bilaterally.
- Motor: Normal bulk, tone throughout, no atrophy. No tremors
noted. motor exam limited by pain and poor effort, moving legs
when repositioning herself in bed several times, Seen moving all
extremities antigravity.
- Sensory: deferred
-DTRs: deferred
-___: reaching out for objects including her phone
without difficulty
-Gait: deferred
Pertinent Results:
---------------
Labs:
---------------
___ 08:29AM ALT(SGPT)-107* AST(SGOT)-128* ALK PHOS-48 TOT
BILI-0.6
___ 08:29AM cTropnT-<0.01 proBNP-21
___ 08:29AM WBC-6.9 RBC-4.14 HGB-13.0 HCT-38.4 MCV-93
MCH-31.4 MCHC-33.9 RDW-13.0 RDWSD-43.8
___ 08:29AM NEUTS-64.5 ___ MONOS-6.2 EOS-2.5
BASOS-0.7 IM ___ AbsNeut-4.45 AbsLymp-1.78 AbsMono-0.43
AbsEos-0.17 AbsBaso-0.05
Imaging results
CXR ___:
No focal consolidations concerning for pneumonia
MR ___ ___:
Unremarkable MRI of the cervical spine. No cord signal
abnormality. No
high-grade spinal canal or neural foraminal narrowing.
MR Brain: ___. Unremarkable MRI brain. No mass, infarct or suspicious
parenchymal FLAIR signal abnormality.
2. Dural venous sinuses are patent. Unremarkable orbits
CT-Head: ___
No acute intracranial process.
Brief Hospital Course:
___ woman hepatic adenomas (confirmed on biopsy), ADPKD,
chronic migraines, RLE DVT/PE, PCOS, endometriosis s/p ex lap
___, chronic pain, anxiety, nutrition intolerance s/p NG.
Neuro:
She presented to BI with L sided chest pain, L arm
numbness/tingling, inability to open L eye, L face weakness, L
face numbness/tingling, L arm weakness and paresthesias. There
was a large amount of functional overlay to her exam, which
complicated evaluation, there were components that were
anatomically inconsistent (she reported facial weakness, however
her eye is kept closed, rather than open). Therefore imaging
was obtained to rule out structural lesion. CT head, MRI brain
and C spine were all normal. Her presentation was therefore
consistent with with a functional neurological disorder. Patient
was unable to walk due to functional disease, and is at risk for
further deconditioning. ___ was consulted and recommended rehab,
patient was not accepted at rehab and chose to be discharged to
a shelter. Her godmother brought her wheelchair from home.
Psych:
Psych was consulted due to history of anxiety, social stressors
and functional neurological disease, Psych evaluated patient,
diagnosed her with somatoform disorder and recommended that her
Ativan be discontinued and tizanidine be discontinued. Patient
endorsed pain and was allowed 2 mg Tizanidine nightly PRN.
Gabapentin was continued at home dose.
___:
Patient complained of chest pain on ___, exam, EKG and chest
X-ray were normal. Patient was saturating well on room air.
Patient asked to be placed on oxygen for comfort, which was
placed overnight but removed as patient had reassuring
saturations and exam.
Heme:
Patient was on Lovenox at admission due to her history of DVT
and PE, however she refused her Lovenox on some days during the
admission. Psych determined that she has the capacity to make
decisions. Risks for not taking Lovenox were discussed with
patient and that DVT and PE can be fatal.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Tizanidine 6 mg PO TID
3. Enoxaparin Sodium 70 mg SC Q12H
4. Famotidine 40 mg PO DAILY
5. Gabapentin 600 mg PO TID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. LORazepam 0.5 mg PO Q8H:PRN acute anxiety
8. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
9. Topiramate (Topamax) 25 mg PO DAILY
10. Venlafaxine 75 mg PO BID
Discharge Medications:
1. Gabapentin 200 mg PO BID
2. Topiramate (Topamax) 50 mg PO DAILY
3. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*20
Syringe Refills:*4
4. Famotidine 40 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
7. Venlafaxine 75 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Functional Neurological Disorder
Discharge Condition:
unchanged
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You presented to ___ Department chest pain,
arm
numbness/tingling, inability to open left eye, left face
weakness, left face numbness/tingling, L arm weakness and
paresthesias. CT head, MRI brain and C spine were normal. Based
on your presentation, you were diagnosed with a functional
neurological disorder. From a cardiac standpoint, you complained
of chest pain on ___, your EKG and chest X-Ray were normal.
You were on Lovenox at admission due to history of DVT and
pulmonary embolism, however you refused her Lovenox on some days
during the admission. Psychiatry team determined that you are
competent to make your decisions, we discussed risks for not
taking Lovenox and that DVT and pulmonary embolism can be fatal
and can leave you with disabilities or organ injuries, however
you still chose to not take Lovenox. Nutrition team saw you
during admission, you were able to eat by mouth and NG tube was
removed. Physical therapy saw you during your stay and
recommended rehab, however due to non-compliance with treatments
we were told that rehab facilities declined your case. We also
explored the option of skilled nursing facility but were told
that you were told by Case management that this is also not an
option due to age barriers. You continues to be non-compliant
with the Lovenox and wanted to leave for a shelter. It was also
discussed if you could go to godmother or grandmother's home,
but due to you refusing to take lovenox godmother did not allow
this. On several occasions when asked you chose to be discharged
to a shelter. A shelter was identified, godmother had brought
your wheelchair from home, Lovenox script was given. You
reported you have all other medications at godmother's home. We
still recommend physical therapy, psych therapy and psychiatry
follow up.
We changed your medications as follows:
- Discontinued Ativan and Tizanidine
- Decreased Gabapentin dose
- Encourage intake by mouth, NG feeds are not needed
Please call your ___ if you decide to return to home, as ___
will be unable to visit you at the shelter.
Please take your other medications as prescribed.
Please follow up with your Neurologist and your primary care
physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, 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 a pleasure taking care of you!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10519840-DS-19 | 10,519,840 | 23,149,090 | DS | 19 | 2172-08-20 00:00:00 | 2172-08-20 20:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
CT guided biopsy
History of Present Illness:
HPI: The patient is a ___ y/o F with PMHx of A. fib not on
anticoagulation as well as distant bladder carcinoma in
remission
who presented to ___ with RLQ pain with associated emesis,
with imaging showing L kidney mass. OSH course was complicated
by
A. fib with RVR, for which she was given 20 mg IV diltiazem and
subsequent 30 mg PO diltiazem with good effect. She was
transferred here for evaluation of her L kidney mass.
The patient reports that she initially developed pain in her RLQ
2 days PTA. This was associated with emesis whenever she tried
PO
intake, without true nausea. Pain ranged in intensity from
___
to ___. She denies associated fevers or diarrhea. Given
persistence of symptoms, she presented to the ED for evaluation.
Labs at ___ notable for WBC of 15.1. Cr 1.3. Tn 0.02. UA
with + nitrites, + leukesterase, WBC TNTC, and 4+ bacteria. UCx
with > 100k e.coli. CT A/P with L renal mass (suggestive
transitional cell carcinoma), lymphadenopathy, lung nodules.
___ ___ Exam:
A&Ox3
CV: irregularly irregular with nl S1S2, 2+ radial and DP pulses
Resp: CTAB with no wheezes/rales/rhonchi
Abd: +BS, nondistended with mild tenderness
MSK: no BLE leg edema
ED Course:
Initial VS: 98.3 64 161/89 18 100% 4L NC Pain ___
Labs significant for leukocytosis 12.9, BNP 3361. Otherwise
largely unremarkable.
Imaging: OSH imaging as above. CT chest, TTE (see below).
Meds given:
___ 00:41 PO/NG Sertraline 50 mg
___ 00:41 PO/NG Aspirin 81 mg
___ 02:02 PO Verapamil 40 mg
___ 04:44 IVF NS 1000 mL
___ 09:27 PO/NG Cilostazol 50 mg
___ 09:27 PO/NG Losartan Potassium 100 mg
___ 09:27 IV CefTRIAXone (1 gm ordered)
___ 09:27 PO Verapamil 40 mg
___ 09:27 PO/NG Propranolol 20 mg
___ 09:27 PO/NG Apixaban 5 mg
___ 09:27 SC Insulin 26 UNIT
VS prior to transfer: 97.8 84 181/68 16 97% RA Pain ___
On arrival to the floor, the patient endorses the above story.
She reports feeling thirst, which she attributes to chronic dry
throat. She also endorses a chronic symptom of feeling like she
is going to cough when she lies flat. She also reports chronic
inattention symptoms. Despite positive UA as above, she denies
any urinary symptoms.
ROS: As above. Denies fevers, headache, lightheadedness,
dizziness, sore throat, sinus congestion, chest pain, heart
palpitations, shortness of breath, cough, nausea, diarrhea,
constipation, urinary symptoms, muscle or joint pains, focal
numbness or tingling, skin rash. The remainder of the ROS was
negative.
Past Medical History:
atrial fibrillation - not on a/c
bladder cancer (treated "years ago" in FL)
depression
tremor
HTN
HLD
? PVD
DM
overactive bladder
COPD
Social History:
___
Family History:
Mother with ? brain cancer. Does not know why her
father passed away. Denies any other significant family history
of cancer.
Physical Exam:
ADMISSION
==========
VS - 24 HR Data (last updated ___ @ 1154)
Temp: 97.3 (Tm 97.3), BP: 153/78, HR: 69, RR: 17, O2 sat:
96%, O2 delivery: 2 LNC
GEN - Alert, NAD
HEENT - NC/AT, OP clear, face symmetric, MMM
NECK - Supple
CV - RRR, ___ systolic murmur most appreciated at the heart
base;
no other m/r/g appreciated
BACK - no CVAT
RESP - Breathing appears non-labored; bibasilar rales
ABD - S/NT/ND, BS present
EXT - No ___ edema noted, No calf tenderness
SKIN - No apparent rashes
NEURO - Alert, Oriented x 3 (but got exact date wrong - thought
it was ___ unable to perform ___ backwards but was able to
perform ___ backwards; face symmetric; tongue midline; PERRL;
EOMI; ___ strength in all 4 extremities
PSYCH - Calm, appropriate
DISCHARGE
==========
Pertinent Results:
ADMISSION:
===========
___ 11:00PM BLOOD WBC-12.9* RBC-5.24* Hgb-14.4 Hct-42.4
MCV-81* MCH-27.5 MCHC-34.0 RDW-14.4 RDWSD-42.0 Plt ___
___ 11:00PM BLOOD Neuts-76.0* Lymphs-13.7* Monos-6.2
Eos-2.6 Baso-0.9 Im ___ AbsNeut-9.81* AbsLymp-1.77
AbsMono-0.80 AbsEos-0.33 AbsBaso-0.11*
___ 06:45AM BLOOD ___ PTT-25.1 ___
___ 11:00PM BLOOD Glucose-101* UreaN-17 Creat-1.1 Na-139
K-4.8 Cl-102 HCO3-21* AnGap-16
___ 11:00PM BLOOD ALT-7 AST-17 AlkPhos-86 TotBili-0.4
___ 11:00PM BLOOD Lipase-14
___ 06:45AM BLOOD cTropnT-<0.01
___ 11:00PM BLOOD cTropnT-<0.01 proBNP-___*
___ 11:00PM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.7 Mg-1.7
___ 05:30AM BLOOD %HbA1c-5.8 eAG-120
MICRO:
=======
BCx (___): pending x 2
UCx ___, ___: >100K E.coli
------ ------
AMIKACIN S <=2
AMPICILLIN R >=32
AMPICILLIN/SULBACTAM I 16
CEFAZOLIN S <=4
GENTAMICIN R >=16
IMIPENEM S <=0.25
ERTAPENEM S <=0.5
LEVOFLOXACIN R >=8
NITROFURANTOIN S <=16
PIPERACILLIN/TAZOBACTAM S <=4
TOBRAMYCIN I 8
TRIMETHOPRIM/SULFA R >=320
STUDIES:
========
CT A/P (OSH ___:
1. Abnormal soft tissue mass and underperfusion of an upper pole
left renal mass extending into the upper pole calyces highly
suggestive of a transitional cell carcinoma with adjacent
retroperitoneal necrotic adenopathy on the left renal hilum.
2. Small lung nodules suggesting metastatic disease.
3. Air present within the bladder please correlate to recent
instrumentation.
4. Incidental gallstones no evidence of acute cholecystitis
CXR (OSH ___:
Heart size enlarged left ventricular predominance. Lungs show no
focal areas of consolidation. No pleural fluid or pneumothorax
CT chest w/o contrast (___):
Most likely diagnosis for widespread central adenopathy
involving
the hila, mediastinum, and retrocrural stations and half dozen
lung nodules, up to 2 cm wide, is metastasis. Occasionally
sarcoidosis will present in this fashion.
Moderately severe emphysema.
Aortic valvular calcification is heavy enough to be
hemodynamically significant. Heavy atherosclerotic
calcification, particularly coronary arteries.
TTE (___):
The left atrial volume index is severely increased. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and global systolic function (LVEF>70%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending
and arch levels are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.6cm2). Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. There is a mildly increased
transmitral valve gradient, but no valvular stenosis. At least
mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Left ventricular hypertrophy with severely dilated
left atrium and vigorous global systolic function. At least mild
mitral regurgitation. Sinus rhythm during this study. Moderate
pulmonary hypertension. Grade II diastolic dysfunction with
increased PCWP. Mild aortic stenosis.
Urine cytology: suspicious for urothelial cancer
Brief Hospital Course:
___ y/o F with PMHx of A. fib (not on anticoagulation), remote
bladder CA (reportedly in remission), COPD (previously on ?4L
home O2, none currently), tremor, depression, HTN, HLD,
overactive bladder presented to ___ with nausea/R-sided
abdominal pain, afib w/RVR, and possible UTI, found to have a L
renal mass and transferred for further evaluation.
# LEFT RENAL MASS:
# PULMONARY NODULES:
New L renal mass noted on OSH imaging with pulmonary nodules on
CT chest, concerning for metastatic urothelial cancer given her
hx vs RCC or lymphoma. Admitter spoke to oncology yesterday, who
said to go after lungs and call them back with tissue. ___ said
they can't get to the lungs but could try to go after a
para-aortic lymph node (couldn't do it because the ED gave her a
dose of apixaban when she came in for afib). Urology following.
She ultimately underwent biopsy on ___. She will follow up
with PCP and urology and referral from oncology thereafter.
- urine cytology suspicious for high grade urothelial carcinoma.
This was shared with daughter on discharge. Final LN pathology
pending.
# ATRIAL FIBRILLATION:
# ACUTE ON CHRONIC DIASTOLIC HEART FAILURE:
Presented with afib and RVR to ___, started on diltiazem with
good response. Transitioned to home verapamil on admission with
intermittent RVR, so I switched her back to dilt today to allow
for easier dosing and titration. Precipitant may be volume
overload (BNP elevated, PCWP elevated on TTE in setting of
HFpEF, for which I gave her a dose of Lasix this evening), less
likely UTI. Low suspicion for ACS (no chest pain, trop neg x 2,
EKG non-ischemic). Not on anticoagulation as outpatient;
received one dose of apixaban in the ED. CHADs2 =4, so would
discuss anticoagulation after biopsy in the outpatient setting.
# ABDOMINAL PAIN:
# NAUSEA / EMESIS:
Unclear if this was truly related to patient's renal mass, as
symptoms were contralateral. Ddx includes viral gastritis. LFTs
and lipase WNL, and CT A/P without obvious alternative
pathology. Improving this morning. Caution with Zofran, as QTC
is a bit long (460).
# URINARY TRACT INFECTION:
# LEUKOCYTOSIS:
Patient presented with afib w/RVR, baseline urinary frequency in
the setting of overactive bladder, and leukocytosis. Denies
dysuria, but UA positive and UCx from ___ growing >100K
E.coli. Unclear whether this represents a true UTI vs
asymptomatic bacteriuria, but given renal mass and resolution of
leukocytosis concurrent with antibiotics, reasonable to continue
treatment for now. Treated with Ceftriaxone
# ENCEPHALOPATHY:
Pt noted to be easily distracted on initial evaluation with
question of encephalopathy. No clear deficits on exam ___.
Evaluated by OT and thought likely safe for home.
# COPD:
# COUGH:
Hx of COPD, for which she has previously required home O2
(reportedly as much as 4L home O2, none since moving from
___ not followed by a pulmonologist). Complains of mild
cough and SOB without significant sputum productive. ___ be
secondary to mild volume overload as above vs COPD (but not
clearly a COPD exacerbation). Started advair in place of home
Breo Ellipta, as well as nebs. Needs pulmonologist.
# HYPERTENSION: continue home losartan
# DIABETES MELLITUS:
Mild hypoglycemia initially in setting of being NPO. Home 70/30
decreased from 26 BID to 15 BID. Her A1c was found to be <6 and
even with regular diet her FSBG remained on the low side. Her
insulin was decreased further and she will be discharged on a
lower dose as specified.
# HLD:
Holding statin for now given contraindication to home verapamil;
can readdress with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Verapamil 40 mg PO Q12H
2. Propranolol 5 mg PO DAILY
3. Sertraline 50 mg PO DAILY
4. Cilostazol 50 mg PO BID
5. Losartan Potassium 100 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Oxybutynin 5 mg PO TID
9. 70/30 26 Units Breakfast
70/30 26 Units Dinner
10. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
Discharge Medications:
1. Benzonatate 100 mg PO BID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*15 Capsule Refills:*0
2. Prochlorperazine 5 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg 1 tablet(s) by mouth four
times a day Disp #*30 Tablet Refills:*0
3. 70/30 10 Units Breakfast
70/30 10 Units Bedtime
4. Aspirin 81 mg PO DAILY
5. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
6. Cilostazol 50 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Oxybutynin 5 mg PO TID
9. Propranolol 5 mg PO DAILY
10. Sertraline 50 mg PO DAILY
11. Verapamil 40 mg PO Q12H
12. HELD- Simvastatin 10 mg PO QPM This medication was held. Do
not restart Simvastatin until PCP follow up
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Renal mass
Lung/Chest mass
Urinary tract infection
Atrial fibrillation
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for abdominal pain and found to have a mass in
your kidney, as well as in your lungs and enlarged lymph nodes.
You underwent a biopsy to determine the cause, but this is
concerning for cancer. Urine cytology test was suspicious for
urothelial cancer. Close follow up with your PCP and urologist
is necessary for ongoing care. You may follow up at ___
oncology if you decide to come here. You were also treated for
a urinary tract infection.
Finally, you were found to have atrial fibrillation. Please
discuss taking blood thinners for this condition. We will keep
you on your aspirin for now. Also we found that your blood
sugars were low and you need much less insulin for now.
Followup Instructions:
___
|
10520482-DS-8 | 10,520,482 | 21,550,471 | DS | 8 | 2161-06-20 00:00:00 | 2161-06-22 15:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Wrist fracture s/p fall, delirium
Major Surgical or Invasive Procedure:
Closed reduction of wrist fracture
History of Present Illness:
___ w/ PMH significant for COPD not on home O2, HTN, CAD, and
diverticulitis, sent to ED from PCP's office at ___ for 20lb
weight gain since ___, increasing abdominal girth, and pain
in her left flank.
Pt states that since she was hospitalized for colitis in ___ at ___, her legs have been puffy, and she has had reduced
urine output. It has been worsening acutely over the last few
weeks. She normally weighs 123 lbs, but weighted 136 in ___. Yesterday, she weighed 148 lbs. Pt also feels that her
abdominal girth has been increasing, which she feels has
exacerbated her back pain.
Pt has intermittent back pain and spasms, which have bothered
her for several years. She has a known compression fracture of
vertebral body T11 with no retropulsion. Pt experiences
intermittent "attacks" of back pain/spasm, which last days to
weeks. Pt ususally takes old pills which she has saved of
ibuprofen, hydrocodone/acetaminophen, and tizanidine when this
occurs. Her current back pain spell has lasted for ___ weeks.
She also sometimes experiences "weakness" of her legs, but
states that she walks normally. Pain prevents her from lifting
her legs. Denies any numbness or stool/urine incontinence.
Regarding her abdominal pain, Pt was admitted in ___ for
bloody diarrhea and was found on CT to have colitis involving
the transverse, descending, and sigmoid colon. Extensive stool
studies for infectious cause were all negative. Sigmoidoscopy on
___ showed mild diverticulosis of the colon, some patchy
erythema and petechia consistent with non-specific inflammation,
and no ulcers were seen, thought to be most consistent
infectious colitis. Biopsy was normal.
Per Pt's PCP, ___ was complaining about abdominal bloating and L
sided flank pain. Pt also had bilateral pedal edema up to
abdomen. Pt also had a chest CT to work up a known stable chest
nodule, with incidentally found L sided renal stone of 4mm. Pt
has a history of kidney stones. Pt states that her current back
pain feels different from her kidney stone.
Regarding her weight gain, Pt was recently seen in cardiology
clinic on ___ by Dr. ___ felt that Pt's
peripheral edema may be due to increased pulmonary pressures
given her underlying COPD. She was supposed to get an
echocardiogram, which she has not done yet, with a plan to
increase her diuretic regimen of furosemide 20mg po daily.
.
In the ED, initial VS 98.0 72 182/68 18 98%. Lactate was
elevated at 2.6. CBC, chem panel, chest XR all normal. BNP
normal. CT abdomen showed mild sigmoid diverticulitis and "tiny"
L renal stone. Pt apparently had a very severe back spasm while
lying on the CT scanner and was in excruciating. Required 5mg iv
valium, and once back in ED, medicated w/ 5mg iv morphine and
4mg iv zofran w/ significant relief.
Vitals on transfer: 98.1. HR: 78. BP: 144/85. O2: 93-98%ra, RR:
___.
On arrival to the floor, vitals were 97.5F, 137/68, 66, 18, 99%
RA.
ROS: Denies fever, chills, night sweats, reports weight gain as
per hpi. Denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain.
Sleeps on 1 pillow flat on bed. Reports left sided back pain as
per Hpi. Mild abdominal pain. No nausea, vomiting, diarrhea.
Reports some constipation. No BRBPR, melena, hematochezia,
dysuria, hematuria. Reports reduced urinary output as above and
lower extremity edema.
Past Medical History:
CAD
HTN
COPD, not on home O2
Diverticulitis
intermittent back pain/spasm
pulmonary nodule
nephrolithiasis
Social History:
___
Family History:
No family hx of IBD, colon cancer. Mother had kidney stones.
Reports father died of duodenal ulcer.
Physical Exam:
Admission Exam:
VS - Temp 97.5F, BP 132/74, HR 59, R 16, O2-sat 94% RA, wt
100.8lbs
GENERAL - somulent and asleep when entered the room
HEENT - pupils not constricted, Dry MM
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, limited breath sounds due to shallow breathing
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, R wrist in
splint with ace bandage around it, fingers distal to splint are
WWP and sensation appears to be intact
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - somulent but arouses to voice and touch, very confused
and clearly has no idea where she is or what is going on, able
to tell me her last name and squeeze my fingers with her left
hand on command, but otherwise not able to follow commands
Discharge Exam:
GENERAL - Awake, deaf so difficult to appreciate orientation.
Speaking full fluent sentences but tangential and off topic at
times.
HEENT - NCAT, mmm
NECK - Supple, no ___, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes, rales or rhonchi
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, R wrist
casted, bilateral ___ with ecchymoses
NEURO - Confused at times, alert, interactive though
inappropriate answering to questions (deaf though so difficult
to know if she hears question)
Pertinent Results:
Admission Labs:
___ 12:40PM BLOOD WBC-6.6# RBC-2.93* Hgb-9.2* Hct-29.6*
MCV-101* MCH-31.4 MCHC-31.1 RDW-16.3* Plt ___
___ 12:40PM BLOOD Neuts-77.2* Lymphs-14.6* Monos-7.7
Eos-0.4 Baso-0.3
___ 12:40PM BLOOD ___ PTT-35.2 ___
___ 12:40PM BLOOD Glucose-107* UreaN-23* Creat-1.6* Na-143
K-3.9 Cl-107 HCO3-27 AnGap-13
___ 12:40PM BLOOD CK(CPK)-95
UA on admit:
___ 02:00PM URINE Color-Straw Appear-Hazy Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 02:00PM URINE RBC-<1 WBC-9* Bacteri-FEW Yeast-NONE
Epi-2 TransE-<1
___ 02:00PM URINE CastHy-1*
Micro:
- BCx NGTD x2
- CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Discharge:
___ 06:00AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.6* Hct-28.6*
MCV-103* MCH-31.1 MCHC-30.1* RDW-16.8* Plt ___
___ 06:00AM BLOOD Glucose-99 UreaN-31* Creat-1.8* Na-142
K-3.9 Cl-104 HCO3-27 AnGap-15
Reports:
CT Head: ___
1. No acute intracranial abnormality, with chronic findings, as
above.
2. Possible acute inflammatory findings involving the dominant
sphenoid air cell; correlate clinically.
CT C-Spine ___
IMPRESSION: No acute fracture or malalignment.
CXR PA/LAT ___
Examination is somewhat limited by positioning and AP technique.
Bibasilar opacities may be due to atelectasis, elsewhere there
is no focal
opacity. No pneumothorax or significant pleural effusion is
seen. There is
mild-to-moderate cardiomegaly. Deviation of the trachea to the
right is
unchanged. There is tortuosity and calcification of the aorta. A
calcified
granuloma at the right base appears unchanged. Degenerateive
changes and
multiple levels of retrolisthesis seen in the lower thoracic and
upper lumbar regions noted.
L Knee X-Ray ___
- No acute fracture or dislocation is seen. No joint effusion at
the
knee is detected. There are dense vascular calcifications.
Incidental note
is made of likely enchondroma in the distal femur. The bones are
diffusely
demineralized.
HIP ___
- No acute fracture or dislocation. Stable appearance of total
hip
arthroplasties.
Hand/Wrist ___
There is a transverse, impacted fracture of the distal radius
with
dorsal angulation of the distal fracture fragment (Colles' type
fracture)
without definite intraarticular extension. The bones are
diffusely
demineralized. There is also a minimally displaced ulnar styloid
fracture. There are degenerative changes notable at the first
carpometacarpal and
triscaphe joints. Well corticated osseous fragment seen just
proximal to the trapezium on the oblique view which was present
on prior exam. Degenerative changes are also noted along the
proximal and distal interphalangeal joints
Wrist ___:
Status post two reductions, after impacted fracture of the
distal
radius. Expected alignment of fractured bony elements. Expected
alignment of fractures.
Right Knee ___:
There is no evidence of acute fracture or dislocation. The
minimal joint effusion might be present. Dense vascular soft
tissue calcifications, as an incidental finding, an enchondroma
might be present in the distal right femur. No periarticular
soft tissue swelling
Brief Hospital Course:
Patient is a ___ yo female with PMHx CKD (cr 1.6-2.1), Chronic
sCHF with LVEF35%, CAD, HTN, HLD, and hypothyroidism sent in s/p
fall found to have a R distal radius fracture, delirious in ED
after reduction of fracture and Morphine 5mg IV.
# Distal R Radius Fracture: Seen by orthopedics in ED who
successfully reduced fracture and splinted with overlying
stitches due to skin tear. Films showed successful reduction.
While in acute delirium patient self-removed splint in ED which
was replaced by ortho and follow up films showed successful
reduction. Pain was controlled with standing tylenol and prn
tramadol (though she did not require prn doses). Discharged with
gram positive coverage for prophylactic cellulitis to continue
total 5 day course.
# UTI: Dirty urinalysis in the ED. UTI ___ grew resistant E.
Coli (S only to Meropenem and Cefepime). Patient did not
complain of dysuria though baseline dementia confounding
clinical picture. Delirium likely exacerbated by UTI which may
also have precipitated unwitnessed fall. Ceftriaxone 1gram IV
was started for UTI since bactrim avoided for CKD and avoided
Cipro given Delirium risk in elderly dementia patients. She was
broadened to Cefepime given prior resistant organisms, and she
received 2 doses total (Q24hours). Additionally, Cefepime gives
GPC coverage for coverage of skin tear. After urine culture came
back with pan-sensitive Citrobacter she was switched to
Levofloxacin 250mg PO Q48hours in order to complete 7 day course
for complicated cystitis. Levofloxacin will cover citrobacter
and also confer GPC coverage for skin tear. Bactrim was not
chosen because eGFR of 13. Cephalosporin not chosen because
Citrobacter can become resistant within ___ days of treatment.
# Delirium: Acute delirium on chronic baseline dementia. AOx1 at
baseline, delirious in ED and removed splinting. She was given
5mg IV morphine in the ED and patient became somnolent and slept
all night and the following day. Acute exacerbation of mental
status likely multifactorial from pain, trauma, opiate
administration in ED and UTI. Continued home meds Aripiprazole
5mg at 2pm and 2.5mg Qhs. Patient did not require Haldol during
admission. Treated UTI as above, avoided Opiates and treated
pain with standing Tylenol and tramadol prn.
# CHF: Chronic, systolic CHF with LVEF of 35%, ischemic in
origin and s/p stenting. No evidence of acute exacerbation on
admission. Continue Metoprolol Tartrate 25 mg PO BID, Aspirin 81
mg PO/NG DAILY, Clopidogrel 75 mg PO/NG DAILY, Lisinopril 10 mg
PO/NG DAILY and Furosemide 20 mg PO/NG DAILY per home regimen.
Per discussion with daughter her nurse practitioner had
discontinued aspirin to limit PO medications. Aspirin was
restarted on admission. If she requires medication limitations
then would discontinue Plavix but continue Aspirin given history
of stenting.
# HTN: Chronic, stable with good control. CKD may be
complication. Continued lisinopril and metoprolol as above
# Hypothyroidism: Chronic, stable. Continued Levothyroxine 75
mcg PO DAILY
# Social issues: Patient lives in assisted living facility but
as of right now does not appear she can care for herself. She
was evaluated by physical therapy who thought she would benefit
from inpatient physical rehabilitation. She was discharged to
___ rehab. She may require more aggressive 24
hour home monitoring.
TRANSITIONAL ISSUES:
# CODE: DNR per sheet from ___
# CONTACT: ___ (___)
# HCP is ___ ___ or ___
# Being treated with Levofloxacin, if delirium worsens this may
by quinolone related and consider changing medications to
Bactrim to complete 7 day course ___ Day 1)
# Delirium management is important: Reorientation, sleep wake
cycle and avoid narcotics
# If considering limiting medications then would discontinue
Plavix but continue Aspirin. Would not discontinue calcium or
vitamin D given recent admission for wrist fracture and she
continues to be high fall/fracture risk.
# She will require 24 hour care at home unless mental and
physical status improve at Rehab.
Medications on Admission:
levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day
lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
calcium carbonate 200 mg calcium (500 mg) Tablet 1 BID
metoprolol succinate 25 mg PO BID
allopurinol ___ Tablet 1 PO daily
aripiprazole 5 mg Tablet at 2pm and 2.5mg tab Qhs
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
cholecalciferol (vitamin D3) 400 unit 1 Tablet PO daily
ferrous sulfate 325 mg (65 mg iron) 1 Tablet PO daily
acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day): Do not exceed 4 grams per day.
Disp:*180 Tablet(s)* Refills:*0*
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
8. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
16. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID
(2 times a day).
17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
18. levofloxacin 250 mg/10 mL Solution Sig: Two Hundred Fifty
(250) mg PO Q48H (every 48 hours) for 2 doses.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Wrist fracture
Delirium
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ after a
fall at home and fracture of your wrist. You became confused in
the emergency department which prompted your admission.
Confusion was likely from pain, opiate pain medications and a
urinary tract infection. You were admitted to the hospital and
treated for a urinary tract infection with IV antibiotics. Your
confusion and pain improved and you are being discharged in
improved condition with plan to continue antibiotics by mouth.
The following changes to your medications were made:
- START Senna, Colace and Miralax for bowel regimen
- START Levofloxacin 250mg every 48 hours for 2 doses
- STOP Loratadine as this may increase confusion
- STOP Ranitidine to limit medications you are taking
- If you need to reduce medications would stop Plavix and
continue Aspirin
- No other changes were made, please continue taking as
previously prescribed
Other instructions:
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10520715-DS-10 | 10,520,715 | 21,540,678 | DS | 10 | 2176-06-10 00:00:00 | 2176-06-18 17:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye / Cephalosporins / atenolol /
codeine
Attending: ___.
Chief Complaint:
Febrile neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old male with PMH notable for DM2, HTN,
CKD, PVD (s/p bypass x2), CABG, HFpEF, and AML with adverse
risk
cytogenetics currently receiving palliative decitabine and
transfusion dependent who presented to ___ with
febrile neutropenia (T>101), epistaxis and shortness of breath.
Dr. ___ call from OSH ___ MD who reported that he was
concerned about a possible abdominal wall infection. He was
cultured and received vanc/zosyn there though he has a
documented
allergy to cephalosporin. An ultrasound was performed at the OSH
with reportedly did not show any drainable fluid collection.
He reports over the last week he has been having increasing
dyspnea and orthopnea. Additionally he has a mild cough but he
says this is at baseline. His throat has been sore since his
last
admission but notes his appetite has been good. He states that 3
days ago his abdomen had a pimple in the area he injects his
insulin and began to look worse and more red over the following
few days. He went to ___ yesterday and was started on a Bactrim
which he has taken 3 doses of. Then yesterday he became febrile
to 100.5 at home and presented to ___ prior to being
transferred to ___.
In the ___, initial vitals: T 98.4, HR 96, BP 151/82, RR20, SaO2
94% RA
- Exam notable for cellulitc appearing abdominal wall
- Labs were notable for:
FluAPCR: Negative
FluBPCR: Negative
1.4>7.1/20.5<22 ANC 150
133|99|9
=========<178
4.0|21|1.1
- Imaging:
___ CXR:
Moderate pulmonary edema and small bilateral pleural effusions.
Cannot entirely exclude an underlying pneumonia.
- Patient was given:
- Zosyn 3.375 g @ 0826 (only received half due to call about
history of anaphylaxis with cephalosporins)
- Vancomycin 1 g @ 0826
- Aztreonam 2 g @ 0938
- Decision was made to admit to Omed for febrile neutropenia
- Vitals prior to transfer were T92, BP 145/74 RR 24, SaO2 96%
RA
On arrival to the floor, patient is sitting comfortably in
bedside chair with son.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Found incidentally to have pancytopenia in ___ with bone
marrow biopsy demonstrating ~30% blasts consistent with AML
with
adverse cytogenetics (complex abnormal karyotype including 5q-,
12p-, 17p-) likely arising from background of MDS,induction with
decitabine x 10 ___ c/b febrile neutropenia
without source.
PAST MEDICAL HISTORY:
-Mitral valve prolapse
-HTN
-HL
-CKD
-Hypothyroidism
-DM complicated by neuropathy
-PVD
-Primary open-angle glaucoma
-Hx of Pain medication agreement signed ___
PSH:
-S/P L TKR x2, with 2 prior arthroscopies of that knee
-S/P prosthetic total arthroplasty of the R hip ___
-cholecystectomy
-bypass graft othr,fem-pop (___)
-bypass graft othr,fem-pop (___)
-cataract extraction: - phacoemulsification (Right, ___
-cataract extraction - phacoemulsification (Left, ___
Social History:
___
Family History:
No family history of hematologic disorders or malignancies. His
sister had breast cancer in her ___. Mother had diabetes, died
age ___. Father had either MI or CHF, died in his ___.
No family history of hematologic disorders or malignancies. His
sister had breast cancer in her ___. Mother had diabetes, died
age ___. Father had either MI or CHF, died in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals: T98.5PO BP153/66 HR92 RR20 SaO296% RA
GENERAL: Sitting up in chair NAD
HEENT: EOMI, PERRL, MMM, erythematous pharynx but no exudate or
lesions. Firm symmetric but enlarged submandibular nodess.
NECK: Supple, No JVP in sitting upright
LUNGS: Mild bibasilar crackles
CV: Irreg. Irreg
ABD: Skin with left erythematous hard purpuric nodule on left
with surrounding erythema. BS positive, abdomen non-distended,
soft, non-tender to palpation.
EXT: Pitting edema to knee, with chronic stasis changes, dry
skin. Right with some mild erythema on shin but no obvious
purulence or skin breakdown. Symmetric palpable DP pulses
NEURO: CN2-12 intact, gait slow but no focal deficits. Strength
in UE grossly intact
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
======================
Vitals: T 98.4, BP 100/62, HR 66, RR 18, SpO2 98/RA
GENERAL: sitting in chair. NAD.
HEENT: MMM, no mucositis. No blood around nares.
NECK: Supple, no JVP in sitting upright
LUNGS: faint bibasilar crackles, no wheezes or ronchi.
CV: Irregularly irregular rhythm, ___ systolic murmur, radiating
to carotids
ABD: BS positive, abdomen non-distended, soft, non-tender to
palpation. Resolving LLQ erythema with continued eschar.
EXT: trace edema to knee L > R. Improved LLE rash, now with mild
erythema. Symmetric palpable DP pulses
NEURO: grossly intact cranial nerves
ACCESS: PIV
Pertinent Results:
ADMISSION LABS:
==============
___ 10:08AM BLOOD WBC-1.2* RBC-2.26* Hgb-6.8* Hct-20.3*
MCV-90 MCH-30.1 MCHC-33.5 RDW-15.2 RDWSD-49.1* Plt Ct-15*
___ 10:08AM BLOOD Neuts-6* Bands-0 ___ Monos-14*
Eos-0 Baso-0 ___ Myelos-0 Blasts-36* NRBC-6*
AbsNeut-0.07* AbsLymp-0.53* AbsMono-0.17* AbsEos-0.00*
AbsBaso-0.00*
___ 11:30AM BLOOD Glucose-178* UreaN-19 Creat-1.1 Na-133
K-4.0 Cl-99 HCO3-21* AnGap-17
___ 07:10AM BLOOD ALT-35 AST-38 LD(LDH)-229 AlkPhos-91
TotBili-1.9* DirBili-0.8* IndBili-1.1
___ 07:05AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
___ 07:10AM BLOOD Hapto-241*
___ 11:45AM BLOOD Lactate-1.1
___ 07:44PM URINE Color-Straw Appear-Clear Sp ___
___ 07:44PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 07:44PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
IMPORTANT LABS:
==============
___ 03:23PM BLOOD Thrombn-15.2
___ 06:44PM BLOOD Ret Aut-0.5 Abs Ret-0.01*
___ 07:05AM BLOOD FacVIII-253*
___ 07:05AM BLOOD VWF AG-393* VWF ___
___ 03:23PM BLOOD Inh Scr-POS Lupus-POS
MICRO LABS:
==========
Galactomannan (___): 0.18 (not detected)
Galactomannin (___): 0.12 (not detected)
Beta-glucan (___): 49 (negative)
Beta-glucan (___): Pending
Blood culture ___ x2, ___ x2): Negative
Urine culture (___): Negative
Sputum (___): Negative PCP, contamination
___ viral culture (___): Negative for respiratory viral
antigen
Blood/fungal culture (___): Pending
IMAGES:
=======
CXR (___): Mild improvement in bibasilar airspace opacities.
Findings are concerning for multifocal pneumonia.
___ (___): No evidence of deep venous thrombosis in the right
or left lower extremity veins.
CT chest w/o contrast (___): 1. Progression of diffuse
bilateral peripheral opacities and reactive mediastinal
lymphadenopathy, most likely infection, pathogens including
aspergillus, nocardia, and bacteria via septic embolization. 2.
Mild emphysema and bronchial inflammation. 3. Possible
pulmonary artery hypertension. 4. Extensive coronary artery and
aortic valve calcifications. 5. Status post median sternotomy
with small unchanged postoperative mediastinal hematoma.
CTAP w/o contrast (___): 1. No evidence of intra-abdominal
infection. 2. Right nonobstructing 2 mm renal stone. 3.
Diastases recti.
Sinus CT (___): 1. Mild mucosal thickening of the right frontal
and bilateral maxillary sinuses without air-fluid levels or bony
destruction.
TTE (___): FOCUSED STUDY/LIMITED VIEWS OBTAINED: LV systolic
function appears depressed. Right ventricular chamber size is
normal The number of aortic valve leaflets cannot be determined.
The aortic valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthetic mitral leaflets appear normal. No
mass or vegetation is seen on the mitral valve. No mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion. Compared with the report of the prior
study (images unavailable for review) of ___ (full
study), pulmonary artery pressures are higher. No mitral
regurgitation is present. The other comparable findings are
similar.
DISCHARGE LABS:
==============
___ 07:05AM BLOOD WBC-1.3* RBC-2.49* Hgb-7.5* Hct-22.4*
MCV-90 MCH-30.1 MCHC-33.5 RDW-14.7 RDWSD-47.8* Plt Ct-44*
___ 07:05AM BLOOD Neuts-11* Bands-0 ___ Monos-3*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 Blasts-48* NRBC-1*
AbsNeut-0.14* AbsLymp-0.49* AbsMono-0.04* AbsEos-0.00*
AbsBaso-0.00*
___ 07:05AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:05AM BLOOD Plt Smr-VERY LOW Plt Ct-44*
___ 07:05AM BLOOD ___ PTT-48.2* ___
___ 07:05AM BLOOD Glucose-151* UreaN-36* Creat-1.1 Na-134
K-4.2 Cl-98 HCO3-26 AnGap-14
___ 07:05AM BLOOD ALT-29 AST-25 AlkPhos-130 TotBili-0.7
___ 07:05AM BLOOD Albumin-3.5 Calcium-9.0 Phos-4.4 Mg-2.1
Brief Hospital Course:
Mr. ___ is an ___ year old male with PMH notable for DM2, HTN,
CKD, PVD (s/p bypass x2), CABG, HFpEF, and AML with adverse
risk cytogenetics currently receiving palliative decitabine and
transfusion dependent who presents with cellulitis in the
setting neutropenia. He was also found to have is acute on
chronic systolic and diastolic heart failure as well as invasive
aspergillosis.
He originally presented with fever and abdominal cellulitis in
the setting of neutropenia. He was started on aztreonam and
vancomycin IV for empiric treatment. He continued to be febrile
throughout the first 6 days, at which point he was transitioned
to PO Bactrim and clindamycin (he is allergic to penicillins).
His cultures at ___ showed MSSA sensitive to
Bactrim, so he was switched to Bactrim DS BID per infectious.
However, he continued to spike fevers on bactrim so he was
broadened again to vancomycin and aztreonam. He had a CT chest
w/o contrast that showed halo sign concerning for invasive
aspergillosis, even though he was galactomannan negative twice.
Thus, he was started on voriconazole. He completed his course
for his cellulitis while in the hospital and so the vancomycin
and aztreonam were discontinued. He will continue on
voriconazole and will get a repeat CT chest in 1 month to assess
for resolution. Pulmonology was consulted and given his
extensive comorbidities he was deemed a high-risk candidate for
bronchoscopy with cultures. Infectious disease also started him
on ciprofloxacin for bacterial prophylaxis. He also has symptoms
of orthopnea and sleeps in a recliner, so he was diuresed with
Lasix IV and PO. He also had an echocardiogram to evaluate for
endocarditis (negative), but it did find new depressed LV
function. He is pancytopenic from his AML and required 5 u PRBCs
and 3 u PLTs while here. His platelets were transfused when they
were ~___ and he was having epistaxis. He had an elevated PTT
throughout his hospital course and he was diagnosed with lupus
anticoagulant. He also has new hoarseness and laryngitis from
his last discharge, but ENT stated they would not pursue
laryngoscopy in the setting of low platelets. He had abnormal
LFTs with mild transaminitis and tbili/alk elevation, but he had
a negative RUQ US and no intra-abdominal complaints of pain. His
tbili/alk improved, but his transaminitis has been persistent
and still elevated upon discharge (unknown etiology). He had a
slight ___ to creatinine 1.4, but this was near his baseline of
1.1-1.2 upon discharge (1.3). He was hyponatremic towards the
end of his hospitalization, but this remained stable (130s) for
several days. He was continued on all of his home medications
for his CAD (not on aspirin with low platelets), neuropathy,
hypertension, GERD, hypothyroidism.
TRANSITIONAL ISSUES:
====================
-Will follow-up with his hematologist and infectious disease
-New medications: Voriconazole 200 mg BID, ciprofloxacin 500 mg
BID. He will take these medications until infectious disease
says it is alright to discontinue them.
-Changed medications: Switched Lasix 40 mg BID to 60 mg BID,
please monitor weight and electrolytes and adjust as needed
-He is pancytopenic (neutropenic as well) and requires frequent
blood transfusions for both anemia and thrombocytopenia
-He has had persistent voice hoarseness since his last
discharge. Would consider outpatient ENT evaluation.
-He had an EKG concerning for atrial flutter, but cardioversion
and systemic anticoagulation are not recommended in the setting
of low platelets.
-He has an elevated PTT and he was found to be positive for
lupus anticoagulant, however he is not a candidate for
anticoagulation in the setting of low platelets.
-Pending labs: Beta-glucan and galactomannin
-Has AML and is transfusion dependent, will need frequent labs
for blood counts and transfusions PRN.
-Has been having epistaxis periodically, but responds to
platelet transfusions (> 15 to prevent epistaxis)
-Recommend frequent electrolyte and kidney function checks
(sodium, potassium, creatinine) as we increased his home Lasix.
-Recommend LFT check at his next appointment. He had AST/ALT
~60s upon discharge. Unknown etiology.
-ID said he would benefit from antibacterial prophylaxis in the
setting of neutropenia and they will discuss this at his
outpatient clinic appointment.
-HCP/Contact: Son ___ ___
-Code: Full Confirmed
#Cellulitis:
#Invasive aspergillosis:
#Febrile Neutropenia:
He originally presented with fever and abdominal cellulitis in
the setting of neutropenia. He was started on aztreonam and
vancomycin IV for empiric treatment. He continued to be febrile
throughout the first 6 days, at which point he was transitioned
to PO Bactrim and clindamycin (he is allergic to penicillins).
His cultures at ___ showed MSSA sensitive to
Bactrim, so he was switched to Bactrim DS BID per infectious.
However, he continued to spike fevers on bactrim so he was
broadened again to vancomycin and aztreonam. He had a CT chest
w/o contrast that showed halo sign concerning for invasive
aspergillosis, even though he was galactomannan negative twice.
Thus, he was started on voriconazole. He completed his course
for his cellulitis while in the hospital and so the vancomycin
and aztreonam were discontinued. He will continue on
voriconazole and will get a repeat CT chest in 1 month to assess
for resolution. Pulmonology was consulted and given his
extensive comorbidities he was deemed a high-risk candidate for
bronchoscopy with cultures. Infectious disease also started him
on ciprofloxacin for bacterial prophylaxis.
#Lupus anticoagulant:
He had elevated PTT throughout his hospital stay and he is not
on systemic anticoagulation. He had mixing study that showed
lupus anticoagulate. However, he is not a candidate for
anticoagulation given his thrombocytopenia.
#Atrial fibrillation and atrial flutter:
He is rate-controlled without pharmacologic management. He was
previously on Coumadin and aspirin, but this was stopped
recently for low platelets. His EKG (___) showed atrial flutter
with variable block (new from admission). He remained
asymptomatic.
#Hyponatremia:
This was originally thought to be due to hypervolemia, however
it was not improving with Lasix. This is possibly a component of
SIADH as it improved with fluid restriction of 1.5 L/day.
#Acute on chronic kidney disease stage 3:
His creatinine was 1.4 with baseline 1.1-1.2. This was possibly
secondary to overdiuresis, but he still has significant lower
extremity edema. It improved after holding diuresis.
#Abnormal LFTs:
He had elevated tbili (1.8) and dbili (0.8) on ___. His
AST/ALT also increased to < 100. RUQUS (___) was unremarkable.
The etiology was not fully elucidated.
#Thrombocytopenia:
#Epistaxis:
He had epistaxis multiple times when his platelets were ~15. He
required 3 u PLT. His epistaxis always improved with platelet
transfusions > 15.
#Anemia:
His hemoglobin was borderline low throughout this admission. He
had 5 u PRBC. His Tbili was elevated at one time (direct), but
haptoglobin and LDH were normal. Thought to be likely due to
anemia of chronic disease and bone marrow suppression, but he
also probably had component of blood loss from nose bleed.
#Acute on chronic systolic/diastolic heart failure:
His last ECHO ___ showed low normal EF -50-55%. A CXR and
clinical exam were consistent with volume overload. His
creatinine bumped to 1.3 on ___ over his baseline of 1.1-1.2.
His TTE (___) showed depressed LV function. He was digressed
intermittently with lasix IV and PO. He still required sleeping
in a recliner upon discharge.
#Acute myelogenous leukemia:
He is currently on palliative Dacogen C15D28, but this was held
during this hospitalization. He was continued on his home
acyclovir 400 mg TID, allopurinol ___ mg qd, iron 325 mg qd.
#Diabetes mellitus Type 2:
At home he is on glargine 40 U qhs, Humalog 15 breakfast, 15
lunch, and 20 dinner. This was adjusted based on his blood
glucose to mealtime 3, 3, 5 and long-acting 10.
#Coronary artery disease:
#Peripheral vascular disease:
He was continued on his home Atorvastatin 80 mg PO QPM. Aspirin
81 mg was discontinued on his previous admission given his
thrombocytopenia.
#Hypertension:
He was continued on his home terazosin 2mg qhs.
#Gastroesophageal reflux disease:
He was continued on his home omeprazole 40mg daily.
#Neuropathy:
He was continued on his home Gabapentin 100 mg PO TID.
#Hypothyroidism:
He was continued on his home Levothyroxine Sodium 200 mcg PO
DAILY.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 40 mg PO BID
7. Gabapentin 100 mg PO TID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Levothyroxine Sodium 200 mcg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Terazosin 2 mg PO QHS
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Glargine 30 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 20 Units Dinner
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*0
2. Oxymetazoline 2 SPRY NU BID:PRN epistaxis Duration: 3 Days
RX *oxymetazoline 0.05 % 2 spray nasal BID:prn Disp #*1 Spray
Refills:*0
3. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 %
apply to itchy skin as needed TID:prn Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*21 Tablet Refills:*0
5. Voriconazole 200 mg PO Q12H
RX *voriconazole 200 mg 1 tablet(s) by mouth twice a day Disp
#*84 Tablet Refills:*0
6. Glargine 30 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 20 Units Dinner
7. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
8. Allopurinol ___ mg PO DAILY
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
10. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
11. Furosemide 40 mg PO BID
12. Gabapentin 100 mg PO TID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 200 mcg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Omeprazole 40 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Terazosin 2 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==============
Cellulitis
Invasive aspergillosis
Epistaxis
Acute myelogenous leukemia
Acute on chronic Diastolic and systolic heart failure
Atrial fibrillation
Lupus anticoagulant
Chronic kidney disease stage 3
Diabetes mellitus type 2
Coronary artery disease
Hypertension
Gastroesophageal reflux disease
Neuropathy
Hyponatremia
Hypothyroidism
Secondary diagnosis:
================
Anemia
Thrombocytopenia
Neutropenia
Abnormal liver function tests
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
You were admitted to ___ from
___ to ___ for fever and were found to have cellulitis
(skin infection). You were treated with antibiotics and your
rash improved. However, you continued to have a fever and so
imaging was done of your chest that was concerning for a fungal
infection. You were started on two new antibiotics. You were
started on a medication called voriconazole, which will treat
your fungal infection. You were also started on a medication
called ciprofloxacin, which you should take to prevent
infections in the future. You were started on another medication
called acyclovir, which will help prevent any serious viral
infections while you take the voriconazole. You also had a nose
bleed and required blood and platelet transfusions for this. The
ear, nose, and throat doctors came and placed ___ packing in
your nose to stop the nose bleed. You were given lasix for
swelling. Please follow-up with your oncologist as well as
infectious disease. You will also need to get a chest CT scan in
1 month to evaluate the resolution of your fungal infection.
Continue nose bleed precautions x2 weeks. (Avoid nose blowing.
Sneeze with the mouth open. Avoid vigorous activity, straining,
or heavy lifting.)
If you redevelops a nosebleed:
1. Spray three sprays of Afrin in each nostril. 2. Apply
pressure
to the outside of the nose (over the flexible end of the nose)
for 30 minutes and lean forward so that the you do not
swallow blood. Hold constant, firm pressure for the entire
duration without "peeking" to see if it has stopped as this will
likely result in repeated bleeding. If you continue to
have a nose bleed or if the bleeding is very rapid or excessive,
please come to the nearest emergency department emergently for
medical evaluation.
It was a pleasure caring for you,
-Your ___ care team
Followup Instructions:
___
|
10521546-DS-13 | 10,521,546 | 27,093,789 | DS | 13 | 2128-01-10 00:00:00 | 2128-01-11 17:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx atrial fibrillation and pancreatic Ca diagnosed
___, started gem/abraxane ___, last cycle ___, and began
cyberknife ___. Has been sleeping a little more but otherwise
was feeling fine until early last night, when he noted
diaphoresis and fever to 101.9F. Per wife he awoke from a nap
drenched in sweat, had chills and was mildly disorientated, now
resolved. He reports persistent cough for weeks, but has been
more wet sounding for ___ days, productive of white sputum, no
hemoptysis. No dyspnea, chest discomfort, new ab discomfort,
nausea, vomiting, dysuria, hematuria, sore throat, rhinorrhea,
headache or neck pain or myalgias. states that he has ongoing
pain in his L flank/back from his tumor but overall much better
since he started oxycontin. No using oxycodone only about once
per day. Does have constipation from pain meds but able to stay
regular w/ frequent use of stool softeners.
Past Medical History:
Onc history: Mr. ___ was diagnosed with
pancreatic cancer in ___ during evaluation for back pain
in the setting of 25lb weight loss over three months. He was
found to have elevated LFTs and OSH CT scan revealed an
obstructing pancreatic head mass. ERCP on ___ found a 15mm
CBD stricture; s/p sphincterotomy, cytology obtained, and metal
stent placed. EUS confirmed a 3 cm head of pancreatic mass
abutting the portal confluence concerning for invasion,
FNA/biopsy consistent with adenocarcinoma. CTA panc protocol on
___ showed 3.8 cm panc head mass with concern for tumor
involvement of the celiac and SMA and abutment of the PV and
SMV.
Dr. ___ that he is not an upfront surgical
candidate and pt started neoadjuvant FOLFIRINOX on ___.
PMHx:
Bronchiectasis, found incidentally after dx of pneumonia ___
ago
H/o pneumonia as above
Atrial fibrillation, dx ___ ago during pneumonia -- was only
on ASA and diltiazem
PSHx:
Hernia repair
Basal cell carcinoma s/p removal from the face/eyelid
Social History:
___
Family History:
FHx:
Congenital heart disease in father
___ in mother
Sister who died ___ ___ lupus
No known history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD, cachectic
VITAL SIGNS: 97.5 90/50 88 20 98%RA
HEENT: MMM, no OP lesions
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: exp rhonchi otherwise clear, nonlabored
ABD: BS+, soft, NTND
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 98.4 112/58 80 18 98% RA
General: NAD, cachectic
HEENT: MMM, no OP lesions
Neck: supple, no JVD
CV: irregularly irregular, variable S1S2 no S3S4 or MRG
PULM: diffuse rhonchi but decreased from prior exam. No wheezes
or rales.
ABD: BS+, soft, NTND
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, CN II-XII intact.
Pertinent Results:
ADMISSION LABORATORY VALUES:
___ 11:00PM WBC-5.1 RBC-2.56* HGB-8.0* HCT-24.9* MCV-97
MCH-31.3 MCHC-32.1 RDW-15.7* RDWSD-54.8*
___ 11:00PM NEUTS-83* BANDS-0 LYMPHS-9* MONOS-8 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-4.23 AbsLymp-0.46*
AbsMono-0.41 AbsEos-0.00* AbsBaso-0.00*
___ 11:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 11:00PM PLT SMR-NORMAL PLT COUNT-154
___ 11:07PM LACTATE-2.0
___ 11:00PM GLUCOSE-161* UREA N-21* CREAT-0.7 SODIUM-130*
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-24 ANION GAP-15
___ 11:00PM ALT(SGPT)-26 AST(SGOT)-16 ALK PHOS-116 TOT
BILI-0.2
___ 11:00PM LIPASE-13
___ 11:00PM ALBUMIN-3.2*
DISCHARGE LABORATORY VALUES:
___ 05:28AM BLOOD WBC-4.1 RBC-2.35* Hgb-7.7* Hct-23.2*
MCV-99* MCH-32.8* MCHC-33.2 RDW-15.8* RDWSD-56.7* Plt ___
___ 05:28AM BLOOD Neuts-73* Bands-1 Lymphs-14* Monos-12
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.03 AbsLymp-0.57*
AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*
___ 05:28AM BLOOD Plt ___
___ 05:28AM BLOOD Glucose-96 UreaN-17 Creat-0.6 Na-132*
K-4.0 Cl-101 HCO3-27 AnGap-8
___ 05:28AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
PERTINENT IMAGING:
CT CHEST W/CONTRAST ___:
1. Re- identified are multifocal areas of subpleural reticular
interstitial abnormality which is most prominent in the
dependent portions of the upper lobes and in the dependent
aspects of the lung bases. The degree of interstitial
abnormality seen in the dependent portion of the right upper
lobe (series 6, image 44) is mildly more conspicuous since prior
from ___. Otherwise, there is no appreciable interval
change elsewhere.
2. Traction bronchiectasis is again seen most conspicuously in
the dependent portions of the bilateral lower lobes, similar in
appearance to prior chest CT from ___.
3. Re-demonstration of a more consolidative subsegmental opacity
involving the superior segment of the right lower lobe (series
6, image 113), possibly slightly more extensive in comparison to
___.
4. Inspissated secretions filling the bronchus intermedius is
new (series 6, image 153), and extending into several right
lower lobar bronchi (series 6, image 169).
5. Post stenting pneumobilia is noted in the upper abdomen,
unchanged and expected.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND ___:
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Chronic appearing thrombosed superficial varicose veins of
the upper calf bilaterally without extension to the deep system.
CXR PA&LAT ___
IMPRESSION:
Fibrotic changes in the lungs, appear increased in conspicuity
from prior
chest radiograph, may reflect worsening fibrosis versus
superimposed atypical pneumonia.
Brief Hospital Course:
Mr ___ is a ___ yr old male with hx of Afib on lovenox,
locally advanced pancreatic cancer treated with
abraxane/gemcitabine (last dose ___ who started CK ___ who
was admitted with fever and cough with imaging concerning for
developing unilateral multilobar pneumonia.
#Fever
Patient on admission febrile in mild discomfort. Never in
respiratory distress. Initially started on empiric abx in ED.
CXR not suspicious for PNA, but subsequent CT of chest showed
consolidations suspicious for aspiration or multilobar
pneumonia. Sputum gram stain positive for gram positive cocci in
pairs and clusters. Transitioned to PO levofloxacin to finish 10
day course. Stable on d/c. At no point did Mr. ___ require
oxygen.
#Hypotension
Per pt his baseline SBP is frequently <100. slightly lower on
admission likely ___ mild hypovolemia from fever. Held bp meds
and volume resuscitated. Appropriate response to fluids.
#Hyponatremia
Nadir 129. Lab findings most consistent with SIADH. At no
point did he have altered mental status. Existing pulmonary
disease predisposes for SIADH and increases with new pulmonary
process. Pt has hx of SIADH on prior admissions. Also, poor PO
intake raised possibility for contribution of hypovolemic
hypoNa. Is already taking NaCl tabs. Likely to resolve as PNA
resolves.
Chronic Issues:
#Atrial fibrillation
cirregular rhythm and rate controlled on digoxin, dilt. is on
lovenox for anticoagulation. cont home meds and monitor BP
#Locally advanced pancreatic cancer -
on gem/abraxane last ___. Started cyberknife ___, was due
for next treatment
=====================
*****TRANSITION ISSUES*****
# CODE: Full (confirmed)
# HCP: Wife, ___ ___
[] complete 10 day course of levofloxacin (___)
[] F/UP Sputum culture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 2 CAP PO QIDWMHS
2. Docusate Sodium 100 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
6. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
7. Senna 17.2 mg PO BID
8. Aspirin 81 mg PO DAILY
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Metoclopramide 5 mg PO TID
11. Sodium Chloride 1 gm PO BID
12. Diltiazem Extended-Release 240 mg PO DAILY
13. Lorazepam 0.5 mg PO Q6H:PRN nausea/insomnia
14. Digoxin 0.125 mg PO DAILY
15. Simethicone 40-80 mg PO TID:PRN gas
16. Furosemide 20 mg PO DAILY
17. Docusate Sodium 100 mg PO TID
18. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Creon 12 2 CAP PO QIDWMHS
3. Digoxin 0.125 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Docusate Sodium 100 mg PO TID
7. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Lorazepam 0.5 mg PO Q6H:PRN nausea/insomnia
9. Metoclopramide 5 mg PO TID
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
13. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
14. Senna 17.2 mg PO BID
15. Simethicone 40-80 mg PO TID:PRN gas
16. Sodium Chloride 1 gm PO BID
17. Furosemide 20 mg PO DAILY
18. LOPERamide 2 mg PO QID:PRN diarrhea
19. Levofloxacin 750 mg PO DAILY Duration: 8 Doses
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: health-care associated pneumonia
SECONDARY: pancreatic cancer
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 meeting you and taking care of you. You were
admitted with fevers and cough. We were concerned that you may
have an infection of your lungs. We obtained imaging that showed
scarring and inflammation in your lungs, we concerned that you
had inflammation from your chemotherapy. Following a cat scan of
your chest it was determined that you most likely had an
underlying infection. You were prescribed antibiotics to which
you quickly began responding to.
You should continue to take your antibiotic as prescribed and
follow up with Dr. ___ one week.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10521573-DS-21 | 10,521,573 | 20,940,586 | DS | 21 | 2169-05-17 00:00:00 | 2169-05-17 20:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / valerian / shellfish derived
Attending: ___.
Chief Complaint:
Low grade fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with a history of neuroendocrine
tumor who underwent a whipple procedure in ___, liver
segmentectomy x2, tumor RFA ablation x2, and most recently a
pancreatic lymphnode excision on ___. Patient reports that
over the past week she was having low grade fevers in the 101s.
She saw her oncologist yesterday on ___ who had the patient
report to the emergency department.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Insomnia.
3. Hyperlipidemia.
4. Bilateral carpal tunnel syndrome.
5. Cataracts.
6. History of pleurisy.
7. Lung nodule.
8. Osteoarthritis of the hand.
9. Depression.
10. neuroendocrine tumor
PSH: Whipple procedure for pancreatic neuroendocrine tumor in
___, total abdominal hysterectomy and bilateral
salpingo-oophorectomy in ___ due to endometriosis.
Social History:
___
Family History:
Her mother died of metastatic breast cancer.
There is no family history of liver disease.
Physical Exam:
Alert and oriented x3
rrr no m,r,g
CTABL
abd soft non distended. incisions clean, healing,
non-erythematous
Pertinent Results:
___ 06:00AM BLOOD WBC-5.8 RBC-3.26* Hgb-9.6* Hct-30.5*
MCV-94 MCH-29.3 MCHC-31.3 RDW-12.8 Plt ___
___ 01:35PM BLOOD WBC-8.6# RBC-3.85* Hgb-11.7* Hct-36.3
MCV-94 MCH-30.4 MCHC-32.3 RDW-12.9 Plt ___
___ 06:00AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-137
K-3.2* Cl-102 HCO3-28 AnGap-10
___ 01:35PM BLOOD Glucose-111* UreaN-9 Creat-0.7 Na-133
K-2.9* Cl-95* HCO3-27 AnGap-14
___ 06:00AM BLOOD ALT-71* AST-96* AlkPhos-306* TotBili-0.6
___ 01:35PM BLOOD ALT-94* AST-199* AlkPhos-356* TotBili-1.0
Brief Hospital Course:
Patient was admitted on the evening on ___ for fever and
chills for the past week. Once on the floor her initial
evaluation showed her to be stable, afebrile. Her admission labs
revealed some mildly elevated LFTs and hypokalemia, a stable
white blood cell count, and a non concerning urinalysis. Her
potassium was repleted and the patient was monitored overnight.
She did not have any fevers or demonstrate any overt infectious
symptoms. A cat scan of the chest abdomen pelvis showed expected
post-operative changes and no sources of infection. Her LFTs the
morning after admission were slightly improved. Her white count
again was stable. She was evaluated by both the pancreas and
transplant services who felt that if the patient was stable and
afebrile for 24 hours she could be discharged home without
further work up and close follow up with an outpatient check to
ensure that her LFTs continue to normalize.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Zolpidem Tartrate 2.5 mg PO HS
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 20 mg PO QOD
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Lorazepam 0.5 mg PO HS:PRN insomnia
8. Losartan Potassium 25 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO QOD
2. Hydrochlorothiazide 25 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Zolpidem Tartrate 2.5 mg PO HS
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. Docusate Sodium 100 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Lorazepam 0.5 mg PO HS:PRN insomnia
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6 hours Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for observation because you reported fevers,
although you had none here, and because some of your liver
function tests were elevated compared to your previous level.
The following day, your liver function tests were trending down
and you had not had any fevers. Your CT scan was read by the
radiologist as reflective of postoperative/post-RFA changes.
Please have liver function tests assessed as an outpatient
before your appointment with Dr. ___ on ___.
Please resume all regular home medications.
Followup Instructions:
___
|
10521666-DS-13 | 10,521,666 | 28,942,795 | DS | 13 | 2176-04-22 00:00:00 | 2176-04-22 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Spinal cord injury in setting of C6-7 fracture
Major Surgical or Invasive Procedure:
___ Posterior fusion, C3-T3, Laminectomies of C4-T4
___ Trach & PEG placement
History of Present Illness:
This is a ___ year old M syncopal episode while using the
bathroom, fall to
ground with head strike. Neck pain and lower extremity
paralysis immediately.
Taken to ___ where CT Cspine showed DISH, C7 fx through
superior endplate and bilat C6 facet fractures and he was found
to have flaccid paralysis in his lower extremities Bilat and
weakness in Bilat UE. Medflight to ___ for further care.
Foley
catheter in place. + Bowel incontinence.
Past Medical History:
PMH: HTN, small CVA ___ (unknown side), ankylosing spondylitis,
prostate cancer
PSH: prostatectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: BP: 130/80 on Dopamine HR: 60 R: 18 O2Sats: 100%
Gen:
HEENT: normocephalic
Neck: Cervical collar in place
Extrem: cool 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 WE WF IP Q H AT ___ G
R 3 3 0 0 0 0 0 0 0 0 0
L 3 3 0 0 0 0 0 0 0 0 0
Sensation: No sensory below the level of the upper chest, no
reaction to painful stimuli in the lower extremities
Reflexes: B T Br Pa Ac
Right Absent
Left Absent
No Clonus, No ___
Toes mute
No rectal tone
On discharge:
EO spont, A+O x3 w/ speaking valve, BUE tri ___, bicep ___, grip
___, BLE: ___
Pertinent Results:
___ CXR:
1. Widening of the mediastinum, aortic injury can't be evaluated
on already ordered torso CT.
2. No definite displaced rib fractures.
3. Endotracheal tube slightly high in position ending
approximately 7 cm above the carina.
___. Unchanged, previously described fracture through the C7
vertebral body and C6 lamina with marked narrowing of the V1
segment of the right vertebral artery The overall findings are
highly suspicious for vascular compression related with
extrinsic perivertebral hematoma.
2. Additional lesser degree of narrowing of the V1 segment of
the left
vertebral artery also suspicious for dissection.
3. Prevertebral hematoma at the level the fracture site and
possible hematoma adjacent to the right aspect of the esophagus,
at the T3-T4 level, as described.
4. Atherosclerotic vascular disease including less than 30%
stenosis of the bilateral proximal internal carotid arteries.
___ CT spine without contrast:
1. Fracture through the C7 vertebral body, extending completely
through the superior endplate, with associated marked
hyperextension and prevertebral hematoma. There is no associated
spinal canal narrowing or retropulsion of osseous fragments. An
MRI of the cervical spine is recommended for further evaluation
for ligamentous and spinal cord injury.
2. Additional bilateral C6 lamina fractures with perched facets
of C6 on C7 bilaterally.
3. Multilevel cervical spondylosis and changes of diffuse
idiopathic skeletal hyperostosis (DISH).
___ CT torso with contrast
1. No evidence of intrathoracic or intra-abdominal injury.
2. Bilateral lower lobe collapse.
3. Diverticulosis without evidence of diverticulitis.
4. Changes of ankylosing spondylitis.
___ CT t-spine with contrast:
1. No evidence of acute fracture or subluxation within the
thoracic spine.
2. Thoracic spondylosis including changes of diffuse idiopathic
skeletal
hyperostosis (DISH).
3. Soft tissue density adjacent to the right aspect of the
esophagus at the T3-T4 level concerning for prior esophageal
hematoma.
___ CXR:
As compared to the previous radiograph, the patient has received
the new right
internal jugular vein introduction sheet. No pneumothorax. The
endotracheal
tube is in unchanged position. The nasogastric tube has been
removed. In the
interval, minimal pleural effusions have progressed and cause
atelectasis at
the left and right lung bases. Mild pulmonary edema persists. No
change in
appearance of the moderately enlarged cardiac silhouette.
___ CXR:
ET tube in standard placement. Left subclavian line ends at the
origin of the
SVC. Right internal jugular sheath ends at the junction with
the right
subclavian vein. The right paratracheal mediastinal widening
predating the
insertion of that device, is probably venous engorgement
exaggerated in the
semi supine patient.
Since earlier in the day large right pleural effusion has
increased and
moderately severe ipsilateral pulmonary edema worsened. Both
are less severe
in the left hemithorax. There is no pneumothorax.
___ CT Head:
No loss of gray-white matter differentiation or intracranial
hemorrhage.
Hypodensity within the anterior limb of the right internal
capsule is
unchanged from head CT dated ___.
___ CT T-Spine:
Partially visualized posterior spinal fusion hardware through
the level of T3 is visualized in expected location without
evidence of hardware failure. Moderate degenerative changes
throughout the thoracic spine are noted. The known fracture
through the superior endplate of T7 is in improved alignment
compared to the initial injury. Expected postsurgical fat
stranding is seen without evidence of fluid collection. The
right internal jugular line ends at the origin of the SVC, and
the left subclavian line ends within the distal brachiocephalic
vein. Endotracheal tube and enteric tube are in appropriate
position. Moderate bilateral pleural effusions have increased
from the prior chest radiograph with complete collapse of
bilateral lower lobes.
___ CT C-Spine:
New posterior spinal fusion hardware is in place from C3-T3
without evidence
of hardware failure. Patient is status post posterior
laminectomy from C6-T1
with a single corticated bony fragment in the soft tissues
posterior to C6
(602b:39), which likely represents a small retained spinous
process fragment.
Alignment is significantly improved from the initial injury.
Diffuse
calcification of the supraspinous and interspinous ligaments is
noted. An
endotracheal tube, nasogastric tube, right internal jugular
line, and left
subclavian line are partially visualized in expected positions.
There are
small bilateral pleural effusions.
___ ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is small.
Left ventricular systolic function is hyperdynamic (EF = 75%).
The right ventricular free wall thickness is normal. The right
ventricular cavity is markedly dilated with at least moderate
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ CT C-Spine:
Unchanged posterior spinal fusion hardware transfixing a
fracture through the C7 vertebral body extending to the superior
endplate with a persistent 1 cm gap between C6 and C7. Overall
alignment is unchanged compared with prior CT ___.
Moderate pleural effusions with associated bilateral lower lobe
collapse are unchanged
___ CT Head:
No intracranial hemorrhage or loss of gray-white matter
differentiation.
Unchanged age-related involutional changes and chronic small
vessel ischemic
changes. Frontal, ethmoidal, maxillary, and sphenoid sinuses are
fluid-filled.
Overall little change from the prior head CT ___.
___ CTA Chest/abdomen/pelvis:
1. No acute aortic pathology. No pulmonary embolism to the
levels visualized.
2. Interval increase in bilateral nonhemorrhagic pleural
effusions, now
moderate, with adjacent bilateral lower lobe collapse and
progression of
atelectasis. New heterogenous opacities in the right and left
upper lobes, some with a peribronchovascular distribution, are
concerning for infection.
3. No acute intra abdominal abnormality.
4. Cholelithiasis and diverticulosis. Ankylosing spondylitis
with post
surgical changes in the spine.
___ CXR:
In comparison with the study of ___, there is continued
bilateral
opacification is, consistent with substantial pulmonary edema
and bilateral layering effusions with compressive atelectasis at
the bases. Continued enlargement of the cardiac silhouette.
In the appropriate clinical setting, superimposed pneumonia
would have to be considered.
___ CXR:
Moderately severe pulmonary edema has improved since ___. Heart is still severely enlarged, and bilateral pleural
effusion is still present, large on the right, somewhat smaller
on the left. Whether concurrent pneumonia is also present is
radiographically indeterminate and would require chest CT
scanning for assessment, if appropriate.
ET tube and left internal and left subclavian lines are in
standard placements respectively. No pneumothorax.
___ CXR:
In comparison with the study of ___, there is little
overall change.
Diffuse bilateral pulmonary opacifications are again seen,
consistentwith is severe pulmonary edema. Continued enlargement
of the cardiac silhouette with bilateral layering effusions and
compressive atelectasis at the bases.
In the appropriate clinical setting, superimposed pneumonia
would have to be seriously considered.
CHEST (PORTABLE AP) Study Date of ___ 4:47 AM
Mild cardiomegaly and widening mediastinum are unchanged. Large
bilateral
effusions larger on the right side associated with adjacent
atelectasis are probably smaller allowing the difference in
positioning of the patient. Consolidations in the upper lobes
right greater than left have improved. Lines and tubes are in
unchanged position. Hardware in the cervical spine is again
noted. Component of pulmonary edema has also improved
BILAT LOWER EXT VEINS Study Date of ___ 11:27 AM
No evidence of deep venous thrombosis in the bilateral lower
extremity veins. Bilateral subcutaneous edema.
Chest X-Ray: ___
Cardiomegaly and widening mediastinum are unchanged. Bilateral
diffuse
opacities have increase partially due to worsened pulmonary
edema. Large right and moderate left pleural effusions with
adjacent large atelectasis are unchanged. Lines and tubes are in
unchanged position.
CXR ___
In comparison with the study of ___, there again are
substantial
layering pleural effusions, more prominent on the right with
bibasilar
atelectatic changes. It is difficult to assess the pulmonary
vascularity,
which could well be engorged. Monitoring and support devices
essentially
unchanged.
___ CXR
In comparison with the study of ___, the monitoring and
support
devices appear unchanged. Prominent haziness of the
hemithoraces is again consistent with substantial layering
pleural effusions, more prominent on the right, with basilar
atelectatic changes. Again the pulmonary vascularity is somewhat
difficult to assess, but may the
___ CXR
In comparison with the study of ___, there is little
change in the substantial enlargement of the cardiac silhouette,
pulmonary edema, and bilateral layering pleural effusions more
prominent on the right with basilar atelectatic changes.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
9:30 AM
IMPRESSION:
Moderate cardiomegaly, mediastinal venous engorgement, and
bilateral pleural effusions are stable since ___. Mild
pulmonary edema is new. There is no pneumothorax. Bibasilar
atelectasis is severe, particularly on the left. Right PIC line
ends in the region of the superior cavoatrial junction. .
Radiology Report CHEST (PORTABLE AP) Study Date of ___
3:04 ___
In comparison with the earlier study of this date, there again
is a
tracheostomy tube in place with the right subclavian PICC line
extending to the lower portion of the SVC. There is substantial
enlargement of the cardiac silhouette with pulmonary edema and
bilateral layering effusions, more prominent on the right, with
underlying compressive atelectasis at the bases. Cervical spine
fixation device is again seen.
Chest X-Ray: ___
Unchanged examination with bilateral pleural effusions and
associated
bibasilar atelectasis.
Chest X-Ray: ___
1. Persistent pulmonary edema with increase in size of large
right pleural effusion and of unchanged moderate left pleural
effusion.
2. Persistent bibasilar opacities concerning for bilateral lower
lobe
collapse.
Chest X-Ray: ___
Doubt significant interval change.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
8:18 AM
IMPRESSION:
There has been no appreciable change since ___. Compared
to ___ moderate bilateral pleural effusions are smaller
and mild pulmonary edema has almost resolved, and moderate to
severe cardiomegaly has improved. Severe lower lobe atelectasis
is presumed. No pneumothorax. Right PIC line ends in the upper
right atrium. Tracheostomy tube midline. No pneumothorax.
Radiology Report C-SPINE NON-TRAUMA ___ VIEWS PORT Study Date
of ___ 8:07 AM
FINDINGS:
Posterior fusion hardware extending from C3 to the upper
thoracic spine.
Fracture through C7 visualized on previous cross-sectional
imaging is
difficult to appreciate on the current radiographs but some
irregular lucency at C6-7 level is present. Within limits of the
provided projections, no evidence of hardware related
complication. If needed, fine osseous detail could be further
assessed with cross-sectional imaging.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service for further
management of his C7 vertebral body fracture. Due to concerns
of bleeding and his daily administration of aggrenox, the
patient was given a unit of platelets. He was admitted to the
ICU for further management and observation. The patient was
intubated for airway protection. Multiple diagnostic imaging
was obtained to further assess Mr. ___ C7 fracture and
spinal cord injury. To better perfuse his spinal cord, his mean
arterial pressure goal was raised to greater than 85 mmHg.
Plans were made to take the patient to the operating suite on
___ for fixation of his spinal injury. On ___, patient was
antigravity in BUE and following commands. He was taken to the
OR after family meeting was held. Intraoperatively there was
severe blood loss. Patient was resussitated during the case with
10u RBC, 10u FFP, 3u Plt, 5u Plasmalyte. BP tenuous during case.
During closure extreme bradycardia progressing asystole with sat
88%. Surgery aborted, pt flipped & removed from ___. Cod
was called. Patient recieved 2 mins of chest compressions and 1
mg of epi was given. Rhythm was reassessed after 2 mins and
patient found to be in sinus tachycardia with ROSC. Patient
rolled to side and incision closed with staples, JP half noted
to be half pulled out. Patient was kept intubated and
transferred to the ___. Family was updated on the events.
On ___, patient remained intubated and off sedation was able to
extend his bilateral wrist, he had no movement to noxious. He
was febrile to 102.5 and he was placed on ancef 2mg Q8H x 3
doses after cultures were sent. His hct came up to 27. In the
evenign he was febrile to 102.5 and was pancultured. His JP
drain was also removed.
On ___ he remained stable and underwent a CT of the cervical and
thoracic spines. He also was noted to have the flu and was
placed on appropriate precautions.
On ___ He was noted to have some bicep and tricep movement. He
continued to be intubated and was OOB to chair.
On ___ his MAP was liberalized to > 65 and he was noted to have
intermittent hypoxia and hypotension. He underwent a TTE with RV
hypokinesis and dilitation concerning for PE
On ___ his exam was slightly worse on AM rounds and he underwent
imaging of the chest, abdomen, pelvis, head, and C-spine. He
recived 40mg of Lasix and his exam improved in the afternoon and
he was antigravity with BUE.
On ___ his motor exam was improved, he was more awake, and was
placed on CPAP. In addition he was noted to have increasing
leukocytosis and was started on antibiostics.
On ___, the patient worked with physical therapy. His WBC count
was elevated to 23.
On ___, the patient became bradycardic to the ___ upon position
change for evaluation of his posterior neck incision. He
received atropine. He remained on Neo with a systolic BP in the
___. To assess posterior neck incision sat the patient up at 90
degrees and pulled forward slightly with no bradycardia. The
patients staples were intact. Cardiology recommended Lasix gtt
for UOP>200/hr. The white blood count was 23.4 and the
hematocrit was 22.4.
On ___, The goal was to wean the patient as tolerated from the
ventilator. Plan was determined that if the patient ventilator
was not weaned by the following ___ then a traeostomy would
be considered. Lower extremity ultrasounds were performed and
consistent with no deep vein thrombosis. move to trach. The
vancomycin was discontinued and the patient remained on Cefepime
and Cipro since ___ fro ventilatory assisted pneumonia. The
patients white blood count was 20.8 and hematocrit was 22.7.
On ___, the patient remained neurologically stable and was
actively being diuresed.
On ___, the patient remained stable. On ___, his blood
pressure goals were liberalized and the pressors were
discontinued.
On ___, the patient's neurologic examination remained stable.
He was scheduled to undergo placement of a trach today.
On ___, the patient's neurologic examination remained stable.
He went to the OR with ACS for placement of PEG and trach.
Patinet noted to be more lethargic on examination post surgery.
CT was deferred. Exam improving as sedation wears off.
On ___ the patient was more bright on examination. Rehab
planning is pending. He was breathing off the ventilator.
On ___ Mr. ___ was restarted on the ventilator when a blood
gas obtained was concerning for hypercapnea. His neurological
exam remained stable.
On ___, The patient was on CMV setting on the ventilator
overnight.
On ___, The patients temperature was 101. A chest xray was
performed with substantial bibasilar consolidation and mod
pleural effusion. A mini bal was sent that was consistent with
gm + rods/cocci. A urine was negative. Blood cultures were
**********
On ___, The patient spiked fever to 101.4. Vancomycin and
Cefepime was started for presumed VAP. The patient was on a
trach mask in am and at 2:40 pm the patient became bradycardic
to ___ and desated. 0.5 atropine was administered and the
patient was placed back on the ventilator.
On ___, The patient was neurologically stable. The patient was
mobilized out of bed to that chair.
On ___, The patient was on trach mask in am. Stool was sent
for cdiff. The patient was mobilized out of bed to the chair.
The patient had speech therapy and a passey muir valve was
placed.
On ___, the patient was tolerating a speaking valve. He was
A+O x3 while using it. He was OOB to chair. Antibiotics were
DC'd because of negative Cx results. Cardiology did not
recommend a pacer. He was screened for rehab.
On ___, the patient was stable and there were no events over
night. He was still pending rehab placement.
On ___. The patient was mobilized out of
bed to the chair dailiy. His hematocrit was low but stable at
25. the patient remained neurologically stable and was pending
transfer to rehabilitation on ___. He remained stable on
the trach mask and vent intervals.
Medications on Admission:
metop 25mg BID, dipyrimidol/asa BID, simvastatin 20mg Daily
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Sarna Lotion 1 Appl TP QID:PRN rash/pruritus
6. Pantoprazole 40 mg IV Q24H
7. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
8. Miconazole Powder 2% 1 Appl TP TID:PRN funal rash
9. Morphine Sulfate ___ mg IV Q2H:PRN Pain
10. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
11. Docusate Sodium (Liquid) 100 mg PO BID
12. Gabapentin 400 mg PO TID
13. Heparin 7500 UNIT SC TID
14. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
15. Senna 8.6 mg PO BID
16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
17. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
18. Furosemide 20 mg PO BID
19. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
20. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
21. Glucose Gel 15 g PO PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C7 vertebral body fracture
Left vertebral artery dissection
Respiratory failure
Dysphagia
VAP
Acute anemia
Bradycardia
Discharge Condition:
trach
oriented to name
and place
legs ___
grip ___
biceps ___, triceps ___ delt ___
posterior neck incision well healed
Discharge Instructions:
Surgery
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
Followup Instructions:
___
|
10521848-DS-5 | 10,521,848 | 25,821,218 | DS | 5 | 2137-12-29 00:00:00 | 2137-12-30 16:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / aspirin / olanzapine
Attending: ___
Chief Complaint:
transfer from OSH for mesenteric and ___ SMV and
portal vein thrombosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of HCV cirrhosis s/p Sofosbuvir (Harvoni) and
Ribivarin, history of grade I varices who presents from ___
___ with multiple ___ vascular thrombi.
The patient states that he has had progressive, midepigastric,
nonradiating abdominal pain for 1 week. On the day of admission,
it got so severe that he presented to ___.
The patient states that the pain has made him nauseated and he
has not been able to take much PO. In addition, he has noted
frequent, yellow diarrhea without melena or hematochezia. He
reports no vomiting.
Upon arrival to ___ the patient underwent a CT
Abd/Pelvis with contrast which demonstrated a thrombus in
peripheral mesenteric veins with nonocclusive thrombus in the
superior mesenteric vein, distal splenic vein and portal veins.
He was started on a heparin gtt at 1350U/hr and sent to ___
ED. While in the ED, his PTT was noted to be 150 but his gtt was
not d/c'd. He was hemodynamically stable and transferred to the
floor.
The etiology of the patient's cirrhosis is EtOH and HCV
genotype 2b. He is s/p Sofosbuvir (Harvoni) and Ribivarin
(___). His last endoscopy was on ___ and
demonstrated 3, grade 1 varicese. He states he has had a history
of variceal bleeding treated at ___ on ___. He has not had any history of hepatic encephalopathy or
spontaneous bacterial peritonitis.
Past Medical History:
HCV genotype 2b ___, Sofosbuvir (Harvoni) and
Ribivarin (___)
EtOH use
Cirrhosis, history of esophageal varices
Cholecystitis
Bipolar Disorder
Chronic R shoulder Pain
Gout
Social History:
___
Family History:
Father with alcoholism. Mother with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: T 98.0 BP 131/70 HR 70 R 18 SpO2 95% RA
GEN: anxious, NAD
HEENT: sclerae anicteric, clear OP
___: regular without murmurs
RESP: No increased WOB, CTAB
ABD: mild, diffuse TTP. No rebound or guarding, no HSM
EXT: warm without edema
NEURO: CN ___ grossly intact. No asterixis. B/L tremor. RUE
ROM limited due to chronic shoulder pain.
PSYCH: pressured speech
DISCHARGE PHYSICAL EXAM
=======================
VS: T 97.5, BP ___, HR ___, RR 18, SpO2 95% RA
GEN: sitting up in bed, appears comfortable. NAD.
HEENT: sclerae anicteric, MMM
CV: RRR, S1+S2, no M/R/G
RESP: CTAB, no W/R/C
ABD: ___, soft, tender to light palpation diffusely,
normoactive BS
EXT: WWP, no edema
NEURO: moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS
==============
___ 01:10PM ALT(SGPT)-26 AST(SGOT)-59* LD(LDH)-202 ALK
___ TOT ___
___ 01:10PM HCV ___ DETECT
___ 01:10PM ___
___
___ 01:10PM ___
___ 01:10PM PLT ___
___ 02:47AM ___ TOP
___ 02:47AM ___
___ 02:40AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 02:40AM ALT(SGPT)-28 AST(SGOT)-62* ALK ___ TOT
___
___ 02:40AM ___
___ 02:40AM ___
___
___ 02:40AM ___
___
___ 02:40AM ___
___ IM ___
___
___ 02:40AM PLT ___
___ 02:40AM ___ ___
MICRO
=====
__________________________________________________________
___ 10:17 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference ___.
__________________________________________________________
___ 2:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
DISCHARGE LABS
==============
___ 05:17AM BLOOD ___
___ Plt ___
___ 01:29PM BLOOD ___
___ 05:17AM BLOOD Plt ___
___ 05:17AM BLOOD ___ ___
___ 05:17AM BLOOD ___
___
___ 05:17AM BLOOD ___ LD(LDH)-185 ___
___
___ 05:17AM BLOOD ___
___
___ 05:17AM BLOOD ___
___ 05:17AM BLOOD ___
___ 05:17AM BLOOD ___
IMAGING/STUDIES
===============
___ Imaging MRI LIVER W&W/O CONTRAS
1. Liver cirrhosis with stigmata of portal hypertension
including
splenomegaly and large paraesophageal varices. No ascites.
2. No suspicious enhancing hepatic mass lesions meeting OPTN
Class 5 criteria for HCC.
3. The splenic vein, superior mesenteric vein, portal vein and
hepatic veins are patent without evidence of thrombosis.
4. Cholelithiasis.
Brief Hospital Course:
___ with history of HCV cirrhosis s/p Harvoni and ribavarin
presents as transfer from ___ after evaluation for
abdominal pain reveals multiple intraabdominal thrombi.
#ABDOMINAL PAIN:
___ PORTAL VEIN AND SUPERIOR MESENTERIC VEIN
THROMBOSIS: Initially with abdominal pain; found to have
multiple, ___ intraabdominal vascular thrombi, per CT
abdomen read at ___. Patient started on heparin
gtt. Abdominal pain improved throughout admission. MRI/MRA liver
on ___ showed patent hepatic and portal vasculature, with no
evidence of thrombus or obstruction. Heparin gtt was stopped; no
further anticoagulation was needed. Unclear what the etiology of
abdominal pain was - may have been mesenteric clots that
resolved, or may be related to newly initiated metformin
(metformin was held while admitted in favor of insulin sliding
scale).
#HCV CIRRHOSIS: at the time of admission, MELD 11, Childs Class
A. EGD ___ showed 3 cords of grade I varices, unclear
history of variceal bleed in the past. No history of HE or SBP.
HCV VL on ___ 16 IU/mL. s/p 12 weeks sofosbuvir and ribivarin
(___). No HE throughout admission; no evidence
of ascites on ultrasound performed in ED. HCV VL drawn ___
still pending at the time of discharge. Propranolol was held
while patient was on heparin gtt, for fear of masking
hemodynamic evidence of bleeding. Restarted when heparin gtt
stopped.
#ANEMIA: discharge Hgb of 12.2, baseline appears near 15.
Reports small amount of blood within diarrhea preceding
admission to ___. No hemodynamic compromise. ___ be due to
slow variceal bleed, as iron studies are WNL (effectively ruling
out iron deficiency and anemia of chronic inflammation). Will
either need documentation of recent EGD (patient claims he had
recent EGD at ___, or a repeat EGD in the near
future to assess known varices.
#HTN: BP stable throughout admission. Continued home Lisinopril
10 mg PO/NG DAILY.
#DM2: held oral agents (metformin and glipizide) while admitted,
in favor of insulin sliding scale. Of note, patient reports
significant GI side effects with metformin, and had
___ metformin to 500mg BID, which was helping to
minimize symptoms. Discharged on metformin 500mg BID and
glipizide 5mg daily; may need gradual uptitration of metformin
as outpatient, if tolerating.
#CHRONIC PAIN: due to shoulder pain which has required multiple
surgeries. Currently takes gabapentin qHS. Has broken narcotics
contract with PCP in the past, and is not currently prescribed
any narcotics as an outpatient. Continued home Gabapentin 300 mg
PO/NG QHS; was also treated with Lidocaine 5% Patch 1 PTCH TD
QAM and Acetaminophen 650 mg PO/NG Q8H:PRN Pain - Mild (no more
than 2g per day) while admitted.
#BIPOLAR DISORDER: pressured speech, somewhat tangential during
admission. Review of OMR notes reveals that he has previously
been on multiple typical and atypical antipsychotics and has
refused to take others. Currently controlled on diazepam (he is
being weaned from this as an outpatient). Also with history of
leaving AMA from previous hospitalization. Continued home
Diazepam 5 mg PO/NG Q12H:PRN anxiety - discharged on this dose,
though NOT with a new prescription.
TRANSITIONAL ISSUES:
====================
[ ] no RX for diazepam or narcotics given on discharge
[ ] DIABETES CONTROL: Discharged on metformin 500mg BID (lower
dose due to GI side effects) and glipizide 5mg daily; may need
gradual uptitration of metformin as outpatient, if tolerating.
[ ] CIRRHOSIS SCREENING:
- Will either need documentation of recent EGD (patient claims
he had recent EGD at ___, or a repeat EGD in the
near future to assess known varices.
- ___ HCV viral load, drawn on ___
[ ] Discharged late in the day - given contact info for liver
clinic and strongly encouraged to call and make a ___
appointment. PCP - please ___ importance of liver
___ at next visit.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO Q12H:PRN anxiety
2. Gabapentin 300 mg PO QHS
3. GlipiZIDE XL 5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Propranolol LA 60 mg PO DAILY
Discharge Medications:
1. Diazepam 5 mg PO Q12H:PRN anxiety
2. Gabapentin 300 mg PO QHS
3. GlipiZIDE XL 5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Propranolol LA 60 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Hepatitis C cirrhosis
Anemia
Type 2 diabetes
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were sent here from ___, where you were found
to have blood clots in several blood vessels in your abdomen.
They sent you here for further treatment of these blood clots.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were treated with a blood thinner called heparin.
- You had an MRI of your liver, which showed that you did NOT
have blood clots in the blood vessels around your liver. It's
unclear what exactly was seen at the outside hospital, but based
on our MRI, we felt confident that you did not have any blood
clots. We stopped the heparin.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will continue to take all of the medications that you were
on prior to coming into the hospital. Please take them as
prescribed.
Please do you best to keep your ___ appointments.
Followup Instructions:
___
|
10521848-DS-6 | 10,521,848 | 26,905,077 | DS | 6 | 2139-07-06 00:00:00 | 2139-07-06 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / aspirin / olanzapine
Attending: ___.
Chief Complaint:
Abdominal distension, jaundice
Major Surgical or Invasive Procedure:
___ Diagnostic paracentesis
Paracentesis - ___ and ___
EGD - ___
History of Present Illness:
___ w/ PMHx HCV cirrhosis s/p treatment who presents as a
transfer from an OSH w/ asterixis, ascites and
hyperbilirubinemia. Patient reports first noticing increasing
abdominal distention about ___ days ago. He notes that this
discomfort was associated by some nausea and decreased PO
intake.
He said this got to a point where he decided he wanted to go to
the hospital for evaluation. Patient also reported that he
started drinking again over a week ago (though maintains that he
had just one can of beer and it was 10 days ago). He denied
fevers, chills, CP, SOB, cough, vomiting, diarrhea, constipation
or urinary symptoms. Denied melena or hematochezia.
Past Medical History:
HCV genotype 2b ___, Sofosbuvir (Harvoni) and
Ribivarin (___)
EtOH use
Cirrhosis, history of esophageal varices
Cholecystitis
Bipolar Disorder
Chronic R shoulder Pain
Gout
Social History:
___
Family History:
Father with alcoholism. Mother with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vital Signs: 97.5 156 / 74 59 20 98 Ra
GEN: Jaundiced, pleasant for the most part but irritable at
times
___: RRR,no m/r/g
RESP: CTAB
ABD: Soft, distended, diffuse TTP
EXT: WWP, no c/c/e
NEURO: AAOx3 though throughout conversation can be tangential at
times and responds inappropriately to questions, +asterixis
DISCHARGE PHYSICAL EXAM:
=======================
T 98.0 BP 108/62 HR 63 RR 18 O2 sat 97 Ra
GEN: comfortable, NAD
HEENT: mild scleral icterus, moist mucous membranes
___: RRR, no m/r/g
RESP: CTAB
ABD: Soft, mild distension, RUQ TTP without bruising
EXT: WWP, no c/c/e
NEURO: Alert and oriented to month, name, and place. Able to say
days of the week backwards. No asterixis.
SKIN: palmar erythema present, jaundiced, hyperemia of nail beds
Pertinent Results:
ADMISSION LABS:
===============
___ 11:00PM BLOOD WBC-3.9* RBC-3.53* Hgb-12.6* Hct-37.5*
MCV-106* MCH-35.7* MCHC-33.6 RDW-16.3* RDWSD-64.0* Plt Ct-76*
___ 11:00PM BLOOD Neuts-54.8 ___ Monos-17.6*
Eos-2.6 Baso-0.5 Im ___ AbsNeut-2.12 AbsLymp-0.93*
AbsMono-0.68 AbsEos-0.10 AbsBaso-0.02
___ 11:00PM BLOOD ___ PTT-30.7 ___
___ 11:00PM BLOOD Plt Smr-VERY LOW* Plt Ct-76*
___ 11:00PM BLOOD Glucose-63* UreaN-15 Creat-0.6 Na-139
K-3.8 Cl-105 HCO3-26 AnGap-8*
___ 11:00PM BLOOD ALT-54* AST-147* AlkPhos-160*
TotBili-18.6*
___ 11:00PM BLOOD Lipase-26
___ 11:00PM BLOOD Albumin-2.5*
___ 06:10AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
INTERVAL LABS:
==============
___ 11:00PM BLOOD Lipase-26
___ 02:25PM BLOOD %HbA1c-5.3 eAG-105
___ 06:39AM BLOOD Osmolal-295
___ 06:35AM BLOOD Osmolal-294
___ 06:27AM BLOOD Osmolal-302
___ 06:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 11:00PM BLOOD Ethanol-NEG
___ 06:00PM BLOOD HCV VL-NOT DETECT
DISCHARGE LABS:
===============
___ 06:27AM BLOOD WBC-4.5 RBC-3.06* Hgb-10.7* Hct-32.1*
MCV-105* MCH-35.0* MCHC-33.3 RDW-16.1* RDWSD-61.5* Plt Ct-52*
___ 06:27AM BLOOD Plt Ct-52*
___ 06:27AM BLOOD ___ PTT-39.6* ___
___ 06:27AM BLOOD Glucose-203* UreaN-47* Creat-0.7 Na-132*
K-5.1 Cl-97 HCO3-21* AnGap-14
___ 06:27AM BLOOD ALT-137* AST-238* AlkPhos-246*
TotBili-15.5*
___ 06:27AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.5 Mg-1.9
PERTINENT IMAGING/STUDIES:
==========================
RUQUS ___
1. New main portal vein thrombosis.
2. Cirrhotic liver with splenomegaly and moderate volume
ascites. No focal
hepatic lesions identified.
CXR ___
No focal pneumonia.
3-phase CT Abdomen w/ and w/out contrast ___
1. Cirrhotic appearing liver. No evidence of portal vein
thrombosis. No
suspicious liver lesions.
2. Sequela of portal hypertension include moderate ascites,
splenomegaly, and extensive gastroesophageal varices.
3. Cholelithiasis.
L Shoulder ___
1. Left total shoulder arthroplasty without evidence of hardware
complication or periprosthetic fracture.
2. Moderate to severe degenerative changes of the left
acromioclavicular
joint.
EGD: ___: 2 cords grade I varices in distal esophagus. Varices
were not bleeding. Stomach mucosa with diffuse congestion,
petechiae and mosaic mucosal pattern of mucosa was noted in the
stomach fundus and stomach body. Findings compatible with portal
hypertensive gastropathy. Diffuse erythema, firability and
petechiase of the mucosa was noted in the stomach antrum. These
findings are compatible with GAVE.
URINE:
======
___ 03:54PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-2 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 11:35AM URINE Hours-RANDOM UreaN-1542 Creat-124 Na-21
___ 11:35AM URINE Osmolal-812
Paracentesis studies:
___ 08:14AM ASCITES TNC-734* RBC-1405* Polys-11* Lymphs-12*
___ Mesothe-13* Macroph-64* Other-0
___ 12:14AM ASCITES TNC-272* RBC-1269* Polys-18* Lymphs-13*
Monos-3* Macroph-66*
___ 08:14AM ASCITES TotPro-0.7 Albumin-0.3
___ 12:14AM ASCITES TotPro-0.8 Glucose-93
Brief Hospital Course:
SUMMARY:
========
Mr. ___ is a ___ w/ PMHx HCV cirrhosis s/p treatment who
presents as a transfer from an OSH w/ asterixis, ascites and
hyperbilirubinemia. He was found to have alcoholic hepatitis and
was started on a trial of prednisone given ___
discriminant function of 45. Unfortunately, he did not have a
robust response and was supplemented with tube feeds to optimize
nutrition. Patient refused tube feeds and was discharged with
specific diet recommendations. He was started on lasix and
aldactone for ascites, also underwent 2 paracenteses that were
negative for SBP. He was also given lactulose and rifaximin for
hepatic encephalopathy, which improved.
TRANSITIONAL ISSUES:
====================
[ ] If potassium is okay, please consider resuming aldactone.
[ ] Requested prior authorization for rifaximin. Patient
discharged with short supply. Ensure patient able to get
rifaximin.
[ ] Please follow up on his blood sugars. Elevated transiently
during hospitalization given prednisone for alcoholic hepatitis
and tube feeds. Given refusal of tube feeds at time of
discharge, his insulin needs will likely change. Was discharged
on home glipizide.
[ ] Needs ongoing counseling for nutrition and nutrition follow
up.
[ ] Meals on Wheels with ___ (___) set up for
him.
[ ] Received hepatitis B vaccination on ___, will need 2 more
doses at ___ months and at 6 months.
[ ] Needs chemistries, LFTs, and CBC within one week of
discharge.
[ ] Lisinopril held given normotensive on this admission.
Already on propranolol for variceal prophylaxis. Given history
of diabetes, consider re-adding low dose lisinopril if there is
room in his blood pressure.
[ ] Continue to encourage alcohol abstinence
[ ] Titrate lactulose to ___ BM daily
[ ] Recommend he seek psych follow up at discharge
[ ] Received one month supply of medications. Will need
renewals. Ensure he has all the medications he needs to take.
ACTIVE ISSUES:
===============
# HCV cirrhosis
# Alcohol hepatitis: DF 45 with patient acknowledging recent
consumption of EtOH after a period of sobriety. AST and ALT
elevated w/ ratio > 2:1. To optimize his nutrition, he was given
three doses of IV thiamine and recommended Ensures daily with
each meal. Two diagnostic paracenteses showed no signs of
infection. He was given Lasix IV for diuresis and then
transitioned to PO lasix 40 and aldactone 100mg. Aldactone was
held at the time of discharge due to hyperkalemia (see below).
He was maintained on lactulose for hepatic encephalopathy,
rifaximin was also added. He was started on prednisone on ___
which was continued until ___, discontinued as his LFTs and
Tbili did not show significant improvement. Nutrition education
counseling was provided regarding salt reduction and alcohol
abstinence. He was started on tube feeds given poor response to
prednisone for alcoholic hepatitis, but refused to continue tube
feeds upon discharge. He was set up with Meals on Wheels.
Hepatitis serologies indicating that he was non-immune to
hepatitis B so he received first dose of hepatitis B
vaccination. Had EGD that showed 2 cords of grade 1 esophageal
varices that were not bleeding. He was continued on propranolol
for variceal prophylaxis.
#Portal vein thrombus: RUQUS on admission noting main portal
vein thrombus. Patient has had this read before but during last
imaging (MRI in ___ portal vein was notedto be patent. A
3-phase CT scan was done to evaluate portal vein thrombus and
did not show any thrombosis. Therefore anticoagulation was not
started.
# Hyperkalemia: two episodes with peaked T waves, in the setting
of aldactone use. Improved with Ca gluconate, insulin/dextrose,
lasix and kayexalate.
# Hyponatremia: may have occurred in setting of aldactone use
versus cirrhosis.
CHRONIC ISSUES:
#Chronic macrocytic anemia: Hgb 12.6, baseline appears in ___
range. Likely i/s/o EtOH abuse and chronic liver disease. No
history of melena or hematochezia.
#HTN: On lisinopril and propranolol at home. Was continued on
propranolol but due to borderline blood pressures was not
resumed on lisinopril. Will need to consider lisinopril given
concomitant diabetes.
#DM2:
-HISS while in house. Insulin needs increased while on steroids
and tube feeds. Held home glipizide
#Bipolar Disorder
#Anxiety Disorder: Patient reportedly takes diazepam as an
outpatient to manage his issues with "bipolar and severe
anxiety." Patient reportedly was seeing a psychiatrist that left
the area and is in the process of arranging another one.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. GlipiZIDE XL 5 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Propranolol LA 60 mg PO DAILY
4. multivitamin-minerals-lutein 1 tab oral DAILY
Discharge Medications:
1. Boost High Protein (food supplemt,
lactose-reduced;<br>protein) 0.06 gram- 1 kcal/mL oral DAILY
RX *food supplemt, lactose-reduced [Boost High Protein] 0.06
gram-1 kcal/mL 1 Bottle by mouth Breakfast, lunch, and dinner
Disp #*9954 Milliliter Milliliter Refills:*2
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Lactulose 30 mL PO QID Confusion
RX *lactulose 10 gram/15 mL 30 mL by mouth four times a day Disp
#*3784 Milliliter Milliliter Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain, on right rib
RX *lidocaine 5 % Apply to area of rib pain Daily Disp #*10
Patch Refills:*0
6. Miconazole Powder 2% 1 Appl TP BID
RX *miconazole nitrate [Desenex] 2 % Apply to groin rash twice a
day Refills:*0
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
10. GlipiZIDE XL 5 mg PO DAILY
11. multivitamin-minerals-lutein 1 tab oral DAILY
12. Propranolol LA 60 mg PO DAILY
RX *propranolol 60 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
13. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor states that it is
okay to do so.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: alcoholic hepatitis
SECONDARY DIAGNOSIS: HCV and EtOH cirrhosis, hyperkalemia,
hyponatremia, hepatic encephalopathy, ascites, diabetes, anemia,
esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why were you admitted?
- You were admitted for abdominal pain.
What happened while you were in the hospital?
- There was initially concern for a clot in your portal vein. A
CT scan was done which did NOT show any clots.
- You were noted to have very bad cirrhosis and liver damage.
This is likely related to your alcohol use.
- You received steroids for the damage in your liver.
Unfortunately, these did not help so we stopped them.
- We removed some fluid from your belly called paracentesis and
started you on medications to remove the fluid from your
abdomen.
What should you do when you leave the hospital?
- We recommended that you work on your nutrition and drink
plenty of Ensures
- It is important to abide by a low salt diet. DO NOT ADD SALT
TO ANY OF YOUR FOODS.
- It is important to NEVER drink alcohol.
- If you start to develop swelling in your belly, please let
your doctor know.
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
10522176-DS-19 | 10,522,176 | 27,337,016 | DS | 19 | 2179-04-16 00:00:00 | 2179-04-17 13:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP and EUS on ___ with sphincterotomy
History of Present Illness:
___ h/o HTN, hypothyroid, s/p CCY in ___ with one day of RUQ
radiating to mid-abdomen. She was at beach yesterday and ate a
salad and chicken and later in the day she ate corn. In the
evening she developed a terrible pain in her RUQ that radiated
in
a band across the upper abdomen without radiation to the back.
This pain was severe ___ and sharp at first and felt like past
episode of gallstone pancreatitis. She went to urgent care
locally and lfts were abnormal so she was referred to ___ ED.
At the time of her acute pain she lacked any nausea, vomiting,
chest pain or SOB but when breathing deeply she had sharp
sub-xyphoid pain.
In the ED she was initially hypertensive with systolic > 200
which reduced to 170 without intervention. Lipase was >___bdomen did not show ductal dilation. She was given
analgesic, fluid and admitted.
On arrival to the floor her pain is controlled and is less
sharp,
now about a ___ and she feels bloated. There is some nausea
now.
ROS:
as per HPI, otherwise 10pt ROS negative
She has not had acute abdominal pain since having
cholecystectomy.
PMH:
ANXIETY
DEPRESSION
FIBROIDS
GASTROESOPHAGEAL REFLUX
HEALTH MAINTENANCE
HYPERTENSION
HYPOTHYROIDISM
LUMBAR RADICULOPATHY
MIGRAINES
OBESITY
OSTEOARTHRITIS
OVERACTIVE BLADDER
UTERINE FIBROIDS
ABNORMAL LIVER FUNCTION TESTS
LIPOMA
gallstone pancreatitis
fatty liver disease
positional vertigo when turning head to R side when laying
supine
PAST SURGICAL HISTORY:
s/p lap chole ___
s/p lumbar spine surgery at ___ in ___ w laminectomy
s/p lipoma excision
SH:
married, ___, no kids, cats, works as ___ for
local ___
___:
not pertinent to management of current diagnosis
exam
98.8 159/93 ___ ___
avoids looking to R side due to chronic position vertigo
perrl eomi
pink oral mucosa
ctab clear without wheezes
regular s1 and s2 without murmurs
slight discomfort to deep RUQ palpation and below her xyphoid,
but no guarding or rebound, unable to appreciate organomegaly
no peripheral edema
no focal or diffuse rashes
not jaundiced
calm and cooperative
aox3
Past Medical History:
PMH:
Obesity
HTN
GERD
Depression
Hypothyroidism
Headaches
Vertigo
PSH:
Back surgery in ___
Denies any previous abdominal surgeries.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
98.8 159/___ ___
avoids looking to R side due to chronic position vertigo
perrl eomi
pink oral mucosa
ctab clear without wheezes
regular s1 and s2 without murmurs
slight discomfort to deep RUQ palpation and below her xyphoid,
but no guarding or rebound, unable to appreciate organomegaly
no peripheral edema
no focal or diffuse rashes
not jaundiced
calm and cooperative
aox3
Discharge Physical exam
Vitals: 98.7 171/94 73 18 98% on RA
GENERAL: Alert and in no apparent distress friendly woman
sitting
in chair
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs
___ 02:45AM BLOOD WBC-11.1* RBC-4.86 Hgb-13.5 Hct-41.5
MCV-85 MCH-27.8 MCHC-32.5 RDW-13.2 RDWSD-41.0 Plt ___
___ 02:45AM BLOOD ___ PTT-22.1* ___
___ 02:45AM BLOOD Glucose-108* UreaN-20 Creat-0.8 Na-137
K-4.6 Cl-100 HCO3-21* AnGap-21*
___ 02:45AM BLOOD ALT-176* AST-276* CK(CPK)-201
AlkPhos-168* TotBili-2.4*
___ 02:45AM BLOOD Lipase-3885*
___ 02:45AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.5* Mg-1.8
Discharge labs
___ 06:00AM BLOOD WBC-9.1 RBC-4.27 Hgb-12.0 Hct-36.4 MCV-85
MCH-28.1 MCHC-33.0 RDW-13.2 RDWSD-41.1 Plt ___
___ 06:00AM BLOOD Glucose-58* UreaN-9 Creat-0.5 Na-140
K-3.6 Cl-102 HCO3-24 AnGap-18
___ 06:00AM BLOOD ALT-306* AST-166* AlkPhos-245*
TotBili-2.9*
___ 06:00AM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.5* Mg-1.8
Imaging:
Ultrasound:
IMPRESSION:
1. No biliary dilation or stone. Post cholecystectomy.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
ERCP ___
Impression: There was a filling defect that appeared like sludge
in the lower third of the common bile duct.Otherwise normal
post-cholecystectomy biliary tree. Normal pancreatic duct.A
sphincterotomy was performed.
Sludge extracted successfully using a balloon.
sphincterotomy, stone extraction) Polyps in the stomach body and
antrum (biopsy) Otherwise normal ercp to third part of the
duodenum
Recommendations: Watch for complications - bleeding ,
perforation, pancreatitis. NPO today and then advance diet per
primary team's instructions
EUS ___
Impression: EUS was performed using a linear echoendoscope at
___ MHz frequency: The head and uncinate pancreas were imaged
from the duodenal bulb and the second / third duodenum. The body
and tail [partially] were imaged from the gastric body and
fundus.
Pancreas parenchyma: The parenchyma in the uncinate, head, body
and tail of the pancreas was homogenous, with a normal salt and
pepper appearance.
Bile duct: The bile duct was imaged at the level of the
porta-hepatis, head of the pancreas and ampulla. The maximum
diameter of the bile duct was 5.4 mm. A small hyperechoic focus
with anechoic shadow consistent with a small stone was noted in
the duct.
Brief Hospital Course:
___ with h/o HTN and hypothyroidism and s/p cholecystectomy with
one day of acute RUQ/mid abdominal pain, elevated lipase and t
bili consistent with suspected gallstone pancreatitis s/p ERCP
with sphincterotomy performed.
# Gallstone pancreatitis: S/p ERCP on ___ with sphincterotomy.
Likely etiology of RUQ abdominal pain though currently pain has
resolved. Low suspicion for cholangitis clinically at this time
given
absence of fever or leukocytosis. She tolerated POs day after
ERCP and was discharged for close follow up with PCP and GI.
# HTN: continued atenolol
# Hypothyroid: levothyroxine
# GERD: not on PPI any more per PCP
# Anxiety: bupropion, fluoxetine, Ativan
TRANSITIONAL ISSUES
=====================
# New Medications
- None
# Old Medications
- None
# Changed Medications
- None
To dos
===========
- Please ensure has GI follow up
- Trend LFTs and ensure downtrending
- Monitor blood pressures as outpatient and consider adjustment
of antihypertensives
- Follow up on biopsy of stomach polyps
The total time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Fluoxetine 10 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Meclizine 12.5 mg PO Q8H:PRN vertigo
6. LORazepam 0.25 mg PO Q6H:PRN anxiety
7. Aspirin 81 mg PO DAILY
8. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY
9. Famotidine 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY
5. Famotidine 20 mg PO DAILY
6. Fluoxetine 10 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. LORazepam 0.25 mg PO Q6H:PRN anxiety
9. Meclizine 12.5 mg PO Q8H:PRN vertigo
10. Oxybutynin 5 mg PO BID
Start: ___, First Dose: Next Routine Administration Time
11. Oxybutynin 5 mg PO BID
Start: ___, First Dose: Next Routine Administration Time
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gallstone acute pancreatitis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted due to abdominal pain and likely due to
gallstone pancreatitis. ___ had an ERCP which showed sludge and
had a sphincterotomy. Your symptoms improved prior to discharge
and ___ were tolerating food.
Please follow up with your doctor to trend your labs and ensure
your liver enzymes keep going down. ___ also had biopsy of
polyps taken. Please ensure to follow up with your doctor for
the results
___ was a pleasure being part of your care.
Your ___ team
Followup Instructions:
___
|
10522253-DS-18 | 10,522,253 | 22,736,406 | DS | 18 | 2169-06-05 00:00:00 | 2169-06-06 08:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
BuSpar
Attending: ___.
Chief Complaint:
left tibial plateau fracture
Major Surgical or Invasive Procedure:
ORIF left tibial plateau fracture
History of Present Illness:
___ with ex-fix on ___ for tibial plateau fracture presenting
from ___ with concern of infected inferior pin. WBC at
OSH 15.0. Patient notes that he's had chills for the past 3
days. Tmax 101 at home. Has been afebrile today and yesterday
with Tmax 99.1. ___ today noted drainage from inferior pin and
referred patient to ED. He notes some redness surrounding the
pin. Denies nausea/vomiting, tingling, or numbness.
Past Medical History:
Hypertension
Hyperlipidemia
Social History:
___
Family History:
non-contributory
Physical Exam:
Gen: NAD, aaox4
LLE: in unlocked ___, leg wrapped with ACE bandage, c/d/I.
Wounds c/d/I with overlying xeroform gauze. Minimal drainage.
Distal pin sites with moderate serosanguinous drainage. No pus.
Moderate edema, with some erythema, which has been steadily
resolving. Mild ecchymoses. Incision site with staples to skin.
No pus, minimal drainage from incision. Calf compartments soft,
compressible. SILT s/s/spn/dpn/tn; fires ___. Distally
there is moderate pedal edema, 1+ DP pulse, wwp toes.
Pertinent Results:
___ 09:40AM BLOOD WBC-11.1* RBC-3.26* Hgb-9.1* Hct-29.0*
MCV-89 MCH-27.9 MCHC-31.4* RDW-13.2 RDWSD-42.7 Plt ___
___ 04:43AM BLOOD WBC-19.4* RBC-3.00* Hgb-8.7* Hct-27.5*
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.5 RDWSD-45.5 Plt ___
___ 11:30AM BLOOD WBC-17.9*# RBC-3.40* Hgb-10.0* Hct-30.6*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.3 RDWSD-43.5 Plt ___
___ 04:40AM BLOOD WBC-11.6* RBC-3.73* Hgb-10.7* Hct-33.8*
MCV-91 MCH-28.7 MCHC-31.7* RDW-13.3 RDWSD-43.8 Plt ___
___ 04:15AM BLOOD WBC-16.4* RBC-3.53* Hgb-10.3* Hct-32.2*
MCV-91 MCH-29.2 MCHC-32.0 RDW-13.1 RDWSD-43.2 Plt ___
___ 09:40AM BLOOD Plt ___
___ 04:43AM BLOOD Plt ___
___ 11:30AM BLOOD Plt ___
___ 04:40AM BLOOD Plt ___
___ 04:40AM BLOOD ___ PTT-31.2 ___
___ 04:15AM BLOOD Plt ___
___ 04:15PM BLOOD Plt ___
___ 04:15PM BLOOD ___ PTT-29.3 ___
___ 04:40AM BLOOD Glucose-116* UreaN-14 Creat-0.8 Na-139
K-4.2 Cl-101 HCO3-31 AnGap-11
___ 04:15AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-137
K-3.9 Cl-98 HCO3-29 AnGap-14
___ 04:15PM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-139
K-3.9 Cl-100 HC___ AnGap-14
Brief Hospital Course:
The patient re-presented to the emergency department after going
home in his external fixator several days prior, and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibial plateau fracture, stable, in the ex-fix,
with severe swelling to LLE and an evolving cellulitis in the
left lower leg. He was admitted to the orthopedic surgery
service initially for treatment of cellulitis, edema management
and optimization prior to definitive fixation. He was treated
with IV vancomycin to combat his cellulitis, transitioned to IV
ancef for several days, and finally to PO Keflex to finish out
his course at home. The patient was taken to the operating room
on ___ for ORIF of the left tibial plateau, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with home ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
ANTIBIOTICS / ID: treated with IV vanc, IV ancef in-house;
transitioned to PO Keflex prior to discharge
DIABETES: n/a
HOME MEDS: continued throughout hospitalization
TRANSFUSIONS: n/a
Medications on Admission:
1. Enoxaparin Sodium 40 mg SC QPM
2. Acetaminophen 1000 mg PO Q6H
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
6. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*24 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day
Disp #*30 Capsule Refills:*0
7. Enoxaparin Sodium 40 mg SC QPM Duration: 28 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc every evening Disp #*28
Syringe Refills:*0
8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
please decrease dose as pain improves
RX *hydromorphone 4 mg ___ tablet(s) by mouth every three hours
Disp #*60 Tablet Refills:*0
9. Milk of Magnesia 30 ml PO BID:PRN Constipation
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice per day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Left lower extremity non weight bearing in unlocked ___
brace; ROMAT
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
- Please continue oral Keflex (antibiotic) as directed.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
non weight bearing in left lower extremity in unlocked ___
brace; ROMAT
Treatments Frequency:
please monitor distal pin sites for healing, s/s of infection
(increasing redness, oozing, edema, pus). Please check
leg/wounds during each visit (atleast every other day) and
change dressings prn. After 1 week, should be ok to shower and
pat dry. Do not submerge wounds.
Followup Instructions:
___
|
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