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10522319-DS-23 | 10,522,319 | 26,331,794 | DS | 23 | 2190-07-22 00:00:00 | 2190-07-24 14:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
sigmoidoscopy with biopsy
History of Present Illness:
___ year old man with ulcerative colitis who presents with one
week of vomitting, diarrhea and abdominal pain. He was in his
usual state of health unil ___ when he developed abdominal pain
and diarrhea which he attributed to a flair of his UC. He took
prednisone 10mg daily x2 days and mesalamine 1000mg TID and then
had a colonscopy (scheduled as routine) on ___ which showed
chronic focally active and inactive inflammation with increased
lamina propria inflammatory infiltrate. Symptoms improved,
however on ___ (one week PTA), he awoke from sleep with
concurrent vomitting and profuse diarrhea. This persisted until
the next morning when he had persistent LLQ abdominal pain
"excruciating like ripping intestines out", non-radiating,
somewhat relieved with bowel movements. He was unable to eat,
began to feel lightheaded when standing, and the
diarrhea/vomitting persisted so he presented to ___
___ where a CT scan was completed. He then was transferred
to ___ where he was admitted from ___ and
diagnosed with C.diff colitis and was started on metronidazole.
He was discharged but vomitting and diarrhea persisted (2 bowel
movements/hr of varying amounts). Emesis is mostly bilious,
today had specks of blood. No melena/hematochezia. No fever, but
has chills and night sweats. Feels lightheaded when standing. He
has had a persistent productive cough with mild shortness of
breath for the past 2 days.
In the ED, initial VS: 97.9 84 121/83 18 99%. Labs notable for
WBC 13, HCT 38, Plt 547 and PO4 1.6. Abdominal xray showed no
evidence for megacolon. Given 2L NS, Simethicone 80mg,
MetRONIDAZOLE 500 mg PO, Vancomycin PO 125mg, OxycoDONE 10mg,
Ondansetron 4mg. Most recent set of vitals 99.4,127/86, 75, 18
96%RA.
Upon arrival to the floor he has abdominal pain and nausea.
REVIEW OF SYSTEMS:
Had a headache which has improved with pain meds, no vision
changes, rhinorrhea, congestion. Mild sore throat. No chest
pain. No dysuria, hematuria. When he coughs he feels a hernia in
femoral region of groin which is new
Past Medical History:
Ulcerative colitis diagnosed in ___, with history of perianal
abscess
Asthma since age ___
Migraines
Low back pain
Recent aphthous stomatitis
___
___ surgical removal of a squamous cell carcinoma
foot surgery for bone pain
Social History:
___
Family History:
Mother and sister with asthma. Maternal uncle with ___
disease. Maternal grandfather with emphysema, maternal
grandmother with cancer (unknown type). Does not know father's
history.
Physical Exam:
VS - 98.4 117/87 97 18 100% RA
GENERAL - well-appearing, NAD
HEENT - sclerae anicteric, MMM, OP clear, healing apthous ulcer
on lateral aspect of tongue
NECK - supple, no LAD
LUNGS - CTA bilat, expiratory wheeze on forced expiration
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, pain to palpation in
LLQ with no rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
Labs on Admission:
___ 11:30AM WBC-13.0* RBC-4.26* HGB-12.5*# HCT-38.3*
MCV-90 MCH-29.3 MCHC-32.5 RDW-13.0
___ 11:30AM NEUTS-72.0* ___ MONOS-6.1 EOS-2.7
BASOS-0.2
___ 11:30AM PLT COUNT-547*
___ 11:30AM GLUCOSE-94 UREA N-5* CREAT-0.7 SODIUM-138
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
___ 11:30AM ALT(SGPT)-6 AST(SGOT)-19 ALK PHOS-59 TOT
BILI-0.9
___ 11:30AM LIPASE-14
Pertinent Labs:
___ 04:50AM BLOOD CRP-7.6*
___ 04:20AM BLOOD CRP-26.2*
___ 04:20AM BLOOD ESR-40*
Labs on Discharge:
___ 04:25AM BLOOD WBC-14.5* RBC-4.61 Hgb-13.2* Hct-40.1
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.7 Plt ___
___ 04:25AM BLOOD Glucose-84 UreaN-6 Creat-0.8 Na-139 K-4.1
Cl-106 HCO3-26 AnGap-11
___ 04:25AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.5
Microbiology:
blood cx: ___ negative
urine cx: ___ < 10,000 organisms
stool cultures: ___
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
stool CMV culture: pending
CMV antibody:
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
58 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
Radiology:
CXR: ___
Lungs are fully expanded and clear. Normal cardiomediastinal and
hilar
silhouettes and pleural surfaces. Minimal relative elevation of
the left
hemidiaphragm is unchanged, of no active clinical significance.
KUB: ___
Bowel gas pattern appears non-obstructive, without evidence of
marked colonic dilatation to suggest megacolon. Air is seen
scattered within non-dilated loops of small and large bowel.
There are no soft tissue calcifications or evidence of
pneumatosis. Evaluation of free air is limited on this single
supine study.
IMPRESSION: No evidence for megacolon.
sigmoidoscopy: ___
Diffuse continuous friability, erythema and congestion with
contact bleeding were noted in the rectum and sigmoid colon.
There was mucous that was able to be washed off. There was some
areas of white plaque that may represent resolving
pseudomembrane. Cold forceps biopsies were performed for
histology at the rectum and sigmoid colon.
Impression: Friability, erythema and congestion in the rectum
and sigmoid colon (biopsy). Otherwise normal sigmoidoscopy to
sigmoid colon
Brief Hospital Course:
1. Clostridium Difficile Colitis: Patient admitted with severe
clostridium difficile: >10 bowel movements daily in setting of
underlying IBD and recent immunosupression. CT scan at the
outside hospital and KUB on arrival to ___ showed no evidence
of toxic megacolon or obstruction. Clostridium difficle toxin
here was negative but PCR at outside hospital had been positive.
Other stool studies, including cultures for
salmonella/shigella/campylobacter/CMV. Due to rising
leukocytosis, a sigmoidoscopy was performed on ___ which
was consistent with pseudomembranous colitis (biopsy still
pending).
Initially, patient was given bowel rest and supportive care with
intravenous fluid. Throughout hospital course, he was
maintained on oral vancomycin with subsequent improvement in
diarrhea. By time of discharge, patient was tolerating low
ressidu, BRAT diet with ___ episodes of nonbloody diarrhea/ day.
He will continue a 14 day course of vanc and follow up with
outpatient gastroenterologist to review biopsy results.
- continue oral vancomycin x 8 days to complete 14 day course
- f/u with outpatient gastroenterologist to follow pathology
results
2. Ulcerative Colitis: recent colonoscopy performed at the
beginning of ___ showed evidence of chronic active
inflammation, increased inflammatory infiltrate consistent with
flare. Patient was subsequently treated with prednisone x 2
days with improvement in symptoms. During current admission,
there was initial concern that symptoms could be secondary to
recurrence of IBD flare especially given ESR/ CRP elevation. As
patient was improving only slowly on oral vancomycin, he
underwent a sigmoidoscopy to assess for active IBD. On gross
examination, appearrance was more similar to pseudomembranous
colitis but pathology was still pending. Patient continued on
mesalamine which was uptitrated to 4mg daily
- continue mesalamine 1gm QID
- orabase/magic mouthwash PRN oral ulcers (likely not related to
IBD)
- f/u sigmoid biopsies
- f/u with outpatient gastroenterologist
3. Leukocytosis: patient admitted with wbc count of 13,000 which
peaked at 18,000 over hospital course. Most likely cause of
leukocytosis was clostridium difficile infection although IBD
flare was also considered in the differential diagnosis. CXR,
urine and blood cultures were negative. Stool studies were also
negative for any additional infectious cause (shigella,
salmonella, ecoli, CMV). By time of discharge, WBC count had
returned to 14,500
4. Asthma: patient complained of cough and increased dyspnea
requiring frequent albuterol. This was likely secondart to
asthma exacerbation caused by viral URI. CXR was negative for
pneumonia. Symptoms improved with administration of scheduled
nebulizers and home advair.
TRANSITIONS OF CARE:
- continue oral vancomycin for full 14 day course
- increase mesalamine to 4 grams daily
- follow up sigmoid biopsies to rule out ulcerative colitis
flare
Medications on Admission:
ALBUTEROL SULFATE 90 mcg q6H PRN
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk BID
TRIAMCINOLONE IN ORABASE - apply to ulcers BID PRN
ZOLPIDEM - 2.5 mg qHS
ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - ___ mg q6H
ASACOL 1000mg TID
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: do not take medication with alcohol
or before driving .
Disp:*20 Tablet(s)* Refills:*0*
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
4. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO QID (4 times a day).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puff Inhalation every six (6) hours.
6. zolpidem 5 mg Tablet Sig: ___ Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
clostridium difficile colitis
Secondary Diagnosis:
ulcerative colitis
asthma
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 with abdominal pain and
diarrhea which was likely due to infection by clostridium
difficile. You had a sigmoidoscopy which was consistent with
this kind of infection, although you will have to follow up
biopsy results to ensure that there is no evidence of active
ulcerative colitis. Your symptoms improved with antiobiotics.
Please make the following changes to your diet:
CONTINUE vancomycin 125mg every 6 hours for 8 additional days
(until ___
INCREASE your mesalamine to 1000mg every 6 hours until you see
your gastroenterologist
START oxycodone 5mg every 6 hours as needed for pain. Only take
this medication if your pain is not controlled with
acetaminophen. Never take this medication withn alcohol or
while driving as it can make you sleepy.
Followup Instructions:
___
|
10522319-DS-25 | 10,522,319 | 23,105,270 | DS | 25 | 2191-03-11 00:00:00 | 2191-03-11 18:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___- biopsies taken from rectum and
sigmoid colon
History of Present Illness:
___ yo M with PMH of UC and prior episode of c. diff most
recently ___ presents with increasing diarrhea, intermittent
abd pain in the LLQ for the past 10 days. The patient initially
notes increasing stool frequency that was initially formed but
progressively becoming more watery and foul smelling. The abd
pain in the LLQ that radiated to the back started 3 days PTA.
The pain is described as intermittent, stabbing-like and crampy.
Upon stooling, the patient does not relief of symptoms. As of
now, the patient notes stooling every ___ minutes of watery,
foul smelling stool. 1 day PTA, he notes hematochezia as well.
He endorses fecal urgency and nocturnal bowel movements that
wake him up from sleep. He presented to his PCP for his
worsening abd pain 1 day PTA. The workup was noticeable for a
WBC of 22,000. PCP referred him to the ED for further work up.
Past Medical History:
-Ulcerative Colitis: First diagnosed in ___. Treated with
prednisone and mesalamine without any surgical interventions.
With presdnisone symptoms improved but his flares persisted.
These flares are characterized by abd pain, cramping, diarrhea
___ per day, hematochezia, urgency and nocturnal symptoms.
-Recent Shingles treated ___
-Alcohol abuse
-Perianal abscess and ___ placement ___ years ago
-External hemorrhoids removed 4 weeks ago
- Migraine
- Asthma
- s/p LLE cellulitis ___
- Low back pain
- Rosacea
- s/p superficial thrombophlebitis of right forearm ___
- s/p left foot surgery
Social History:
___
Family History:
Uncle with ___. No family history of GI or colon cancer.
Mother's father died of lung disease after tobacco use.
Estranged from father who had problem with alcohol ___
Physical Exam:
On admission ___
PHYSICAL EXAMINATION:
VITALS: 98.5, 130/90, 110, 18, 99% RA
GENERAL: Moderate abdominal pain, otherwise NAD
HEENT: PERRL, EOMI, anicteric, rhinophyma on nose (rosacea)
NECK: no carotid bruits, JVD not elevated
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: soft, TTP most focally in LLQ but also with tenderness
to midepigastrium. No rebound, slight voluntary guarding,
hyperactive bowel sounds
RECTUM: External hemorrhoids, no visual blood, no fistulous
tract
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
On discharge:
VS 97.9F 130/94 80 20 95%RA
GA: NAD, interacting appropriately
HEENT: PERRL, EOMI, anicteric sclerae, rhinophymatous nose
Neck: supple, no masses
CV: RRR, no m/r/g
Pulm: CTAB, no w/r/rh
Abd: soft, no tenderness to palpation diffusely, no rebound, no
guarding, normoactive bowel sounds, no HSM
Rectum: external hemorrhoids, no active bleeding, no fistula,
non-tender 1x1cm subcutaneous nodule (cyst) with opening, no
drainage.
Ext: no peripheral edema, 2+ peripheral pulses
Neuro: A&Ox3, CNII-XII grossly intact
Pertinent Results:
On admission:
___ 10:49AM BLOOD WBC-23.2*# RBC-5.56 Hgb-11.7* Hct-41.9
MCV-75* MCH-21.0* MCHC-27.9* RDW-21.0* Plt ___
___ 02:30PM BLOOD Glucose-118* UreaN-16 Creat-0.8 Na-134
K-3.8 Cl-99 HCO3-25 AnGap-14
___ 10:49AM BLOOD ALT-9 AST-21 AlkPhos-91 TotBili-0.9
___ 06:40AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7
___ 02:30PM BLOOD CRP-163.6*
___ 08:45AM BLOOD CRP-194.4*
___ 03:07PM BLOOD Lactate-2.5*
___ 08:09AM BLOOD Lactate-2.6*
On discharge:
___ 06:25AM BLOOD WBC-10.0 RBC-4.29* Hgb-8.9* Hct-31.0*
MCV-72* MCH-20.7* MCHC-28.6* RDW-21.1* Plt ___
___ 06:25AM BLOOD ___ PTT-25.4 ___
___ 06:25AM BLOOD Glucose-134* UreaN-12 Creat-0.5 Na-137
K-3.8 Cl-100 HCO3-31 AnGap-10
___ 06:25AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.2 Iron-PND
Microbiology:
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___
10:15AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
MANY RED BLOOD CELLS.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Radiology:
___ CT abdomen
ABDOMEN: The visualized lung bases are clear. There is no
pleural effusion
or pneumothorax. The heart size is normal and there is no
pericardial
effusion.
The liver enhances homogeneously. The gallbladder is normal and
there is no
intrahepatic biliary ductal dilatation. The spleen, pancreas,
and adrenal
glands are normal. The kidneys enhance symmetrically and
excrete contrast
without hydronephrosis. The ureters are normal in caliber. The
stomach and
small bowel are unremarkable. There is no retroperitoneal
lymphadenopathy,
free air or free fluid. The abdominal aorta and its major
branches are
normal.
There is diffuse pericolonic vascular engorgement. Bowel wall
thickening is
seen extending from the rectum to the cecum most marked within
the left
hemicolon and sigmoid colon. In addition, multiple reactive
mesenteric lymph
nodes, measuring up to 8.2 mm are seen. There is no evidence of
fistula or
abscess formation.
PELVIS: The bladder and prostate are unremarkable. Evaluation
of the
previously seen intersphincteric fistula cannot be characterized
on this
study. There is no free pelvic fluid.
BONES: There are no suspicious osseous lesions. In particular,
the
sacroiliac joints are unremarkable. There is grade 1 L5 on S1
anterolisthesis
as seen on recent L-spine radiograph.
IMPRESSION:
1. Findings consistent with an active ulcerative colitis with
mild reactive
changes in the mesentery. No fistula or abscess formation
present.
2. The previously seen intersphincteric fistula cannot be
evaluated on this
exam.
Brief Hospital Course:
___ yo gentlemen with h/o C diff and ulcerative colitis admitted
with diarrhea, abdominal pain, leukocytosis, and fever
concerning for infection c. diff colitis and UC flare.
#Severe C. difficile colitis and Ulcerative Colitis Flare:
Given + stool antigen test for C. diff and abdomnal CT,
diagnosis was made of UC flare exacerbated by C. difficile
infxn. Per GI recommendations, IV flagyl and PO vancomycin were
initiated. Patient was transitioned later on to PO flagyl and
PO vancomycin (2 week course). CT abdomen ruled out
intraabdominal abscess, toxic megacolon or other anatomical
etiologies for abd pain/diarrhea. PO morphine and IV morphine
were used to manage pain. Per GI recs, PO prednisone was stepped
up to IV salumedrol for 48 hours after performing flexible
sigmoidoscopy on ___ which showed moderate diffuse erythema
and scattered ulceration in the rectum of mucosa, and mild
erythema, granularity and scattered ulceration in the sigmoid
colon. Biopsies were taken from rectum and sigmoid colon. During
hospitalization pt also complained of chronic R sided hernia
which was contributing to abdominal pain from UC flair and
infectious colitis- it was decided with PCP that this would be
addressed as outpatient. Patient re-transitioned to PO
prednisone on ___ after clinical improvement and resolution of
leukocytosis. Over the course of hospital stay, BM decreased
from every 20 to 30 minutes to 3 bowel movements in 12 period
from ___ to ___. Pt also had decrease in bloody streaks in
stool with improved abdominal pain throughout course. ___
patient restarted solid diet, tolerating well. Pt's abd pain
manageable and PO flagyl was discontinued. Pt was discharged
with vancomycin and was to complete a two week course.
#Alcoholism: Patient has a long history of alcoholism with most
recent episode requiring ED visit on ___ with homicidal
and suicidal ideations. During course of stay here, patient
exhibited 1 night of anxiety, agitation, hand tremor and fever
spike to 102. He scored a positive CIWA of 14 and given 10 mg
Valium to good relief. IV lorazepam given PRN for next two
nights, and was discontinued ___ reoccurance of symptoms.
His anxiety and anger likely stems from his alcohol addiction.
Recommend follow-up with alcohol abuse specialist.
#Microcytic anemia
Hct down from 37.8 on admission to 31.7 with average MCV of 72.
Given bleeding from UC/c. diff most likely cause is GI losses
with increased demand for iron in addition to insufficient
intake (malnutrition). Iron studies done and iron added to
patient's discharge medications.
Transitional Issues:
- Pt is to complete 2 week course of oral Vancomycin on ___
- Pt is to start oral Prednisone 60mg with 10mg taper weekly:
60mg x7d (___)
50mg x 7d (___)
40mg x7d (___)
30mg x7d (___)
20mg x 7d (___)
10mg thereafter and will discuss with GI specialist regarding
further treatment/management
- Pt is to follow-up with PCP ___ in one week
- Pt is to follow-up with Dr. ___ (GI) in two weeks
- Pt is to work with PCP in referral to outpt psychiatrist
and/or addiction specialist
- Pt is to f/u with PCP to work on nutrition (monitor INR and
iron deficiency anemia).
- Pt is to f/u with PCP for referral to general surgery to
evaluate right-sided hernia
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Azathioprine 150 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. PredniSONE 10 mg PO EVERY OTHER DAY
5. Tizanidine 4 mg PO TID
6. Zolpidem Tartrate ___ mg PO HS
7. Acetaminophen 500 mg PO Q6H:PRN pain
8. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Azathioprine 150 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Vitamin D 400 UNIT PO DAILY
6. Zolpidem Tartrate ___ mg PO HS
7. Tizanidine 4 mg PO TID
8. Vancomycin Oral Liquid ___ mg PO Q6H
RX *Vancocin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*52 Capsule Refills:*0
9. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*77 Tablet
Refills:*0
10. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp
#*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Severe Clostridium difficile colitis, recurrent
Ulcerative colitis flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you at the ___.
You were admitted for severe abdominal pain and bloody stools.
You were found to have another episode of C. difficile colitis
with an ulcerative colitis flare. You underwent a procedure with
gastroenterology which took biopsies from your GI tract. You
improved throughout your hospitalization very well and your
abdominal pain and diarrhea improved with antibiotics and IV
steroids. We switched you to oral prednisone 60mg which you will
taper down by 10mg weekly until you are back to your original
home dose of 10mg daily.
You are to complete a two week course of oral vancomycin for
your C. diff infection, ending on ___.
Please follow-up with your outpatient physicians including your
primary care physician, gastroenterologist and psychiatrist.
Be sure to talk to your GI doctor,Dr. ___ refills for your
prednisone to continue your steroid taper properly.
Followup Instructions:
___
|
10522575-DS-4 | 10,522,575 | 24,097,143 | DS | 4 | 2168-03-01 00:00:00 | 2168-03-01 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ no significant medical history presents w/ abdominal pain
and bloating x 4 days described as mild-moderate epigastric
abdominal pain that started soon after eating a large meal at a
buffet. That night it was associated with diarrhea that has not
recurred. Symptoms persisted but didn't interfere with his day
to day activities. He eventually noticed yellowing of his skin
and pale stools and starting having subjective fevers, prompting
him to see his PCP. Labs revealed abnormal LFTs (TBili 5.5,
direct bili 3.6, ap 391. ast 160, alt 410) and he was instructed
to come to the ED. He had 2 similar episodes in the past w/ the
most recent one year ago that prompted workup for H.pylori w/
negative urea breath test and eventual resolution of his
symptoms.
No reported sick contacts. No one else got sick from the buffet
meal. Never had hepatitis. Vaccinated against hepatitis A + B
virus. Drinks one drink/month. Never has binge-drank. No new
medications including over the counter. Denies unprotected sex
but tells me he gets tested frequently for STDs as recently as
yesterday at his PCPs office. HIV screen ___ negative. He
does have outdoor exposure.
In the ED, initial VS were: T99, HR 81, BP 124/76, RR 16, 99%
RA. ED labs were notable for: INR/Hct/Plt - Labs: INR 1, Hct
46.1, plt 229, ALT 376, AST 148, AP 383, TB 4.8, DB 3.9, lip
108, UA +WBC. Imaging showed: RUQUS (___): No cholelithiasis or
cholecystitis. Gallbladder polyps measuring up to 3 mm. OSH CT:
no signs of obstruction, no stone. ERCP team was consulted and
recommended admitting to medicine and obtaining an MRCP.
Past Medical History:
none
Social History:
___
Family History:
Father had remote h/o "liver problems" but reportedly healthy
now.
Physical Exam:
-Vitals: reviewed in OMR, afebrile
-General: NAD, laying comfortably in bed
-HENT: atraumatic, normocephalic, moist mucus membranes
-Eyes: PERRL, EOMi, no icterus
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: soft, nontender, nondistended, bowel sounds presents -
overall improved from yesterday back to baseline
-GU: no foley, no CVA/suprapubic tenderness
-MSK: No pedal edema, no joint swelling
-Skin: No rashes or ulcerations. no appreciable jaundice.
-Neuro: no focal neurological deficits, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 02:49AM BLOOD WBC-7.4 RBC-5.03 Hgb-15.2 Hct-46.1 MCV-92
MCH-30.2 MCHC-33.0 RDW-12.0 RDWSD-40.4 Plt ___
___ 02:49AM BLOOD Neuts-78.0* Lymphs-9.4* Monos-7.9 Eos-3.8
Baso-0.4 Im ___ AbsNeut-5.80 AbsLymp-0.70* AbsMono-0.59
AbsEos-0.28 AbsBaso-0.03
___ 02:49AM BLOOD ___ PTT-36.9* ___
___ 02:49AM BLOOD Glucose-104* UreaN-5* Creat-0.7 Na-140
K-3.6 Cl-99 HCO3-25 AnGap-16
___ 02:49AM BLOOD ALT-376* AST-148* AlkPhos-383*
TotBili-4.8* DirBili-3.9* IndBili-0.9
___ 02:49AM BLOOD Lipase-108*
___ 02:49AM BLOOD Albumin-4.6 Calcium-9.2 Phos-2.5* Mg-2.1
___ 02:49AM BLOOD Lactate-1.2
MRCP: IMPRESSION: Normal MRI appearance of the liver and biliary
system. No MRCP explanation for elevated LFTs.
RUQ US IMPRESSION: No findings of biliary obstruction. No
cholelithiasis or cholecystitis.
DISCHARGE LABS
___ 05:52AM BLOOD WBC-9.7 RBC-4.64 Hgb-14.2 Hct-42.5 MCV-92
MCH-30.6 MCHC-33.4 RDW-12.0 RDWSD-40.0 Plt ___
___ 05:52AM BLOOD ___
___ 05:52AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-137 K-4.1
Cl-95* HCO3-25 AnGap-17
___ 05:35AM BLOOD ALT-280* AST-91* AlkPhos-412* TotBili-1.5
___ 05:52AM BLOOD Calcium-9.4 Mg-2.2
___ 06:00AM BLOOD Triglyc-159* HDL-35* CHOL/HD-5.2
LDLcalc-114
___ 01:10PM BLOOD Smooth-NEGATIVE
___ 01:10PM BLOOD IgG-1370 IgM-134
___ 01:10PM BLOOD HIV Ab-NEG, HIV1 VL-NOT DETECT
___ 06:10AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS*
___ 06:10AM BLOOD HCV Ab-NEG
___ 01:10PM BLOOD IgM HAV-NEG
___ 01:10PM BLOOD tTG-IgA-14
___ 05:20AM BLOOD QUANTIFERON-TB GOLD- negative
___:10PM BLOOD LYME DISEASE ANTIBODY: IgM positive, IgG
negative
___ 01:10PM BLOOD LEPTOSPIRA ANTIBODY- negative
___ 06:00AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM- negative
___ 05:20AM BLOOD BRUCELLA ANTIBODY, AGGLUTINATION-PND
Brief Hospital Course:
___ w/ no significant medical history presents with 4 days of
abdominal pain and nausea/vomiting found to have transaminitis
and cholestasis.
1. Lyme disease
-IgM positive and initiated doxycycline treatment ___, which
will be continued for 2 weeks through ___.
2. Transaminitis, cholestasis, hyperbilirubinema (conjugated),
and abdominal pain
-Mixed picture with unclear etiology in setting of normal MRCP.
As per ERCP team no indication for ERCP at this time. Initial
diagnosis broad including infectious, autoimmune, and
infiltrative process. Lyme IgM resulted positive ___, which
is likely cause of lab abnormities and liver biopsy not
indicated at this time. He will follow up w/ GI/hepatology
outpatient follow w/ Dr. ___ to ensure LFTs normalize
following lyme treatment.
3. Constipation and ileus
-Unclear etiology potentially related to decreased activity,
decreased PO intake, and acute illness. There is not a common
association with lyme and ileus but may be related. Patient will
good response to suppository and will continue w/ docusate &
senna outpatient.
4. Asymptomatic pyuria
-Urine culture with 10,000-100,000 alpha hemolytic strep without
indication for treatment. Gonorrhea and chlamydia negative.
5. GERD, hiccups
-Patient with good response to Chlorpromazine. At discharge
patient requests short course of antacid and antinausea meds
given prescriptions for ranitidine and metoclopramide PRN.
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate
sodium 100 mg 1 tablet(s) by mouth BID PRN Disp #*30 Tablet
Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H take through ___ RX
*doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*25 Tablet Refills:*0
3. Metoclopramide 10 mg PO TID:PRN nausea/vomiting RX
*metoclopramide HCl 10 mg 1 tab by mouth TID PRN Disp #*15
Tablet Refills:*0
4. Ranitidine 75 mg PO BID:PRN indigestion Duration: 14 Days
take before eating RX *ranitidine HCl 75 mg 1 tablet(s) by
mouth BID PRN Disp #*28 Tablet Refills:*0
5. Senna 17.2 mg PO DAILY RX *sennosides [senna] 8.6 mg ___ tab
by mouth daily PRN Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abnormal liver testing, elevated bilirubin
Lyme disease
Constipation, Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted with elevated bilirubin and abnormal liver
testing. Your imaging was normal and lab tests positive for
lyme disease and you were started on doxycycline, which you
should continue for 14 days. You will continue outpatient
follow up with gastroenterology to ensure your liver numbers
have resolved.
Your hospital course was complicated by ileus, which improved
with aggressive bowel regimen. You can continue a bowel regimen
as needed to ensure you have 1 soft bowel movement every ___
days.
It was a pleasure taking care of you.
-Your ___ team
Followup Instructions:
___
|
10522581-DS-19 | 10,522,581 | 22,180,686 | DS | 19 | 2126-09-23 00:00:00 | 2126-09-23 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Robitussin
Attending: ___
Chief Complaint:
LLQ Abdominal Pain, Colitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female PMHx DVT not on
anticoagulation presents for evaluation of 1 day of LLQ
abdominal pain and 6 episodes of bloody diarrhea after starting
azithromycin.
This all started approximately 3 weeks ago at which time pt
developed uri type symptoms and was seen by primary care and
found to have the flu and strep throat. Pt was treated with a
course of abx and completed them approximately 1 week ago.
Symptoms did not resolved so presented to primary care 1 day
prior to presentation and was given azithromycin and started
taking it at 12pm on the day prior to presentation and
subsequently developed acute onset of LLQ abdominal pain
followed by 6 episodes of frankly bloody diarrhea associated
with lightheadedness and nausea but not emesis/fevers/chills/uti
symptoms.
Pt does have a known history of a DVT and was on Coumadin for
6mths and stopped it in ___. Last colonoscopy ___ yrs ago,
negative. No travel/sick contacts.
In the ED, pt was afebrile HD stable. wbc ct 13k and hgb 15.
chemistries wnl. CT scan w/ descending colitis-- no abcess/perf.
Pt was given cipro and flagyl and admitted for additional
evaluation and treatment.
Past Medical History:
Provoked DVT not currently on anticoagulation
Primary Hypertension
hyperlipidemia
Social History:
___
Family History:
Brother with generalized osteoarthritis
Physical Exam:
GENERAL: NAD
EYES: Anicteric
HENT: oral mucosa moist
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Soft, non-distended, non-tender, normal bowel sounds.
GU: No suprapubic tenderness.
MSK: superior and posterior L shoulder tender to palpation
SKIN: No rashes.
NEURO: Alert, oriented. L hand grip ___ motor strength. L arm
sensation intact.
PSYCH: Calm.
Pertinent Results:
___ 04:00PM BLOOD Hgb-15.0 Hct-44.2
___ 11:00AM BLOOD WBC-13.2* RBC-5.06 Hgb-14.7 Hct-43.6
MCV-86 MCH-29.1 MCHC-33.7 RDW-13.8 RDWSD-43.5 Plt ___
___ 11:00AM BLOOD Neuts-73.0* ___ Monos-4.8*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.65* AbsLymp-2.85
AbsMono-0.63 AbsEos-0.01* AbsBaso-0.03
___ 11:25AM BLOOD ___ PTT-27.5 ___
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-139
K-3.5 Cl-101 HCO3-24 AnGap-14
___ 11:00AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-139
K-3.5 Cl-101 HCO3-24 AnGap-14
___ 11:00AM BLOOD ALT-41* AST-36 AlkPhos-88 TotBili-0.5
___ 11:00AM BLOOD Lipase-31
___ 11:00AM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD Albumin-4.6
___ 12:48PM BLOOD Lactate-1.4
___ 07:40PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 4:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
CHEST (PA & LAT) Study Date of ___ 12:46 ___
IMPRESSION:
Cardiomediastinal silhouette is at the upper limits of normal
for size. Mild emphysematous changes. Mild blunting of the
right costophrenic angle, better appreciated on the lateral view
may represent small pleural effusion with compressive
atelectatic changes. There are no pneumothoraces.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2:50 ___
IMPRESSION:
Findings suggestive of colitis affecting the descending colon.
No evidence of perforation nor abscess formation.
EKG: NSR@52, QTc 428, Q-waves AVF, RSR' V2
Brief Hospital Course:
___ yo F with history of DVT (not on anticoagulation), presented
with 1 day LLQ abdominal pain and bloody diarrhea. Vitals were
stable, Hgb was stable. C diff stool was negative. CT abdomen
showed descending colon wall thickening, consistent for colitis.
Differential for colitis included infection vs inflammatory
bowel disease. The abdominal pain and bloody diarrhea resolved
within a day without intervention. Therefore, the patient was
not treated with antibiotics. The patient was advised to follow
up with Gastroenterology within 4 weeks for colonoscopy to
evaluate for resolved infection versus inflammatory bowel
disease.
The patient was also found with left shoulder pain. MRI showed
mild tendinosis of the supraspinatus, infraspinatus and
subscapularis tendons, and also a shallow 3 mm articular sided
partial-thickness tear of the infraspinatus insertional fibers.
Discussed image with orthopedics, who recommended physical
therapy and no surgical intervention.
The patient was stable upon discharge. The patient was advised
to follow up with gastroenterology for colitis. The patient was
advised to follow up with Primary care and physical therapy for
L infraspinatous partial tear. Risks and benefits were
discussed, the patient verbalized understanding and agreed to
plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 250 mg PO Q24H
2. Simvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*0
2. Hydrochlorothiazide 25 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5.Outpatient Physical Therapy
Physical therapy for left shoulder (with partial tendon tear).
Discharge Disposition:
Home
Discharge Diagnosis:
1) Bloody diarrhea
2) Colitis
3) Left shoulder tendon partial tear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Reason for admission to hospital:
1) Bloody diarrhea
2) Colitis
Instructions for after discharge from the hospital:
1) Follow up with Gastroenterology for evaluation of colitis.
2) Follow up with Primary Care physician ___ 1 week to follow
up of Left shoulder pain with partial tendon tear.
3) Plan for physical therapy for left shoulder.
Followup Instructions:
___
|
10523012-DS-3 | 10,523,012 | 24,390,795 | DS | 3 | 2177-02-19 00:00:00 | 2177-02-26 21:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Erythromycin Base / vancomycin / Bactrim
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman s/p MVR in ___ on warfarin, s/p DCCV for
a-fib in ___, tricuspid annuloplasty, hyperlipidemia, Hx of
breast cancer, OSA, IBS and pulmonary artery hypertension who
presents to the ED for fevers. Patient reports that 5 days ago
she noted bilateral clavicle pain. Described as "achy" and
constant. Somewhat pleuritic in nature. Relieved by Tylenol.
Somewhat exacerbated by movement. Patient reports that 3 days
ago, fevers started. Denies cough, dyspnea, nasal congestion,
chest pain, abdominal pain, nausea, diarrhea, urinary frequency,
dysuria. Denies fatigues, joint pains, lightheadedness,
dizziness, vision changes, palpitations. Endorses some left calf
pain, but no other myalgias. Endorses intermittent headache for
the past five days, but no headache currently.
Patient presented to ___ urgent care in ___ yesterday.
At that time, febrile to ___. She was told to present to ___
ED given concern for endocarditis. Laboratory evaluation was
notable for absence of leukocytosis, elevated CRP to 123.2. BCx
drawn and are pending. CXR notable for postoperative changes,
increased size and globular appearance of the cardiopericardial
silhouette, may represent postoperative changes, progressed
cardiac chamber enlargement, or pericardial effusion.
Of note, patient was seen in the CDAC with similar complaints in
___. Was determined to have a viral illness at that time. TTE
in the interim did not show any evidence of vegetation.
On further review of symptoms, patient endorses 10 pound
unintentional weight loss over the past two months, which she
somewhat attributes to her post-op recovery. No recent travel,
no
sick contacts. No obvious TB risk factors.
- In the ED, initial vitals were:
T 99.2 HR 86 BP 109/61 RR 17 O2 100% RA
- Exam was notable for:
General: Well appearing, in NAD
HEENT: No cervical or supraclavicular LAD appreciated.
Fundoscopic exam significantly limited in ED, but no obvious
___
spots appreciated
Cardiac: Normal rate and rhythm with occasional premature beats.
Grade ___ systolic murmur heard loudest at left parasternal
border. No rubs or gallops.
Pulm: Lungs clear to auscultation bilaterally. No increased work
of breathing.
Abdomen: Soft, nontender, nondistended
Extremities: Warm. No edema. Symmetric calves. No splinter
hemorrhages, ___ lesions, ___ nodes.
Neuro: AAOx3. Pupils equal and reactive. EOMI. Motor and sensory
function grossly intact and symmetric throughout.
- Labs were notable for:
136 99 17
-------------<91
4.5 25 0.8
8.4
5.7>---<264
28.1
___: 33.8 PTT: 35.1 INR: 3.1
D-Dimer: 943
FluAPCR: Negative
FluBPCR: Negative
- Studies were notable for:
CTA
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral small right and trace left pleural effusions.
___
No evidence of deep venous thrombosis in the left lower
extremity
veins.
On arrival to the floor, the patient confirms the history as
above. She does note that she has felt more pain in her left
temple the last few days. Denies any jaw claudication or hip or
shoulder weakness. Last sick contact 1 month ago before her
previous fevers.
Past Medical History:
1. Mitral valve replacement - #31mm ___ porcine
___
with Dr. ___ @ ___
2. Tricuspid valve annuloplasty -28 mm ___
Physio ring; ___ with Dr. ___ @ ___
2. Irritable bowel syndrome
3. Breast cancer - s/p chemotherapy and mastectomy, ___
4. Obstructive sleep apnea - mild; intolerant of CPAP
5. Migraines - ___ not severe
6. Asthma (___)
7. Osteoporosis
8. Hypothyroidism
9. Hyperlipidemia
10. Atrial fibrillation - ___, presented with L MCA stroke;
RF
MAZE ___ with ___ excision.
11. Left MCA stroke treated with thrombectomy - ___, ___;
Neck
MRA unremarkable
Social History:
___
Family History:
Her parents are deceased (father, ___, sudden death,
hypertension,
CAD at autopsy; mother, ___, COPD). She has no siblings or
children.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.5 PO 126 / 82 L Sitting 81 17 94 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. TTP
in left temple.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Soft ejection murmur on
left sternal border
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Mild TTP in left
calf, DIP joint slightly swollen, no warmth or tenderness
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
======================
VITALS: 24 HR Data (last updated ___ @ 800)
Temp: 98.1 (Tm 98.7), BP: 109/63 (105-129/54-76), HR: 79
(76-87), RR: 16 (___), O2 sat: 98% (95-98), O2 delivery: Ra,
Wt: 105.38 lb/47.8 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. TTP
in left temple.
NECK/SHOULDER: Slightly tender clavicles bilaterally. No
cervical
lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Healing incision on
anterior chest w/out surrounding erythema or tenderness
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Mild TTP in left
calf, DIP joint slightly swollen, no warmth or tenderness, no
___ lesion, no splinter hemorrhages
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS
==============
___ 06:20PM BLOOD WBC-7.1 RBC-3.03* Hgb-8.0* Hct-25.4*
MCV-84 MCH-26.4 MCHC-31.5* RDW-15.1 RDWSD-45.8 Plt ___
___ 06:20PM BLOOD Neuts-77.7* Lymphs-9.3* Monos-10.6
Eos-1.7 Baso-0.3 Im ___ AbsNeut-5.48 AbsLymp-0.66*
AbsMono-0.75 AbsEos-0.12 AbsBaso-0.02
___ 06:08AM BLOOD H/O Smr-AVAILABLE
___ 06:20PM BLOOD ___ PTT-34.8 ___
___ 06:20PM BLOOD cTropnT-<0.01
___ 06:20PM BLOOD CRP-123.2*
PERTINENT LABS
=============
___ 05:45PM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-136
K-4.5 Cl-99 HCO3-25 AnGap-12
___ 05:45PM BLOOD D-Dimer-943*
___ 06:08AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.1 Mg-1.9
Iron-16*
___ 06:08AM BLOOD calTIBC-339 Ferritn-53 TRF-261
___ 06:08AM BLOOD ALT-12 AST-17 AlkPhos-69 TotBili-0.4
DISCHARGE LABS
==============
___ 05:30AM BLOOD WBC-3.8* RBC-3.19* Hgb-8.3* Hct-27.6*
MCV-87 MCH-26.0 MCHC-30.1* RDW-15.3 RDWSD-47.8* Plt ___
___ 05:30AM BLOOD Neuts-57.2 ___ Monos-14.2*
Eos-7.7* Baso-0.5 AbsNeut-2.17 AbsLymp-0.76* AbsMono-0.54
AbsEos-0.29 AbsBaso-0.02
___ 05:30AM BLOOD ___
___ 05:30AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-139
K-4.6 Cl-106 HCO3-24 AnGap-9*
___ 05:30AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
IMAGING
=======
Bilateral temporal artery dopplers: IMPRESSION: No B-mode or
spectral Doppler evidence of temporal arteritis in either right
or left.
CTA chest: IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Small pleural effusions.
3. Cardiomegaly with notable biatrial chamber enlargement and
evidence of
prior tricuspid valve replacement.
4. Emphysema with mild basal dependent atelectasis.
5. Mildly dilated main pulmonary artery, please correlate for
pulmonary
Left lower extremity veins
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
SUMMARY
========
Ms. ___ is a ___ year old woman s/p MVR, tricuspid annuloplasty,
MAZE and left atrial appendage ablation in ___ on warfarin,
s/p DCCV for atrial fibrillation in ___, hyperlipidemia, with
of breast cancer s/p chemotherapy and surgery ___ and ___
arimidex, OSA intolerant of CPAP, and pulmonary artery
hypertension who presented with recurrent fevers, bilateral
sub-clavicular pain, and L calf pain. Despite workup, no cause
was found for her fevers; TEE remains to be done outpatient. She
was also found to have hematuria with unremarkable sediment.
#Recurrent Fevers
Patient reported fevers up to ___ for 9 days preceding
admission, and 1 week of similar fevers in ___ which was
attributed to viral illness. There was initial concern for
temporal arteritis given L temporal soreness, fevers, and
elevated CRP/ESR. Rheumatology was consulted and the decision
was made to defer steroids as GCA was unlikely (no visual loss,
jaw claudication, progression, or other features c/w
vasculitis). Malignancy was considered but thought to also be
less likely given unremarkable differential, absence of LAD, and
no concerning findings on admission CT chest. Does have a remote
history of breast cancer, but no signs of recurrence, no
lymphadenopathy. Also closely followed with breast
MR/mammography. Workup for infection included blood cultures
without growth, CT chest and CXR without acute process, UCx
without growth, skin was unremarkable, and she had no oral
lesions. The fact that she remained in sinus rhythm after recent
cardioversion is also somewhat reassuring against infection. She
did not experience any other localizing signs or symptoms of
infection. Reassuringly, no current stigmata of endocarditis,
though could be subacute presentation or localized abscess. She
does meet 2 Duke minor criteria. CTA without signs of PE and
___ negative for DVT. No signs of infection on CXR and UA
without signs of infection although some hematuria that's been
improved.
She will have a TEE outpatient, and blood cultures must be
followed up.
#Hematuria
Hematuria on UA with sediment showing elevated RBCs, none
dysmorphic, no casts. Protein/Cr ratio of 0.3 but improved to
0.2 on recheck. She has no signs of symptoms of cystitis, though
did recently have UTI at rehab s/p antibiotics. Recommend a U/A
be repeated in ___ weeks as this microscopic hematuria could be
related to her recent infection.
#MVP s/p mitral valve bioprosthesis (___)
#Tricuspid regurgitation s/p annuloplasty (___)
Currently doing well after surgery. High CRP may be explained by
recent surgery. Continued warfarin with goal INR ___, Aspirin 81
mg PO DAILY.
#Atrial fibrillation s/p MAZE, left atrial appendage ablation
(___) and s/p DCCV (___)
Currently in sinus rhythm. Continued Warfarin, goal INR ___.
Continued
atenolol 12.5mg daily.
#Chronic Iron Deficiency Anemia
Hgb stable since ___ at which time Dr. ___ her to
start taking iron supplementation.
CHRONIC/STABLE ISSUES:
======================
#Hypothyroidism
Continued Levothyroxine Sodium 137 mcg PO
___.
#Anxiety
#Depression
Continued BuPROPion 75 mg PO DAILY, LORazepam 0.5 mg PO BID,
Escitalopram Oxalate 20 mg PO QPM.
#Pulmonary HTN
#OSA
Follows with pulmonology as outpatient, suspected to be ___ to
valvular disease more so than OSA. Continue follow-up with pulm
#HLD
Continued atorvastatin 40mg daily
#Hx L MCA CVA
Continued aspirin and atorvastatin daily.
TRANSITIONAL ISSUE
===================
- TEE was requested at earliest opportunity to exonerate valves
as possible source of infection, though only meeting two minor
Duke criteria: mechanical valve, fever. Cards will call to
schedule her.
- Outpatient sleep study and trial of newer CPAP devices, jaw
advancement devices, may benefit patient.
- Recommend a U/A be repeated in ___ weeks as this microscopic
hematuria could be related to her recent infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO DAILY16
2. Omeprazole 20 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Levothyroxine Sodium 137 mcg PO 6X/WEEK (___)
5. BuPROPion 75 mg PO DAILY
6. LORazepam 0.5 mg PO BID
7. Citracal + D Maximum (calcium citrate-vitamin D3) 630 500
mg/iu oral BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Escitalopram Oxalate 20 mg PO QPM
11. Docusate Sodium 200 mg PO QPM
12. erythromycin-benzoyl peroxide ___ % topical QPM
13. hydrocortisone-pramoxine ___ % topical QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 12.5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. BuPROPion 75 mg PO DAILY
5. Citracal + D Maximum (calcium citrate-vitamin D3) 630 500
mg/iu oral BID
6. Docusate Sodium 200 mg PO QPM
7. erythromycin-benzoyl peroxide ___ % topical QPM
8. Escitalopram Oxalate 20 mg PO QPM
9. hydrocortisone-pramoxine ___ % topical QPM
10. Levothyroxine Sodium 137 mcg PO 6X/WEEK (___)
11. LORazepam 0.5 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Fevers of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had fevers to 102
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Blood cultures, urine cultures, and chest CT were performed
without revealing a cause of the fevers
- transesophageal echocardiogram could not be performed until
___, and since you were feeling well, with no fevers,
normal white blood cell count, it was felt safe for you to go
home with close follow-up and to return for the echocardiogram
as an outpatient.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please monitor your temperature and if you start to have
fevers again please call your doctor.
- Please be sure to attend your follow-up appointments. Your
echocardiogram is being arranged for you.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10523060-DS-18 | 10,523,060 | 23,816,812 | DS | 18 | 2177-04-11 00:00:00 | 2177-04-11 10:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Unresposiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Eu Critical, ___ ___ (aka ___ DOB
___
is an ___ female with h/o HTN, HLD, thoracic aortic aneurysm,
CAD s/p 4vessel CABG (___), CKD, A fib (not on
anticoagulation),
and high grade urothelial carcinoma diagnosed ___ year ago, who
presented as transfer from ___ for right MCA syndrome.
Per records and patient's son, ___, she was last known well
at about 2100 last night when she went to bed. She was not
complaining of anything and was feeling well. The next morning
she was found on the ground beside her bed. It was unclear if
she
had fallen or not. Per her daughter in law she was reaching out
with her right hand trying to grab on to something to pull
herself up. She was mumbling but otherwise was not answering
questions. She would squeeze her daughter in laws hand but
wouldn't open her eyes. She said that patient "seemed like she
was in a dream".
She was taken to ___ by EMS. Upon arrival BP 184/78, HR
71, 97% on RA, FSBG 115. NIHSS was 33. CT head was notable for
dense right MCA and "vasogenic edema in the distribution of the
right middle cerebral artery". Discussed with stroke fellow and
transferred for possible thrombectomy. During med flight
received
210cc of HTS. Repeat CT head upon arrival to ___ showed completed
RMCA infarct with ASPECT of 0. Due to large area of infarcted
tissues thrombectomy was not offered. Discussed with patient's
family on the phone who were in agreement. While in ED she had
increasing respiratory distress, desatruating requiring
Non-rebreather and eventual BIPAP. CXR showed pulmonary edema,
she was given nebs and Lasix.
Past Medical History:
CKD
Thoracic aortic aneurysm
CAD s/p 4 vessel CABG
HTN
HLD
A fib (not on AC due to falls)
high grade urothelial carcinoma ~ ___ ago
Social History:
___
Family History:
Sister passed away from large stroke in her ___
Physical Exam:
ADMISSION:
Vitals: BP 184/78- 169/105, HR 71, 80-92% on Non-rebreather
General: keeps eyes closed, does respond to her name and
commands
on right side
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: irregularly irregular, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: awakens after repeated stimulation, keeps eyes
closed but responds, she will briefly open right eye, attends
examiner on the right, able to follow commands to stick out
tongue, wiggle toes, and give thumbs up on the right only, tells
me she is "___", able to repeat "it's a sunny day", language
testing is limited by her respiratory status. When asked who's
hand it is on the left says "your hand"
-Cranial Nerves: pupils 2->1 bilaterally
Likely eyelid opening apraxia, able to slightly open right eye
briefly, left NLFF but doesn't smile to command, right gaze
deviation can get slightly past midline to left with VOR, no BTT
bilaterally
-Motor: Normal bulk, tone throughout
RUE: can hold antigravity for >10 seconds with encouragement
LUE: lets fall to bed without any resistance, sluggish flexion
to
noxious
LLE: withdrawal briefly antigravity to noxious
RLE: spontaneous antigravity
-Sensory: reacts to noxious in all 4 extremities
-DTRs: no clonus, ___ response was flexor bilaterally.
DISCHARGE:
24 HR Data (last updated ___ @ 2326)
Temp: 98.4 (Tm 98.4), RR: 18
General: lethargic, elderly female
CV: afib, irregular rate with occasional PVCs noted
Lungs: breathing comfortably on RA
Abdomen: soft, ND
Ext: No ___ edema.
Skin: no rashes or lesions noted.
Neuro: somnolent, does not open eyes to voice or gentle
physical stimulation. Pushes away examiner gently w/ her right
hand. L facial droop. Moves RUE/RLE spontaneously.
Pertinent Results:
___ 09:25AM BLOOD WBC-11.6* RBC-4.16 Hgb-12.3 Hct-39.4
MCV-95 MCH-29.6 MCHC-31.2* RDW-15.3 RDWSD-53.5* Plt Ct-97*
___ 09:25AM BLOOD Neuts-56.5 ___ Monos-9.2 Eos-2.3
Baso-0.4 Im ___ AbsNeut-6.54* AbsLymp-3.62 AbsMono-1.06*
AbsEos-0.27 AbsBaso-0.05
___ 09:25AM BLOOD ___ PTT-27.9 ___
___ 09:25AM BLOOD Glucose-134* UreaN-27* Creat-1.3* Na-145
K-4.4 Cl-113* HCO3-19* AnGap-13
___ 09:25AM BLOOD ALT-10 AST-16 AlkPhos-63 TotBili-0.9
___ 09:25AM BLOOD Albumin-3.9 Calcium-9.2 Phos-2.9 Mg-2.0
___ 12:12AM BLOOD %HbA1c-5.2 eAG-103
___ 05:56PM BLOOD Triglyc-94 HDL-48 CHOL/HD-2.9 LDLcalc-73
___ 05:56PM BLOOD TSH-1.0
___ 09:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 11:27AM URINE Color-Straw Appear-Hazy* Sp ___
___ 11:27AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 11:27AM URINE RBC-18* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 11:27AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 11:27 am URINE **FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CT head w/o contrast
IMPRESSION:
Cytotoxic edema in the right MCA distribution consistent with
acute right MCA infarction. No hemorrhage.
___ CXR
IMPRESSION:
Moderate pulmonary edema with cardiomegaly.
Brief Hospital Course:
___ y/o F with extensive cardiac history (CAD, 4 vessel CABG,
AFib not on AC due to concerns for falls) found unresponsive at
home. Upon imaging in the ED, found to have R MCA occlusion.
#Acute ischemic stroke: She was taken to ___ by EMS.
Upon arrival BP 184/78, HR 71, 97% on RA, FSBG 115. NIHSS was
33. CT head was notable for dense right MCA and "vasogenic edema
in the distribution of the right middle cerebral artery".
Discussed with stroke fellow and transferred for possible
thrombectomy. During med flight received 210cc of HTS. Repeat CT
head upon arrival to ___ showed completed RMCA infarct with
ASPECT of 0. Due to large area of infarcted tissues thrombectomy
was not offered. Per discussion with the family, with the help
of care team, the patient was made CMO during this
hospitalization.
#Acute respiratory failure: While in the ED, the patient's
desatted to ___ on room air. Chest x-ray was obtained and showed
pulmonary edema. Patient was put on BiPAP, and received Lasix,
after which the patient's respiratory status improved. She was
eventually transitioned to nasal cannula then to room air.
-----
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - () Not confirmed (x) No. If no, reason why: CMO
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 75) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (fall
risk, CMO) () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 300 mg PO DAILY
2. QUEtiapine Fumarate 12.5 mg PO QHS
3. Ferrous Sulfate 325 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Simvastatin 80 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 suppository(s) rectally every 6 hours
as needed Disp #*5 Suppository Refills:*0
2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
RX *glycopyrrolate 0.2 mg/mL 0.2 mL IV every 4 hours as needed
Disp #*5 Vial Refills:*0
3. Haloperidol 0.5-2 mg IV Q4H:PRN agitation (first line)
RX *haloperidol lactate [Haldol] 5 mg/mL 0.5 - 2 mg IV every 4
hours as needed Disp #*1 Ampule Refills:*0
4. Morphine Sulfate 2 mg IV Q4H PRN moderate-severe pain
(___) or respiratory distress if unable to tolerate PO
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) 2 mg
IV every 4 hours as needed Disp #*1 Bag Refills:*0
5. OxycoDONE (Concentrated Oral Soln) 2.5-5 mg PO Q2H:PRN
moderate-severe pain (___) or respiratory distress
RX *oxycodone 20 mg/mL 2.5 - 5 mg sublingual every 2 hours as
needed Disp ___ Milliliter Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of unresponsiveness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might have raised your risk of having
stroke. Your risk factors are:
-ATRIAL FIBRILLATION NOT ON ANTICOAGULATION
-HIGH BLOOD PRESSURE
-HIGH CHOLESTEROL
-KIDNEY DISEASE
After discussion with the neurology team, palliative care, and
social work, your family decided on your behalf to focus on
maintaining comfort. You were discharged to hospice for further
care. Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10523117-DS-11 | 10,523,117 | 21,888,332 | DS | 11 | 2162-04-02 00:00:00 | 2162-04-04 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___.
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
Pacemaker implantation ___
History of Present Illness:
___ year old male with history of atrial fibrillation on
coumadin, CAD s/p PCI, and DM2 who presents with dizziness and
syncope. His symptoms started ___ days ago and have been
intermittent. On ___, while in the driveway he blacked
out and fell backwards while in a seated position. The fall was
not witnessed but the patient was able to ambulate after the
fall. The patient also reports fatigue, though attributes this
to insomnia as he is only able to sleep 3 hours per night. He
denies any fevers, chills, cough, chest pain, and lower
extremity edema. He has chronic shortness of breath, which has
not changed. He has been taking all his medications as
prescribed and there have been no changes.
In the ED initial vitals were: 98.2 36 (32-54) 156/64 18 98%
RA. EKG showed Afib with RBBB. Patient was noted to have
episodes of AIVR without symptoms or changes in blood pressure.
Labs were notable for H/H 10.1/30.0, INR 4.3, K 5.5, Cr 1.2,
troponin 0.03, and lactate 1.5.
Past Medical History:
- Atrial fibrillation on coumadin
- Coronary artery disease s/p DES to LAD (___)
- Diabetes mellitus type 2
- Mild cognitive impairment
- S/p diagnostic pericardiocentesis at ___ (___)
- BPH
- Vertigo
- Kidney stones s/p right ureteroscopy
- Asthma as a child
- Resection of sebaceous cyst from left side of ear
- Deaf in left ear
Social History:
___
Family History:
Mother died from a heart condition at age ___ specifics.
Sister had CABG in her ___. Son had a stroke in his ___- ___
and passed away at age ___. He had carotid artery disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 129/82 79 18 99RA
GENERAL: Comfortable appearing, speaking in full sentences, no
acute distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. Oropharynx
clear.
NECK: Supple, JVP not elevated.
CARDIAC: Bradycardic with distant heart sounds. Normal S1, S2.
No murmurs.
LUNGS: Clear to auscultation bilaterally without wheezes,
crackles, or rhonchi.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Pulsese 2+. No peripheral
edema.
NEEURO: CN II-XII grossly intact. Normal strength and
sensation.
LABS: Reviewed, see below
STUDIES:
CT HEAD ___ ___
No acute intracranial pathology identified.
CT C-SPINE ___ ___
No acute cervical spine fracture or subluxation identified.
CXR ___ ___
Heart size within normal limits. Lungs appear hyperinflated.
Blunted
costophrenic angles question small effusions. No definite
consolidation.
EKG: Bradycardic. Atrial fibrillation with RBBB.
DISCHARGE PHYSICAL EXAM:
Vitals: T97 140-160 / ___ 70-71 200 / 975
Telemetry: some PVC on telemetry, paced.
I/O: 200/975
General: No acute distress.
HEENT: NC/AT. PERRL. EOMI. mucous membranes.
Neck: Supple, No JVD
Left Arm: patient had pacemaker dressing, and is currently
wearing a sling.
Lungs: CTAB/L. No adventitial sounds heard.
Abdomen: +BS. Soft, ND, Non tender to palpitation.
Neuro: CN II-XII grossly intact. Normal strength.
Pertinent Results:
ADMISSION LABS:
___ 07:40PM ___ PTT-44.5* ___
___ 07:40PM PLT COUNT-113*
___ 07:40PM NEUTS-72.0* LYMPHS-10.9* MONOS-13.1* EOS-2.7
BASOS-0.8 IM ___ AbsNeut-6.78* AbsLymp-1.03* AbsMono-1.23*
AbsEos-0.25 AbsBaso-0.08
___ 07:40PM WBC-9.4 RBC-3.06* HGB-10.1* HCT-30.0* MCV-98
MCH-33.0* MCHC-33.7 RDW-17.2* RDWSD-62.3*
___ 07:40PM DIGOXIN-2.0
___ 07:40PM CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-2.2
___ 07:40PM cTropnT-0.03*
___ 07:40PM estGFR-Using this
___ 07:40PM GLUCOSE-142* UREA N-38* CREAT-1.2 SODIUM-136
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
___ 07:45PM LACTATE-1.5 K+-5.5*
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-7.9 RBC-2.88* Hgb-9.4* Hct-27.7*
MCV-96 MCH-32.6* MCHC-33.9 RDW-17.4* RDWSD-61.3* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-103* UreaN-23* Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-24 AnGap-14
___ 05:45AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old with atrial fibrillation on
Coumadin, CAD s/p PCI, and DM2 who presents with dizziness and
one episode of syncope, admitted for bradycardia.
# BRADYCARDIA: EKG with atrial fibrillation with irregular
ventricular response. Heart rate has remained in the ___.
Patient currently very tired, but not dizzy, though had one
episode of syncope 5 days ago. Differential diagnosis includes
medication toxicity, particularly digoxin, sick sinus syndrome,
electrolyte abnormalities (hyperkalemia), infiltrative disease,
lyme, calcification or fibrosis/sclerosis of the conduction
system. Telemetry with irregular rhythm, making complete heart
block less likely. We continued to monitor on telemetry and
followed the digoxin level because there was concern that this
bradycardia was secondary to digoxin toxicity, which would
respond poorly to pacing. Since the half life of digoxin is
about a day and his heart rate did not respond after a few days
of monitoring, a pacemaker was placed ___ SR
L300). He tolerated pacemaker placement well and heart rates
were in the ___ after. On discharge, we held diltiazem and
digoxin.
# ATRIAL FIBRILLATION: Patient rate controlled with diltiazem
and digoxin. On warfarin for anticoagulation. Hold diltiazem and
digoxin as above. Restarted warfarin and trended INR.
# CAD: S/p DES to LAD. Patient not on statin, which should be
further investigated. We continued ASA 81mg.
# DM: We held metformin inpatient.
>> TRANSITIONAL ISSUES:
# Anticoagulation: Please check INR on ___ and monitor until
therapeutic INR ___. INR on discharge of 1.9 on ___
# Post-procedure antibiotics: Patient was given prescription for
Cephalexin 500 mg TID x 2 days.
# Pacemaker: Patient to have f/u with device clinic in 7 days
for interrogation
# Discontinued Medications: Patient's digoxin and diltiazem were
discontinued due to bradycardia. Please follow up blood
pressures as an outpatient and continue to optimize.
# investigate starting a statin
# Pending Reports: Final CXR obtained on ___, please
follow up.
# Code Status: Full
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Warfarin 2.5-5 mg PO DAILY16
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Digoxin 0.25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Urocit-K 10 (potassium citrate) 10 mEq (1,080 mg) oral BID
6. Meclizine 25 mg PO PRN dizziness
7. Finasteride 5 mg PO DAILY
8. Terazosin 5 mg PO QHS
9. Lisinopril 5 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Meclizine 25 mg PO PRN dizziness
5. Terazosin 5 mg PO QHS
6. Cephalexin 500 mg PO Q8H Duration: 6 Doses
RX *cephalexin 500 mg 1 capsule(s) by mouth every 8 hours Disp
#*6 Capsule Refills:*0
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Warfarin 2.5-5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Bradycardia 2. Pacemaker Placement.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted here
after being found to have a significantly low heart rate. While
here, we monitored you for several days to determine that this
was not just a side effect from one of your home medications,
digoxin. Because of your persistent low heart rates, you had a
pacemaker placed and you tolerated that procedure well.
Please follow up with your primary care physician and your
cardiologist upon leaving the hospital. Please continue to take
your warfarin, and have your INR checked to ensure that it is
therapeutic. Further, you will take an antibiotic for the next 2
days to prevent any source of infection.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
10523428-DS-23 | 10,523,428 | 26,250,258 | DS | 23 | 2167-08-12 00:00:00 | 2167-08-12 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
E-Mycin / Flagyl / shrimp
Attending: ___.
Chief Complaint:
R ankle fracture
Major Surgical or Invasive Procedure:
ORIF R ankle fracture - ___
History of Present Illness:
___ female with history of PE on coumadin presents from
clinic for persistent R ankle fracture/deformity. Three weeks
ago, the patient was ambulating in her kitchen to retrieve an
object from her refrigerator when she fell and injured her
ankle. Was seen at ___ ED where x-rays revealed a distal
fibular fracture. The patient was splinted and transferred to
___. She was again seen in consultation with
Dr. ___ on ___ and noted to have a bimalleolar equivalent
fracture. The patient was placed in an aircast boot with
instructions for weightbearing as tolerated.
Was seen in clinic again today at which point plain films showed
persistent malunion/deformity. She was transferred here for
admission and plan for operative management.
Currently, patient is asymptomatic and specifically denies any
chest pain, difficulty breathing, abdominal pain, nausea or
vomiting. Does report mild discomfort in the R foot which she
noticed today prior to her clinic visit.
Past Medical History:
1. Cervical and lumbar spondylosis.
- Anterior cervical corpectomy and fusion at C3 to C7 in
___.
- C7 through T1 laminectomies and partial laminectomy of C6
and T2 on ___
- L4-L4 laminectomy in ___.
- L2-S1 spinal fusion in ___.
- L1 stimulator ? in ___.
2. Osteoarthritis, status post bilateral shoulder surgery.
3. Hypertension
4. Hypercholesterolemia
5. Hypothyroidism
6. MSSA infections associated with hardware- on suppressive doxy
Social History:
___
Family History:
She had a father with a transient ischemic attack. Both parents
have hypertension. There is no family history of coronary artery
disease or diabetes.
Physical Exam:
Exam on Discharge:
Gen:
RLE: in splint
Fires ___
SILT exposed toes
Toes WWP
Pertinent Results:
___ 07:32AM BLOOD WBC-9.3 RBC-3.71* Hgb-11.0* Hct-33.4*
MCV-90 MCH-29.7 MCHC-33.0 RDW-15.1 Plt ___
___ 07:32AM BLOOD ___
___ 07:32AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-138
K-3.9 Cl-99 HCO3-30 AnGap-13
Brief Hospital Course:
=The patient presented to the emergency department from Dr.
___. The patient was found to have a right ankle
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for ORIF
Right ankle fracture which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics. The Medicine team
was consulted regarding recommendations for anticoagulation
bridging. Upon discharge, the patient's INR was therapeutic at
2.4 and she was on her home dose of Coumadin. The rehab facility
was instructed via Page 1 to continue to trend her INR and dose
Coumadin accordingly during her course at rehab.
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, splint was clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the right lower extremity in a splint that will stay on
until follow up with Dr. ___ will be discharged on
Coumadin which is her home medication as the patient has a
history of PE. The patient will follow up with Dr. ___ in ___s with the ___ of ___
as she was preoperatively for Coumadin/INR management as well as
with her PCP. 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:
MEDS: amitriptyline 100', atenolol 37.5', celecoxib 200'',
doxycycline 100'', furosemide 40''', gabapentin 500''',
levothyroxine 150', Nystatin BID, omeprazole 20', percocet
___ PRN, simvastatin 20', warfarin 2.5'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amitriptyline 100 mg PO QHS
3. Atenolol 37.5 mg PO DAILY
4. Calcium Carbonate 1500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Doxycycline Hyclate 100 mg PO Q12H
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 40 mg PO TID
9. Gabapentin 500 mg PO Q8H
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*50 Tablet Refills:*0
11. Levothyroxine Sodium 150 mcg PO DAILY
12. Milk of Magnesia 30 ml PO BID:PRN Constipation
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Senna 8.6 mg PO BID
16. Simvastatin 20 mg PO QPM
17. Warfarin 2.5 mg PO DAILY16
Please take according to ___
instructions.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right ankle fracture
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:
Instructions After Orthopedic Surgery
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing right lower extremity in splint
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:
- Home Coumadin regimen. Please follow up with the
___ at ___ as you were prior to
your hospitalization regarding Coumadin/INR managment.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
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:
NWB RLE in splint.
Splint is to stay on until follow up appointment with Dr. ___.
Please do not get splint wet.
Treatments Frequency:
Please leave splint in place until follow up appointment with
Dr. ___ in 1 week.
Elevate RLE.
___ INR = 2.4, currently on Coumadin 2.5mg (patient's home
dose)
Please titrate Coumadin to maintain INR of goal ___.
Please instruct patient to follow up with the ___
___ of ___ upon discharge from rehab regarding
Coumadin/INR management.
Followup Instructions:
___
|
10523527-DS-9 | 10,523,527 | 22,490,484 | DS | 9 | 2131-10-10 00:00:00 | 2131-10-10 16:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfa
Attending: ___.
Chief Complaint:
RLE pain
Major Surgical or Invasive Procedure:
___: interlaminar epidural steroid injection at L4-L5 level
History of Present Illness:
___ with hx of htn, CKD stage III, osteoporosis with prior
vertebral fractures presenting with progressive RLE pain. Pt
initially presented to PCP ___ ___ with reports of RLE and R
knee pain with R low back pain x4-5 days, severe burning and
sharp in quality, "moderate to severe." She is prescribed prolia
in setting of history of vertebral compression fractures. At
that
time, she denied weakness, decreased sensation, urinary or bowel
incontinence or retention, fever. Per At___ notes, at that time
she had tenderness over R sciatic notch, intact ___ sensation and
strength, with symmetric DTRs and negative straight leg raise.
Gait was apparently normal, including heel and toe walking.
Spine
xray revealed compression fractures, but no new findings. She
was
prescribed tramadol, tylneol, and oxycodone for pain management.
Although pain initially improved, it then progressed to the
point
of interfering with ADLs. She was scheduled for MRI, but was
referred to the ED after notifying her PCP that pain was no
longer relieved by oxycodone. She has been ambulating with a
cane
x 3 weeks. She has had constipation since starting oxycodone,
which resolves with laxatives. Last BM was ___. She denies
fevers, weight loss, night sweats, ___ edema.
Last mammogram was ___, without suspicious findings. Last
colonoscopy was ___, per pt no concerning findings.
In the ___ ED:
VSS
Exam not described in ED dash, per discussion with ED resident,
no focal deficits
Labs notable for Cr 1.5, otherwise unremarkable
Received:
Lidocaine TD
Morphine IV 4 mg IV x1
Oxycodone 5 mg PO x1
On arrival to the floor, pt is initially pain-free. After
walking, pain escalates to ___. She denies urinary retention or
incontinence, fecal incontinence, focal weakness. Confirms above
history in detail.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
Hypertension
HLD
SDH ___
Osteoporosis
Thoracic compression fracture
CKD stage III - baseline Cr ___
s/p R TKR ___
___
___ History:
___
Family History:
Father with melanoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 98 PO 147 / 71 84 18 95 RA
GEN: alert and interactive, comfortable, no acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel
sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema. R knee without
warmth or effusion, nontender to palpation.
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII intact,
strength is ___ in bilateral UEs and LEs, including hip flexors,
knee flexion, knee extension, dorsiflexion, plantarflexion.
Symmetric patellar reflexes, no clonus, negative Babinski
bilaterally. Sensation is diminished to light touch and pinprick
in L4-L5 distribution. Ambulates with cane, unable to perform
heel walking or toe walking. No spinal TTP.
PSYCH: normal mood and affect
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
==============
___ 08:43PM BLOOD WBC-7.4 RBC-4.18 Hgb-12.8 Hct-38.8 MCV-93
MCH-30.6 MCHC-33.0 RDW-13.0 RDWSD-44.0 Plt ___
___ 08:43PM BLOOD Glucose-170* UreaN-36* Creat-1.5* Na-140
K-4.4 Cl-102 HCO3-22 AnGap-16
___ 08:43PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.0
IMAGING/STUDIES:
==============
___ MRI L spine:
1. A disc herniation at L3-L4 extends inferiorly into the right
neuroforamen,
resulting in severe right neural foraminal stenosis. This could
affect the
exiting right L3 nerve root. The deformity of the right-sided
thecal sac at
this level could also affect the right L4 nerve root.
2. Severe chronic compression deformity of the T12 vertebral
body.
3. Additional multilevel degenerative changes as described
above.
DISCHARGE LABS:
==============
Brief Hospital Course:
Ms. ___ is a ___ with hx of htn, CKD stage III, osteoporosis
with prior vertebral fractures presenting with progressive RLE
pain and numbness. She underwent MRI that showed disc herniation
with possible nerve root compression. She was evaluated by spine
surgery who recommended spinal injection and outpatient follow
up. She was seen by ___ and had ongoing significant pain with
ambulation, no weakness. Given ongoing symptoms despite
multimodal pain control, pt underwent interlaminar epidural
steroid injection at L4-L5 level prior to discharge.
# RLE pain secondary to
# L3-L4 disc herniation causing
# neural foraminal stenosis and likely nerve room compression
Progressive pain x1 month despite Tylenol, tramadol, oxycodone
at home, with objective sensory deficits. Denies fevers, weight
loss, urinary or fecal incontinence or retention. MRI showed
disc herniation with possible nerve root compression. She was
seen by neurosurgery who recommended spinal injection (done ___
and f/u with Dr. ___ in 1 month. Given ongoing pain with
movement, pt underwent epidural spinal injection in pain clinic
on ___. She has f/u arranged as outpt with pain.
Analgesia with Tylenol, oxycodone ___ mg PRN (already has rx
from ___, lidocaine patch. Avoided NSAIDs and gabapentin given
renal function. If GFR improves, could trial low dose
gabapentin.
___ evaluation rec home with outpatient ___
# ___ on CKD: Stage III, Cr near baseline (baseline is 1.3).
Followed by nephrology as outpatient. She received IVF for Cr
1.6 with improvement. Home lisinopril and triamterene-hctz were
briefly held and were restarted prior to discharge.
# Osteoporosis: Maintained on ca/vit D and denosumab.
# HLD: Continued home simvastatin
# Htn: Briefly held lisinopril and triamterene-hctz as above due
to ___ and restarted prior to discharge.
TRANSITIONAL ISSUES:
====================
[]continue APAP, lidocaine patch and oxycodone PRN pain. Can
taper oxycodone as spinal injection takes effect. Held off on
gabapentin given fluctuating renal function, continue to re-eval
for this.
[]continue bowel regimen
[]f/u with PCP, neurosurgery and pain clinic
[]recommend outpatient ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
3. Simvastatin 20 mg PO QPM
4. Lisinopril 30 mg PO DAILY
5. TraMADol 50 mg PO TID:PRN Pain - Moderate
6. Denosumab (Prolia) Dose is Unknown SC BIANNUALLY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
you may purchase over the counter
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
you may purchase over the counter
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply one patch daily Disp #*30 Patch
Refills:*0
5. Senna 8.6 mg PO BID
you may purchase over the counter
RX *sennosides 8.6 mg 1 tab by mouth twice daily Disp #*30
Tablet Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
take with stool softeners, you already have a prescription,
filled ___. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
8. Denosumab (Prolia) 60 mg SC BIANNUALLY
9. Lisinopril 30 mg PO DAILY
10. Simvastatin 20 mg PO QPM
11. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
12.Outpatient Physical Therapy
outpatient ___ - eval and treat
ICD 10: M54.16, radiculopathy
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=======
L3-L4 disc herniation
neural foramina stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with R leg pain. You had an MRI that
showed a herniated disc that is causing compression on the
nerves coming out of your spine. You were evaluated by the spine
surgeons while you were in the hospital and will need to follow
up with them in clinic. You also underwent a spinal injection in
the spine clinic while you were admitted. Your pain improved
with pain medications and this injection.
Please continue to take your medications as prescribed. Please
do not drive or drink alcohol while taking oxycodone. Please
follow up your PCP and with Dr. ___ in neurosurgery in 4
weeks (see appointments below).
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ Care Team
Followup Instructions:
___
|
10523725-DS-14 | 10,523,725 | 26,211,802 | DS | 14 | 2138-10-09 00:00:00 | 2138-10-12 06:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ man with history of CAD, HTN, HL, anemia,
OA, atrial flutter, monoclonal gammopathy, PMR, and chronic
renal insufficiency with a recent episode of PNA back in
___ who was sent in by his PCP for acute renal failure. He
was was seen for routine physical today and told to come in for
abnormal labs. He reports increasing SOB mostly just with
exertion. He also mentions having indigestion and frequent
burping since his cholecystectomy last year.
He explains that he presented to his PCP today complaining of
worsening DOE and fatigue. No chest pain, palpitations, nausea
or vomiting. No lower extremity edema, weight gain, orthopnea or
PND. At his PCP's office his VS were 110/60, 54, 16, 99% (92%
with exertion). Exam was notable for clear lungs, bradycardic
heart rate, and no edema. EKG showed sinus bradycardia. Labs
revealed a creatinine at 5.0 from ~1.3 back in ___ and a K+
of 5.8 and so he was sent in to the ED for workup of his new ___
and management of his hyperkalemia.
In the ED, initial VS were: 97.4 60 123/62 15 100%. Repeat labs
revealed a K+ of 5.8 in a moderately hemolyzed specimen with
repeat labs showing a K+ of 5.2. His creatinine was 4.3.
On arrival to the floor he is comfortable and in NAD. He denies
any current shortness of breath, chest pain, metalic taste in
his mouth, sensation of altered mental status. He has no
specific complaints.
REVIEW OF SYSTEMS:
(+) as per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Chronic Renal Insufficiency
Anemia with B12 deficiency
CAD: CABG X 3V (92) ; ETT Thal (___) - no ischemia ; MIBI-ETT
(___) - mild reversible inferolat ischemia, EF-47% ; s/p CABG
redo x 4V (___)
Hypertension
Atrial Flutter s/p DCCV on coumadin
Fatty Liver
Osteoarthritis
DJD: L shoulder ; s/p arthroscopic repair + acromioplasty (___)
GERD
Gout
HERPES ZOSTER
HYPERCHOLESTEROLEMIA
MONOCLONAL GAMMOPATHY ___
POLYMYALGIA RHEUMATICA ___
ACUTE PANCREATITIS ___ gallstones
Social History:
___
Family History:
His father died at age ___ of coronary artery
disease. His mother died at age ___ of "old age". He had four
brothers, five sisters, one son and one daughter. A number of
his siblings suffer from hypertension and diabetes. One brother
suffered a MI at age ___.
Physical Exam:
ADMISSION EXAM
VS: 98.1 151/78 62 100/ra
GENERAL: well-appearing man in NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE EXAM
VS T 98.1 116/71 52 (52-59) 16 100% RA
GENERAL: well-appearing man in NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS
___ 11:50AM ___
___ 11:50AM PLT SMR-LOW PLT COUNT-88*
___ 11:50AM WBC-3.9* RBC-3.18* HGB-10.0* HCT-29.4* MCV-93
MCH-31.5 MCHC-34.0 RDW-15.0
___ 11:50AM TRIGLYCER-145 HDL CHOL-28 CHOL/HDL-4.2
LDL(CALC)-61
___ 11:50AM VIT B12-GREATER TH
___ 11:50AM CHOLEST-118
___ 11:50AM ALT(SGPT)-17 AST(SGOT)-32
___ 11:50AM estGFR-Using this
___ 11:50AM UREA N-83* CREAT-5.0*# SODIUM-137
POTASSIUM-5.8* CHLORIDE-107 TOTAL CO2-20* ANION GAP-16
___ 11:50AM GLUCOSE-81
___ 09:00PM ___ PTT-37.1* ___
___ 09:00PM PLT SMR-LOW PLT COUNT-90*
___ 09:00PM NEUTS-50.6 ___ MONOS-5.6 EOS-2.6
BASOS-0.4
___ 09:00PM WBC-3.3* RBC-3.18* HGB-9.9* HCT-29.3* MCV-92
MCH-31.2 MCHC-33.8 RDW-14.8
___ 09:00PM PEP-AWAITING F IgG-4636* IgA-7* IgM-22*
___ 09:00PM TOT PROT-9.6* CALCIUM-8.4 PHOSPHATE-5.9*
MAGNESIUM-1.9
___ 09:00PM proBNP-3594*
___ 09:00PM cTropnT-<0.01
___ 09:00PM CK(CPK)-292
___ 09:00PM GLUCOSE-136* UREA N-81* CREAT-4.3* SODIUM-137
POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-16* ANION GAP-19
___ 09:13PM LACTATE-1.1 K+-5.2*
___ 09:13PM COMMENTS-GREEN TOP
___ 10:12PM URINE MUCOUS-RARE
___ 10:12PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 10:12PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:12PM URINE HOURS-RANDOM UREA N-630 CREAT-102
SODIUM-77 POTASSIUM-17 CHLORIDE-59 TOT PROT-44 PROT/CREA-0.4*
PERTINENT RESULTS
___ 09:00PM BLOOD IgG-4636* IgA-7* IgM-22*
___ 05:20AM BLOOD b2micro-5.7*
___ 08:06AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-PND
DISCHARGE LABS
___ 05:20AM BLOOD WBC-3.7* RBC-3.25* Hgb-10.2* Hct-30.4*
MCV-94 MCH-31.4 MCHC-33.6 RDW-14.8 Plt Ct-96*
___ 05:20AM BLOOD Glucose-80 UreaN-49* Creat-2.0* Na-135
K-4.9 Cl-106 HCO3-20* AnGap-14
___ 05:20AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7
MICRO
___ URINE URINE CULTURE-FINAL
IMAGING
CHEST (PA & LAT) Study Date of ___ 9:20 ___
IMPRESSION:
No acute cardiopulmonary process.
RENAL U.S. Study Date of ___ 10:03 ___
IMPRESSION:
No sonographic evidence for renal obstruction.
SKELETAL SURVEY (INCLUD LONG BONES) Study Date of ___ 11:54
AM
FINDINGS: Moderate-to-severe degenerative changes in the lower
lumbar spine, both hips, both shoulders and to a lesser degree,
both knees. Extensive vascular soft tissue calcifications. No
safe evidence of lytic lesions suggestive of osteodestruction.
MR has substantially higher sensitivity to detect such
abnormalities.
Protein Electrophoresis ___ 21:00
TWO ANORMAL BANDS IN GAMMA REGION
BASED ON IFE (SEE SEPARATE REPORT),
IDENTIFIED AS MONOCLONAL IGG LAMBDA AND IGG KAPPA
NOW REPRESENTS, BY DENSITOMETRY, ROUGHLY
40% (3850 MG/DL) AND 2% (200 MG/DL) OF TOTAL PROTEIN
REPORTED BY SHU-___ FAN, PHD;FINAL INTERPRETATION BY ___.
___, MD
___ 4636* ___ mg/dL
Immunoglobulin A 7* 70 - 400 mg/dL
Immunoglobulin M 22* 40 - 230 mg/dL
Immunofixation
MONOCLONAL IGG LAMBDA
AND MONOCLONAL IGG KAPPA DETECTED
REPORTED BY ___, PHD;FINAL INTERPRETATION BY ___.
___, MD
Brief Hospital Course:
___ year old male with hx. CAD s/p CABG (___), CHF (most
recent EF 35-40% ___, atrial flutter s/p cardioversion
(___) on coumadin, MGUS, with c/o shortness of breath, found
to be in ___.
# Shortness of breath: patient with worsening dyspnea on
exertion over week prior to admission. He has a significant
cardiac history but no c/o chest pain/chest pressure, EKG showed
no signs of ischemia and was unchanged from prior, troponin was
negative x1. Patient has history of atrial flutter s/p
cardioversion, but no signs of flutter on admission EKG. No
signs of pulmonary edema ___ swelling to suggest CHF. Initial
hypothesis was that patient had symptomatic dyspnea due to
excessive beta-blockade due to atenolol use in the setting of
___ (atenolol being renally cleared). His heart rates were
initially in the ___ and as low as ___ overnight. There also
could have been a contribution from his metabolic acidosis
causing him to have a compensatory respiratory alkalosis and
feel short of breath. His beta blocker was held altogether and
patient reported feeling better. His acidosis improved as his
renal function recovered (see below). The patient was advised
to discontinue atenolol altogether given his renal injury and to
discuss with his primary care doctor when it would be
appropriate to start a beta-blocker again. If he was to be
restarted on a beta-blocker we would suggest metoprolol, as this
is not renally cleared.
# ___: patient's Cr bumped to 5.0 on admission from recent
baseline of 1.4 in ___. A renal ultrasound was done
which showed no signs of obstruction. Patient's atenolol was
discontinued and his lisinopril held. Initial acid base
disturbance based on ABG was non-anion gap metabolic acidosis
with respiratory compensation. Urine lytes revealed a FeNa of
2.5% with a positive urine anion gap, suggestive of RTA. Given
patient's history of MGUS, suspicion was for multiple
myeloma/myeloma kidney. Nephrology and hematology were
consulted. Patient's kidney function improved dramatically over
hospital day ___ without a specific intervention besides holding
his lisinopril and atenolol. It's possible that he had an
element of prerenal etiology due to excessive beta blockade and
poor PO intake. Urine sediment showed hyaline casts without
eosinophils. SPEP and UPEP results were pending at time of
discharge but have since revealed an elevated biclonal
gammopathy with bence ___ proteins. The patient has a
follow-up appointment with nephrology and hematology to further
discuss these results and management. His lisinopril was held
on discharge until further assessment of his kidney recovery by
his PCP.
# MGUS: patient noted to have biclonal gammopathy in ___, IgG
kappa and IgG lambda. Given constellation of renal failure and
pancytopenia, concern was for progression to myeloma. SPEP and
UPEP were ordered. Initial SPEP results showed an elevated IgG
level to 4.6 g/dL, increased from 1.8 g/dL in ___.
Immunofixation results were pending at the time of discharge but
have since returned positive for monoclonal IgG lambda and IgG
kappa representing at 3.8 g/dL. Patient was notified of these
results over the phone on the day after discharge and the likely
diagnosis of myeloma. Of note, a skeletal survery done in house
did not reveal any osteolytic lesions. He has follow-up with
hematology to address bone marrow biopsy and further workup and
management.
# Pancytopenia: patient presented with depressed cell lines,
which appears to be a subacute process over last few months.
Given history of MGUS, concern was for myeloma (as above). His
cell lines remained stably low at the time of discharge.
Possibly representing bone-marrow suppression due to plasma cell
dyscrasia (myeloma). Patient has close follow-up with
hematology for likely bone marrow biopsy.
# CAD s/p CABG: patient did not endorse chest pain, EKG without
signs of active ischemia and unchanged, trop negx1. His beta
blocker was held, as above, given bradycardia. His lisinopril
was also held given ___. Simvastatin was continued. His
lisinopril can be restarted if his renal function stabilizes.
If he needs a beta blocker going forward would favor metoprolol
given not renally cleared.
# Atrial flutter s/p cardioversion: CHADS score of 2 for CHF and
HTN. No reports of recurrence since cardioversion in ___.
Continued coumadin in house.
CHRONIC ISSUES
# GERD: continued omeprazole
# Gout: allopurinol dose was reduced from 300 mg daily to 100 mg
daily.
TRANSITIONAL ISSUES
1. Lisinopril was held, can be reintroduced if appropriate once
kidney function stable
2. Atenolol was discontinued. Likely should not take this
again as has baseline kidney dysfunction.
3. Patient has follow-up with hematology to address SPEP/UPEP
findings and need for bone marrow biopsy given constellationf of
findings concerning for myeloma.
4. Patient has follow-up with nephrology to further address
resolution ___ and consideration of biopsy to confirm light
chain nephropathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. ammonium lactate *NF* 12 % Topical BID
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Cyanocobalamin 1000 mcg IM/SC ONCE PER MONTH
8. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. ammonium lactate *NF* 12 % Topical BID
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
5. Sodium Bicarbonate 650 mg PO TID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth TID with
meals Disp #*90 Tablet Refills:*1
6. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
7. Cyanocobalamin 1000 mcg IM/SC ONCE PER MONTH
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: acute kidney injury
Secondary: Monoclonal gammopathy of uncertain significance
CHF
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted for shortness of breath and kidney injury. Some of
your medications were stopped and your kidney function improved
over several days. You were found to have an elevated protein
in your blood called a monoclonal protein and were seen by the
hematologists (blood doctors). You need to continue to follow
with them going forward and we are working on setting up an
appointment for you with their office. You were also seen by
the nephrologists and will need to see them in clinic going
forward as well.
Please make the following changes to your medications:
Please STOP atenolol. When you see your primary care doctor,
they can decide when/if to start Metoprolol.
Please STOP lisinopril until your kidney function normalizes.
Your primary care doctor or kidney doctor can help decide this.
Please discuss with your primary care provider when to restart
this.
Please CHANGE allopurinol from 300 mg daily to 100 mg daily.
Please START sodium bicarbonate 650 mg three times a day with
meals.
Please continue to take the rest of your medications as
prescribed.
Followup Instructions:
___
|
10524041-DS-17 | 10,524,041 | 20,474,465 | DS | 17 | 2126-01-27 00:00:00 | 2126-01-27 20:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Difficulty writing, word finding difficulties, tremor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ right handed, PMH of BPH, E Coli sepsis in ___, family
physician who presented to the ED with persistent difficulty
writing, word finding difficulties, and intermittent tremor.
Patient states that symptoms first started ___ morning. He
woke up feeling fine, ate breakfast and took a shower. When he
tried to button up his shirt after shower, he found that he was
having trouble doing up the buttons. He denies weakness;
however
he noticed bilateral tremor which he did not have previously.
He then drove to work. While trying to write at work, he
noticed
that he was having trouble writing as the letters were coming
out
as scribbles. He was able to read without any issues. Later in
the day, he was speaking to his colleague, when he noticed that
he had difficulty getting the right words out of his mouth. His
colleague was able to understand him without any difficulties.
However, he felt like there was a "mechanical issue" with him
trying to express what he wanted to say in his mind. The
symptoms never went away.
He then went to the emergency department ___ in
___, which is where he lives. There, they
performed
a head CT and brain MRI which per patient was unremarkable.
They
discharged him home. Unfortunately they did not have a
neurologist on staff at the ___.
The next morning, on ___, he noticed that his symptoms
were
persistent. He then went back to the emergency room where they
called telemetry neurology. He then got another brain MRI. He
also thinks he got another scan, but is not sure whether he had
a
CTA or whether it was a different type of scan. He did get
contrast. The repeat images were unremarkable and he was again
discharged. On ___ night, his wife noticed that he could
not dial his phone properly, and was having some slurred words.
On day of presentation, when the symptoms persisted, he decided
to come to ___ for further evaluation. He thinks that his
symptoms are worse in the morning, although they never
completely
went away. He also noticed that he was having difficulty
picking
up objects and putting on his belt.
Patient states that he was very healthy up until this past
___,
where he was hospitalized for E. coli sepsis. He states that it
is unclear why he had the sepsis.
Past Medical History:
BPH
Right wrist ORIF
Bilateral stapedectomy due to otosclerosis
E. coli sepsis in ___
Social History:
___
Family History:
Father had hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: BP: 139/68 HR: 78
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert. Able to relate history without
difficulty.
Attentive, Language is fluent with intact comprehension. Normal
prosody. There were no paraphasic errors. Able to name both high
and low frequency objects. Able to read without difficulty. No
dysarthria. Able to follow both midline and appendicular
commands.
When asked to write a sentence, he was only able to do so very
slowly and his writing appeared shaky. He normally writes in
cursive. His wife showed me his writing attempts on previous
days and they were just scribbles
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift.
Fine tremor was noted in bilateral fingers with arms
outstretched. No asterixis
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibration, or
proprioception throughout. No extinction to DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
-Coordination: Normal finger-tap bilaterally. No dysmetria on
FNF.
-Gait: Good initiation. Walks independently. Has difficulty
with tandem gait
DISCHARGE EXAM
================
24 HR Data (last updated ___ @ 814)
Temp: 98.1 (Tm 98.6), BP: 124/84 (124-154/62-84), HR: 52
(52-64), RR: 18, O2 sat: 96% (94-98), O2 delivery: Ra
General: sitting up in bed, resting and talking to us and his
wife, pleasant
___: breathing comfortably on RA
MS: alert, oriented to interval events, overall speech improved,
though still w/ some hesitancy, able to identify lapel,
cuticles,
stethoscope among others, has difficulty with Luria sequence on
right >L but improved. Writing much improved without much tremor
CN: pupils appear symmetric 4->2 b/l , left facial droop
(chronic), tongue protrudes midline, EOMI intact
Motor: no pronater drift, improving mildpostural tremor L>R
(L/R)
Delt ___
Bi ___
Tri ___
WE ___
Fex ___-
IP ___
Ham ___
TA ___
Sensation
- Grossly intact to light touch
Coordination
- no dysmetria, mild kinetic tremor
Pertinent Results:
ADMISSION LABS
==============
___ 06:50PM BLOOD WBC-7.3 RBC-4.40* Hgb-13.6* Hct-42.7
MCV-97 MCH-30.9 MCHC-31.9* RDW-13.8 RDWSD-48.9* Plt ___
___ 06:50PM BLOOD Neuts-73.0* Lymphs-17.1* Monos-7.8
Eos-1.0 Baso-0.7 Im ___ AbsNeut-5.31 AbsLymp-1.24
AbsMono-0.57 AbsEos-0.07 AbsBaso-0.05
___ 06:50PM BLOOD Glucose-96 UreaN-21* Creat-1.4* Na-141
K-4.4 Cl-108 HCO3-22 AnGap-11
___ 06:50PM BLOOD ALT-21 AST-24 CK(CPK)-69 AlkPhos-93
TotBili-<0.2
___ 06:50PM BLOOD cTropnT-<0.01
___ 06:50PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.2 Mg-2.1
INTERVAL LABS
==============
___ 07:40AM BLOOD VitB12-350
___ 06:50PM BLOOD TSH-4.0
___ 07:40AM BLOOD Free T4-1.2
___ 03:55PM BLOOD ANCA-NEGATIVE B
___ 07:40AM BLOOD ___ antiTPO-LESS THAN
___ 06:50PM BLOOD RheuFac-<10 CRP-1.5
___ 06:50PM BLOOD ___ Ab-NEG Trep Ab-NEG
___ 06:50PM BLOOD HIV Ab-NEG
___ 01:54PM CEREBROSPINAL FLUID (CSF) TNC-61* RBC-10*
Polys-0 ___ ___ 01:54PM CEREBROSPINAL FLUID (CSF) TNC-50* RBC-350*
Polys-0 ___ ___ 01:54PM CEREBROSPINAL FLUID (CSF) TotProt-66*
Glucose-55
MICROBIO
=========
UCx - NO GROWTH
DISCHARGE LABS
===============
___ 06:15AM BLOOD WBC-6.4 RBC-4.12* Hgb-12.6* Hct-40.0
MCV-97 MCH-30.6 MCHC-31.5* RDW-14.0 RDWSD-50.0* Plt ___
___ 06:15AM BLOOD Glucose-97 UreaN-22* Creat-1.3* Na-144
K-4.3 Cl-110* HCO3-22 AnGap-12
___ 06:15AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
REPORTS/IMAGING
================
MRI HEAD
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. There are few nonspecific supratentorial
T2/FLAIR white matter
hyperintensities, which may represent the sequelae of
microangiopathy. The
ventricles and sulci are normal in caliber and configuration.
There is no
abnormal enhancement after contrast administration.
There is mild mucosal thickening in the ethmoid air cells.
IMPRESSION:
No intracranial hemorrhage, infarct or mass.
MRI C-SPINE
IMPRESSION:
-Cervical spondylosis, most marked at C5-C6, with moderate
spinal canal
narrowing secondary to a posterior disc bulge, with the disc
contacting the
ventral aspect of the cord, without cord deformation or signal
abnormality.
-Multilevel moderate bilateral neural foraminal narrowing from
C3 to C6
levels.
-Apparent linear T2 hyperintensity in the cord at C4-C5 level is
not visible
on axial imaging and is likely artifactual in nature.
EEG REPORT
IMPRESSION: This is an abnormal routine EEG in the awake states.
1) Occasional brief bursts of focal slowing in the left temporal
region,
indicating a focal region of subcortical dysfunction that is
nonspecific in
etiology.
2) Frequent bursts and runs of generalized sharply contoured
slowing,
indicative of mild to moderate deep midline or subcortical
cerebral
dysfunction that is nonspecific in etiology.
No definite epileptiform discharges are seen.
Brief Hospital Course:
Dr. ___ is a ___ yo gentleman w/ pmhx including recent
urosepsis (___) who presented for evaluation of language
difficulties, apraxia and tremor, found to have a lymphocytic
pleocytosis suggestive of likely resolving viral encephalitis.
Transitional Issues
=====================
[ ] Pt with microcytic anemia of 12.5 on discharge, consider
repeat testing as outpatient
[ ] HSV, Arbovirus, and VRDL from CSF and aTPO Ab, ACE from
serum pending at time of discharge; please follow-up results.
Paraneoplastic panel testing deferred because patient was
improving w/o intervention, however could consider in future if
pt with interval worsening.
[ ] Consider neuro-cognitive testing following resolution of
current illness to document baseline given recent difficulties
with memory over last several months
#Presumed Viral Encephalitis
#Apraxia
#Tremor
Pt presented w/ acute-onset word finding difficulties, apraxia,
and new postural/kinetic tremor in the setting of normal
previous brain imaging. We repeated an MRI here which was
notable only for mild atrophy (possibly more prominent in the
cerebellum). He had a routine EEG which was notable for
intermittent mild left temporal slowing, but otherwise did not
demonstrate any interictal epileptiform discharges. Labs were
obtained including ___, ANCA, TSH, B12, treponemal ab, and
MMA which were all wnl or negative. An LP was obtained, which
demonstrated a lymphocytic pleocytosis (Tube 4 TNC 61. 94%
lymph, RBC 10, prot 66, glu 55). Given these results it was
thought that the patient may have had a mild viral encephalitis
given the acute onset of his symptoms and improvement without
targeted intervention. Additionally he was given multivitamins
and IV thiamine supplements. Reassuringly he was improving at
the time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. FLUoxetine 40 mg PO DAILY
3. Tamsulosin 0.8 mg PO QHS
4. Avodart (dutasteride) 0.5 mg oral Daily
Discharge Medications:
1. Thiamine 200 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 2 tablet(s) by mouth once a
day Disp #*60 Tablet Refills:*2
2. Avodart (dutasteride) 0.5 mg oral Daily
3. FLUoxetine 40 mg PO DAILY
4. Pravastatin 40 mg PO QPM
5. Tamsulosin 0.8 mg PO QHS
6.Outpatient Physical Therapy
Viral Encephalitis ___
Outpatient physical therapy with gait and balance training
Discharge Disposition:
Home
Discharge Diagnosis:
Viral Encephalitis
Postural Tremor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to the hospital because ___ were having
difficulty with your language and writing, and ___ had a
new-onset tremor.
___ had an MRI which was largely normal and showed some mild
atrophy. We obtained an EEG which was only notable for some mild
left temporal slowing. We performed an LP which had an elevated
lymphocytic WBC count. ___ received some thiamine and vitamin
supplements. Your symptoms improved markedly over the course of
the hospitalization without intervention.
Overall we think your presentation might have been consistent w/
a mild viral encephalitis. We sent labwork for other less common
infectious and autoimmune causes of your symptoms, and were
still waiting on a few of these tests to return.
Please go to the nearest ED if ___ become acutely confused or
have a fever. We will follow-up with ___ in clinic.
Thank ___ for allowing us to participate in your care!
- Your ___ Neurology Team
Followup Instructions:
___
|
10524387-DS-17 | 10,524,387 | 25,932,273 | DS | 17 | 2173-06-29 00:00:00 | 2173-06-30 17:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hallucinations and delusions
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ w/ HTN, HLD, BPH, CKD II, and no known dementia, substance
use, or psychiatric history who is admitted for acute agitated
delirium.
The patients wife is admitted to ___ and the nocturnist Dr.
___ him the night prior, reporting that he seemed to have
limited insight into his wifes medical condition but seeming
not more than a mild cognitive impairment. On the subsequent
evening (___), he was visiting his wife and was found by
nursing agitated and lying on top of his hospitalized wife,
saying that he was protecting her from the zombie people present
in the room. He seemed to be grossly oriented, generally
well-appearing, and was conversing fluently despite his evident
paranoid delusions/hallucinations. He was taken
semi-consensually to the ED for evaluation.
On arrival to the ED, vitals were stable: 98.5, HR 72, BP
163/75, RR 16, 95% RA. Basic labs including CBC, CMP and
urinalysis were entirely at his baseline (normal except for
anemia and mild CKD). Drug screen was negative. Head CT was
negative. CXR showed no infiltrates. Blood culture x1 was
collected and is pending. He was sent to 8S.
On arrival to the floor he was AOx1 (but still fluently
conversant and generally well-appearing) and refused to go to
his room, saying he was being abducted to be murdered. Code
purple was called and he was taken to his room by security. He
began yelling obscenities (calling staff motherf***ers, ___
___ security guards n***ers, etc.). He required 4-point
restraints in order to medicate him and kicked a nurse in the
jaw while being restrained. He was given 5 mg of Haldol and 1 mg
Ativan in several divided doses which slowed him down enough to
enable evaluation by the psych resident.
ROS
Patient refused to cooperate with ROS.
Past Medical History:
BPH
HTN
HLD
Aortic insufficiency
Sideroblastic anemia (chronic and stable)
Migraines
Social History:
___
Family History:
Reviewed with patient and non-contributory to current
presentation
Physical Exam:
ADMISSION EXAM:
Patient was agitated and did not allow examiner to perform more
than a limited physical exam.
GENERAL: well appearing M in no physical distress
CARDIAC: RRR based on pulse
GAIT: normal gait
NEURO: moves all extremities. EOMI. No facial droop.
MMSE:
APPEARANCE: well-maintained appearance
AFFECT: angry, but seemingly appropriate within the context of
his delusional beliefs.
SPEECH: fluent speech
THOUGHT CONTENT: evidence of visual hallucinations and paranoid
delusions
ORIENTATION: oriented to self only. Intermittently oriented to
location
INSIGHT: poor
DISCHARGE EXAM:
VS: 98.3 164/75 68 18 97% RA
General: Sitting in a chair by the nursing station, reading a
magazine
HEENT: Dry, chapped, lips, MMM
CV: Regular rate, normal rhythm, no m/r/g
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, normoactive bowel
sounds
Extremities: Warm, dry, no edema
MSK: No joint deformities
Neuro: Oriented to self, date only. Asking to "go upstairs" to
see wife. Unable to describe reason for hospitalization
Psych: Calm and euthymic, disorganized thought process
Pertinent Results:
ADMISSION LABS
--------------
WBC-8.6 RBC-2.96* HGB-10.0* HCT-29.9* MCV-101* MCH-33.8*
MCHC-33.4 RDW-14.4 PLT COUNT-256
GLUCOSE-102* UREA N-35* CREAT-1.2 SODIUM-139 POTASSIUM-3.8
CHLORIDE-100 TOTAL CO2-23 ANION GAP-20
ALT(SGPT)-9 AST(SGOT)-18 ALK PHOS-58 TOT BILI-0.6
ALBUMIN-4.7 CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-2.2
URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10
BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG oxycodn-NEG mthdone-NEG
IMAGING
-------
MRI brain ___:
1. There is generalized brain parenchymal atrophy, and mild
chronic small vessel ischemic changes.
2. There are no acute intracranial changes.
CT head
No evidence of an acute intracranial abnormality.
___ EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
mildly disorganized but normal-frequency background in
wakefulness. There were no areas of prominent focal slowing, and
there were no epileptiform features or electrographic seizures.
The superimposed beta rhythm suggests medication effect.
___ EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
normal background in wakefulness for much of the record, with
minimal
disorganization and very infrequent generalized theta slowing.
There were no areas of prominent focal slowing. There were no
epileptiform features or
electrographic seizures.
CXR
1. No radiographic evidence of an acute cardiopulmonary
abnormality.
2. Minimal anterior vertebral body height loss the mid thoracic
spine is indeterminate in chronicity.
Pertinent Interval:
___ 06:20AM BLOOD calTIBC-157* Ferritn-971* TRF-121*
___ 10:37PM BLOOD VitB12-1075* Folate->20
___ 01:00PM BLOOD Ammonia-17
___ 10:37PM BLOOD TSH-3.1
___ 10:37PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 06:30AM BLOOD HEAVY METAL SCREEN-Neg
___ 06:30AM BLOOD COPPER (SERUM)-Neg
___ 01:00PM BLOOD VITAMIN B6 (PYRIDOXINE)-PND
___ 02:10PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-78*
Polys-30 ___ ___ 02:10PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 02:10PM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-77
___ 02:10PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Neg
___: Enterovirus CSF: Negative
___: Cryptococcus CSF: Negative
___ RPR Negative
___: Urine culture negative
___: Blood culture negative
___: B6 WNL
DISCHARGE LABS
--------------
___ 06:00AM BLOOD WBC-7.0 RBC-2.44* Hgb-8.3* Hct-24.4*
MCV-100* MCH-34.0* MCHC-34.0 RDW-14.0 RDWSD-51.0* Plt ___
___ 06:00AM BLOOD Glucose-88 UreaN-23* Creat-1.0 Na-141
K-4.0 Cl-105 HCO3-27 AnGap-13
___ 10:30AM BLOOD ALT-18 AST-22 AlkPhos-53 TotBili-0.8
___ 06:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ year old gentleman with a history of
hypertension, hyperlipidemia, sideroblastic anemia who presented
with altered mental status.
# Dementia with behavioral disturbance: Patient presents without
a previous dementia or psychiatric diagnosis. However, on
further discussion with his children it appears that he has had
a long-standing decline that has been difficult for them to
completely appreciate. His neurologic exam was non-focal and
over the course of his hospitalization his mental status
gradually improved. Psychiatry and neurology were consulted for
assistance with diagnosis and management. Extensive workup with
imaging (MRI/EEG) and toxic-metabolic workup (including CSF, B6,
copper, heavy metal screen, RPR, TSH, liver enzymes, infectious
workup) was unrevealing except for rising ferritin. Concern was
raised for the possibility ___ Body dementia. Per neurology,
patients typically see hallucinations that are not frightening,
which was not the case with the patients initial presentation
where he was seeing zombies. He also did not have classic
Parkinsonian features. Nevertheless, given his presentation of
visual hallucinations in the setting of progressive decline, it
was deemed within a reasonable differential and given this,
seroquel was used for agitation rather than haldol. He will
continue to be followed in the neurology clinic.
Per neurology review of case reports- hemachromatosis can result
in altered mental status. Patient's outpatient hematologist was
contacted regarding this possibility. The patient's RARS is
often associated with biochemical evidence of iron overload
secondary to ineffective erythropoiesis. Clinical complications
are restricted to patients who become transfusion dependent.
Iron overload typically manifests in the liver, heart, joints,
pancreas, and skin prior to the effect on the brain. Further
inpatient workup was not advised.
He was maintained on delirium precautions with seroquel PRN. He
is scheduled for outpatient neurology follow up with Dr.
___ on ___ at 4 pm on ___ 8.
# Anion gap acidosis: positive urinary ketones: Likely from poor
appetite and starvation ketosis. Once he began eating regularly,
this resolved.
# Orthostatic hypotension: Home antihypertensives held
# Hyperlipidemia: Continued simvastastin
# Refractory anemia with ringed sideroblasts: Anemia has been
stable during this admission. Has outpatient follow up arranged
with his hematologist.
Transitional:
- Outpatient neurology follow up scheduled
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. QUEtiapine Fumarate 12.5 mg PO QHS
2. QUEtiapine Fumarate 12.5 mg PO Q8H PRN agitation
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 20 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dementia with behavioral disturbances
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because you had an episode of increased
confusion. You were seen by several doctors who worked together
to try to figure out the cause of the episode. Fortunately, no
serious cause was identified. At this time we feel that you
would benefit from a temporary stay at a rehabilitation
facility.
It was a pleasure to be a part of your care,
Your ___ treatment team
It was a pleasure caring for you during your recent
hospitalization at ___. You came for further evaluation of
agitation and confusion. Further testing showed that you ...
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck!
Followup Instructions:
___
|
10524734-DS-11 | 10,524,734 | 29,539,376 | DS | 11 | 2152-02-18 00:00:00 | 2152-02-22 14:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Constipation x 8 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with a history of ___
disease & chronic constipation presents with 8 days of
constipation. He had been admitted to ___
approximately two weeks ago for constipation, requiring NGT &
aggressive bowel regimen. After discharge, he had been stooling
normally until 8 days ago. 6 days ago he started seeing Dr. ___
___ (Gastroenterologist) who started him on Linaclotide 290mcg
daily. This was started 2 days ago. In response to this,
___ wife noted significant improvement in distension,
bloating and abdominal pain, however no bowel movement. In
addition he has continued his Miralax (no increased dosing) and
an oral stool softener (Colace). His wife tried to give him an
enema & manually disimpact him, but he could not tolerate it.
Besides constipation, he had nausea, decreased appetite, and
some abdominal pain, but no vomiting. He is passing flatus.
(+) Per HPI. He denies fevers, chills, weight loss, chest pain,
shortness or breath, change in bladder habits, dysuria.
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Past Medical History:
-___ disease
-lumbar radiculopathy treated with nerve block
-left hip fracture status post repair with a hemiarthroplasty
years ago
-right knee replacement
-left hip fracture s/p surgical repair
-restless leg syndrome and has difficulty sleeping.
Social History:
___
Family History:
No family history of ___ disease or related disorder.
Physical Exam:
ADMISSION EXAM:
===============
Vital Signs: 98.6 PO 130 / 73 58 17 96 ra
General: well appearing, NAD, nontoxic
HEENT: no scleral icterus, mmm
CV: rrr, no m/r/g
PULM: normal work of breathing on room air, lungs clear
bilaterally
ABD: soft, but mildly distended, no tenderness to palpation,
normal bowel sounds
GU: no foley
EXT: warm, no edema
NEURO: alert, oriented x3; slow speech but appropriate, no gross
neurological deficits
DISCHARGE EXAM:
===============
VS: 98.0PO 147 / 80 62 20 98 RA
GENERAL: No acute distress. Pleasant, but slow in movement and
speech.
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r
HEART: RRR, no M/R/G
ABDOMEN: soft, non-distended. Bowel sounds normoactive. No
rebound or guarding.
EXTREMITIES: WWP, palpable pulses bilaterally without edema.
NEURO: awake. Alert. Not oriented to place or date. Able to say
the DOWB slowly.
Pertinent Results:
LABS ON ADMISSION:
=================
___ 08:07PM K+-4.6
___ 07:50PM POTASSIUM-4.2
___ 07:35PM URINE HOURS-RANDOM
___ 07:35PM URINE UHOLD-HOLD
___ 07:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-SM
___ 07:35PM URINE RBC-2 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-1
___ 07:35PM URINE MUCOUS-RARE
___ 07:07PM K+-6.7*
___ 05:35PM GLUCOSE-94 UREA N-32* CREAT-0.9 SODIUM-133
POTASSIUM-6.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
___ 05:35PM estGFR-Using this
___ 05:35PM WBC-8.5# RBC-4.36* HGB-13.4* HCT-42.0 MCV-96
MCH-30.7 MCHC-31.9* RDW-13.2 RDWSD-47.3*
___ 05:35PM NEUTS-60.9 ___ MONOS-7.6 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-5.20 AbsLymp-2.54 AbsMono-0.65
AbsEos-0.09 AbsBaso-0.03
___ 05:35PM PLT COUNT-255
LABS ON DISCHARGE:
==================
___ 07:07AM BLOOD WBC-6.8 RBC-4.31* Hgb-13.5* Hct-41.2
MCV-96 MCH-31.3 MCHC-32.8 RDW-13.2 RDWSD-47.2* Plt ___
___ 07:07AM BLOOD Glucose-95 UreaN-30* Creat-0.9 Na-136
K-4.3 Cl-100 HCO3-28 AnGap-12
___ 07:07AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
CXR (___):
Low lung volumes with bibasilar atelectasis.
IMPORTANT IMAGING/STUDIES:
=========================
CT Abd&Pelv (___):
IMPRESSION:
1. Moderate amount of stool in the rectum and colon. No
evidence of bowel
obstruction.
2. 10 mm hypodense round lesion in the left kidney is mildly
increased in size from CT ___ and may reflect a mildly
complex cyst.
CXR (___): Low lung volumes with bibasilar atelectasis.
Brief Hospital Course:
This is an ___ year old male with past medical history of
___ disease, chronic constipation on linaclotide,
admitted with 8 days of constipation, without signs of
obstruction, subsequently started on augmented bowel regimen and
able to move bowels and tolerate regular meals without
difficulty, who subsequently left against medical advice before
being assessed by physical therapy.
# CONSTIPATION - Patient has a history of intermittent
constipation, most recently treated at ___
___, requiring NGT placement for bowel prep administration.
He subsequently saw Dr. ___ as an outpatient, who
prescribed Linzess to be added to his current home regimen of
Colace and Miralax. He presented with 8 days of constipation.
On admission, his abdominal exam & vital signs and imaging were
reassuring for no evidence of obstruction or acute abdominal
process. However he was noted to have moderate stool burden.
Patient was started on enhanced bowel regimen with senna 17.2mg
and PR bisacodyl, and he stooled within several hours of his AM
medications. He had no nausea or vomiting throughout this
admission and he tolerated a regular diet. Per discussion with
Dr. ___ was discharged home with a prescription for senna
17.2mg PRN constipation.
# Gait Instability / Discharge Against Medical Advice - after
she initially declined physical therapy earlier in the day, his
wife subsequently reported concerns regarding his safety
(ambulation/transfers) at home, but then did not wish to wait
for a physical therapy evaluation. Given these concerns, team
advised patient to stay in the hospital for safety assessment.
Risks of leaving (including falls, injury, death) were discussed
with patient and wife. They demonstrated understanding and
opted to leave. Team arranged for home services and close
outpatient follow-up. For additional details see OMR notes
dated ___.
___ DISEASE - He was continued on his home
Carbidopa-Levodopa (___) 2 TAB PO/NG 6X/DAY.
#Benign prostate hypertrophy - He was continued on his home
finasteride 5 mg qd and tamsulosin 0.4 mg qhs.
#Gastroesophageal reflux: He was continued on his home omeprazle
20 mg qd
#Mood disorder: He was continued on his home quetiapine fumarate
25 mg qhs
Transitional Issues:
===============
- Patient left the hospital against medical advice--after
initially declining physical therapy earlier in the day, his
wife reported concerns regarding his safety
(ambulation/transfers) at home, but then did not wish to wait
for a physical therapy evaluation; risks were discussed with
patient and wife, they demonstrated understanding, and opted to
leave. Team arranged for close outpatient follow-up.
- Per discussion with primary GI Dr. ___ outpatient
bowel regimen was augmented with senna BID and bisacodyl
suppositories prn
- CT abdomen/pelvis incidentally showed "10 mm hypodense round
lesion in the left kidney is mildly increased in size from CT ___ and may reflect a mildly complex cyst." Radiology
recommended "Left renal hypodense lesion can be further
assessed with renal ultrasound on a nonemergent basis."
- Emergency contact: Wife ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO 6X/DAY
2. Docusate Sodium 100 mg PO BID
3. Doxycycline Hyclate 50 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. QUEtiapine Fumarate 25 mg PO QHS
8. Vitamin D ___ UNIT PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Systane (propylene glycol) (peg 400-propylene glycol)
0.4-0.3 % ophthalmic QID
11. linaclotide 290 mcg oral QD
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30
Suppository Refills:*0
2. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth at bedtime Disp
#*60 Tablet Refills:*0
3. Carbidopa-Levodopa (___) 2 TAB PO 6X/DAY
4. Docusate Sodium 100 mg PO BID
5. Doxycycline Hyclate 50 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. linaclotide 290 mcg oral QD
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. QUEtiapine Fumarate 25 mg PO QHS
11. Systane (propylene glycol) (peg 400-propylene glycol)
0.4-0.3 % ophthalmic QID
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Constipation
___ Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came in because you were having constipation. We gave you
new medication and your constipation resolved.
We started you on a new medication called senna. You should take
two pills every evening. We also are sending you home with a
suppository called bisacodyl. You can use this medication if you
have not had a bowel movement in several days.
We did recommend that you stay overnight for physical therapy
evaluation in the morning since you were feeling weaker than
normal, but you are leaving against our medical advice.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10525033-DS-20 | 10,525,033 | 22,771,210 | DS | 20 | 2111-10-27 00:00:00 | 2111-10-27 16:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / diltiazem / rosuvastatin / Avapro
Attending: ___
Chief Complaint:
Abdominal pain and cold feet
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ transferred from OSH for Vascular Surgery evaluation.
She presented the morning prior with acute onset diffuse sharp
abdominal pain. She also reported transient left foot and calf
numbness the day prior that had resolved. There was no other
changes she noticed from usual. Denied any chest pain, SOB, does
endorse mild nausea, last BM yesterday, passing gas.
Of note, the patient recently had BCC excision approx. 1 week
prior with reconstruction and had her warfarin held. Warfarin
had been re-started with no bridge.
Workup at OSH notable for CTA showing small infrarenal aortic
dissection, splenic infarcts, acute vs chronic renal infarcts, R
SFA occlusion, distal ___, AT occlusions, cold feet, small
infrarenal aortic dissection. She had no appreciable pedal
pulses on manual or Doppler exam. She was started on heparin
drip and esmolol drip and transferred to ___ for further
evaluation.
Past Medical History:
Past Medical History: Afib, DM2, BCC, HTN, HLD, hypothyroidism,
CKD stage III
Past Surgical History: Open CCY, tonsillectomy, BCC excision
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 97.3 HR 80 BP 115/52 RR 16 100% 3l NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregularly irregular
PULM: NO resp distress
ABD: Soft, mildly distended, tender to palpation in lower
quadrants bilaterally, no rebound tenderness
Neuro: Grossly intact
Ext: Bilat cool feet with slight purple discoloration, sensation
and motor function intact
Pulses
Fem / Pop / DP / ___
L P / D / - / - , peroneal signal with doppler
R P / D / - / -
DISCHARGE PHYSICAL EXAM
========================
GENERAL: NAD, lying comfortably in bed
HEENT: AT/NC, Has BCC excision site on L face w/o e/o infection
and healing well. EOMI, PERRL, anicteric sclera, pink
conjunctiva, good dentition
NECK: nontender supple neck. JVP not elevated.
HEART: Irregular rhythm and tachycardic rate, normal S1/S2, no
murmurs, gallops, or rubs
LUNGS: Clear to auscultation. no crackles in lung bases
ABDOMEN: nondistended, mildly tender in the periumbilical area,
no rebound/guarding
EXTREMITIES: no cyanosis, no edema dopplerable pulses of the
lower extremities.
NEURO: CN II-XII intact
Bilateral upper extremities: ___ deltoid, ___ biceps, ___ strength lumbricals
Lower extremities: ___ bilateral hip flexion, ___ bilateral
knee extension,
- Right lower extremity ___ dorsiflexion, ___ plantarflexion
- Left lower extremity 4+/5 dorsiflexion, 4+/5 plantarflexion.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===============
___ 12:45PM BLOOD WBC-17.4* RBC-5.13 Hgb-14.7 Hct-48.3*
MCV-94 MCH-28.7 MCHC-30.4* RDW-14.6 RDWSD-50.8* Plt ___
___ 12:55PM BLOOD ___ PTT-150* ___
___ 12:55PM BLOOD Glucose-195* UreaN-18 Creat-1.3* Na-129*
K-4.5 Cl-93* HCO3-20* AnGap-16
___ 12:55PM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.0 Mg-1.9
DISCHARGE LABS
==============
___ 05:24AM BLOOD WBC-27.0* RBC-4.28 Hgb-12.4 Hct-37.8
MCV-88 MCH-29.0 MCHC-32.8 RDW-15.3 RDWSD-49.0* Plt ___
___ 06:04AM BLOOD Glucose-131* UreaN-12 Creat-1.1 Na-138
K-3.8 Cl-97 HCO3-28 AnGap-13
IMAGING
=======
___ CTA Abdomen and Pelvis:
1. Unchanged appearance of a 1.9 cm long penetrating
atherosclerotic ulcer with an associated dissection along the
infrarenal abdominal aorta in comparison to the ___
reference examination, without associated intramural hematoma or
evidence of rupture. No flow-limiting stenosis.
2. New moderate mesenteric edema and mild abdominopelvic
ascites, with mild wall thickening and edema of a middle segment
of small bowel, without dilation or pneumatosis. Inspissated
oral contrast from prior administration reflects bowel stasis.
While no mesenteric arterial or venous filling defects or bowel
hypoenhancement is seen, early ischemic changes remain a
possibility. Correlate with any episodes of prolonged
hypotension. This appearance can also be seen in volume
overload. No CT evidence for volvulus or mechanical
obstruction.
3. Splenic and bilateral renal infarcts are unchanged in
comparison to the ___ reference study.
4. Heterogeneous density throughout the liver could reflect
variable steatosis.
___ Echo:
Normal biventricular cavity sizes, regional/global systolic
function. Mild aortic regurgitation. Mild pulmonary
hypertension.
___ CT Head
Small hyperdense focus in the superior left parietal lobe,
suspicious for
subarachnoid hemorrhage.
___ CTA Head and Neck
1. Narrowing of the M1 branch of the right MCA, and
calcification of the
bilateral cavernous ICAs and carotid siphons, likely secondary
to
atherosclerosis.
2. No high-grade stenosis, occlusion, or aneurysm of the major
intracranial arteries.
3. Calcified and non calcified atherosclerotic plaque of the
bilateral
proximal internal carotid arteries, resulting in 40% narrowing
on the left. No right-sided narrowing by NASCET criteria.
4. Atherosclerotic changes of the bilateral vertebral arteries.
5. Small left pleural effusion.
6. Thrombus is seen within the superior sagittal sinus.
___ MRI Head
1. Linear FLAIR hyperintense and low GRE signal in the very
superomedial left postcentral sulcus corresponding to the
hypodensity seen on recent same-day CT, consistent with small
volume subarachnoid hemorrhage.
2. Multifocal bilateral acute or very early subacute infarcts,
worst in the left parietal lobe, but also involving the right
parietal and bioccipitallobes, in a distribution suggestive of
central thromboembolic etiology.
3. Chronic intracranial findings include global parenchymal
volume loss and mild-to-moderate changes of chronic white matter
microangiopathy.
4. Nonspecific 11 mm skin/dermis based lesion near the vertex.
Correlate with direct visualization/inspection of this area.
___ Arterial Exam
Severe obstructive arterial disease bilaterally.
Likely right SFA occlusion.
Severe left infrapopliteal disease.
Brief Hospital Course:
___ w/ HTN/HLD, hypothyroidism, AF p/w splenic/renal emboli,
AoD, sagittal sinus thrombosis, embolic CVA after holding
warfarin for an outpatient BCC excision. She was initially
admitted to the SICU for her aortic dissection. The vascular
surgery team evaluated her, and did not recommend surgical
intervention. On hospital day 3, she developed extremity
weakness. Neurology evaluated her for extremity weakness and
stroke. They recommended anticoagulation, and initiation of
statin. Hematology was consulted for anticoagulation. She was
initially given warfarin, which was transitioned to apixaban.
She was discharged to rehab.
#Coagulopathy:
#Vascular disease:
#Embolic strokes:
#Saggital sinus thrombosis:
#Small SAH:
#Upper extremity and lower extremity weakness.
On HD3, the patient started having RUE weakness. A CODE Stroke
was called. The patient underwent CT head which showed a small
focus of convexal SAH vs calcification in the left parietal
lobe. CTA head showed no large vessel occlusion or flow limiting
stenosis. TTE was negative for valvular abnormalities. MRI
showed small volume superomedial left postcentral sulcus and
multifocal bilateral acute or very early subacute infarcts in
the parietal and bioccipital lobes suggestive of central
thromboembolic etiology. She was found to have embolic strokes,
sagittal sinus thrombosis, renal/splenic infarcts, and R SFA
occlusion all thought to be in the setting of holding warfarin
for a ___ excision. She was anticoagulated as above, and started
on a statin. Neurology was consulted, who recommended keeping
the blood pressure below 180 systolic. They recommended that the
patient follow-up with an outpatient neurologist at ___
___. Lupus anticoagulant positive, but can be positive in
the setting of taking warfarin. Rest of hypercoagulable workup
thus far negative. Rheumatology was consulted, and had no
further recommendations. Hematology was consulted. The patient
was maintained on a heparin drip. She was initially transitioned
to warfarin. She received 2 doses of warfarin on ___ and
___. The hematology team recommended that her
anticoagulation be changed to apixaban 5 mg twice daily given
that it would be difficult to manage her INR while at rehab.
Given uptrending INR, she was given 5 mg IV vitamin K on ___. She should start her apixaban in the morning of ___.
There is no need for a loading dose of apixaban. Please check
the patient's INR on ___. If still >2.5, please give 5mg
oral vitamin K.
#Dyspnea
#Mild hypoxia
#CHF
Patient had dyspnea and mild hypoxia during her hospitalization.
She was given aggressive IV fluids in the ICU for ___, so the
hypoxia and dyspnea was thought secondary to volume overload as
her home torsemide was originally held. Her dyspnea and hypoxia
improved with IV Lasix. She was restarted on torsemide 30 mg
daily. Please continue to monitor her volume status and
creatinine and increase or decrease torsemide dose as
appropriate.
#Dysphagia
Patient had dysphagia and there was concern for mild vocal cord
paralysis. Speech and swallow evaluated the patient and
recommended a modified diet. They also recommended that ENT
evaluate the patient for possible mild vocal cord paralysis. ENT
performed a scope, and there was no vocal cord paralysis. The
vocal cords were very dry. They recommended that if the patient
needed supplemental oxygen, it be humidified oxygen. They
recommended outpatient ENT follow-up. Speech and swallow should
continue to monitor her progress at rehab.
#Leukocytosis
The patient had an up trending white blood cell count.
Infectious workup was completely negative. Hematology was also
consulted for leukocytosis. They think it is sequelae from
multiple clots. They do not recommend further intervention for
now. Please continue to monitor CBC. If continued leukocytosis,
consider outpatient hematology follow-up.
#Abdominal pain
#Infrarenal aortic ulcer (1.9 cm) w/ dissection
Abdominal pain concerning for bowel ischemia. Patient was given
7 days of zosyn to be cautions. No infectious etiology
identified. Aortic dissection found on CT A/P after the patient
presented with abdominal pain. Originally in SICU on esmolol
gtt. vascular surgery was consulted who recommended that her
systolic blood pressure goal was less than 130. He did not
recommend any intervention. She was continued on metoprolol for
blood pressure control. She should follow-up with vascular
surgery as an outpatient.
#Peripheral artery disease:
#R SFA occlusion:
#Severe L infrapopliteal disease:
Patient presented with cool lower extremities and had arterial
study which showed SFA occlusion. She was started on heparin and
dopplerable pulses were obtained on hospital day 4. Vascular
surgery recommended anticoagulation, as above. No interventions
indicated. Recommended outpatient follow-up.
___:
Likely from hypovolemia and renal infarcts. Peaked at 2.0,
improved with IV fluids. Cr. on discharge 1.1.
#Atrial fibrillation:
Continued metoprolol as above
Continued anticoagulation as above
#Hypothyroidism:
Continued home levothyroxine
TRANSITIONAL ISSUES
===================
#Anticoagulation:
-Please check the patient's INR on ___. If still >2.5,
please give 5mg oral vitamin K
Please start apixaban 5 mg twice daily in the morning on
___.
#Shortness of breath
#CHF
- Continue to monitor I/O. Patient discharged on torsemide 30mg
daily. Increase or decrease torsemide as appropriate
- Please continue to monitor kidney function. Discharge Cr 1.1.
#Stroke
- Patient should follow-up with ___ Neurology
#Dysphagia
- Speech and swallow team should continue to monitor
- Patient should follow-up with ENT
- if O2 needed, please use humidified O2.
#Leukocytosis
- Please check CBC in one week. If ___ doesn't improve, patient
should follow-up with outpatient hematologist
CODE: DNR/DNI (confirmed)
Contact: ___ (daughter-in-law) Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Metoprolol Succinate XL 400 mg PO 3X/WEEK (___)
5. Metoprolol Succinate XL 200 mg PO 4X/WEEK (___)
6. Niacin 1000 mg PO QHS
7. Spironolactone 25 mg PO DAILY
8. Torsemide 30 mg PO 3X/WEEK (___)
9. Torsemide 20 mg PO 4X/WEEK (___)
10. Calcium Carbonate 500 mg PO Frequency is Unknown
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Senna 8.6 mg PO BID
4. Metoprolol Succinate XL 300 mg PO DAILY
5. Torsemide 30 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Niacin 1000 mg PO QHS
8. Spironolactone 25 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until you are told to do so by your
primary care doctor
11. HELD- Calcium Carbonate 500 mg PO Frequency is Unknown This
medication was held. Do not restart Calcium Carbonate until you
are told to do so by your primary care doctor
12. HELD- Fluticasone Propionate NASAL 2 SPRY NU DAILY This
medication was held. Do not restart Fluticasone Propionate NASAL
until you are told do so by your primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Embolic CVA
#Dyspnea
#Infrarenal aortic dissection
PAD, R SFA occlusion
___
#Leukocytosis
#CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You came to the hospital because you were having abdominal
pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-While you are in the hospital, you were diagnosed with a mild
aortic dissection. This means that part of your aorta was weak,
and it split a little bit. The surgery team did not want to do
any intervention for it. We had just been managing it by making
sure your blood pressure is under control.
You were also found to have clots in various places in your
body: your spleen, your kidney, and your brain. We started you
on heparin for these clots, and transitioned you to a medication
called apixaban.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please follow-up with ___ neurology (appointment
information below.)
It is also important that you follow-up with a vascular
surgery team at ___. We scheduled you an
appointment at ___ if you would like to follow-up at ___
(see info below.)
- Please follow-up with ENT (appointment information below.)
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10525106-DS-4 | 10,525,106 | 23,423,413 | DS | 4 | 2150-12-15 00:00:00 | 2150-12-15 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HA, foot drop, fall 6 wks ago
Major Surgical or Invasive Procedure:
___ Right craniotomy for chronic subdural evacuation
History of Present Illness:
Prev healthy ___ F, internist, presents w/ multiple episodes leg
tremors while walking on ___. Yesterday she also experienced
a transient left foot drop that lasted 1 minute. She denies any
seizure activity, vision changes, or change in speech. Of note
she fell six weeks ago onto the sidewalk. She denied any LOC at
the time and a CT scan was negative for a hemorrhage at
the time. She endorses HA's since the fall. Denies fever,
chills, CP, SOB, numbness, tingling, or neck stiffness. Takes no
medication regularly but does endorse taking ASA for pain
yesterday.
Past Medical History:
Denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Phx: 99.2 93 138/65 16 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ bilat EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
On discharge:
alert and oriented x 3
PERRL
___ strength
no pronator drift
incision c/d/i, closed with sutures
Pertinent Results:
___ CTA Head (prelim read)
1. Bilateral mixed-signal cerebral hemisphere subdural
hematomas, which could represent a component of acute
hemorrhage, with associated mild leftward midline shift and
sulcal effacement.
2. Large arteriovenous malformation centered over the cerebellar
vermis,
likely supplied by bilateral P4 segments, with prominent venous
tributary, as described.
___ CT head
Status post right frontal craniotomy with evacuation of right
subdural
hematoma. Blood products within the right subdural collection
have decreased.
Left subdural hematoma persists. No new hemorrhage. Leftward
deviation of the midline structures has slightly improved
Brief Hospital Course:
Mrs. ___ was admitted to the Neurosurgery service on ___
for further management of her bilateral subdural hematomas. The
patient was also found to have an incidental large AVM over the
cerebellar vermis. Mrs. ___ was neurologically stable
during this time. She was admitted to the inpatient ward for
further management and observation. Keppra was started for
seizure prophylaxis.
The patient was kept NPO on ___ with the hopes of taking her
to the operating suite for evacuation of her right subdural,
which was larger than the left. The patient's case was moved to
___ due to OR scheduling difficulties. She was allowed to eat
dinner that evening and again made NPO after midnight for the
operative procedure.
On ___, Mrs. ___ underwent a right craniotomy for
evacuation of her right subdural hematoma. She tolerated the
procedure well. Please see the operative report for further
details.
___ Patient was mobilized. ___ saw the patient and stated that
would like to have one more visit with patient prior to
discharge. Later in the afternoon patient reported feeling
stronger and more steady on her feet. Patient was requesting to
go home. ___ was consulted and stated that they were comfortable
with the patient going home today despite earlier
recommendations given patient was feeling comfortable going home
and would have 24 hour supervision. Patient was discharged home
in stable condition with instructions for follow up.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6 H PRN pain Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral chronic, subacute subdural hematomas, AV malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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.
Dressing may be removed on Day 2 after surgery.
**Your wound was closed with non-dissolvable sutures, you must
wait until after they are removed to wash your hair. You may
shower before this time using a shower cap to cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
**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.
Followup Instructions:
___
|
10525140-DS-20 | 10,525,140 | 24,300,821 | DS | 20 | 2175-12-25 00:00:00 | 2175-12-26 09:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recurrent metastatic endometrial adenocarcinoma to
lungs and liver
on doxil (C2D1 ___, C1D1 ___ via
port-a-cath placed ___, who preseted with acute onset
SOB; She first noted symptoms on the morning of ___ with
dizziness and lightheadness int eh shower. She had associated
palpitations which spontaneously resolved. She had associated
dyspnea at this time, which did not resolve after laying supine.
No associated CP, calf pain or leg swelling, fevers/chills. She
did have some back pain. Went to ___ urgent care and was told
to come to ED to rule-out PE.
Patient did have mild SOB during last chemo session on ___ but
was able to finish infusion with additional dexamethasone (she
was pre-treated with dex, zofran, and benadryl). She does not
have any h/o asthma, COPD, or smoking.
In the ED, initial vitals: T 98.0 HR 100 BP 120/76 RR 20
SaO2 100% on RA. She recieved 1L IVF. She was given ASA 324mg.
CTA chest revealed likely subsegmental PE and she received 70mg
SQ enoxaparin. Head CT was done to r/o metastatic disease and
showed no acute intracranial process.
Review of Systems: As per HPI. She did have lingering cold from
___, with cough that resolved with robitussin with
codeine. Denies any current n/v/d, though does have some n/v
with
her chemotherapy. All other systems negative.
Past Medical History:
Oncologic History:
Patient with "history of a stage IIIC versus IVB grade 2
endometrial adenocarcinoma who underwent debulking surgery in
___. She subsequently had adjuvant chemotherapy with
Dr. ___ completed in ___. In ___, she had
a PET-CT scan, which was worrisome for recurrence and therefore
had a CT-guided biopsy, which revealed metastatic
poorly-differentiated adenocarcinoma consistent with her
endometrial primary."
--she is s/p "total abdominal hysterectomy, bilateral
salpingo-oophorectomy, bilateral periaortic lymph node
dissection, partial omentectomy with intra-operative vascular
surgery consult for repair of injury to the left gonadal vein on
___ six cycles Carboplatin/Taxol
--___ PET/CT ___:
IMPRESSION: Increased uptake within multiple pulmonary nodules,
retroperitoneal para-aortic, and iliac nodes consistent with
recurrent metastases.
--___ Retroperitoneal Node Biopsy: CT Guided, ___
DIAGNOSIS: Lymph node, left retroperitoneal, core needle biopsy:
Metastatic, poorly differentiated adenocarcinoma, consistent
with
endometrial carcinoma.
--___ PET CT:
Marked disease progression from ___ including increased size
and number of innumerable pulmonary metastases, new FDG-avid
pelvic mass and multiple hepatic metastases, new peritoneal
nodularity with FDG uptake, and increased size and number of
FDG-avid lymph nodes in the chest, abdomen, and pelvis.
--DATE: ___: doxil cycle 1 day 1 (extended vomiting and
constipation with first cycle)
--Received Doxil #2 on ___
Other Past Medical History:
Obesity
Hyperlipidemia
Type II Diabetes (A1C 6.6% in ___
Social History:
___
Family History:
Mother is alive and well. Father died at ___ of a stroke.
Mother
has two siblings who are also well. The patient's sister has a
fibroid, but no other illness, another brother and sister are
also well.
Physical Exam:
On Admission:
VS: T 98.3, BP 110/70, HR 90, RR 16, SaO2 99%RA
GEN: NAD
HEENT: PERRL, EOMI, MMM, oropharynx clear, no cervical ___: CTAB, no wheezes, rales or rhonchi.
CV: RRR with soft SEM, nl S1 S2. JVP<7cm
Chest: R port without surrounding swelling or redness. No TTP.
ABD: normal bowel sounds, non-tender, not distended, minimally
palpable liver edge.
EXTR: Warm, well perfused. No edema or calf TTP b/l. 2+ pulses.
NEURO: alert and orientedx3, motor grossly intact, normal gait
On Discharge:
VS: T 98.4, BP 115/70, HR 84, RR 18, SaO2 99%RA
Remainder of exam unchanged from admission
Pertinent Results:
Pertinent Labs
___ 09:20PM BLOOD WBC-8.0 RBC-3.86* Hgb-8.4* Hct-27.5*
MCV-71* MCH-21.8* MCHC-30.6* RDW-19.8* Plt ___
___ 03:55AM BLOOD Hct-27.8*
___ 09:20PM BLOOD Neuts-61.6 ___ Monos-4.3 Eos-4.3*
Baso-0.6
___ 09:20PM BLOOD ___ PTT-25.0 ___
___ 09:20PM BLOOD Glucose-81 UreaN-10 Creat-0.5 Na-134
K-4.0 Cl-98 HCO3-26 AnGap-14
___ 03:55AM BLOOD cTropnT-<0.01
___ 09:20PM BLOOD cTropnT-<0.01
Imaging/Studies
___ CTA Chest
1. Nonocclusive filling defect in the superior lingular
pulmonary artery
consistent with a pulmonary embolism.
2. Widespread pulmonary, nodal and hepatic metastatic disease;
although
difficult to compare with the PET-CT due to differences in
techique, overall it appears there is slight progression of
disease.
___ Non-contrast Head CT
No evidence of acute intracranial process. Of note, MRI is more
sensitive for the detection of metastatic disease.
___ ECG
Normal sinus rhythm, normal axis, isolated T wave flattening in
lead III, low voltage in precordial leads, no ST segment
changes.
Brief Hospital Course:
Mrs. ___ was admitted with shortness of breath and
dizziness, and was found to have an acute pulmonary embolism.
She was started on therapeutic enoxaparin. There were no signs
of hemodynamic instability or right heart strain. She was
discharged home to self-administer enoxaparin and symptom-free.
ACTIVE ISSUES
# Acute Pulmonary Embolism
CTA chest revealed acute PE in the superior lingular artery. ECG
was without evidence of right heart strain, troponins were
negative, and she remained hemodynamically stable. She was
started on therapeutic enoxaparin twice a day and she
successfully self-administered prior to discharge. She will
follow-up with her oncology team as previously scheduled. She
did not require any oxygen, sats 99% on RA
# Recurrent, Metastatic Endometrial Carcinoma
She is currently on cycle 2 of doxorubicin (C2D1 ___. She
will go forward as previously planned with cycle 3 in ___.
Her home medications of lorazepam, compazine, and ondansetron
were continued, but she only uses these around the time of
chemotherapy.
CHRONIC ISSUES
# Type II Diabetes Mellitus
Last A1C was 5.5% in ___. She is diet-controlled.
TRANSITIONAL ISSUES
- Will self-administer enoxaparin 80mg BID indefinitely, no
current plans to change to warfarin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety, nausea
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ Two times a day Disp #*60
Syringe Refills:*0
2. Lorazepam 0.5 mg PO Q6H:PRN anxiety, nausea
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pulmonary embolism
Secondary: metastatic endometrial adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your stay at ___.
You were admitted wtih shortness of breath. You were found to
have a blood clot in your lung (pulmonary embolism). The cancer
put you at risk of this clot. You were started on a blood
thinner called Lovenox to prevent more clots from occurring. You
had improvement in your symptoms.
You will need to take Lovenox shots two times a day.
Please follow up with your doctors as listed below.
Followup Instructions:
___
|
10525140-DS-21 | 10,525,140 | 29,585,804 | DS | 21 | 2176-10-26 00:00:00 | 2176-10-27 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Oxycodone
Attending: ___.
Chief Complaint:
lower leg edema and abdominal pain
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ with metastatic endometrial cancer to the liver and lymph
nodes refractory to treatment recently with everolimus, history
of PE who presents with LLE swelling and pain. Began 1 week ago.
Has had associated with abdominal bloating. Denies fevers,
chills, nausea, vomiting, changes in bowel habits, urinary
symptoms. Had recent fall 1 week ago however reports that
swelling began before she fell. She had negative bilateral LENIs
on ___. ___ called her in for imaging and symptom control.
Of note, patient has been notably tachycardic since the start of
her chemotherapy with a negative work-up including CTA and echo.
She denies any palpitations or chest pain. Also denies
lightheadedness.
In the ED, initial VS were: 98.6 111 128/72 18 100% RA
Labs were notable for: Hgb 11.5
Imaging included: LLE lenis negative for DVT.
Treatments received: 5mg IV morphine
On arrival to the floor, patient continues to have pain in left
lower extremity.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
ONCOLOGY HISTORY:
___ Irregular vaginal bleeding
___ Endometrial biopsy (Dr. ___.
Pathology: Endometrial carcinoma, favoring serous type although
cells only focally + p53 and p16. ER-. FSH=25.
___ Seen by Dr. ___:
___ (Preop CA 125 181.)
Total abdominal hysterectomy, bilateral salpingo-oophorectomy,
bilateral periaortic lymph node dissection, partial omentectomy
with intra-operative vascular surgery consult for repair of
injury to the left gonadal vein.
___ reviewed at ___ tumor board, recommended adjuvant
chemotherapy
Postop CA 125 13
___ Cycle #1 Carboplatin/Taxol
___ Cycle ___ Cycle ___ Cycle ___ Cycle ___ Cycle #6
___ PET/CT ___:
graphic
___ Retroperitoneal Node Biopsy: CT Guided, ___
DIAGNOSIS:
Lymph node, left retroperitoneal, core needle biopsy:
Metastatic, poorly differentiated adenocarcinoma, consistent
with endometrial carcinoma.
Note: Prior slides (___) were reviewed and
morphologically tumor is similar to the current biopsy.
___ Discussed biopsy results, chemotherapy recommended. Pt
chose alternative therapies and prayer.
___ We saw her for follow-up appointments, the last in
___. She was participating in an alternative program in ___
___, felt well, declined chemotherapy.
___ Marker elevated, agreed to PET
___ PET: Marked disease progression from ___ including
increased size and number of innumerable pulmonary metastases,
new FDG-avid pelvic mass and multiple hepatic metastases, new
peritoneal nodularity with FDG uptake, and increased size and
number of FDG-avid lymph nodes in the chest, abdomen, and
pelvis.
___ #1 Doxil 30mg/m2 IV - ___ 3 cyces
___ Cycle #2 with mild infusion reaction
___ Admitted ___ with pulmonary emboli, d/c'd on
lovenox, which she subsequently stopped.
___ CTA ___:
HISTORY: Endometrial cancer presenting with shortness of breath
and near syncope today. Evaluate for PE TECHNIQUE: Axial helical
MDCT images were obtained from the suprasternal notch to the
upper abdomen after administration of 100 cc of Omnipaque
intravenous contrast scanning in the early arterial phase.
Multiplanar reformat images in coronal, sagittal and oblique
axes were generated. DLP: 417 mGy-cm COMPARISON: PET-CT dated ___
FINDINGS: Although this study is not designed for assessment of
intra-abdominal structures, the visualized upper abdomen is
notable for increased size of hypodensities in the liver
consistent with metastases. CT chest: The thyroid is
unremarkable and there is no supraclavicular lymph node
enlargement. The airways are patent to the subsegmental level.
The heart, pericardium and great vessels are within normal
limits. There are multiple enlarged mediastinal, bilateral hilar
and epicardial lymph nodes consistent with metastases. No hiatal
hernia or other esophageal abnormality is present. There are
innumerable pulmonary nodules and masses, the largest of which
in the left upper lobe measures 3.5 x 3.7 cm, previously 3.1 x
3.3 cm. No pleural effusion or pneumothorax is present.
CTA chest: The aorta and major thoracic vessels are well
opacified. The aorta demonstrates normal caliber throughout the
thorax without intramural hematoma or dissection. The pulmonary
arteries are opacified to the subsegmental level. There is an
eccentric filling defect in the superior lingular artery which
appears nonocclusive
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy is present.
IMPRESSION:
1. Nonocclusive filling defect in the superior lingular
pulmonary artery consistent with a pulmonary embolism.
2. Widespread pulmonary, nodal and hepatic metastatic disease;
although difficult to compare with the PET-CT due to differences
in techique, overall it appears there is slight progression of
disease.
Started on Lovenox, discontinued by patient in 2 weeks.
___ Cycle #3 - Tolerated doxil with solumedrol
___ Cycle Doxil Added back Carboplatin (Cycle 1) - 4
cycles
___ CT Torso:
___ Cycle #5 Doxil ___ cycle 2 (lifetime cycle 8)
___ Cycle #6
___ ABDOMEN/ PELVIS CT W/ CONTRAST
___ Cycle ___ Echocardiogram EF 60-65%
___, rising CA125, No significant response by imaging (above)
started Everolimus.
PAST MEDICAL HISTORY:
H/o PE
Obesity
Hyperlipidemia
Type II Diabetes (A1C 6.6% in ___
Social History:
___
Family History:
Mother is alive and well. Father died at ___ of a stroke.
Mother
has two siblings who are also well. The patient's sister has a
fibroid, but no other illness, another brother and sister are
also well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98.9 135/82 108 20 98%RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: tachycardic regular, nl S1 and S2, no murmurs
LUNG: CTAB no w/r/rh
ABD: slightly distended, dullness to percussion laterally. no
obvious fluid wave. +BS, TTP in epigastric to central abdomen
EXT: entire left lower extremity below the knee and ankle edema,
2+pulses.
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact.
SKIN: Warm and dry
DISCHARGE PHYSICAL EXAM:
=========================
___: ___, 130/78, 100, 18, 95% on RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CHEST: Right chest port in place.
CARDIAC: Tachycardic regular, nl S1 and S2, no murmurs
LUNG: CTAB no w/r/rh
ABD: soft, moderately distended, mild tenderness in all
quadrants on deep palpation with no flank tenderness,
normoactive bowel sounds
EXT: Tense bilateral lower extremity edema L>R
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. FROM x 4 of upper and lower
extremities.
SKIN: Warm and dry
Pertinent Results:
ADMISSION LABS:
================
___ 03:23PM BLOOD WBC-8.4 RBC-4.64# Hgb-11.5*# Hct-36.1#
MCV-78* MCH-24.8* MCHC-31.9 RDW-21.8* Plt ___
___ 03:23PM BLOOD Neuts-81.7* Lymphs-12.1* Monos-5.0
Eos-1.1 Baso-0.2
___ 03:23PM BLOOD ___ PTT-29.4 ___
___ 03:23PM BLOOD Glucose-108* UreaN-16 Creat-0.8 Na-136
K-3.8 Cl-100 HCO3-24 AnGap-16
___ 03:23PM BLOOD ALT-24 AST-83* AlkPhos-201* TotBili-0.5
___ 06:09AM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.9 Mg-1.9
OTHER PERTINENT LABS:
====================
___ 06:16AM BLOOD WBC-10.0 RBC-3.72* Hgb-8.8* Hct-28.4*
MCV-76* MCH-23.8* MCHC-31.1 RDW-22.3* Plt ___
___ 05:09AM BLOOD WBC-9.8 RBC-3.67* Hgb-8.9* Hct-28.3*
MCV-77* MCH-24.1* MCHC-31.3 RDW-22.2* Plt ___
___ 06:14AM BLOOD Neuts-76.9* Lymphs-15.4* Monos-6.7
Eos-0.4 Baso-0.7
___ 05:09AM BLOOD Neuts-76.2* Lymphs-14.9* Monos-8.2
Eos-0.4 Baso-0.4
___ 05:09AM BLOOD ___ PTT-34.4 ___
___ 05:09AM BLOOD Plt ___
___ 06:16AM BLOOD Glucose-89 UreaN-22* Creat-1.3* Na-129*
K-4.4 Cl-90* HCO3-24 AnGap-19
___ 05:09AM BLOOD Glucose-78 UreaN-20 Creat-1.1 Na-132*
K-4.3 Cl-93* HCO3-24 AnGap-19
___ 05:28AM BLOOD ALT-29 AST-89* LD(___)-1747* AlkPhos-261*
TotBili-0.7
___ 06:14AM BLOOD ALT-21 AST-80* LD(___)-1564* AlkPhos-246*
TotBili-0.7
___ 06:16AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.1
___ 05:09AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
MICROBIOLOGY:
==============
___: Urine culture - negative
IMAGING:
========
CT Abdomen and Pelvis ___:
1. Significant interval worsening of the widespread metastatic
lesions within the liver, with near complete replacement of the
liver by tumor.
2. Significant interval progression of peritoneal disease
throughout the abdomen and pelvis, with evidence of extrinsic
compression on the first portion of the duodenum and surrounding
the sigmoid colon. Omental metasasis are also present
3. Moderate to severe right-sided hydroureteronephrosis and left
sided hydronephrosis, secondary to retroperitoenal lymph
adenopathy.
4. Interval worsening of patient is moderate ascites.
CT CHEST ___:
1. Worsening metastatic disease in the chest, with the largest
mass at the left lower lobe measuring up to 7.3 cm, resulting in
compression of the adjacent airways and partial atelectasis.
There is also increased interstitial spread of disease to the
peripheral pleural surfaces, and areas without a clear fat plane
between the lateral border of the aorta and epicardium,
concerning for invasion, as described in detail above.
2. New small bilateral pleural effusions, right greater than
left.
3. Eccentric, non-occlusive filling defect in the superior
lingular artery, similar to the prior exam; this could represent
a bland thrombus or tumor thrombus.
Ultrasound ___:
1. No evidence of ascites.
2. Limited evaluation of the multiple metastatic lesions within
the liver and
moderate bilateral hydronephrosis.
CT Lower Extremities ___:
1. Minimally displaced fracture along the proximal first
metatarsal, of
indeterminate chronicity. Please correlate clinically.
2. Diffuse edema/ anasarca of the soft tissues, however no
drainable fluid
collection identified.
Lower extremity dopplers ___:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
___ y/o F with metastatic endometrial cancer refractory to
treatment recently with everolimus, history of PE who presents
with LLE swelling and pain x 2 wks, found to have progression of
her disease including abdomen, pelvis, and compression on the GI
tract. Patient changed her code status to DNR/DNI this
admission, and went home with ___ and bridge to hospice.
# Bilateral Hydronephrosis and Rising Creatinine
Creatinine stable, but as per CT scan this is from tumor
progression. Urology consulted on AM ___ to consider
ureteral stents. ___ previously consulted and risks > benefits
for percutaneous nephrostomy unless Cr elevated. Patient
continued to have good urine output >30 cc/hour during
hospitalization, and tolerated having her foley catheter removed
with successful voiding trial. Both urology and interventional
radiology are willing to intervene if patient's urine output
decreases or her renal function deteriorates, particularly to
Cr>1.5. However, given her stable course, she was discharged
home with close followup and plan for frequent re-evaluations of
her renal function.
# Lower Back Pain
Patient with increased left lower flank pain on ___,
responsive to pain medications. Currently on morphine and
tramadol, but refused all morphine. Notes that tramadol alone
fully controls her pain and requests discharge with only
tramadol. Provided patient tramadol on discharge. She was asked
to continue to work with her outpatient oncologist to manage her
pain.
# Metastatic Endometrial Cancer
Patient has extensive metastatic endometrial cancer that has
been progressing. This is likely the cause of her other below
problems. Has tumor progression on palliative chemotherapy, and
had goals of care discussion. Not ready for hospice, but OK with
___. Patient is now DNR/DNI but not ready to discuss hospice. As
an outpatient, goals of care should continue to be discussed as
the patient is likely not a chemotherapeutic candidate
currently. Can continue to discuss her ___ bridge to hospice.
# LLE Swelling:
Likely an obstructive etiology, given extensive malignancy and
likely lymphatic obstruction. Non-pitting, tense edema. As an
outpatient, patient was encouraged to continue elevation of her
lower extremities and TEDS. Lower extremity dopplers were
negative for DVT.
# Abdominal distension/Transaminitis:
Likely due to peritoneal carcinomatosis, as per CT scan, liver
almost entirely replaced by tumor and this explains both the
ascites and her transaminitis.
She had frequent constipation and this likely contributes to her
abdominal distension, and was provided an aggressive bowel
regimen both in the hospital and on discharge.
# Tachycardia:
Patient has history of tachycardia in prior documentation. Had
PE back in ___ and was on lovenox which has since been
stopped. Given no SOB/chest pain, and chronic etiology this may
also be related to demand from her malignancy or from
hypovolemia. Tachycardia improved throughout hospitalization
with better PO intake, and pain control.
# H/o PE: Previously on Lovenox but stopped due to
risks>benefits. This medication was not continued during this
hospitalization, although the patient did receive DVT
prophylaxis.
# DM2: diet-controlled
TRANSITIONAL ISSUES:
====================
-Please recheck Chem 7 at follow up visit. If worsening renal
function patient will need referral to interventional radiology
and urology for consideration of percutaneous nephrostomy tubes
or ureteral stenting
- DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Omeprazole 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Semi Electric Hospital Bed ___ Bed w/siderails
Diagnosis: Malignant neoplasm of corpus uteri, except isthmus
ICD9:182.0
2. Commode
Diagnosis: ICD 9: 182.0 Malignant neoplasm of uterus
Prognosis: Good
Length of need: 13 months
3. Rolling Walker
Diagnosis: ICD 9: 182.0 Malignant neoplasm of uterus
Prognosis: Good
Length of need: 13 months
4. Omeprazole 20 mg PO BID
5. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
6. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
10. Sarna Lotion 1 Appl TP BID:PRN leg discomfort
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply to
irritated skin area twice a day Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
12. Simethicone 40-80 mg PO QID:PRN gas, bloating
RX *simethicone 80 mg 1 tablet by mouth four times a day Disp
#*60 Tablet Refills:*0
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Bilateral Hydronephrosis
Metastatic endometrial cancer
Secondary:
Diabetes Mellitus 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with abdominal and leg swelling which is due to the progression
of your tumors. There is also tumor progression on your kidneys
but your kidney function remained stable so you did not need an
intervention. You were offered additional services to help you
at home and you chose a visiting nurse. If in the future you
feel you need more support at home, your nurse can assist you
with getting more help in the form of hospice services.
It has been a pleasure caring for you, and we wish you all the
best.
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10525168-DS-16 | 10,525,168 | 24,699,389 | DS | 16 | 2171-01-08 00:00:00 | 2171-01-09 08:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
aspirin
Attending: ___.
Chief Complaint:
toe discoloration bilaterally, ___, toe pain
Major Surgical or Invasive Procedure:
___: Right open transmetatarsal amputation
___: Right foot debridement
___: Left transmetatarsal amputation
___: ALT free flap to right foot wound
History of Present Illness:
Mr. ___ is a ___ man with history of alcohol and
tobacco abuse and history of previous bilateral hallux
amputation ___ frostbite who now presents from OSH to the ___
ED with bilateral pedal frostbite and wet gangrene. Patient is a
poor historian and so details of history are acquired both from
patient and from available medical records. Per report, patient
was found lying in a snowbank today; per patient report, he had
multiple episodes over the past 4 days cold and wet feet while
collecting cans, which condition has progressed to swelling,
discoloration and severe pain and malodor of both feet. Patient
denies any fevers / chills or other associated symptoms.
.
Patient was seen by surgery resident at ___
who.recommended transfer to ___ for Vascular Surgery
evaluation. Patient received Vancomycin at OSH prior to
transfer.
.
Patient's prior history is notable for prior lower extremity
surgery: in addition to prior bilateral hallux amputation for
frostbite, patient also underwent admission to Orthopaedic
Surgery at ___ in ___ for bilateral LC1 pelvic fx, left
femur AVN, non-displaced L lateral tibial plateau fx, and L left
medial condyle distal femur fx. He underwent L femoral ORIF on
___.
Past Medical History:
PMH:
- Alcohol abuse at risk for withdrawal per prior admission notes
- Multiple traumatic orthopaedic injuries as per ___
admission
- L femoral head AVN w/ collapse (followed by Dr. ___ at
___ with plan for THA)
- Prior frostbite requiring amputations of b/l great toes
.
PSH:
___: ORIF of L distal femur
___: Amputations of left and right great toes (separate
procedures) for frostbite, patient reports performed at ___ (immediate access to ___ records not available)
Social History:
___
Family History:
Denies any significant family history. Father deceased age ___,
mother alive although her age is unknown to patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 78 107/53 19 99% RA
Gen: Malodor in exam room presumed from gangrenous lower
extremities. Patient in discomfort from lower extremities but
no
acute distress. AAOx3. Thin.
HEENT: ?slight scleral icterus? PERRL, EOMI. O/w grossly
normocephalic and atraumatic.
CV: Distant heart sounds, RRR, no clearly auscultated m/r/g
Pulm: No respiratory distress, grossly CTAB
Abd: Soft, NT/ND
Ext: Bilateral upper extremities WWP no c/c/e, bilateral upper
extremity tattoos. Bilateral lower extremities are grossly
normal above the knee save for orthopaedic post-surgical LLE.
Bilaterally palpable femoral and popliteal pulses.
Left foot: s/p L hallux amputation, site healed. Stump of
hallux and digits ___ are grossly gangrenous with black dry
distal gangrene but wet line of demarcation at proximal
phalanges
dorsally; tissue proximal to line of demarcation is erythematous
with blanching and edematous to the mid-foot. Line of
demarcation is slightly more proximal on plantar aspect of foot.
Palpable DP, easily dopplerable ___.
Right foot: S/p R hallux amputation, site healed. Extensive
dry
gangrene of the toes and distal foot to mid-foot with
transition/demarcation zone of 0.5-1 cm consistent with wet
gangrene. As with left foot, gangrene is modestly more
extensive
on plantar surface of foot than dorsal. Mild blanching erythema
and edema of right mid-foot. Palpable right DP and ___ pulses.
Pertinent Results:
ADMISSION LABS:
___ 07:15AM BLOOD WBC-13.3* RBC-3.71* Hgb-11.3* Hct-34.4*
MCV-93 MCH-30.5 MCHC-32.8 RDW-16.5* RDWSD-56.5* Plt ___
___ 07:30AM BLOOD WBC-12.7* RBC-3.62* Hgb-10.8* Hct-33.9*
MCV-94 MCH-29.8 MCHC-31.9* RDW-16.5* RDWSD-56.4* Plt ___
___ 06:55AM BLOOD WBC-9.6 RBC-3.84* Hgb-11.7* Hct-35.9*
MCV-94 MCH-30.5 MCHC-32.6 RDW-16.3* RDWSD-55.4* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-140 K-4.3
Cl-103 HCO3-23 AnGap-18
___ 07:15AM BLOOD Calcium-8.8 Mg-2.6
DISCHARGE LABS:
___ 06:09AM BLOOD WBC-8.2 RBC-3.28* Hgb-9.9* Hct-30.6*
MCV-93 MCH-30.2 MCHC-32.4 RDW-17.0* RDWSD-57.9* Plt ___
___ 06:15AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-139
K-4.4 Cl-101 HCO3-25 AnGap-17
___ 06:15AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.9
___ 06:39AM BLOOD Vanco-14.9
.
___ ___ M ___ ___
Radiology Report CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND
RECONS Study Date of ___ 6:05 ___
Final Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
FINDINGS:
VASCULAR:
Atherosclerotic disease is heavy. There is no aneurysmal
dilatation of the visualized aorta. There is mild origin
narrowing of the celiac trunk. There is high-grade origin
narrowing of the upper of the 2 right renal arteries. There is
probably moderate proximal narrowing of the left renal artery.
SMA, ___ are patent.
On the right, there is mild atherosclerotic narrowing of the
proximal right superficial femoral artery, right popliteal
artery. Otherwise, the iliacs, common femoral, superficial,
deep femoral and popliteal arteries are widely patent. There is
a three-vessel runoff to the level of the ankle and into the
foot vessels are patent including dorsalis pedis.
On the left, there is mild-to-moderate narrowing of the left
internal iliac artery. There is mild atherosclerotic narrowing
of the distal superficial femoral artery. Otherwise, the
iliacs, common femoral, superficial and deep femoral and
popliteal arteries are widely patent. There is thready flow in
the posterior tibial artery, distally. Anterior tibial artery
and peroneal artery are widely patent. Patent dorsalis pedis.
LOWER CHEST: There is mild scarring at the lung bases,
bilaterally. There is a large granuloma incidentally noted at
the left lung base (series 3A image 2).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits, without stones or
gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: Left adrenal gland is thickened, new since ___. Normal right adrenal gland.
URINARY: The kidneys are of normal and symmetric size. Images
are mildly
grainy, there is possible striated nephrogram in the lower right
kidney,
suggesting focal pyelonephritis, clinically correlate.
Hydronephrosis..
There is no evidence of stones, focal renal lesions, or
hydronephrosis. There are no urothelial lesions in the kidneys
or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall thickness and enhancement throughout. There is sigmoid
diverticulosis without evidence of diverticulitis. Appendix
contains air, has normal caliber without evidence of fat
stranding. There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
PELVIS: There are multiple large bladder diverticula.
Prominent, bilateral pelvic and inguinal lymph nodes not meet CT
size criteria for lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable.
BONES: There is severe degenerative change at the left hip
joint. There is a surgical plate, screws at the distal left
femur. There is right midfoot amputation. There is amputation
of the left great toe there is a chronic, healed fracture of the
right inferior, superior pubic ramus pubic ramus. There are
right posterior chronic rib deformities suggestive of prior
trauma. Left lower extremity musculature is a trophic compared
to the right. There is severe degenerative arthritis of the
left hip. There is collapse of the superior femoral head,
suggestive of chronic AVN, similar. Large left hip joint
effusion is similar.
SOFT TISSUES: There are small bilateral fat containing inguinal
hernias.
IMPRESSION:
1. Three-vessel runoff to the level of ankle, bilaterally.
Moderate
atherosclerotic disease throughout the visualized abdomen.
2. Multiple large bladder diverticula.
3. Suggestion of striated nephrogram the lower right kidney
versus artifact,
consider pyelonephritis. No hydronephrosis.
4. Postoperative changes bilateral feet.
.
MICROBIOLOGY:
Time Taken Not Noted Log-In Date/Time: ___ 1:11 pm
TISSUE ___ METATARSAL RIGHT FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
.
___ 8:50 am TISSUE RIGHT FIRST METATARSAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 9:00 am TISSUE RIGHT SECOND METATARSAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
GRAM POSITIVE COCCUS(COCCI). RARE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 9:00 am TISSUE ___ METATERSAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
MIXED BACTERIAL FLORA.
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 9:00 am TISSUE ___ METATARSAL.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
Sensitivity testing per ___ ___.
STAPHYLOCOCCUS SIMULANS. 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.
CLINDAMYCIN sensitivity testing confirmed by ___
___.
STAPHYLOCOCCUS EPIDERMIDIS. RARE GROWTH. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS SIMULANS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 9:00 am TISSUE ___ METATARSAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 2:30 pm TISSUE FIRST METTATASAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS SIMULANS. RARE GROWTH.
Sensitivity testing per ___ ___.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CLINDAMYCIN sensitivity testing performed by ___
___.
GRAM POSITIVE RODS. RARE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS SIMULANS
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 11:00 am TISSUE RIGHT FOOT BONE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Mr. ___ admitted to ___
on ___ due to bilateral foot ___ progressing to wet
gangrene on his right foot. He was started on IV antibiotics
including Vancomycin/Ciprofloxacin and Flagyl. Vascular surgery
and Podiatric Surgery were consulted. He underwent a right sided
open transmetatarsal amputation on ___ with Pods. A wound
VAC device was placed on his right transmetatarsal amputation
wound on ___. He was transferred to the podiatric surgery
service on ___. He was taken back to the operating room for
debridement of the right foot open TMA site and wound vac
placement on ___. His left forefoot also suffered from
frostbite and his toes became demarcated and he began to have
wet gangrene to his distal left forefoot. He was taken to the
operating room on ___ for a left foot transmetatarsal
amputation. He tolerated all of his podiatric procedures well.
For details of the procedures, please see the operative reports
in OMR. Plastic surgery service was also consulted for possible
flap reconstruction of his right foot. Patient underwent a free
ALT flap to right foot defect on ___ and was transferred to
Plastic Surgery service with a PICC in place and continued on
vancomycin and zosyn IV per Infectious Disease recommendations.
Flap was monitored per pathway with vioptix monitor and Doppler
checks. On ___ s/p flap, patient attempted a 5 minute dangle
but flap became congested and was immediately re-elevated.
Vioptix value increased back to baseline and Doppler signal
remained intact. Dangle trials were suspended until POD#5 when
they were re-attempted and tolerated to a maximum of 10 minutes
BID and then TID. Dangles were eventually tolerated to 15
minutes TID. Pain was controlled with a morphine PCA initially
and a right leg nerve catheter which was discontinued on POD#4.
The PCA was discontinued on POD#2 in favor of PO pain
medications. Patient remained on bedrest until POD#5 when he
was liberated for short dangle periods. Foley catheter was
removed on POD#2 and patient able to void freely. Plavix was
discontinued post-operatively in favor of aspirin and heparin
SQ. Patient was transitioned from heparin SQ to Lovenox 40mg SQ
daily on POD#7. Zosyn was discontinued on POD#6 per ID
recommendations. Vancomycin will be continued until at least
___, per ID recommendations. Patient discharged to rehab
facility on hospital day #32. Free flap was warm, pink and
viable with strong Doppler pulse.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees
2. Aspirin EC 121.5 mg PO DAILY Duration: 2 Weeks
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC Q24H Duration: 2 Weeks
Start: ___ - ___, First Dose: Next Routine Administration
Time
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Vancomycin 1250 mg IV Q 12H Duration (until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral toes ischemia with dry gangrene progressing wet
gangrene due to ___ injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on
___ due to bilateral foot ___ progressing to wet
gangrene on your right foot. You were started on IV antibiotics
including Vancomycin/Ciprofloxacin and Flagyl. You underwent a
right sided open transmetatarsal amputation (amputation the
anterior half of your foot) on ___ with Podiatry. A wound
VAC device was placed on your right foot. You were taken back
the operating room on ___ for a debridement of the right
foot wound with placement of a wound vac. Your left foot also
began to progress to wet gangrene along your forefoot, so you
were taken to the operating room on ___ for a
transmetatarsal amputation on the left.
You went to the operating room with plastic surgery on ___
for a Suprafascial anterior lateral thigh flap from right thigh
to right foot.
.
You have now recovered from surgery and are ready to be
discharged. Please follow the instructions below to continue
your recovery:
.
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your right foot until your follow up appointment. You
should keep these sites elevated when ever possible (above the
level of the heart!)
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, Please call Dr. ___ office
to report this.
.
Exercise:
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
You should sponge bathe for now.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
.
FOLLOW-UP APPOINTMENTS:
Be sure to keep your medical appointments.
Followup Instructions:
___
|
10525472-DS-5 | 10,525,472 | 23,042,524 | DS | 5 | 2183-02-07 00:00:00 | 2183-02-09 10:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with hx of PUD disease from NSAID use presents with
abdominal pain and hematemesis.
Patient states he had an episode of hematemesis evening prior to
admission. He was seen at a hospital in ___ but his father took
him out AMA to bring him here. He has a history of PUD and
ulcers in the past from ibuprofen use. He was seen at ___
for this about ___ years ago.
He reports feeling sick for the past ___ weeks and having
received a course of abx or "strep throat." He sas he has
vomited once a week for the past few weeks and then on the night
prior to admission had many episodes of emesis. Although he is a
poor historian, he says he though he saw a lot of blood in the
toilet. He was dizzy at one time which has resolved. He had no
BM in many days. Also reports +chills and cough. He denies an
recent alcohol or illicit drug use.
In the ED intial vitals were: 98 72 95/58 16 98% RA. Labs were
unremarkable. Patient was given: IV protonix and zofran.
Vitals on transfer:98 72 95/58 16 98% RA. Currently, he reports
feeling well and denies any ongoing complaints.
Review of Systems:
(+) per HPI, chills, cough, abdominal pain, constipation
(-) fever, headache, vision changes, shortness of breath, chest
pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Peptic ulcer disease (s/p NSAID use)
- Migraine headaches
Past surgical history
- Tracheoesophageal fistula and esophageal atresia surgery at
birth.
Social History:
___
Family History:
Mother: age ___ with hypercholesterolemia
Father: age ___, alive and well
one sister alive and well
Physical Exam:
Physical Exam:
===========================
Vitals- 97.9 104/50 63 19 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx with large tonsils with
white exudate
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, mild TTP in LUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs:
====================
___ 02:15AM BLOOD WBC-8.9 RBC-4.92 Hgb-14.7 Hct-41.5 MCV-84
MCH-29.9 MCHC-35.5* RDW-12.5 Plt ___
___ 10:45AM BLOOD WBC-5.3 RBC-4.72 Hgb-13.2* Hct-39.7*
MCV-84 MCH-28.1 MCHC-33.3 RDW-12.6 Plt ___
___ 02:15AM BLOOD Neuts-70.0 ___ Monos-7.4 Eos-0.3
Baso-0.4
___ 02:15AM BLOOD ___ PTT-41.9* ___
___ 02:15AM BLOOD Plt ___
___ 10:45AM BLOOD Plt ___
___ 02:15AM BLOOD Glucose-90 UreaN-15 Creat-1.2 Na-137
K-4.3 Cl-100 HCO3-23 AnGap-18
___ 10:45AM BLOOD Glucose-89 UreaN-14 Creat-1.1 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
___ 02:15AM BLOOD ALT-17 AST-31 AlkPhos-58 TotBili-0.6
___ 02:15AM BLOOD Albumin-4.5
___ 10:45AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0
___ 05:52AM BLOOD K-3.7
Micro:
==================
___ 01:10PM BLOOD HIV Ab-NEGATIVE
Monospot: Negative
Imaging:
==================
# CXR ___:
FINDINGS: There is no focal consolidation, pleural effusion or
pneumothorax. The cardiomediastinal and hilar contours are
normal. Again seen is a bifid rib on the right. There is no
free air.
IMPRESSION: No free air. No acute cardiopulmonary process.
# Spleen U/S (___)
FINDINGS: The spleen is not enlarged, measuring 11.7 cm. No
splenic abnormality is identified.
IMPRESSION: No splenomegaly.
Brief Hospital Course:
___ with history of PUD disease from NSAID use who presents with
abdominal pain and hematemesis.
# Abdominal pain and hematemeis
Given the history of PUD, ddx includes PUD vs gastritis vs
___ tear from frequent vomiting. Although patient
reports large volume hematemesis, his Hct was normal and he did
not have an elevated BUN. He was treated with IVFs and was made
NPO. He did not have any additional episodes of hematemesis or
melena on this admission. He was seen by GI who offered to do an
upper endoscopy on ___ ___eclined and will follow up as an
outpatient. He was continued on pantoprazole daily and follow up
with PCP this week.
# ?viral illness
Concern for underlying infection given 3 week course of chills,
sore throat, LUQ pain. HIV and monospot were negative and
ultrasound was negative for splenomegaly. Patient was instructed
to maintain good PO intake and return should any of his symptoms
worsen.
Transitional Issue:
============================
# Would recommend outpatient EGD to evaluate progression of PUD
# Code: Full (discussed with patient)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. SUMAtriptan 5 mg/actuation NU daily:prn migraine
2. Amitriptyline 10 mg PO QHS:PRN migraine
3. Finasteride 1.25 mg PO DAILY
Discharge Medications:
1. Amitriptyline 10 mg PO QHS:PRN migraine
2. Finasteride 1.25 mg PO DAILY
3. SUMAtriptan 5 mg/actuation NU daily:prn migraine
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Upper GI bleed
Hematemesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in with bloody vomiting which may be
related to you previously diagnosed peptic ulcer disease. Your
blood counts were stable and you did not have any additional
episodes over the last 24hours. You have decided to have an
elective upper endoscopy as an outpatient. You will continue to
take protonix to reduce stomach acid.
Followup Instructions:
___
|
10525659-DS-20 | 10,525,659 | 21,120,912 | DS | 20 | 2117-07-15 00:00:00 | 2117-07-16 12:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with 2 days of abdominal pain which began as diffuse
pain ___ morning and migrated to RLQ within hours, also with
one episode of non-bloody diarrhea and 1x NBNB emesis later that
day. Intermittent nausea since, no change in appetite. Pain
worsened yesterday, slightly improved today, currently ___. She
describes sharp pain in the RLQ plus less severe generalized
crampy pain. Did not take temp at home. Also notes internal
pubic
discomfort with urination and mildly weakened stream, no
external
dysuria.
Her RLQ pain worsened yesterday and she presented to OSH
(___), where CT was read as small amount of stranding/free
fluid in RLQ, appendix not fully visualized. TVUS had limited
view of R adnexa. WBC 14.5 \ 13.0 | 39.0 / 432, 77.8% PMNs.
Serum
glucose 450. UA SG >1.040, 1+ acetone, 3+ glucose, 3+ RBC, 0
WBC.
Of note, the patient is currently menstruating (LMP ___
and has a multi-fibroid uterus which causes intermittent
abdominal discomfort but this current pain feels very different
and more severe.
Also of note, she recently had one week of n/v and diarrhea with
mild chest pain for which she received inpatient care at ___,
discharged ~10 days ago with diagnosis of gastroenteritis and
cardiac workup negative for MI.
Past Medical History:
- T1DM ___ pancreatectomy
- Fibroid uterus ___ planned with Dr. ___
- ___ aortic ?thrombus (patient describes "tear") with
arterial emboli to ___ (previously on Coumadin, no longer is)
- Chronic back pain
Social History:
___
Family History:
no family history of clotting/bleeding disorders or sudden death
Physical Exam:
Vitals: T 98.2F HR 98 BP 114/70 RR 18 O2 95%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: ___ incision scar. Decreased bowel sounds. Soft,
nondistended. Mild-mod tender in LLQ, w/o rebound or referral of
pain. Markedly tender in RLQ and R suprapubic region with
localized rebound tenderness. No palpable masses.
Ext: No ___ edema, dorsalis pedis pulses intact and symmetric
bilaterally, ___ and ___ perfused.
VSS
HEENT: MMM
___: RRR, no murmurs
Pulm: clear bilaterally
Abdomen: abdominal scar well healed. Soft, non distended, tender
in the right lower quadrant no rebounding or guarding. No masses
palpable
Ext: no edema, wwp
Pertinent Results:
___ 06:50AM BLOOD WBC-9.1 RBC-4.19 Hgb-12.1 Hct-36.4 MCV-87
MCH-28.9 MCHC-33.2 RDW-14.5 RDWSD-45.8 Plt ___
___ 06:50AM BLOOD WBC-11.2* RBC-4.34 Hgb-12.4 Hct-38.2
MCV-88 MCH-28.6 MCHC-32.5 RDW-14.5 RDWSD-46.3 Plt ___
___ 01:10PM BLOOD WBC-12.2* RBC-4.42 Hgb-12.6 Hct-39.2
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.6 RDWSD-47.2* Plt ___
___ 06:50AM BLOOD Glucose-291* UreaN-8 Creat-0.5 Na-136
K-4.3 Cl-100 HCO3-23 AnGap-17
___ 06:50AM BLOOD Glucose-230* UreaN-4* Creat-0.5 Na-140
K-4.3 Cl-102 HCO3-22 AnGap-20
___ 01:10PM BLOOD Glucose-180* UreaN-6 Creat-0.5 Na-137
K-3.8 Cl-98 HCO3-22 AnGap-21*
___ 06:50AM BLOOD %HbA1c-13.3* eAG-335*
Brief Hospital Course:
Ms ___ was admitted to the acute care service after a CT
scan revealed some stranding and questionable ruptured appendix.
The patient also was evaluated by the gynecologists for a
fibroid uterus. She had a pelvic ultrasound in the emergency
department that revealed a large, fibroid uterus. The left
ovary not definitively visualized. right ovary is prominent
with normal arterial and venous waveforms. They gynecologists
felt that she did not have ovarian torsion and since she is
going for a hysterectomy they will evaluate her ovaries at that
time. The patient was started on antibiotics, IV fluids and IV
pain control. The patients diet was advanced once her abdomen
was less tender. It was explained to the patient that she will
need an interval appendectomy and she requested that she have
her appendectomy and hysterectomy at the same time.
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:
- Lantus 15 units subQ qhs
- Humalog sliding scale, starting at 2
- Tramadol 50mg tid
- Gabapentin 200 tid
- Depo-provera injection - 1 month ago
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours for
pain Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
12 hours Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
12 hours Disp #*20 Capsule Refills:*0
4. Gabapentin 200 mg PO TID
5. Glargine 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drink alcohol or drive on this medication
RX *oxycodone 5 mg 1 capsule(s) by mouth every ___ hours Disp
#*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ruptured appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10525752-DS-8 | 10,525,752 | 25,863,359 | DS | 8 | 2146-06-15 00:00:00 | 2146-06-15 18:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ ERCP with distal stent placement
___ ERCP with removal of prior stent, sphincterotomy, new
stent placement at ampulla
___ Laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ yo man with h/o cardiomyopathy (EF 35-40%
per patient) who presents with 3 days of abdominal pain, found
to have cholangitis, now admitted to ___ with septic shock.
He reports he had 3 days of RUQ abdominal pain. It initially
started after eating a bowl of pea soup. Pain resolved with 2
aleve but recurred the following day after eating a chicken
sandwich. He denies fevers at home. He went to ___ where
he was reportedly febrile and had RUQ u/s and CT a/p showing
dilatation of pancreatic duct and CBD with GB wall thickening
and labs notable for elevated bilirubin and elevated lipase. He
was given 3L NS, morphine, and pip-tazo. He was transferred to
___ ED with plan for likely ERCP.
Of note patient reports multiple episodes of similar abdominal
pain in the past that have typically resolved spontaneously
within 3 days. Unclear whether these are precipitated by eating.
He has never sought medical care for these episodes.
In the ED at ___, initial vitals: 100.4 110 68/45 20 94%RA.
Patient reports he was asymptomatic at that time. Labs were
notable for: transaminitis to 100s with elevated alk phos and
tbili 3.8. Na 132, Cr 1.8. Lactate 1.4. Lipase 294. He was given
2L NS and started on levophed gtt. ACS were consulted and agreed
with cholecystectomy during this hospitalization. ERCP were
consulted.
On arrival to the MICU, patient is lying still but reports
feeling well. His abdominal pain has resolved. He has no
complaints.
Past Medical History:
asthma
type 2 diabetes
cardiomyopathy (nonischemic per patient) with EF 35-40%
OSA on home CPAP
Social History:
___
Family History:
History of similar nonischemic cardiomyopathy in mother
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 98.2 105 106/49 21 97% RA
HEENT: PERRL, dry MM
CARDIAC: Tachycardic, regular, no appreciable m/r/g
LUNG: CTAB, no w/r/r
ABDOMEN: Soft, very mild RUQ tenderness without
rebound/guarding, normoactive bowel sounds
EXTREMITIES: WWP, trace edema
NEURO: AOx3 moving all extrems equally
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 99.1,93, 106/66, 18, 97% RA
HEENT: EOMI PERRLA
CARDIAC: S1S2 normal, RRR, no m/r/g
LUNG: CTAB, no w/r/r
ABDOMEN: Soft, normoactive bowel sounds, nondistended, mild
tenderness to palpation in RUQ
EXTREMITIES: WWP, peripheral pulses present
NEURO: AOx3 moving all extremities equally
Pertinent Results:
ADMISSION LABS
==============
___ 11:45PM BLOOD WBC-7.4 RBC-4.55* Hgb-13.5* Hct-40.3
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.0 RDWSD-45.2 Plt ___
___ 11:45PM BLOOD Neuts-94.5* Lymphs-2.4* Monos-1.5*
Eos-0.9* Baso-0.3 Im ___ AbsNeut-6.97* AbsLymp-0.18*
AbsMono-0.11* AbsEos-0.07 AbsBaso-0.02
___ 11:45PM BLOOD ___ PTT-25.4 ___
___ 11:45PM BLOOD Plt ___
___ 11:45PM BLOOD Glucose-202* UreaN-31* Creat-1.8* Na-132*
K-4.0 Cl-97 HCO3-19* AnGap-20
___ 11:45PM BLOOD ALT-151* AST-177* AlkPhos-260*
TotBili-3.8*
___ 11:45PM BLOOD Lipase-294*
___ 11:45PM BLOOD Albumin-3.6 Calcium-8.4 Phos-2.1* Mg-1.8
___ 05:19AM BLOOD ___ pO2-43* pCO2-35 pH-7.30*
calTCO2-18* Base XS--7 Intubat-NOT INTUBA
IMAGES
======
___ ERCP:
The common bile duct, common hepatic duct, right and left
hepatic ducts, and biliary radicles were filled with contrast
and well visualized. There was evidence of a distal CBD filling
defect consistent with a possible CBD stone. Procedures: A ___ Fr
x 9 cm biliary stent was placed successfully.
Impression:
There was evidence of a small amount of pus at the major
papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification. The procedure was not difficult.
The common bile duct, common hepatic duct, right and left
hepatic ducts, and biliary radicles were filled with contrast
and well visualized.
There was evidence of a distal CBD filling defect consistent
with a possible CBD stone.
Given this patient's clinical status, and temporary oxygen
desaturation, a sphincterotomy was not performed
A ___ Fr x 9 cm biliary stent was placed successfully.
___ ERCP:
Limited exam of the esophagus was normal
Limited exam of the stomach was normal
Limited exam of the duodenum was normal
The scout film revealed a plastic stent in the RUQ.
A stent was emerging from the major papilla.
A small needle knife sphincterotomy was successfully performed
over the stent.
The stent was successfully with a snare.
The CBD was cannulated with the Hydratome sphincterotome
preloaded with a 0.035in guidewire.
The guidewire was advanced into the intrahepatic biliary tree.
Contrast injection revealed a mildly dilated CBD to
approximately 10 mm in diameter and normal intrahepatic biliary
tree.
No discrete filling defects were noted.
The biliary sphincterotomy was successfully completed at the12
o'clock position.
Mild oozing of blood was noted at the apex of the
sphincterotomy site.
The CBD was swept several times with successful removal of
small amounts of sludge material.
No stones were seen.
Because of the ongoing bleeding at the sphincterotomy site a
10mm X 60mm Wallflex fully covered metal stent ___ REF
___ was successfully placed across the ampulla with
excellent hemostasis.
No bleeding was noted at the end of the procedure.
There was excellent spontaneous drainage of bile and contrast
material at the end of the procedure.
The PD was not injected or cannulated.
TEE (___): The left atrium and right atrium are normal in
cavity size. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is mild to moderate global
left ventricular hypokinesis (biplane LVEF = 37%). Doppler
parameters are indeterminate for left ventricular diastolic
function. 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. There is no aortic valve stenosis. The
mitral valve leaflets are structurally normal. Mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. IMPRESSION: Dilated left ventricle with global LV
systolic dysfunction. Mild to moderate mitral regurgitation. No
vegetations seen.
MICRO
=====
___ Blood Culture: ___ bottles
1. RAOULTELLA PLANTICOLA
___ RX
--------- ---
CEFTRIAXONE <=1 S
AMOXACILLIN/CLAVULANATE <=2 S
AMPICILLIN >=32 R
AMPICILLIN/SULBACTAM 4 S
CEFAZOLIN <=4 S
CEFEPIME <=1 S
CEFTAZIDIME <=1 S
CIPROFLOXACIN <=0.25 S
GENTAMICIN <=1 S
IMIPENEM 0.5 S
ERTAPENEM <=0.5 S
LEVOFLOXACIN <=0.12 S
TRIMETHOPRIM SULFAMETHOXAZOLE <=20 S
PIPERACILLIN/TAZOBACTAM <=4 S
TOBRAMYCIN <=1 S
___ Urine Culture: negative
___ Blood Cx: negative
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-12.8*# RBC-4.62 Hgb-14.0 Hct-42.2
MCV-91 MCH-30.3 MCHC-33.2 RDW-15.3 RDWSD-50.0* Plt ___
___ 06:56AM BLOOD WBC-16.5* RBC-4.28* Hgb-12.7* Hct-38.5*
MCV-90 MCH-29.7 MCHC-33.0 RDW-14.7 RDWSD-48.3* Plt ___
___ 06:48AM BLOOD WBC-16.8* RBC-3.99* Hgb-12.0* Hct-35.9*
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.7 RDWSD-48.8* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:56AM BLOOD Plt ___
___ 06:48AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-156* UreaN-9 Creat-1.2 Na-133
K-4.5 Cl-94* HCO3-27 AnGap-17
___ 06:56AM BLOOD Glucose-190* UreaN-10 Creat-1.2 Na-131*
K-4.3 Cl-94* HCO3-25 AnGap-16
___ 06:48AM BLOOD Glucose-200* UreaN-10 Creat-1.1 Na-130*
K-4.1 Cl-91* HCO3-27 AnGap-16
___ 06:40AM BLOOD ALT-120* AST-48* AlkPhos-236* TotBili-1.0
___ 06:56AM BLOOD ALT-77* AST-27 AlkPhos-193* TotBili-0.9
___ 06:48AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.9
___ 06:56AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8
___ 06:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ yo man with h/o cardiomyopathy (EF 35-40%)
who presented with acute cholangitis and septic shock,
successfully undergoing ERCP with distal stent placement, called
out to medical floor for continuing care and cholecystectomy.
#Acute cholangitis/Septic shock: Patient presented with acute
cholangitis. Cholelithiasis was not clearly visualized on
imaging however demonstrated symptoms consistent wtih
symptomatic cholelithiasis including precipitating this episode.
Cholangitis c/b septic shock requiring levophed. S/p ERCP on
___ with distal stent placement. Given a rise in AST, ALT,
alkaline phosphatase with steady bilirubin, white blood cell
count a repeat ERCP was performed on ___. At that time, prior
stent was removed, a sphincterotomy was performed and stent was
placed across the ampulla to achieve hemostasis. Surgical team
had been following for cholecystectomy, which was performed on
___. Per outside records grew ___ bottles of GNR's in blood
cultures, speciated as pan-sensitive raoultella planticola. As
such, patient underwent full abx course on Zosyn to treat his
bacteremia with likely source from cholangitis.
#Anion gap metabolic acidosis: Pt presented with AG metabolic
acidosis with AG of 17, bicarb of 17, and delta-delta of 2
consistent with concurrent anion gap and non-anion gap acidosis.
In absence of significant lactate elevation or ketones (only
minimally elevated in urine), most likely due to acute kidney
injury and decreased clearance of unmeasured anions.
#Acute kidney injury: Cr 1.8 from unknown baseline ___ presumed
___ in setting of septic shock. This resolved with fluid
resuscitation and treatment of infection as above.
#Cardiomyopathy: History of cardiomyopathy of unclear etiology,
EF 35-40% per pt report. Pt remained euvolemic on exam and
tolerated large volume fluid resuscitation without developing
dyspnea ___ edema. Home BB and ACEI were held initially given
active sepsis/shock. Home statin held iso LFT abnormalities.
Home ASA was held ___ as well. Prior to discharge,
these medications were re-started on transfer out to the ICU. A
transthoracic echo showed LVEF 35-40% with mild global systolic
dysfunction. Cardiology clearance was obtained prior to
surgery. On discharge his cardiac function was at baseline and
his home medications were restarted.
#DM2: Home metformin was held while inpatient and patient was
managed on sliding scale insulin. Restarted as outpatient.
#OSA: CPAP continued while inpatient.
TRANSITIONAL ISSUES
[] Repeat ERCP in 4 weeks for stent pull
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 6.25 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 750 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN rash at beltline
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q4H:PRN
Disp #*20 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Carvedilol 6.25 mg PO BID
9. Lisinopril 40 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 750 mg PO BID
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholangitis complicated by septic shock
Cholelithiasis
Bacteremia - blood cultures growing RAOULTELLA PLANTICOLA
Acute kidney injury (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
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:
___
|
10525806-DS-3 | 10,525,806 | 29,043,908 | DS | 3 | 2111-07-06 00:00:00 | 2111-07-06 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with CAD, HTN, HLD, stage IV-V
CKD (not on dialysis), anemia, DM2 controlled with weight loss,
and gastric bypass who presents with pneumonia.
Patient presented to ___ for 2 days of generalized
weakness, dizziness, chills, cough, fevers and dyspnea. He has
also noted worsening ___ swelling. At ___ he was found to
have a CXR with infiltrates and elevated BUN/Cr, so he was
transferred to ___ for consideration of initiation of
dialysis. He was given azithromycin & ceftriaxone prior to
departing ___.
Of note, patient was hospitalized about 3 months ago with
pneumonia, course complicated by renal failure, heart failure.
He reports that the heart failure essentially resolved. He was
noted 1.5 wks ago to have GFR 16 on routine labs. His
nephrologist had told him to stop exercising with weights and
this improved. Otherwise he was in usual state of health up
until the past 2 days. Denies any recent fevers, chills,
dysuria, nausea/vomiting/diarrhea, chest pain, palpitations.
In the ED at ___, initial vitals: T 98, HR 83, BP 124/68, R
20, SpO2 91% on 6L.
- Labs were notable for WBC 10.6, Hgb 6.8, bicarbonate 15,
BUN/Cr 105/5.2, negative influenza PCR
- CXR at ___ showed extensive consolidation in the right
lower lobe and right middle lobe.
- Ceftriaxone and azithromycin was given at the OSH
- Renal was consulted. They recommended checking urine studies,
renal ultrasound, diuresis with 80 mg IV furosemide (though
consideration of dose escalation or addition of
metolazone/chlorothiazide for poor output), antibiotics, though
no indication for urgent RRT
- Given his hypoxia on 6L NC, he was switched to NRB and SpO2
rose to 100%
On arrival to the MICU, patient is feeling improved. Breathing
comfortably on NRB. He is very hungry. No other complaints.
Past Medical History:
- Coronary artery disease, MI ___
- Chronic kidney disease, stage IV-V, not on RRT
- ___
- ___
- Chronic anemia
- Diabetes mellitus, weight loss controlled
- Obesity
- History of gastric bypass surgery ___
Social History:
___
Family History:
Mother with dementia, father died from complications related to
obesity.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 88 123/65 80 23 93% NRB
I/Os: ~1500 cc UOP since Lasix bolus
GENERAL: Pale man, slightly short of breath but speaking in full
sentences on NRB
HEENT: Sclerae anicteric, MMM
NECK: supple, JVP to earlobe 45 deg
LUNGS: Crackles ___ way up posterior lung fields, good air
movement throughout, no wheezes/rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, nontender, nondistended, normoactive bowel sounds, no
HSM
EXT: WWP, 2+ pitting edmea in LEs extending to below knee b/l.
Fingernails thin and ridged.
SKIN: No rashes noted.
NEURO: AOx3, moving all extremities equally
DISCHARGE PHYSICAL EXAM:
97.6 126/66 56 18 100%RA weight 98.9kg
NAD, pleasant
RRR
JVP <8cm
CTAB
sntnd
wwp, neg edema
A&O grossly, MAEE
Pertinent Results:
ADMISSION LABS:
___ 06:30PM BLOOD WBC-10.6* RBC-2.20* Hgb-6.8* Hct-20.6*
MCV-94 MCH-30.9 MCHC-33.0 RDW-14.6 RDWSD-49.4* Plt ___
___ 06:30PM BLOOD Neuts-90.3* Lymphs-5.5* Monos-3.4*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.60* AbsLymp-0.58*
AbsMono-0.36 AbsEos-0.01* AbsBaso-0.02
___ 06:30PM BLOOD Glucose-157* UreaN-105* Creat-5.2* Na-135
K-4.6 Cl-100 HCO3-15* AnGap-25*
___ 06:30PM BLOOD Calcium-7.4* Phos-5.9* Mg-1.9
___ 09:00PM BLOOD ___ pO2-69* pCO2-28* pH-7.38
calTCO2-17* Base XS--6 Intubat-NOT INTUBA Comment-O2 DELIVER
___ 04:30PM BLOOD Lactate-1.6
PERTINENT LABS:
as above
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-7.4 RBC-2.49* Hgb-7.6* Hct-23.4*
MCV-94 MCH-30.5 MCHC-32.5 RDW-15.9* RDWSD-53.5* Plt ___
___ 06:45AM BLOOD Glucose-125* UreaN-94* Creat-4.4* Na-139
K-4.2 Cl-104 HCO3-23 AnGap-16
___ 06:55AM BLOOD LD(LDH)-244 CK(CPK)-189
___ 06:45AM BLOOD Calcium-8.3* Phos-5.7* Mg-2.0
___ 06:55AM BLOOD calTIBC-225* Ferritn-394 TRF-173*
___ 06:50AM BLOOD Triglyc-89 HDL-53 CHOL/HD-2.8 LDLcalc-78
___ 06:55AM BLOOD TSH-1.9
STUDIES:
___ PORTAL CXR
Large scale pneumonia in the lower right lung and a smaller
region in the left lower lobe, not changed appreciably.
Distribution suggests massive
aspiration. Heart size top- normal. Pulmonary vasculature is
mildly engorged but there is no edema. Pleural effusions are
presumed, but not large. No pneumothorax.
___ RENAL ULTRASOUND
Small nonobstructing stone in the midportion of the right
kidney. Normal
cortical echogenicity and corticomedullary differentiation seen
bilaterally. No evidence of hydronephrosis.. Trace free fluid in
the abdomen.
MICROBIOLOGY:
___ Blood culture
___ Urine culture
Brief Hospital Course:
This is a ___ with morbid obesity s/p bypass, DM, HTN, HL,
likely CAD, and CKD with relatively recent progression with some
volume overload symptoms, relatively recently started on lasix,
who presented with worsening dyspnea and was admitted to ICU for
hypoxemic respiratory failure, thought to be from pneumonia and
CHF. He was also noted to have acute on chronic renal failure.
He was treated with ceftriaxone and azithromycin for pneumonia,
which was transitioned to levofloxacin on discharge. He was
diuresed with furosemide 80mg IV daily with TBB -2L daily for
several days, and this was subsequently transitioned to
torsemide 80mg PO qd. It was thought that he was at dry weight
at 98.9kg at time of DC, so torsemide dose was continued to
maintain euvolemia.
His medications were adjusted to optimize his regimen for his
other medical problems.
See below for additional detail.
# Acute respiratory failure with hypoxia
# Community acquired pneumonia
# Acute on chronic heart failure, now confirmed systolic with EF
of 40%: He improved with both antibiotics and diuresis. TTE done
___ showed evidence of prior MI as well as systolic dysfunction
with EF of 40%. Received antibiotics to complete 7 day course
(last day ___, torsemide dose was eventually settled at 80mg
po qd. Continued his Toprol 25mg qd. Can consider outpatient HIV
testing as he has had a few bouts of pneumonia. He will need
very close monitoring of his laboratories and weights and his
above regimen will likely need further adjustment as outpatient.
He may benefit from another trial of ACE inhibitor (though prior
attempts limited by hyperkalemia, and given acute renal failure
this should only be considered after reaching a steady state
renal function). Can consider referral to Cardiology as
outpatient.
# Metabolic acidosis
# Hyperphosphatemia
# Acute on chronic renal failure: He has CKD with typical
baseline in the 2 range, does have occasional bouts ___ in
setting of insults, which have resolved with return to baseline.
Had noted recent increase to 3.9 and some associated volume
overload, so started on Lasix prior to admission. Underlying
diagnosis is uncertain, never had biopsy, thought DM + HTN +
oxalate + prior insults of likely ATN. Pt will have outpatient
nephrology followup as below. Patient preferred to transition
his care to ___. We started sodium bicarbonate, continued
calcium acetate and vitamin D.
# Chronic anemia: Labs consistent with anemia of chronic
disease/renal disease. Had been on epogen per outpatient
nephrologist. Was taking iron supplements at home but his iron
studies showed iron sufficiency so these were discontinued. Did
receive 1 U pRBC on admission in ED. Renal recommended epo. Hct
stable to improving since starting Epo. Continue Epo 10,000U sc
weekly
# Confirmed CAD
# HL
# HTN: Was on simvastatin/ amlodipine/labetalol at home, but
with volume management he required no BP meds here. He reported
MI in past at "bottom of my heart." This is confirmed by TTE.
Changed simva to atorva for LDL of 78 slightly above goal.
Started ASA. Started toprol. Continued low dose ASA. Recommend
following BPs and adjust regimen as needed
# Sore throat: No signs of thrush. Improved with Cepastat PRN.
# DM: Resolved after gastric bypass. Fingersticks were all in a
reasonable range.
# Social issues: He says his job is very bad at letting him make
it to appointments and he has had difficulty with following up
closely with his former outpatient nephrologist Dr ___. He was
seen by SW. His PCP is in ___ system and he thought it would
make things easier for continuity if he were to begin a course
of followup for his kidney disease at ___.
# Prior gastric bypass: Stable. Continued low dose PPI given
ASA, pill burden. Continued vitamin supplements
# Code status: Full code here.
>30 minutes spent coordinating discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO BID
2. Vitamin D ___ UNIT PO Frequency is Unknown
3. Ferrous Sulfate 325 mg PO BID
4. Allopurinol ___ mg PO DAILY
5. Labetalol 400 mg PO BID
6. Doxazosin 4 mg PO BID
7. Cyanocobalamin 1000 mcg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Epoetin Alfa 4000 UNIT SC QMOWEFR
7. Omeprazole 20 mg PO DAILY
8. Sodium Bicarbonate 650 mg PO BID
9. Vitamin D ___ UNIT PO 1X/WEEK (___)
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Torsemide 80 mg PO DAILY
12. Levofloxacin 500 mg PO Q48H Duration: 2 Doses
Please take this several hours separated from your calcium
acetate.
13. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxemic respiratory failure
Community acquired pneumonia
Acute systolic congestive heart failure
Acute renal failure
Chronic kidney disease
Anemia likely secondary to CKD
Coronary artery disease
Diabetes mellitus
Hyperlipidemia
Prior gastric bypass
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 respiratory failure with
low oxygen levels. You were also noted to have worsening renal
function. It was thought that you likely had pneumonia with
acute renal failure and also some fluid accumulation from a
combination of poor heart squeeze as well as a possible
progression of your chronic kidney disease. You were initially
admitted to the medical ICU. You were given antibiotics to treat
the infection and Lasix to help remove some of the extra fluid.
You were found to be anemic and transfused with red blood cells.
You have a tiny kidney stone that hopefully will not be of any
significance. You did well and then came out to the floor, where
antibiotics and diuretics were continued. You were started on
some other medications for your medical problems.
Followup Instructions:
___
|
10526072-DS-19 | 10,526,072 | 26,461,364 | DS | 19 | 2146-12-06 00:00:00 | 2146-12-06 22:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female with anxiety and headaches who
presents with her second lifetime event concerning for seizure.
She was in her USOH until 7:40pm at ___ at which time
she noticed poor appetite, anxious feelings, and "heavy chest."
These feelings were similar to anxiety she had been experiencing
recently. 10 minutes later, her boyfriend witnessed head version
to left, eyes rolling up, loss of consciousness, all four limbs
stiffening with synchronous low amplitude shaking, gnashing of
teeth, and tongue bite. The episode lasted ___ minutes.
Afterward, she was disoriented for 5 minutes. The patient
recalls
the anxiety as above but does not recall the event and the next
thing she recalls is getting loaded into the ambulance (20
minutes after event). At the time of interview, she feels back
at
baseline except for nausea. No associated gastric ___, eye deviation, incontinence.
Of note, she had an event concerning for seizure ___ years ago
during intercourse. That event was also characterized by LOC,
whole body shaking, and tongue bite for ___ minutes. She
presented to ___, where a head CT was reportedly
normal. Her PCP recommended that she see a neurologist and
gastroenterologist, but she did not follow-up. She saw her PCP
again recently, and she was scheduled for a neurology
appointment
in ___ (in ___, patient does not recall name).
Of note, she recently took ___ a pill of Xanax (not prescribed)
3
days ago. She has never done this before. She sleeps well
without
interruptions between 10pm-6am. No recent illnesses. No
antecedent trauma. No problem's during mother's pregnancy and no
perinatal problems. Met all milestones. No childhood or febrile
seizures. No history of meningitis. No prior EEGs or seizure
meds.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus, and hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, and 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:
Headaches
Anxiety
Social History:
___
Family History:
___, anxiety. GM--glaucoma. Father--DM.
Cousin--leukemia. No history of seizures.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.5 HR: 94 R: 17 BP: 109/55 SaO2: 100RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was 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 or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
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 and tone. No pronation, no drift. No
orbiting
with arm roll. No adventitious movements, such as tremor, noted.
No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation,
proprioception throughout.
-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: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Discharge Physical Exam:
General: Sitting up in bed, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx, +nose ring
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
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 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. No adventitious movements, such as tremor, noted.
No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch
-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.
-Gait: Good initiation. Narrow-based.
Pertinent Results:
___ 05:50AM BLOOD WBC-7.2 RBC-3.79* Hgb-11.3 Hct-32.2*
MCV-85 MCH-29.8 MCHC-35.1 RDW-12.8 RDWSD-39.4 Plt ___
___ 10:05PM BLOOD Neuts-72.9* Lymphs-12.6* Monos-11.0
Eos-2.3 Baso-0.7 Im ___ AbsNeut-6.39* AbsLymp-1.10*
AbsMono-0.96* AbsEos-0.20 AbsBaso-0.06
___ 05:50AM BLOOD Glucose-76 UreaN-6 Creat-0.7 Na-140 K-3.8
Cl-102 HCO3-27 AnGap-15
___ 10:05PM BLOOD ALT-9 AST-14 AlkPhos-45 TotBili-0.3
___ 05:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0
___ 10:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:13PM BLOOD Lactate-1.6
CT HEAD ___:
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or
mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of acute fracture. The visualized portion
of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute infarction or intracranial hemorrhage.
BRAIN MRI ___:
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. The ventricles and sulci are normal in caliber
and
configuration. There is no abnormal enhancement after contrast
administration.
Bilateral hippocampal formations and mammillary bodies are
preserved in signal
and configuration. There is no disproportionate medial temporal
atrophy. There
is no focal lobar encephalomalacia. There are no focal cortical
dysplasias or
gray matter heterotopia noted.
IMPRESSION:
1. No evidence of gray matter heterotopia, focal cortical
dysplasia or mesial
temporal sclerosis.
2. No intracranial mass, acute hemorrhage or infarct.
Brief Hospital Course:
Ms. ___ is a ___ right-handed female with h/o anxiety and
headaches who presented with her second lifetime event
concerning for seizure. After eating dinner the night of
presentation she had an aura of anxious feelings, and "heavy
chest" prior to having sudden loss of awareness, left head
version, eyes rolling back, followed by all extremities
stiffening and generalized shaking of all extremities and tongue
bite. The episode lasted ___ minutes and she was sleepy
afterward. While in the ED she had a second generalized tonic
clonic seizure. She received Ativan 2mg IV and had no further
seizures.
She had one prior similar event during intercourse ___ years ago.
She had a normal CT at that time and Neurology follow-up was
recommended but not done. Notably recently she had taken a
non-prescribed Xanax and daily marijuana, which may have been a
seizure trigger.
While admitted she had a brain MRI with no clear seizure focus
and otherwise normal. She was started on Keppra 750mg BID. Her
labs (CBC, chem, LFTs) were normal and urine tox was negative.
She will have Neurology follow-up and should follow-up with her
PCP as well. She should have an outpatient EEG. We discussed
seizure precautions including no driving until at least 6 months
seizure-free.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. LevETIRAcetam 750 mg PO BID
2. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with two generalized tonic clonic seizures.
You had an MRI that was normal. You were started on Keppra, a
medication to prevent further seizures. You will have close
outpatient follow-up to further evaluate the reason for these
seizures. You should avoid sleep deprivation, alcohol or other
drugs as these can lower the seizure threshold.
SEIZURE PLAN:
If ___ has a seizure, carefully lower her to the ground or
other safe area, gently turn her head to the side, and do not
place any objects in her mouth while having a seizure. Seek
urgent medical care. If she has a prolonged seizure, any color
changes (ex. turns blue) or has difficulty breathing, call an
ambulance (___) for immediate medical assistance and
evaluation.
Best,
Your ___ Neurology Team
Followup Instructions:
___
|
10526134-DS-20 | 10,526,134 | 24,057,129 | DS | 20 | 2170-01-09 00:00:00 | 2170-01-10 11:11:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Plavix / scallops / latex
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/ recently discovered CAD w/ STEMI event 2 weeks ago s/p
PCI p/w neck pain, ___ arm pain. Patient recently admitted
(___) with substernal chest pain found to be a STEMI.
She was catheterized on ___ and found to have single vessel
(LAD/D1) stenosis s/p DES. Pt states that she occasionally has
some chest tightness ever since her MI. This morning she
developed pain down ___ arms and up through neck that gradually
worsened. No back pain. No n/v.
In the ___, vitals were: 97.9 80 126/80 12 100% RA
EKG interpreted by Cards fellow: "slightly worsening T wave
inversions in V2-6 w/o STE." Trops negative. CBC/CMP
unremarkable. Lactate 1.6. UA unremarkable. CXR revealed faint
linear density at R apex equivocal for pneumothorax in clinical
context, but otherwise negative for acute cardiopulmonary
process.
___ 275-33-40 other record)
On arrival to the floor, pt reports having slight throat
discomfort but is without CP/SOB/N/V/F/C.
Past Medical History:
Appendectomy (___)
Fibroid removal (___)
Social History:
___
Family History:
No family history of cardiac disease
Physical Exam:
ADMISSION
VS: 98.0 117/62 71 17 100%RA
General: ___ woman laying in hospital bed in NAD
HEENT: NCAT EOMI MMM
Neck: supple, no JVD
CV: regular rhythm S1/S2, no m/r/g
Lungs: CTAB
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: AAOx3 moving all extremities grossly
DISCHARGE
VS: 98.5 91-128/52-65 64-734 16 100%RA
wt 82.4 kg ___ 82.2 kg)
General: ___ woman laying in hospital bed in NAD
HEENT: NCAT EOMI MMM
Neck: supple, no JVD
CV: regular rhythm S1/S2, no m/r/g. Mild palpable tenderness
along LL chest wall.
Lungs: CTAB
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: AAOx3 moving all extremities grossly
Pertinent Results:
ADMISSION
___ 12:00PM BLOOD WBC-9.8 RBC-4.79 Hgb-13.8 Hct-43.4 MCV-91
MCH-28.8 MCHC-31.7 RDW-13.4 Plt ___
___ 12:00PM BLOOD Neuts-74.8* Lymphs-14.7* Monos-8.2
Eos-1.8 Baso-0.6
___ 12:00PM BLOOD ___ PTT-28.3 ___
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-86 UreaN-18 Creat-0.9 Na-139
K-5.1 Cl-102 HCO3-27 AnGap-15
___ 12:00PM BLOOD cTropnT-<0.01
___ 06:48PM BLOOD cTropnT-<0.01
___ 08:47PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Calcium-9.5 Phos-3.3 Mg-2.4
DISCHARGE
___ 07:30AM BLOOD WBC-6.6 RBC-4.29 Hgb-12.8 Hct-39.9 MCV-93
MCH-29.9 MCHC-32.1 RDW-13.5 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-140
K-4.4 Cl-104 HCO3-22 AnGap-18
___ 07:30AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2
STUDIES
___ CXR IMPRESSION:
1. Faint linear density at right lung apex is equivocal for
pneumothorax. If this is of clinical concern, then further
assessment with an AP view obtained at end-expiration of the
respiratory cycle could help for further assessment.
2. Otherwise, no acute pulmonary process is identified. No focal
infiltrate detected to suggest pneumonia.
___ ECHO
Report pending
Brief Hospital Course:
___ w/ recently discovered CAD w/ STEMI event 2 weeks ago s/p
PCI p/w neck pain, ___ arm pain found to have accentuated T-wave
inversions on EKG with negative troponin x3. Outside records
from cardiologist showed recent negative stress ECHO 2 days PTA.
Increased amlodipine to 10 mg PO daily and started on Imdur 30
mg PO daily, however, patient started having headaches and Imdur
discontinued on day of dischage. Underwent ECHO and was
dischaged to f/u w OSH cardiologist in 2 weeks. Pt advised to
return to ___ should sustained CP/SOB sx refractory to
nitroglycerine re-arise.
#Chest pain:
Given acute worsening of sx, pt admitted with concern for ACS.
Accenuated anterolateral T wave inversions from last tracing in
our system, troponins negative x3. Patient sx decreased
siginficantly by the time of admission, light chest tightness
disappated day prior to discharge. Given pattern of sx, recent
cath showing disproportionate EKG changes in setting of
minimally discovered CAD at distal D1, as well as negative
stress ECHO ___ at her outpatient cardiologist, suspicion for
coronary vasospasm. Increased her amlodipine from 5 to 10 mg PO
daily. She was also started on Imdur 30 mg PO daily, however, pt
was unable to tolerate the medication with persistent headache
starting the evening of admission through the next morning.
Repeat ECHO obtained, report pending at time of discharge and
will be faxed to outpatient cardiologist. Discharged on home
medication regimen with increase in amlodpipine to follow-up
with outpatient cardiologist. Pt advise to call doctor or return
to ___ should concerning symptoms re-arise, particularly if chest
pain redevelops and is refractory to nitroglycerin.
- Increased to Amlodipine 10 mg PO daily
- Continued ASA 81mg PO daily
- Continued Atorvastatin 80mg PO daily
- Continued Losartan 25 mg PO daily
- Continued metoprolol succinate 25mg PO BID
- Continued anticoagulation with ticagrelor
- ECHO report pending.
#CAD
Contined ASA, Atorvastatin, ticagrelor per above
TRANSITIONAL ISSUES
-Pt had ___ HA on imdur 30 mg PO daily, increased amlodipine
dose to help with suspected coronary vasospasm.
-ECHO performed but not read prior to dischage. Will fax or
email results to outpatient cardiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Epinephrine 1:1000 0.3 mg IM DAILY:PRN anaphylaxis
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. TiCAGRELOR 90 mg PO BID
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. Amlodipine 5 mg PO DAILY
9. Levalbuterol Neb 0.63 mg/3 mL inhalation q6:prn dyspnea
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. TiCAGRELOR 90 mg PO BID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Epinephrine 1:1000 0.3 mg IM DAILY:PRN anaphylaxis
8. Levalbuterol Neb 0.63 mg/3 mL inhalation q6:prn dyspnea
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Suspected coronary vasospasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure treatign you at ___
___. You were admitted with concerning for your chest pain.
While admitted, you underwent a number of EKGs and blood tests
that, which combined with your recent negative stress test from
last ___, make us less concerned for emergent heart problems
related to your coronary artery disease. Given the findings of
your recent cardiac catheterization that were disproptionate to
EKG findings, its suspected your chest pain may be related to
abnomal contraction of the vessels that supply your heart. You
were started and increased on medications to help with this
issue, however, one of them caused headaches and it was stopped.
Its important you follow-up with your outpatient cardiologist at
the visit scheduled for your.
Wishing you the best of health,
Your ___ team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10526151-DS-4 | 10,526,151 | 23,552,168 | DS | 4 | 2141-05-26 00:00:00 | 2141-05-26 18:30:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
gabapentin / Lyrica / Codeine / aspirin
Attending: ___
Chief Complaint:
Seizure, motor vehicle collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ RH woman with a remote history of
epilepsy (last seizure ___ years ago?), anxiety, migraines,
substance dependence (opiates and Fiorinal), and a bleeding
ulcer
s/p bowel/gastric resection, who presents with two seizures
today. Per the ED admission note, Mrs. ___ was driving in
___ when she was witnessed to have a seizure. She was a
restrained driver when she struck a tree at approximately 35-40
mph. There was significant damage to the front end with minor
intrusion into the compartment, and the airbags were deployed.
Witnesses reported that she continued to seize after crashing,
and EMS found her to be post-ictal. The patient did not recall
the accident, and there are no witnesses to question. At the
scene, glucose was 190. Ms. ___ reported sternal pain and
bilateral knee pain, worse on the right. She remained
hemodynamically stable and upon arrival to the ED got Morphine
10mg IV for her pain. CT head was negative, but CT chest showed
2 rib fractures and plain films showed a R patella fracture.
Upon arrival to the floor, Ms. ___ was observed to have
another
seizure by her friend that began as stuttering speech and then
bicycling movements of her upper extremities which lasted 1
minute. I am unsure if this is similar to her previous seizures.
She received Ativan 1mg IV and when I went to speak with her,
her
mental status fluctuated between alert and responsive to
confused
(telling me she was ordering me food).
On neuro ROS, the pt endorses "beginning of a migraine" and
complains of some photosensitivity. She denies other changes in
her vision. She states that she has been "getting a cold from my
cat" but denies other signs of illness including fever,
vomiting,
or diarrhea. She endorses pain in her back, neck and kness. She
states she recently stopped Topamax, which she took for
migraines
and started amitriptyline but then cannot tell me additional
history.
Past Medical History:
- Epilepsy (history per patient and her mother): per mother,
patient had first seizure at ___ or ___ which was a "generalized
tonic clonic seizure" that caused her to fall. Mother and
patient
are unsure of how many seizures she has had in total but notes
that she had "big and petit" ones, ones that caused her to "stop
talking sometimes but not fall down." Mother does not recall
seizure frequency. Patient reports she has had abnormal EEGs but
normal brain scans but mother does not remember. Patient reports
having been on Dilantin in past but this was stopped many years
ago.
- Anxiety
- Bipolar disorder
- Atrophic vaginitis
- Cervical radiculopathy
- Chronic migraines managed by ___
- Epilepsy
- GERD
- Narcotic addiction
- Osteopenia
- Gastrectomy
- Peptic ulcer disease s/p gastric resection
- Sciatica
- Sleep apnea
Social History:
___
Family History:
Mother: ___, HTN. Living.
MGM: Rheumatoid Arthritis, CHF. Deceased.
MGF: Deceased.
Father: CVA. Deceased.
PGM: Deceased.
PGF: Deceased.
Physical Exam:
ADMISSION EXAM
Vitals: T= 97.8F, BP=136/72 , HR=113 , RR=20, SaO2= 100%
General: Lying in bed, cervical collar in place, moaning.
Occasionally wakes up and is responsive but frequently closes
eyes.
HEENT: NC/AT
Neck: In collar.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated; pain with movement of
right leg
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Only answers questions
intermittently and fluctuates between being quite confused to
being able to answer questions appropriately. Language
fluctuates
between fluent speech with intact repetition and comprehension
to
mild stuttering speech. Inattentive and unable to name ___
backward. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both
midline and appendicular commands at times but then sometimes
follows no commands. There was no evidence of apraxia or
neglect. Calculations (9quarters = $2.25) intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 4mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI full; question of some down-beating nystagmus
on upgaze. Normal saccades.
V: Facial sensation intact to light touch in all distributions,
and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. Mild R pronator drift. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 5 ___ ___ 5 5 5 5
5
R 5- 5 ___ ___ 5- 5- 5- 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
-Sensory: On brief exam, no deficits to light touch, cold
sensation, or proprioception throughout. No extinction to DSS.
-Coordination: No intention tremor. No dysmetria on FNF though
slow.
DISCHARGE EXAM
VS: AF, HR 90-105; BP 90-116/50-60s; 18, 98% RA
Gen: NAD, lying in bed
HEENT: MMM, anicteric
CV: RRR, nl S1S2, no murmurs
Resp: CTAB; discomfort when sternum is touched.
GI: +BS, soft, NTND
Ext: WWP, pain over right knee; pain in chest with movements of
arms
Neuro
MS: A&Ox3, speech fluent, memory and attention intact
CN: PERRL, EOMI, no nystagmus, face symmetric, tongue and palate
midline,
Motor: Normal bulk and tone; strength ___ in ___ equal
bilaterally
___: Intact to light touch, temperature and propioception
distally
DTRs: 2+ throughout, toes downgoing, no clonus
Gait: Slow but narrow-based
Pertinent Results:
CT ___:
1. No acute cervical spine injury.
2. Significant narrowing of the C5/6 right neural foramen, due
to
uncovertebral spondylosis, with possible exiting C6 neural
impingement.
CT Brain (___): There is no evidence of acute intracranial
hemorrhage, edema, large vessel territorial infarction, or shift
of the midline structures. The ventricles and sulci are normal
in size and configuration. Punctate calcification is noted in
the right basal ganglia (5:14). There is no significant
extracalvarial soft tissue injury and no acute fracture is
identified. The mastoid air cells, middle ear cavities and
visualized paranasal sinuses are
clear.
CT Abdomen (___):
1. Non-displaced fracture of the lateral right sixth rib with
suggestion on a non-displaced fracture of the lateral right
fifth rib.
2. No acute thoracic, abdominal, or pelvic processes otherwise.
3. Evidence of constipation with a large amount of feces
throughout the
colon.
4. Bilateral breast parenchyma appear prominent, correlation
with
mammogram history is recommended.
X-ray Knee (___)
RIGHT KNEE: There is lipohemarthrosis in the right knee with
layering blood and fat. Non-displaced lucencies in the patella
suggests a
comminuted fracture. There is no dislocation. The patella
appears intact. There is significant soft tissue swelling.
LEFT KNEE: There is no evidence of fracture or dislocation.
There is no joint effusion. The soft tissues are unremarkable.
CTA Chest (___):
1. No evidence of pulmonary embolism.
2. Minimally displaced acute fracture of the sternum, newly
appreciable since prior exam.
3. Unchanged nondisplaced right lateral ___ and 6th rib
fractures.
4. Stable old fracture of the manubrium.
CT ___ (___):
1) Nondisplaced comminuted fracture of the patella with a 1 mm
step-off on the medial articular surface.
MRI BRAIN (___): Preliminary Report
1. No mass lesion.
2. Subcortical and periventricular white matter signal
abnormality is
nonspecific, but likely represents the sequela of small vessel
disease. The largest region near the ventricle ___ also be an
area of prior infarct.
EEG (___): This is an abnormal continuous ICU EEG monitoring
study due to abundant, high amplitude generalized spikes,
polyspikes, spike & wave and polyspike and wave discharges, both
isolated and in brief runs at ___ lasting up to 5 seconds.
Fragments of epileptiform discharges are also seen in bilateral
frontal/fronto-central regions independently. These findings are
consistent with a diagnosis of primary generalized epilepsy.
Excessive intermixed theta in waking background suggests mild
encephalopathy. There are no clincal or electrographic seizures
during the study.
EEG (___): This is an abnormal continuous ICU EEG monitoring
study because of both isolated and brief runs of high amplitude
generalized spikes, polyspikes, spike & wave and polyspike and
wave discharges. Also seen are fragments of generalized
discharges in bilateral frontal/fronto-central regions
independently. These findings are consistent with a diagnosis of
primary generalized epilepsy. Excess theta in waking suggest
mild encephalopathy. There are no clinical or electrographic
seizures during the study. Compared to the previous day's study,
the epileptiform discharges are less frequent.
Brief Hospital Course:
#NEURO: Ms. ___ was admitted initially to the surgery service
after an MVC and had a second seizure upon arriving on the floor
described in the HPI. We did recommend that she begin Keppra
500mg BID at that time and obtained an EEG to rule-out
non-convulsive status given her fluctuating mental status. The
EEG showed generalized bursts of sharp waves but no clear
seizures. She was then transferred to the Neurology Service for
further work-up of her seizures. In addition to the Keppra, she
was restarted on Topamax 100mg BID (as per her pharmacy
records). She had no further seizures. By the next day, her
mental status had cleared and she had a normal neurlogic exam.
Her MRI done to look for seizure focus showed only chronic
vascular changes but no mesial temporal sclerosis. She was
discharged home on Keppra 500mg BID and Topamax 100mg BID to
follow-up with Dr. ___.
#PYSCH: By the second day of hospitalization, Ms. ___ mental
status had largely cleared and her neurologic exam was normal.
We had difficulty clarifying the medications she was supposed to
be taking, as the patient did not know them and the information
we found in her OMR notes, from her psychiatrist and her
pharmacy was somewhat contradictory. We did increase her
Seroquel from 50mg BID to 50mg QAM and 200mg QPM and stop the
Prozac as per her psychiatrists recommendations. In addition,
Ms. ___ and ___ psychiatrist did confirm that she had come off
of the Topamax which she was reportedly on for headaches (though
she was on the large dose of 200mg BID) in the last few months
(it was unclear if she weaned or abruptly stopped the drug).
Given that we felt the Topamax ___ have been preventing seizures
in her before, we did restart it at 100mg BID.
#CV: The patient had one episode of tachycardia with normal BPs
(90-100/50-60) after working with ___ and experiencing pain; this
did respond to fluid. EKG at that time was unremarkable and the
patient did not have left sided chest pain, jaw or arm pain, SOB
or dizziness. She did continue to have mildly high HRs (90-100s)
for the remainder of her admission, so in the setting of her
trauma, we got a PE/CT to look for PEs, which was negative. We
ultimately felt this slightly high heart rate was due to
deconditioning and pain.
#ORTHO: The patient was found to have 2 right rib fractures
(non-displaced lateral ___ and ___, a non-displaced right
patellar fracture, and a non-displaced sternal fracture. Surgery
and cardiothoracic surgery evaluated her and CT surgery will
follow her as an outpatient. She was given a knee brace and will
get in-home ___.
#PAIN: Ms. ___ was on IV morphine and then transitioned to PO
oxycodone. She had ___nd ___ pain with
movement, most prominently across the sternum. She felt that
this was a tolerable level for discharge. Ms. ___
psychiatrist, Dr. ___, was quite concerned about Ms. ___
recent history of opiate abuse. We did discharge her with only 1
week of oxycodone, and created a pain-medication contract with
her. She agreed to only speak to her PCP about these medications
if she needed more or needed a longer supply. We set-up an
appointment with her PCP for the day after discharge.
Medications on Admission:
This is presumed list:
1) Buspirone 30mg PO QD
2) Clonidine 0.3mg PO BID
3) Famotidine 20mg PO BID
4) Nortriptyline 50mg QHS
5) Seroquel 5mg QAM and 200mg QPM
6) Sumatriptain 100mg PO PRN Headache
7) Tizanidine 12mg PO BID
Discharge Medications:
1. BusPIRone 30 mg PO DAILY
2. CloniDINE 0.3 mg PO BID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
4. Famotidine 20 mg PO BID
5. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
6. Nortriptyline 50 mg PO HS
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
q4hr Disp #*60 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 gram by
mouth once a day Disp #*600 Gram Refills:*1
9. Quetiapine Fumarate 50 mg PO QAM
10. Quetiapine Fumarate 200 mg PO QHS
11. Sumatriptan Succinate 100 mg PO DAILY:PRN migraine
12. Tizanidine 12 mg PO BID
13. Topiramate (Topamax) 100 mg PO BID
RX *topiramate [Topamax] 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure
motor vehicle collision
Patellar fracture
Rib fractures
Discharge Condition:
Gen: NAD, A&Ox3
HEENT: no injuries, MMM
CV: RRR, nl S1S2, no m/r/g
Resp: CTAB; pain with deep inspiration
GI: +BS, soft, NTND
MS: Awake, alert, with normal speech, memory,
registration/recall, naming and attention.
CN II-XII intact
Motor: Normal tone and full strength in ___, symmetric. There
is pain in right patella.
Discharge Instructions:
Dear Ms. ___,
You were admitted after having a seizure that led to a car
accident and while here you had a second seizure. We did an EEG
while you were here that showed generalized spike waves (meaning
all of the brain had irregular activity at the same time, which
puts you at higher risk for seizures). Based on your
description that you have had a 30 minute period of confusion
before each seizure, we are concerned that you ___ also have
complex partial seizures (meaning seizures that start in one
area of the brain and then generalize to the whole brain).
Because of this, we got an MRI to see if there are any
abnormalities in your brain that are triggers for your seizures,
which showed some chronic changes in your brain but no obvious
cause of your seizures.
In the meantime, we have started you on a medicine called Keppra
that can treat both generalized and complex partial seizures. We
have also restarted your Topamax. Topamax is not just a medicine
for migraine but also an anti-seizure drug, so we think that it
___ have been protecting you against seizures while you were on
it and that suddenly stopping this ___ have contributed to the
seizures you experienced ___. Please do not stop the
Topamax or Keppra without speaking first with your doctor.
Please follow-up with Dr. ___ will make adjustments
to these medications.
Since you have had seizures, you must take precautions to
protect yourself and others. You are not allowed to drive for
6months after your most recent seizure. In addition, please be
careful when in situations that would be dangerous if you were
to suddenly lose consciousness, such as in high places, around
hot surfaces or open flames, and in bodies of water (including
pools, lakes, the ocean and even the bathtub). Please know that
you are at higher risk for seizures when you are ill, when you
take certain medications and when using recreational drugs.
In addition, you have sustained two rib fractures, a sternal
fracture, and a patellar fracture. Surgery and cardiothoracic
surgery has evaluated you and recommended supportive care and
physical therapy but you do not require any surgical
interventions. You will follow-up with cardiothoracic surgery as
an outpatient. We are discharging you with oxycodone to treat
your pain as per the pain contract. Please follow-up with your
primary care doctor if you feel you need additional medication
or a longer prescription.
Lastly, you had a mildly elevated heart rate while you were here
(90-100s). This is most likely due to pain, but we also got a CT
of your lungs to look for blood clots (called pulmonary emboli),
and we did not see any. We think the high heart rate is likely
from pain.
Please follow-up with your PCP, neurologist and cardiothoracic
surgeon as below and schedule follow-up with your psychiatrist.
Thank you.
Followup Instructions:
___
|
10527032-DS-2 | 10,527,032 | 27,909,870 | DS | 2 | 2188-03-18 00:00:00 | 2188-03-19 07:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Hypoxia, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking female with hx dementia (normally oriented
to person only), hypothyroidism, CAD, HTN, and GERD presenting
with hypoxia and hypotension.
She was apparently brought in earlier today by chair-car to get
a
CT scan to evaluate her chronic hypoxia which shows a known lung
mass but otherwise no pneumonia or acute process.
She reportedly was down to the ___ on 2 L this evening and had a
junky cough. She is also reportedly warm to touch, she has been
increasingly somnolent over the last few days so she was brought
back in for hospital admission.
In the ED the patient was initially hypotensive into the ___ but
was fluid responsive and BP improved to the 110s.
In the ED, initial VS were: T98.1, HR 101, BP 93/53, RR18, SaO2
97% 3L NC
Exam notable for: Grimacing and withdrawing from painful
stimuli,
wet cough
ECG: NSR, TWI in II and AVR, RBBB
Labs showed:
12.3>10.3/32.8<234
143|98|36
=========<136
4.3|34|0.7
Imaging showed:
CXR
1. Dense opacification the left lung base better evaluated on
same day chest CT may represent a mass.
2. Low lung volumes. No frank pulmonary edema.
3. Large hiatal hernia.
Chest CT
1. Dense consolidation containing central calcification in the
left
cardiophrenic angle, raising suspicion for underlying neoplasm.
Appearance is atypical for an infectious or inflammatory
process.
A PET-CT may be considered to assess for metabolic activity.
2. Very large hiatal hernia, with the entire stomach and likely
the pancreas flipped into the chest. This results in mass effect
on the left mainstem bronchus, although without appreciable
luminal narrowing.
3. Age indeterminate compression fractures of T5 and T7.
CT Head
Mildly motion limited exam. Within this limitation, no acute
intracranial
process.
Pelvic xray
Chronic appearing right femoral neck fracture is noted. Screw
through the right femoral neck as well as proximal
intramedullary
right femoral rod as well as plate and screw hardware along the
lateral distal right femur is noted. No evidence of hardware
complication. No evidence of acute fracture.
Extensive vascular calcifications are noted. Degenerative
changes
of
bilateral hip joints are noted
No acute fracture.
Patient received:
___ 01:58 IV Piperacillin-Tazobactam
___ 02:00 IVF NS 500ml
___ 03:07 IV Vancomycin
___ 03:10 IVF NS 500 mL ___
Transfer VS were: T98.6 HR91 BP111/58 RR20 SaO296% 4L NC
On arrival to the floor, patient reports productive cough.
Denies
any CP, SOB, nausea, vomiting, diarrhea, fevers, or chills.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
dementia
asthma
CAD
HTN
GERD
depression
constipation
left fibular fracture
Social History:
___
___ History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: ___ 0628 Temp: 98.5 PO BP: 107/60 R Lying HR: 92 RR: 20
O2 sat: 94% O2 delivery: 3l
GENERAL: NAD
HEENT: AT/NC, EOMI, lens in place with sluggish pupillary
response to light, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: decreased breath sounds, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: unable to assess orientation or perform neurologi exam
(noncompliant with commands)
SKIN: warm and well perfused, purpura in lower extremities
bilaterally
DISCHARGE PHYSICAL EXAM
===========================
VITALS: ___ 0732 Temp: 98.2 PO BP: 121/70 HR: 103 RR: 18 O2
sat: 100% O2 delivery: 2l
GENERAL: no acute distress, minimally conversant but awakens to
voice
HEENT: AT/NC, EOMI, sluggish pupillary response to light,
anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS/CHEST: prominent chest wall, decreased breath sounds, no
wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: knees with bilateral effusions, hands with
bilaterally edema, no cyanosis, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx1 (person), unable to perform neurologic exam
(noncompliant with commands)
SKIN: warm and well perfused, purpura in upper and lower
extremities bilaterally
Pertinent Results:
ADMISSION LABS
==================
___ 11:52PM BLOOD WBC-12.3* RBC-3.26* Hgb-10.3* Hct-32.8*
MCV-101* MCH-31.6 MCHC-31.4* RDW-13.5 RDWSD-50.5* Plt ___
___ 11:52PM BLOOD Neuts-83.4* Lymphs-7.5* Monos-8.1
Eos-0.3* Baso-0.1 Im ___ AbsNeut-10.23* AbsLymp-0.92*
AbsMono-1.00* AbsEos-0.04 AbsBaso-0.01
___ 11:52PM BLOOD Plt ___
___ 11:52PM BLOOD Glucose-136* UreaN-36* Creat-0.7 Na-143
K-4.3 Cl-98 HCO3-34* AnGap-11
DISCHARGE LABS
================
___ 06:00AM BLOOD WBC-9.1 RBC-3.86* Hgb-12.0 Hct-39.1
MCV-101* MCH-31.1 MCHC-30.7* RDW-13.8 RDWSD-50.8* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-128* UreaN-14 Creat-0.5 Na-145
K-4.2 Cl-98 HCO3-39* AnGap-8*
___ 06:00AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.0
IMAGING
==========
___ CT chest noncontrast
IMPRESSION:
1. Dense consolidation containing central calcification in the
left
cardiophrenic angle, raising suspicion for underlying neoplasm.
Appearance is atypical for an infectious or inflammatory
process. A PET-CT may be considered to assess for metabolic
activity.
2. Very large hiatal hernia, with the entire stomach and likely
the pancreas flipped into the chest. This results in mass
effect on the left mainstem bronchus, although without
appreciable luminal narrowing.
3. Age indeterminate compression fractures of T5 and T7.
___ CT Head noncontrast
FINDINGS:
Mildly motion limited exam, particularly at skullbase. There is
no evidence of infarction, hemorrhage, edema, or mass.
Prominence of the ventricles and sulci is suggestive of
age-related involutional changes. Mild periventricular white
matter hypodensities are suggestive of chronic small vessel
ischemic
disease.
No osseous abnormalities seen. There are aerosolized secretions
in the left sphenoid sinus. There is mild mucosal thickening of
the left frontal sinus and partial opacification of the left
frontoethmoidal recess. Otherwise, the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits
are unremarkable. Bilateral lens replacements are noted.
IMPRESSION:
Mildly motion limited exam. Within this limitation, no acute
intracranial
process.
Pelvis Xray ___
IMPRESSION:
No acute fracture.
CXR ___
IMPRESSION:
1. Dense opacification the left lung base better evaluated on
same day chest
CT may represent a mass.
2. Low lung volumes. No frank pulmonary edema.
3. Large hiatal hernia.
Brief Hospital Course:
SUMMARY STATEMENT
==================
___ year old woman with a past medical history of dementia
(normally oriented to person only), hypothyroidism, CAD, HTN,
and GERD presenting with hypoxia and hypotension, found to have
coagulase negative staph bacteremia s/p 5 doses of vancomycin,
large hiatal hernia, and pulmonary consolidation concerning for
malignancy. Problems addressed during her hospitalization are as
follows:
#Coagulase negative staphylococcus bacteremia:
Overall low suspicion for true infection. Initially presented
with leukocytosis x1 (WBC 12.3), fever x1 (100.9), cough. No
clear infectious source, chest imaging with low suspicion for
infectious process, fever possibly related to underlying
malignancy (see #hypoxia below). Found to have gram positive
cocci in blood culture, subsequently started IV vancomycin. No
source for her bacteremia was suspected. On return of culture
speciation, was found to have coagulase negative staph isolated
from one set, thought to represent skin contaminant. As such, IV
vancomycin was discontinued after receiving 5 doses. Remained
afebrile and hemodynamically stable >24 hours off antibiotics.
#Hypoxia
#Hiatal hernia
#Left cardiophrenic consolidation with central calcification:
Unclear what patient's baseline oxygen requirement is.
Throughout admission, required up to 3L supplemental oxygen on
nasal cannula, maintaining saturations in the mid-90s. At time
of discahrge was saturating high ___ on room air. Etiology of
her hypoxia is likely multifactorial. Patient with known left
lung mass with concerning for malignancy, hiatal hernia with
abdominal contents in chest, and concern for aspiration
pneumonitis, all of which are contributing to her poor
oxygenation. After discussion with health care proxy, PET CT to
further investigate concern for lung malignancy was not within
goals of care.
#Hypothyroidism
Continued levothyroxine
#GERD
Continued omeprazole
#Dementia
Held sedating medications in setting of poor baseline mental
status (AAOx1) (Zolpidem, mirtazapine, LORazepam)
#CAD
Continued ASA, held metoprolol, furosemide, and acetazolamide
#Glaucoma
Continued latanoprost and timolol
TRANSITIONAL ISSUES:
=====================
[] Discharge weight: 66.8 kg (bed)
[] Please draw surveillance blood cultures ___
[] Continue to monitor need for supplemental oxygen
administration (intermittently ___ NC, at time of discharge 96%
on room air, goal oxygen saturation >88%)
[] Continue incentive spirometry
[] Continue to monitor for aspiration and follow aspiration
precautions.
[] Held home furosemide and acetazolamide. Remained euvolemic
throughout admission. Increasing oxygen requirement and
shortness of breath most likely from large hiatal hernia into
chest in addition to lung consolidation rather than volume
overload.
[] Continue to monitor bilateral knee effusions, if develops
knee pain would consider aspiration
[] Held home sedating medications (zolpidem, mirtazapine,
lorazepam) given poor baseline mental status, consider
discontinuing indefinitely
[] The patient has a dense consolidation containing central
calcification in the left cardiophrenic angle, raising suspicion
for underlying neoplasm. Appearance is atypical for an
infectious or inflammatory process. A PET-CT may be considered
to assess for metabolic activity.
[] The patient has a very large hiatal hernia, with the entire
stomach and likely the pancreas flipped into the chest. Please
follow up this finding as appropriate.
[] an age-indeterminate compression fractures of T5 and T7 was
noted on CT of the chest. Please avoid aggressive spinal
manipulations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
5. Ipratropium-Albuterol Neb 1 NEB NEB BID:PRN SOB
6. LORazepam 0.5 mg PO Q8H:PRN anxiety
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
9. Potassium Chloride 20 mEq PO BID
10. Omeprazole 20 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO DAILY
12. Mirtazapine 30 mg PO QHS
13. Zolpidem Tartrate 2.5 mg PO QHS
14. Senna 17.2 mg PO BID:PRN Constipation - First Line
15. AcetaZOLamide 250 mg PO Q12H
16. Furosemide 60 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Ipratropium-Albuterol Neb 1 NEB NEB BID:PRN SOB
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 17.2 mg PO BID:PRN Constipation - First Line
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
10. HELD- AcetaZOLamide 250 mg PO Q12H This medication was
held. Do not restart AcetaZOLamide until you see your primary
care provider
11. HELD- Furosemide 60 mg PO DAILY This medication was held.
Do not restart Furosemide until you see your primary care
provider
12. HELD- LORazepam 0.5 mg PO Q8H:PRN anxiety This medication
was held. Do not restart LORazepam until you see your primary
care provider
13. HELD- Metoprolol Tartrate 50 mg PO DAILY This medication
was held. Do not restart Metoprolol Tartrate until you see your
primary care provider
14. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do
not restart Mirtazapine until you see your primary care provider
15. HELD- Potassium Chloride 20 mEq PO BID This medication was
held. Do not restart Potassium Chloride until you see your
primary care provider
16. HELD- Zolpidem Tartrate 2.5 mg PO QHS This medication was
held. Do not restart Zolpidem Tartrate until you see your
primary care provider
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
==========
#Coagulase negative staphylococcus bacteremia
#Hypoxia
#Hiatal hernia
#Left cardiophrenic consolidation with central calcification
SECONDARY
============
#Hypothyroidism
#GERD
#Dementia
#CAD
#Glaucoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You came to the hospital because you developed
low oxygen levels and appeared more tired in your home facility.
In the hospital, we found that you had bacteria growing in your
blood. We briefly treated you with antibiotics. This bacteria
may have represented a true infection or may have been
contaminant from your skin. We also found that you had a
"hernia" in which some organs from your belly are in your chest.
Because of this, it has been difficult for you to breathe and
you will be given oxygen supplementation when you leave the
hospital.
Please continue to take your medications as prescribed and to
follow-up with your doctors as ___.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10527186-DS-6 | 10,527,186 | 25,241,870 | DS | 6 | 2191-12-09 00:00:00 | 2191-12-09 16:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / ciprofloxacin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with metastatic renal cell carcinoma on Axitinib and
prednisone 10 (?) presented initialy to the outside hospital
with abdominal pain since ___, found to have free air on
OSH CT abd/pelvis.
Per ACS, patient was admitted to the surgical service with
conservative management given that she was thought to be a poor
surgical candidate. It was thought that her chemotherapy may
have led to the perforation in the setting of having
diverticular disease. Patient was initially started on IV
ciprofloxacin and metronidazole. However, over the course of
her hospital stay, she was noted to have worsening hypoxia and
tachycardia. CXR was concerning for possible edema vs infection
vs toxic/allergic reaction. Patient was started on furosemide
20 mg BID with good urine output, about net negative for a
couple of days. Her antibiotics was changed to vancomycin (for
HAP) and cefepime (for HAP and GI GNR) and flagyl (for the
anaerobes) on ___. ACS was planning to continue for a
total of 14 day course for the diverticular perforation coverage
(cefepime and flagyl). The shortness of breath continued
___ despite furosemide for diuresis 20 mg IV BID, so
medicine consult team was contacted for management of
respiratory distress. There was thought for possible PE given
the hypoxia/hypoxemia (improves with BiPAP) and sinus
tachycardia. However, given that patient only has a single
kidney and an ARF during this admission, CTA was thought to be
not indicated. VQ scan was also thought to be not indicated
given the underlying intrathoracic mets. LENIS were negative.
Heparin gtt was started empirically. An echocardogram was done
on ___ to look for right heart strain, and there is no
clear evidence of such. Patient has clearly stated that she
would want to be DNR/DNI per multiple family meetings with the
___ team. Has been requiring supplemental O2 via shovel mask for
past few days. Today was up to 5L NC with 40% face mask prior to
transfer. However, she is still interested in trying the BiPap
for the dyspnea at this time.
Of note, there is a suspicion that she has rapid progression of
her underlying metastatic disease. Patient and her family was
made aware of her poor prognosis.
Patient reports feeling better being on the BiPap trial on the
floor. Currently denies pain.
.
10 point ROS is otherwise negative
Past Medical History:
ONCOLOGY HISTORY:
In ___ she had a renal ultrasound for evaluation of
recurrent UTIs that showed a renal mass and she subsequently had
a CT that revealed an exophytic mass in the right kidney in the
lower pole, measuring 4 x 3.6 cm with heterogeneous enhancement
and a filling defect in the right renal vein. No other obvious
lesions were found in the abdomen, although there was a 6mm lung
nodule. She underwent right nephrectomy in ___ and was
found to have a pT3N1, ___ grade 4, clear cell carcinoma.
She had repeat scans in ___ and ___ that
showed increase in the size of the pulmonary nodules, consistent
with metastatic disease. On ___, she was started on
Pazopanib 800mg daily by Dr. ___ at ___. Her
repeat CT scan on ___ showed interval improvement with
decrease in size of pulmonary nodules. She tolerated treatment
well until ___, when she developed fatigue, dizziness,
nausea and diarrhea. Pazopanib dose was reduced to 600mg daily
by Dr. ___. CT scan on ___ showed stable disease,
however she continued to have worsening fatigue, diarrhea and
weight loss. She was last seen at ___ on ___ and
pazopanib was discontinued
because of the side effects. Since early ___, she developed
persistent dry cough and shortness of breath and became oxygen
dependent and wheelchair bound. She was seen by her PCP in ___
and was started on Prednisone, which slightly alleviated her
symptoms. Her last CT scan on ___ showed significant disease
progression with increase in size of the pulmonary nodules. She
started bevacizumab on ___. On ___ CT chest showed
disease progression and she was started on Axitinib on ___.
Since being on axitinib therapy, repeat scans have not been
obtained at ___, but clinically, the pt feels much better and
states that her breathing has significantly improved.
Other PMHx:
Recurrent UTIs
Hypertension
Gastroesophageal reflux disease
Hypercholesterolemia
Osteoarthritis
Chronic kidney disease stage IV
Gout
Renal cell carcinoma
TAH
Appendectomy
CCY
R Nephrectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals:98.5 70 157/81 16 94RA
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. Tender LLQ w/ no guarding or rebound. No rigidity,
nondistended.
Ext: No ___ edema, ___ warm and well perfused
On discharge:
98.1 164/92 82 18 94% on 5L NC
Gen: AAOX3, lethergic, in NAD
HEENT: atrophic tongue, no obvious ___ or oral lesions or
bleeding
CV: RRR, no RMG
Lungs: decreased BS but CTAB no wrr
Abdomen: NTND, no HSM, no rebound
Extremities: somewhat cool to touch, pulses equal and 1+, no
edema
Psyc: mood and affect wnl
Neuro: CN, MS, strength and sensation wnl
.
Pertinent Results:
Admission labs:
___ 05:00PM BLOOD WBC-12.9* RBC-4.03* Hgb-11.7* Hct-35.0*
MCV-87 MCH-29.2 MCHC-33.6 RDW-20.2* Plt ___
___ 08:35AM BLOOD ___ PTT-32.6 ___
___ 05:00PM BLOOD Glucose-105* UreaN-23* Creat-1.3* Na-144
K-3.7 Cl-104 HCO3-28 AnGap-16
___ 08:35AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.6
___ 06:58PM BLOOD Type-ART pO2-66* pCO2-28* pH-7.37
calTCO2-17* Base XS--7
___ 05:06PM BLOOD Lactate-2.2*
Discharge labs:
WBC 8.7
Hgb 10.8
Plt 103
Creat 1.2
K 3.1 (was repleted)
Ca 8.1
-labs were otherwise wnl
Pertinent micro:
___ MRSA SCREEN MRSA SCREEN-negative
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD - negative
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD - negative
___ URINE URINE CULTURE-FINAL EMERGENCY WARD -
negative
Pertinent imaging:
CXR ___
Increasing bilateral diffuse opacities most concerning for new
edema. Alternatively, could be due to infection, a toxic or
allergic drug
reaction or hemorrhage.
B/L ___ ___
No bilateral lower extremity DVT.
ECHO ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The left ventricular inflow pattern suggests impaired
relaxation. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
.
___ 434
Sinus rhythm. Delayed R wave progression is likely a normal
variant.
Non-specific repolarization abnormalities. Compared to the
previous tracing
of ___ the rate has slowed. Otherwise, findings are similar.
Brief Hospital Course:
Ms ___ was transferred to the Emergency Department from an
OSH with complaints of abdominal pain. An abd CT scan was
consistent with diverticulitis and free air. The patient was
given intravenous Zosyn and transferred to ___. Upon arrival,
the patient was maintained on bowel rest and admitted to the
Acute Care Service for ongoing observation including serial
abdominal exams and intravenous antibiotics was breifly treated
in the ICU and then transitioned to the floor after a family
meeting was held and they decided against aggresive
interventions
# perforated sigmoid diverticula:
Initially she was kept NPO with frequent abdominal exams. Over
the course of several days her exam improved and her diet
advanced slowly. She was noted to have episodes of loose stools
and abdominal cramping with eating a regular diet, so resumed
NPO status for an additional day before being re-advanced to
sips and then a regular diet. While she did tolerate PO intake
with regards to her GI function, her appetite remained poor, and
in the setting of her shovel-mask O2 requirement was unable to
obtain much oral nutrition. In the FICU, she was put on a
regular diet as tolerated. Her pain was well controlled with IV
morphine. On initial presentation to ___ her WBC was 12.9,
and in the setting of her perforated diverticulitis and cipro
allergy was started on IV Zosyn and Flagyl. Her WBC trended down
to 8.6 on HD 3, and per Infectious Disease recommendations her
antibiotics were changed to IV Ceftriaxone and Flagyl. On HD5
she was transitioned to PO Augmentin and Flagyl, but when her
labs came back with a WBC significantly elevated to 19.1 despite
a benign abdominal exam she was placed back on IV Ceftriaxone
and Flagyl, and by HD7 her WBC was 27.7. Upon transfer to the
___, she was afebrile and antibiotics were broadened to vanc
and cefepime. Vanc was d/c'd, and she continued on cefepime
without breakthrough fever. On the medical floor the patient
WBC normalized and she was unable to tolerate metronidazole po
and had an allergy to cipro. As a result the patient was placed
on Augmentin which she tolerated well.
# metastatic RCC:
Initially her PO Inlyta chemotherapy medication was held in the
setting of her acute perforated sigmoid diverticulitis, and she
was continued on the equivalent of her home prednisone using 8mg
of IV Solu-Medrol each day to prevent adrenal failure in her
acute illness period. On the recommendation of Heme/Onc the
patient's steroids were weaned down to 6mg IV Solu-Medrol on
___, and the plan was to taper them by 2mg Q3days until she
was off of them. On ___ it was felt that in the setting of her
acutely worsening SOB while off of her chemo that she should
resume her Inlyta, as it was likely that her perforated
diverticulitis had healed over and that she may be getting SOB
due to rapid progression of her pulmonary metastases. In the
FICU, despite pt's ___, she decided to resume taking her
axitinimab and steroids. She felt this made her feel better.
Although, per discussion with her primary oncologist, her
condition is not likely reversible. The patient and family
decided that they would like to continue her oral medications
and elected to not pursue hospice care for now. This may be
re-visited in the future
.
# Nausea with oral ___ patient had nausea which initially was attributed to
metronidazole and oral electrolyte repletion. Her nausea
persisted after this and palliative care was involved in the
patients symptom management. The patient had excessive sedation
from ativan. As a result, the patient should be placed on the
following:
- Zofran 8mg ODT Q8H prior to meals
- Zyprexa Zydis 5mg PO BID standing
- Compazine 25mg PR BID PRN nausea not controlled with her
standing meds
For the patients ___, she was initially having trouble
tolerating this. As a result she will be treated with a 21 day
course of fluconazole. Last day of treatment is ___.
.
## Neuro:
The patient remained alert and oriented throughout her
hospitalization. Pain was managed initially with prn
acetaminophen, but was also given IV morphine for more acute
episodes of pain and to relieve symptoms of air-hunger. The
patient was pain free for several days prior to her discharge.
## Sinus tachycardia:
The patient remained stable from a hemodynamic standpoint,
although she did develop tachycardia to the 110's-120's on ___
that persisted. In the setting of her broad antibiotic coverage,
tachycardia and increasing O2 requirements it was clinically
felt that she may have a pulmonary embolism despite negative
lower extremity ultrasounds on ___, so a heparin drip was
started at that time. An Echocardiogram was ordered on ___ to
evaluate for cardiac stigmata of a pulmonary embolus (she could
not receive IV contrast in the setting of unirenal physiology
and a rising creatinine, and a V/Q scan would not be useful in
the setting of diffuse pulmonary metastatic disease), and the
Echo showed no signs of RV/RA strain. The risk benefit of AC
was discuss was discussed with the family and it was decided
that AC should be stopped. Following this and re-starting the
patients anti-HTN regimen, the patients ST resolved.
## hypoxia:
The patient receives baseline oxygen supplementation via nasal
cannula. Her O2 requirements began to rise on HD4, and on HD5
she was triggered for increasing dyspnea on exertion, shortness
of breath and an increasing oxygen requirement. Nebulizers were
administered with slight improvement in symptoms. A CXR showed
increasing bilateral diffuse opacities concerning for new edema
overlapping with her known diffuse pulmonary metastases, and the
worsening respiratory status was attributed to both metastatic
disease and fluid overload. She was given intermittent IV Lasix
on ___ and ___, however her creatinine began to trend up with
her creatinine bumping to 2.2 on HD7 (baseline 1.3) and her
urine output was low so no more lasix was administered. She was
also given 50mL of 25% albumin in an attempt to intravascularize
some of her third spaced fluid. The patient continued to
receive nebulizer treatment with albuterol and ipratropium. On
___, the pt transferred to the FICU service, where bipap was
attempted with some improvement in respiratory status. Given
patient's goals of care focusing on comfort, it was not clear
that heparin gtt would make a significant long term difference
for presumed PE. In the FICU, the pt's heparin gtt was stopped.
She was given a one time trial of lasix with little improvement.
We discussed her ___ with her pt and family, who decided that
bipap woud not be within goals of care. She was given morphine
IV for palliation of dyspnea, nebulizer treatments, and remained
comfortable on a non-re breather. She was transferred to the
floor for inpatient comfort oriented care. The patients
respiratory status stabilized on a NC and she was breathing
comfortably on 5L NC on discharge.
.
# ___:
Pt had a creatinine bump thought to be due to excess diuresis.
Her IV lasix was weaned down, and her Cr improved.
.
# Transitional Issues:
-Patients symptoms should be controlled, main one has been
nausea
-For questions in management, call patients Oncologist:
___ MD
___
.
Medications on Admission:
Pravachol 40', Amlodipine 10', ASA 81', Atenolol 50'', Colcae
100'', Omeprazole 40', Zofran 8', Prednisone 10', Axitinab 60''
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. axitinib *NF* 5 mg Oral BID Chemotherapy for RCC
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Ondansetron 8 mg PO Q8H
please give prior to meals, patient can refuse is not nauseous
7. PredniSONE 20 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Fluconazole 100 mg PO Q24H
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
13. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN wheezing
14. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal dryness
15. Prochlorperazine 25 mg PR Q12H:PRN nausea
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID
please give standing for nausea, may refuse if patient is not
nauseous or is sedated
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Perforated diverticulitis
Acute Pulmonary Edema
Secondary diagnosis:
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ with a condition called
perforated diverticulitis where there is an area within your
intestines that have vessels which become inflammed and
perforate. You were placed on bowel rest and your abdominal exam
was montiored very closely. As your exam improved your diet was
very slowly re-introduced. You also had nausea which was likely
partially caused by an antibiotic, which was stopped. This
nausea persisted after and you were placed on an anti-emetic
regimen which provided you with some relief.
Also during your stay you were noted to have fluid build up in
your lungs requiring that you wear oxygen and be given a
diurietic to get rid of the extra fluid. Your breathing was
stable for several days prior to discharge.
We had a family meeting and you and your family decided to focus
your care on comfort and maximize your quality of life while
continuing to take your medications. They also decided to not
escalate your care. You will go to rehab for further treatment.
.
Medication changes-see below
Followup Instructions:
___
|
10527386-DS-20 | 10,527,386 | 24,458,264 | DS | 20 | 2151-07-06 00:00:00 | 2151-07-06 22:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ACE Inhibitors / Cosopt
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is an ___ yo ___ woman with medical
history of HTN, HLD, DM and previous LT stroke in ___
transferred to the ED for neurosurgical evaluation after she was
found incidentally to have a LT thalamic IPH on imaging
performed
after a mechanical fall.
Per ED report she was in her usual state of health (which
involves moving with a walker, living in a NH and requiring
assistance with ADLs) until this morning when she got up and
reached for her bedroom door without her walker. She then lost
her balance and fell on her LT side sustaining a LT wrist
injury.
She did hit her head at the time but did not loose
consciousness.
At OSH she denied lightheadedness, dizziness, or confusion. Per
ED reports her daughter at the bedside thought mental status was
intact. She is not on anticoagulation.
Of note at OSH was evaluated for triquetral fracture and
sandwich
splint was placed. Here this was replaced with a neutral resting
splint.
General and neurologic review of systems limited by poor
hearing.
However she reports LT wrist pain and denies headache or
dizziness.
Past Medical History:
DMII
HTN
HLD
Glaucoma
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION Vitals:
98
86
173/60
14
99% RA
General: NAD
HEENT: NCAT, irritated sclera
___: RRR
Pulmonary: CTAB
Abdomen: Soft
Extremities: Warm, mild LT wrist edema
Neurologic Examination:
MS: Awake, alert, oriented to person, birthday and partially to
place. Speech is fluent in creole and able to say short phrases
in ___.
Cranial Nerves: PERRL 2.5->2 brisk. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Grossly hard of hearing bilaterally. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
Motor: Decreased bulk and normal tone. No drift. Mild intention
tremor. Confrontational strength testing limited by effort and
language barrier but at least ___ in bilateral upper extremities
(limited by LT wrist pain)and moves bilateral lowers
antigravity.
Sensory: withdraws to pin in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
Coordination: No dysmetria with finger to nose testing
bilaterally.
Gait: Deferred.
==============================
DISCHARGE PHYSICAL EXAMINATION:
Tm/c: 98.9/98.4 BP: 134-192/57-99 HR ___ RR 18 SaO2 95% RA
General: Awake, NAD
HEENT: NC/AT, no scleral icterus noted, tacky mucous membranes.
Pulmonary: breathing comfortably on RA
Cardiac: no pallor nor diaphoresis, skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema. L wrist in cast, fingertips
warm with good capillary refill. mild L shoulder pain with
abduction, improved.
Neurologic:
-Mental Status: Awake, fluent speech output. Speaks in ___
but occ reverts to ___ Creole. Regards and tracks examiner.
Intermittently follows simple axial and appendicular commands.
-Cranial Nerves: Gaze crosses midline to both sides. Face
symmetric at rest and with activation. Hearing intact to loud
conversation, hearing better via R ear than L ear, family states
chronic.
-Sensorimotor: briskly antigravity throughout. Responds to
tickle throughout.
Pertinent Results:
___ 02:10AM BLOOD WBC-3.3* RBC-3.55* Hgb-11.0* Hct-33.9*
MCV-96 MCH-31.0 MCHC-32.4 RDW-13.6 RDWSD-48.0* Plt ___
___ 05:55AM BLOOD WBC-3.8* RBC-3.16* Hgb-9.6* Hct-30.5*
MCV-97 MCH-30.4 MCHC-31.5* RDW-13.2 RDWSD-47.2* Plt ___
___ 02:10AM BLOOD Glucose-104* UreaN-11 Creat-0.9 Na-139
K-3.6 Cl-104 HCO3-24 AnGap-15
___ 05:55AM BLOOD Glucose-104* UreaN-15 Creat-0.8 Na-142
K-3.5 Cl-108 HCO3-22 AnGap-16
___ 02:10AM BLOOD ALT-<5 AST-13 AlkPhos-67 TotBili-0.5
___ 02:10AM BLOOD Lipase-14
___ 08:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:10AM BLOOD cTropnT-<0.01
___ 05:55AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7
___ 06:10AM BLOOD VitB12-617 Folate-13
___ 03:46AM BLOOD %HbA1c-5.5 eAG-111
___ 02:10AM BLOOD Triglyc-82 HDL-66 CHOL/HD-4.5
LDLcalc-213*
___ 08:40AM BLOOD TSH-0.80
___ 02:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 07:21PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:45PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 07:21PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
___ 09:45PM URINE RBC-88* WBC->182* Bacteri-FEW Yeast-NONE
Epi-<1
___ 07:21PM URINE Hours-RANDOM UreaN-430 Creat-175 Na-58
___ 05:10AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ Urine culture: >100,000 CFU/mL Proteus mirabilis
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
OSH: Imaged with NCHCT which showed LT thalamic bleed. MRI with
corresponding findings on GRE sequence, also has chronic small
vessel disease and periventricular white matter disease. There
is
an area of encephalomalacia in the occipital horn of the LT
lateral ventricle.
CXR: No acute process
___ CTA head/neck:
1. Unchanged 11 x 7 mm hyper density in the left thalamus
consistent with acute to subacute hemorrhage. No new focus of
hemorrhage.
2. Unchanged chronic left parietal infarct.
3. Severe narrowing of the bilateral supraclinoid internal
carotid arteries, moderate narrowing of the left V4 segment of
the vertebral artery, and severe narrowing of the basilar artery
just proximal to the superior cerebellar artery origins, and
focal severe narrowing of a left M3 branch likely secondary to
atherosclerotic disease.
4. 2 mm outpouching of the communicating segment of the left
internal carotid artery, representing either infundibulum or
small aneurysm.
5. Otherwise patent intracranial vasculature without occlusion.
6. Patent cervical vasculature without significant stenosis,
dissection, or occlusion.
7. Millimetric bilateral hypodense thyroid nodules. The
___
College of Radiology guidelines suggest that in the absence of
risk factors for thyroid cancer, no further evaluation is
recommended.
___ wrist radiograph: Ossific density over the dorsal
aspect
of the wrist which is compatible with a triquetral fracture.
___ renal u/s: No evidence of hydronephrosis, as clinically
questioned. No sonographic findings to explain patient's
symptoms.
___ AXR: Nonobstructive bowel gas pattern.
___ CXR/AXR for NG placement: Enteric tube tip in the mid
stomach. Increased heart size with borderline pulmonary
vascularity. Probable small pleural effusions. Bibasilar
opacities, likely atelectasis, consider pneumonia if clinically
appropriate.
___ NCHCT: 1. Unchanged left thalamic intraparenchymal
hemorrhage.
2. Suggestion of zone of low-attenuation centered on left basal
ganglia, may represent subacute infarct.
___ Shoulder XR: No acute fracture dislocation is seen.
Minor acromioclavicular degenerative change. 1.5 cm irregular
density adjacent to the greater tuberosity may be posttraumatic
in nature, or alternatively sequela of calcific tendinitis.
Brief Hospital Course:
Ms. ___ was admitted with small L thalamic hemorrhage likely
secondary to hypertension given location and uncontrolled
hypertension. Course was complicated by severe delirium which
was refractory to conservative measures and antipsychotic
therapies. In the setting of delirium, she frequently refused PO
food and medications, which led to refractory hypertension
requiring frequent IV therapies. As her delirium and lack of
consistent PO medication intake continued, NG tube was briefly
placed, though the patient quickly pulled it out. Transdermal
antihypertensive therapy was maximized with clonidine patch
0.3/24 hr patch. Discussion was initiated with family regarding
prolonged delirium and expected prolonged recovery, and how to
manage PO food, medication and therefore BP. Options presented
included PEG vs eating and taking meds as tolerated and
tolerating a higher BP. Her son and daughter discussed this
among each other and with PCP and decided on ___ to allow
Ms. ___ to eat and take PO medications as tolerated, knowing
that her BP will likely run high and she will have higher risk
of stroke, hemorrhage, and MI. She was therefore discharged back
to her chronic facility with this plan.
Additionally, she was found to have developed UTI during
admission and completed a 7 day course of ceftriaxone.
Additionally, she was found to have L triquetral fracture on
presentation, casted by hand clinic. She is to follow up in hand
clinic.
===================
Transitional Issues:
[ ] continue clonidine patch
[ ] Allow patient to eat and take PO medications crushed in
applesauce as tolerated by patient.
[ ] consider swallow re-evaluation as mental status improves.
[ ] Ideally, her BP would be lower than 140 systolic, however we
are tolerating higher BP per family preference, and they are
aware of the risks associated with uncontrolled hypertension.
[ ] If tighter blood pressure control is desired, recommend
consideration of topical NTG
[ ] f/u in hand clinic for L triquetral fracture.
===================================
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. Atorvastatin 80 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Acetaminophen 650 mg PO/PR Q6H:PRN Pain - Mild
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
9. Aspirin 81 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
12. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT
3. Labetalol 400 mg PO TID
4. Lidocaine 5% Patch 1 PTCH TD QPM L shoulder
5. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation
6. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
7. Lisinopril 20 mg PO DAILY
8. Acetaminophen 650 mg PO/PR Q6H:PRN Pain - Mild
9. Atorvastatin 80 mg PO QPM
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES DAILY
11. Docusate Sodium 100 mg PO BID
12. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
13. Hydrochlorothiazide 25 mg PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 8.6 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
Resistant hypertension
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of fall resulting from an
ACUTE HEMORRHAGIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain bleeds. The brain is
the part of your body that controls and directs all the other
parts of your body, so damage to the brain from being deprived
of its blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high blood pressure
We are changing your medications as follows:
Changing several blood pressure medications
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
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10528023-DS-12 | 10,528,023 | 23,115,337 | DS | 12 | 2164-06-12 00:00:00 | 2164-06-12 18:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
sulfamethoxazole-trimethoprim
Attending: ___.
Chief Complaint:
Right ankle infection
Major Surgical or Invasive Procedure:
Right ankle irrigation and debridement, primary closure.
History of Present Illness:
___ s/p right ankle arthroscopy, partial synovectomy and the
peroneal brevis tendon repair on ___ increasing
sanguinous to purulent drainage from the superior aspect of the
wound. Denies fever or chills currently. Denies swelling in the
rest of the leg. No history of DVT or PE. Has been taking
oxycodone and aspirin intermittently for the pain.
Past Medical History:
right ankle arthroscopy, partial synovectomy and the peroneal
brevis tendon repair on ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
AVSS
NAD, A&Ox3
RLE wrapped in dressing which is c/d
SILT toes
Foot wwp
___ fire
Pertinent Results:
___ 04:03PM GLUCOSE-104* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-28 ANION GAP-16
___ 04:03PM WBC-9.3 RBC-4.34* HGB-13.3* HCT-38.7* MCV-89
MCH-30.8 MCHC-34.5 RDW-12.7
___ 04:03PM PLT COUNT-361
___ 04:03PM ___ PTT-32.3 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right foot post-op infection and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for irrigation and debridement and
primary closure of wound, 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 was ambulating
safely. 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
partial weight bearing in the right lower extremity extremity.
The patient will follow up with Dr. ___ in 1 week per routine.
A thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. 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
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsul by mouth twice a day Disp
#*60 Capsule Refills:*0
5. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Right ankle infection
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:
- Partial weight bearing
- Activity as tolerated
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.
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.
- Keep your dressing on the wound until follow up in clinic
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with Dr. ___ in clinic in 1 week. Please call
to confirm your appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
10528165-DS-18 | 10,528,165 | 23,895,697 | DS | 18 | 2123-05-31 00:00:00 | 2123-06-08 22:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
no major invasive procedures were performed.
History of Present Illness:
___ with h/o T2DM, HTN, HLD presents with SOB, orthopnea and
brief episode of chest pain.
Pt reports first noting dyspnea while working in the yard on
___ AM (___). On ___, ___ felt similar SOB while packing
for his trip. ___ is from ___ and arrived to ___ on
___. ___ reports over the course of the week, ___ had
worsening dyspnea and last night ___ had SOB at rest that was the
worst of the week. ___ reports orthopnea this week and PND. SOB
is generally worse in evening and overnight. ___ reports ___ had
to sit straight up last night and could not sleep. ___ reports ___
edema and abdominal distention this week as well. ___ had chest
pain for a few minutes this morning, that was sharp and not
pleuritic. ___ reports no calf pain. ___ had a ___ on
___ and then a 2 hours flight. Symptoms preceded travel but
worsened after arriving to ___. ___ reports 2 months of slight
decrease in energy level and functional capacity. No
fevers/chills. ___ notes a few days of burning with urination.
___ follows with a cardiologist every 6 months and gets an annual
TTE for "leaking heart valve", possibly MR. ___ has had 2 prior
caths. No prior MI. Pt had a colonoscopy 2wks ago that had a
couple of polyps that were removed. ___ reports a recent prostate
exam that was normal.
In the ED, initial vitals were: 96.7 56 128/41 18 97% RA
- rectal: no stool in the rectal vault
- EKG: 55bpm NI borderline LAD no acute ST
- Labs were significant for: Hb 9.9, proBNP 1368, trop <0.01,
BUN/Cr ___, K 5.6 --> 4.9, d-dimer 2804
- Imaging revealed: CXR with Mild pulmonary vascular
engorgement. Bibasilar atelectasis; CTA with Bilateral segmental
and subsegmental pulmonary emboli without evidence of infarction
or right heart strain
- The patient was given: 100mg SQ enoxaparin
Vitals prior to transfer were: 97.7 61 146/51 24 98% Nasal
Cannula
Upon arrival to the floor, pt reports some SOB. No chest pain.
Past Medical History:
T2DM
HTN
Obesity
Gout - no flare in ___, on allopurinol
HLD
Hypothyroidism
H/o kidney stones s/p lithotripsy ___
S/p L TKA
Social History:
___
Family History:
Brother with prostate cancer
Sister x2, Mother and Brother with VTE, no known testing for
hypercoagulable states
Physical Exam:
ADMISSION:
Vitals: 97.7, 153/57, 65, 18, 96% 2L NC
General: elderly male looks slightly younger than stated age,
sitting up in bed, in NAD
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP at 10cm
CV: RRR, slightly distant heart sounds, no murmurs evident
Lungs: bibasilar rales, good air movement, no resp distress
Abdomen: soft, NT, obese
Ext: Warm, well perfused, 1+ pitting edema bilaterally, no calf
tenderness, calves appear symmetric
Neuro: grossly intact, alert and attentive
DISCHARGE:
General: patient walking around room without difficulty.
HEENT: anicteric sclera, MMM
Lungs: CTA b/l. improved from last night.
CV: no JVP, ___ systolic murmur best appreciated in axilla.
Abdomen: bs+, soft, NTND
Ext: well perfused, trace edema
Neuro: motor grossly intact, alert and oriented
Pertinent Results:
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-6.9 RBC-3.39* Hgb-10.5* Hct-32.4*
MCV-96 MCH-31.0 MCHC-32.4 RDW-13.8 RDWSD-47.6* Plt ___
___ 07:15AM BLOOD Glucose-145* UreaN-22* Creat-1.2 Na-139
K-4.6 Cl-105 HCO3-23 AnGap-16
ADMISSION LABS:
___ 11:22AM BLOOD WBC-9.6 RBC-3.16* Hgb-9.9* Hct-30.4*
MCV-96 MCH-31.3 MCHC-32.6 RDW-14.0 RDWSD-48.8* Plt ___
___ 11:22AM BLOOD Glucose-216* UreaN-29* Creat-1.2 Na-136
K-5.6* Cl-109* HCO3-20* AnGap-13
___ 11:22AM BLOOD proBNP-1368*
___ 12:11PM BLOOD D-Dimer-2804*
IMAGING/OTHER STUDIES:
ECHO ___
Mild eccentric left ventricular hypertrophy with mild cavity
dilatation and preserved regional and global biventricular
systolic function. Severe diastolic dysfunction. Mild posterior
mitral valve prolapse with moderate eccentric regurgitation.
Dilated aortic root and ascending aorta with eccentric (probably
underestimated) moderate aortic regurgitation. Severe pulmonary
artery systolic hypertension.
CTA CHEST W&W/O C&RECON ___. . Bilateral segmental and subsegmental pulmonary emboli
without evidence of infarction or right heart strain. 2. Small
to moderate right, and small left, bilateral pleural effusions
with adjacent compressive atelectasis. 3. Diffuse areas of
ground-glass opacity, interlobular septal thickening, and reflux
of IV contrast into the hepatic venous system suggestive of
volume overload and heart failure. 4. 8 mm right upper lobe
pulmonary nodule. In setting of risk factors for malignancy,
followup chest CT is recommended in ___ months and again at ___
and 24 months if unchanged. In the absence of such risk factors,
followup chest CT is recommended in ___ months and again at
___ months if unchanged.
Brief Hospital Course:
___ M with T2DM, HTN, HLD, who presented with several days of
progressive SOB, orthopnea, and bilateral lower extremity edema.
___ was found to have bilateral subsegmental PEs as well as HFpEF
and severe pulmonary hypertension. For his pulmonary emboli, ___
was started on lovenox and transitioned to xarelto. ___ was also
heavily diuresed with IV lasix and sent home on a PO regimen
after reaching his dry weight.
#Pulmonary emboli: Patient found to have a D-dimer of 2804 in
the ED. The following CTPE revealed bilateral segmental and
subsegmental pulmonary emboli without evidence of infarction or
right heart strain. Lower extremity dopplers were not obtained.
___ was initially started on therapeutic lovenox and then
transitioned to xarelto. ___ will continue on a loading dose
until ___ follows up with his doctors in ___ for
further management.
#HFpEF: BNP was also obtained at the time of admission and found
to be elevated at 1368. His exam was notable for lower extremity
edema and crackles half way up lung fields bilaterally. Echo was
notable for mild eccentric left ventricular hypertrophy with
mild cavity dilatation, severe diastolic dysfunction, and
severe pulmonary artery systolic hypertension. ___ was diuresed
with multiple doses of 40mg IV lasix with good response, losing
___ pounds. Once ___ reached his dry weight of around 210 lbs, ___
was transitioned to 20 mg PO lasix daily. ___ remained euvolemic
without rise in creatinine and was discharged on this regimen.
#Nocturnal hypoxia: Patient was maintained on continuous
telemetry to monitor oxygen saturation. ___ was noted to have
several episodes over the course of three nights where his
oxygen saturation decreased to as low as 83%. Upon further
history, his wife reports that ___ does typically snore at night
and she has witnessed episodes of apnea. Taking into account
with his echo evidence of severe pulmonary hypertension, it is
highly likely that the patient has OSA. ___ was notified of the
need to have a sleep study and plans to do so upon his return to
___.
*Transitional Issues*
- Patient started on loading dose of xarelto, ___ will need to
have his dosing readjusted after 21 days. ___ end of loading
dose).
- Patient started on 20mg PO lasix daily. Please assess adequacy
of duiresis. **PLEASE CHECK ELECTROLYTES WITHIN 7 DAYS OF
DISCHARGE**
- Patient urgently needs a sleep study when home in ___. During his admission, ___ had nocturnal desaturations
as low as 83% on room air.
- Patient had an 8 mm right upper lobe pulmonary nodule noted on
CT. Recommended f/u in ___ months.
- Patient was transitioned to aspirin 81mg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acebutolol 200 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Fenofibrate 145 mg PO DAILY
6. GlipiZIDE XL 10 mg PO DAILY
7. hydroquinone 4 % topical BID to hyperpigmentation on hands
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO TID
11. Tamsulosin 0.4 mg PO BID
12. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
13. Aspirin 325 mg PO DAILY
14. Magnesium Oxide 400 mg PO DAILY
15. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
16. Omeprazole 20 mg PO DAILY
17. Vitamin E 400 UNIT PO DAILY
18. Ezetimibe 10 mg PO DAILY
19. Doxycycline Hyclate 100 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*40 Tablet Refills:*0
2. Acebutolol 200 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Ezetimibe 10 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Fenofibrate 145 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tamsulosin 0.4 mg PO BID
10. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Amlodipine 5 mg PO DAILY
13. Doxycycline Hyclate 100 mg PO DAILY
14. GlipiZIDE XL 10 mg PO DAILY
15. hydroquinone 4 % topical BID to hyperpigmentation on hands
16. Lisinopril 20 mg PO DAILY
17. Magnesium Oxide 400 mg PO DAILY
18. MetFORMIN (Glucophage) 500 mg PO TID
19. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
20. Vitamin E 400 UNIT PO DAILY
21. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: bilateral pulmonary emboli; diastolic heart
failure
secondary diagnosis: pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
It was a privilege caring for during your time at the ___
___. You were diagnosed with blot
clots in both of your lungs. You were first started on a blood
thinner called Lovenox but will take a different medication
called Xarelto (rivaroxiban) once you leave the hospital. Also,
you were found to have excessive fluid in your body related to
the function of your heart. You will need to continue a
medication known as furosemide daily in order to keep excess
fluid from reaccumulating. Please also limit the amount of salt
and liquids that you consume.
Lastly, we have noticed that you occassionally have lower levels
of oxygen at night. This may be due to a previously undiagnosed
sleep apnea versus issues related to your recent clots.
Furthermore, your most recent echocardiogram showed signs of a
condition known as pulmonary hypertension. Therefore, it is of
utmost importance that you follow-up with a sleep study once you
return to ___. We will schedule for you to follow up
with a doctor in the area prior to your return home. Please feel
free to reach out if you have any further questions.
In summary please make the following changes:
1. Please continue the Xarelto twice daily until ___.
2. Please continue the 20mg furosemide daily until you follow up
as an outpatient.
3. You will now be taking a lower dose of aspirin daily. You
will now take a "baby" aspirin of 81 mg.
4. It is very important that you follow up with your
cardiologist in ___ to obtain a sleep study. It is highly likely
that you have a condition known as sleep apnea.
5. Please follow up with your doctors in ___ regarding all
aspects of this recent admission. (f/u appointment scheduled,
see below)
6. You will be seen by our doctors as ___ outpatient before you
return home.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10528291-DS-12 | 10,528,291 | 24,109,075 | DS | 12 | 2197-10-26 00:00:00 | 2197-10-26 10:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Gentamicin / shrimp
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Aortic valve replacement with 19mm On-X valve)/coronary artery
bypass grafting times three (LIMA to LAD, SVG to OM, SVG to
___
History of Present Illness:
Ms. ___ is a ___ year old female with a history of diabetes
mellitus, hyperlipidemia, and hypertension, diabetic nephropathy
s/p renal
transplant (___), cardiac murmur for years. She describes a
couple of months of substernal chest pain, described as a
burning sensation, that radiates to her neck. The pain was
attributes to a new finding of aortic stenosis. She was
scheduled to meet with Dr. ___ cardiac surgery next week to
discuss an aortic valve replacement. Two days ago her insulin
pump was malfunctioning and
her blood sugars were elevated in the 400s. During this time she
began to experience similar chest pain but it was now occuring
at rest. She was
seen by ___ and ___ pump was fixed. After blood sugars
normalized her chest pain resolved. EKG however showed new ST
depressions in the lateral leads. Initial troponin was negative,
repeat troponins were elevated at 0.2 -> 0.7. She was given ASA
325mg, started on IV heparin, and admitted to the cardiology
service. She is to undergo cardiac catherization ___. Cardiac
surgery
was consulted to evaluate for aortic valve replacement and
possible coronary artery bypass grafting.
Past Medical History:
TYPE I DM with renal failure, retinopathy
AORTIC STENOSISmild, last echo ___ ef 60-70% and valve area
1.6 peak velocity 2.5 gradient 26X
GASTROESOPHAGEAL REFLUxdocumentation of severe edema in the
hypopharynx and larynx by laryngoscopic exam, Dr ___. PPI RX
instituted ___
s/p TAHBSO endometriosis and large ovarian cyst. Followed by Dr.
___
MULTINODULAR GOITER
OSTEOPENIApremenopausal. On estrogen
RETINOPATHY s/p laser surgery. Followed by Dr. ___,
___.
S/P KIDNEY TRANSPLANTTransplant was from brother, Followed by
Dr. ___, nephrologist, and Dr. ___
Clinic
SKIN CANCERSMultiple nevi, ___ required ___ surgery for a
squamous cell lesion rt leg
dyslipidemia
PSH renal transplant ___ years ago and also a total abdominal
hysterectomy in ___.
Social History:
___
Family History:
sister with DM and ESRD, received kidney from her father, recent
KP transplant at ___. She has a son in his ___ with bipolar
disorder. mom with breast cancer.
Physical Exam:
Admission PE:
Pulse:88 Resp:16 O2 sat: 98 RA
B/P Right:150/60 Left:150/60
Height: 5'4" Weight:134lbs
General:
Skin: Dry [x] intact [x]Scars from skin ___ biopsy/treatment,
surgical scar well healed
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ___
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema none [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+2 Left:+2
DP Right:+1 Left:+2
___ Right:+1 Left:+2
Radial Right:+1 Left:+1
Carotid Bruit Right:+1 Left:+1
Pertinent Results:
ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ TEE
(Complete) Done ___ at 4:58:50 ___ PRELIMINARY
Referring Physician ___
___ of Cardiothoracic Surg
___
___ Status: Inpatient DOB: ___
Age (years): ___ F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: intraop CABG AVR. Evauate aortic valve, ventricles,
aortic contours
ICD-9 Codes: 402.90, 786.05, 786.51, V43.3, 424.1
___ Information
Date/Time: ___ at 16:58 ___ MD: ___, MD
___ Type: TEE (Complete) Sonographer: ___, MD
Doppler: Full Doppler and color Doppler ___ Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: ___-: Machine: u/s 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *56 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT pk vel: 1.31 m/sec
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.9 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 100 ms
Mitral Valve - MVA (P ___ T): 2.2 cm2
Findings
LEFT ATRIUM: No mass/thrombus in the ___. No spontaneous
echo contrast is seen in the ___. Good (>20 cm/s) ___ ejection
velocity. All four pulmonary veins identified and enter the left
atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the body of the RA. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (area
<1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. ___ MR.
___ VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
___. Informed consent was obtained. A TEE was performed in
the location listed above. I certify I was present in compliance
with ___ regulations. The ___ was under general anesthesia
throughout the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Prebypass: Overall left ventricular systolic function is normal
(LVEF>55%). Thick ventricular walls with no wall motion
abnormalities visualized. 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 simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area <1.0cm2). Mild (1+) aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Postbypass: ___ is AV paced on phenylepherine infusion on
phenylepherine infusion. Preserved Biventricular function LVEF
>55%.
___ CXR
In comparison with the study of ___, there is increased
opacification
at the bases consistent with worsening pleural effusions and
continued
compressive atelectasis. Continued moderate cardiomegaly with
some elevation
of pulmonary venous pressure. Given the basilar changes, in the
appropriate
clinical setting superimposed pneumonia would have to be
considered.
___. ___
___ 06:00AM BLOOD WBC-12.5* RBC-2.69* Hgb-8.7* Hct-27.0*
MCV-100* MCH-32.5* MCHC-32.4 RDW-18.4* Plt ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Glucose-99 UreaN-96* Creat-2.3* Na-135
K-5.0 Cl-100 HCO3-27 AnGap-13
___ 06:00AM BLOOD WBC-12.5* RBC-2.69* Hgb-8.7* Hct-27.0*
MCV-100* MCH-32.5* MCHC-32.4 RDW-18.4* Plt ___
___ 05:50AM BLOOD ___
___ 05:50AM BLOOD Glucose-122* UreaN-96* Creat-2.4* Na-133
K-5.3* Cl-99 HCO3-30 AnGap-9
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of severe
aortic stenosis, diabetes mellitus, s/p living kidney
transplant, presenting with chest pain, ST depressions in
lateral leads and elevated troponins concerning for NSTEMI. She
has a history of CP on exertion and had thought to be due to
severe aortic stenosis. She was treated with heparin drip,
statin, metoprolol and aspirin. She underwent a diagnostic
catheterization and was found to have three vessel disease.
Cardiac surgery was consulted. Her surgery was initially delayed
48 hours to protect her transplant kidney from contrast induced
nephropathy. On the morning of surgery she had an episode of
chest pain that was less intense than when she presented but it
did respond to nitroglycerin. On ___ she underwent an aortic
valve replacement with an On-X valve and a coronary artery
bypass grafting times three. Please see the operative note for
details. She tolerated the procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. By the following day she awoke sleepy but neurologically
intact and extubated. Coumadin was started for her On-X valve.
On post-operative day two her chest tubes and wires were
removed.By the following day her INR became supratherapeutic and
she was given vitamin K. As her mental status became more alert
her insulin pump was restarted and she transferred to the
surgical step down floor. She continued to progress. She was
started on heparin gtt when her INR became subtherapeutic. She
developed ___ which initially improved then worsened. She was
followed by the nephrolgy service. There was concern that she
was rejecting her kidney. She was started on IV steroids, TTE
suggested that she was dry and fluids were pushed. Her renal
function improved although not yet at baseline. Her maintainance
prednisone dose was increased and cyclosporin adjusted per
levels. As a result of the steroid load she was hyperglycemic,
which was difficult to manage on insulin pump alone. She was
readmitted to the CVICU for blood sugar management. With the
help ___ she was transitioned back to her insulin pump and
her blood sugars have stabilized. She was seen by the physical
therapy department and deemed safe for discarge to rehab once
she was medically cleared.Renal continued to follow and felt a
renal biopsy was not warranted at this time. On the day of
discharge her BUN/Cr were slightly elevated at 96/2.4. Discussed
with ___ and they felt she was OK for discharge with the
appropriate lab monitoring and results faxed to ___
Renal Transplant. Her INR was therapeutic for her mechanical
AVR. And her blood sugar control was improving. On pod# 15 she
was ambulating, wounds were healing well and pain was well
controlled. She was cleared for discharge to ___ in
___. All follow-up apppointments arranged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO EVERY OTHER DAY
2. PredniSONE 2.5 mg PO EVERY OTHER DAY
3. Valsartan 40 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety / insomnia
5. Diltiazem Extended-Release 240 mg PO BID
6. Estradiol Transdermal Patch (estradiol) 0.025 mg transdermal
twice weekly
7. Atorvastatin 40 mg PO DAILY
8. Azathioprine 50 mg PO DAILY
9. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. Aspirin 81 mg PO DAILY
13. Hydrochlorothiazide 25 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: ___
Fingersticks: QAC and HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
pleas check cyclo troughs daily 12hrs after ___ dose
4. Insulin Pump SC (Self Administering Medication)
Basal Rates:
Midnight - 4 am: .7 Units/Hr
4 am - 7 am: 1 Units/Hr
7 am - 10 pm: .9 Units/Hr
10 pm - 12 am: .7 Units/Hr
Meal Bolus Rates:
Breakfast = 1:6
Lunch = 1:6
Dinner = 1:7
Snacks = 1:7
High Bolus:
Correction Factor = 1:50
Correct To ___ mg/dL
MD acknowledges ___ competent
MD has ordered ___ consult
MD has completed competency
5. Omeprazole 20 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Bisacodyl ___AILY:PRN constipation
9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
10. Docusate Sodium 100 mg PO BID
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. Metoprolol Tartrate 25 mg PO TID
14. Polyethylene Glycol 17 g PO DAILY
15. Sucralfate 1 gm PO QID
16. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
17. ___ MD to order daily dose PO DAILY16 MECH valve
18. Estradiol Transdermal Patch (estradiol) 0.025 mg transdermal
twice weekly
19. Multivitamins 1 TAB PO DAILY
20. Azathioprine 50 mg PO DAILY
21. PredniSONE 5 mg PO DAILY
22. Warfarin 3 mg PO ONCE Duration: 1 Dose
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
severe aortic stenosis
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10528291-DS-13 | 10,528,291 | 25,609,322 | DS | 13 | 2197-11-19 00:00:00 | 2197-11-20 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gentamicin / shrimp
Attending: ___
Chief Complaint:
abdominal cramping and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ T1DM c/b ESRD s/p living relative kidney transplant ___ on
immunosuppression, CAD+AS s/p CABGx3 and AVR w mech valve
___, htn/hl, now p/w severe diffuse abdominal cramping and
diarrhea.
Since CABG and AVR early ___, pt has stayed 2 weeks at
rehab. She returned home on ___. In past month, she has been
constipated ___ pain meds. She repors sig. cramping this past
___. On day of admisison, pt c/o diffuse abd cramping w/
radiation to back, diarrhea, n/v. She also notes blood w/ mucus
mixed with diarrhea. No fevers or chills. she denies recent
drinking or history of gallstones. She reports that insulin pump
is functional. She denies unusual food, sick contact, recent
travels. she denies recent antibiotics. no cp, no sob. She has
been taking warfarin daily as instructed. She denies
palpitation.
Of note, her immune suppression regimen was increased due to
concern for rejection at last hospitalization.
In the ED initial vitals were: 10 97.9 90 167/77 20 100%. Labs
were significant for UA 30 prot, trace ketones; WBC 8.7; H/H
9.6/29.8; plt 485; LFT's WNL; Cr 1.7 (Cr had been in mid 1's
through early ___, then increased to mid 2's to peak 4,
down to 2.4 on ___,
- Patient was given cipro/flagyl, metoprolol tartrate 25mg,
warfarin, cyclosporin, dilaudid 0.5mg x 1. zofran 4mg x 2. 500ml
NS.
Vitals prior to transfer were: 97.7 94 156/70 16 97% RA
On the floor, pt c/o n/v, as well sig. abd cramping. she was
unable to tolerate drinks.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
TYPE I DM with renal failure, retinopathy
AORTIC STENOSISmild, last echo ___ ef 60-70% and valve area
1.6 peak velocity 2.5 gradient 26X
GASTROESOPHAGEAL REFLUxdocumentation of severe edema in the
hypopharynx and larynx by laryngoscopic exam, Dr ___. PPI RX
instituted ___
s/p TAHBSO endometriosis and large ovarian cyst. Followed by Dr.
___
MULTINODULAR GOITER
OSTEOPENIApremenopausal. On estrogen
RETINOPATHY s/p laser surgery. Followed by Dr. ___,
___.
S/P KIDNEY TRANSPLANTTransplant was from brother, Followed by
Dr. ___, nephrologist, and Dr. ___
___
SKIN CANCERSMultiple nevi, ___ required ___ surgery for a
squamous cell lesion rt leg
dyslipidemia
PSH renal transplant ___ years ago and also a total abdominal
hysterectomy in ___.
Social History:
___
Family History:
sister with DM and ESRD, received kidney from her father, recent
KP transplant at ___. She has a son in his ___ with bipolar
disorder. mom with breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.7 185/80 100 18 100%RA
GENERAL: c/o abd cramping
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, diffusely tender 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
DISCHARGE PHYSICAL EXAM:
VSS, Afebrile
GENERAL: NAD resting in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1 loud S2
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, moving all 4 extremities
with purpose, lower extremities with nonpitting edema to knees
PULSES: 2+ DP pulses bilaterally
NEURO: grossly normal, aox3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION
___ 03:25PM BLOOD WBC-8.7 RBC-3.12* Hgb-9.6* Hct-29.8*
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.7* Plt ___
___ 03:25PM BLOOD Neuts-87.7* Lymphs-6.4* Monos-5.0 Eos-0.8
Baso-0.2
___ 03:25PM BLOOD Plt ___
___ 11:30PM BLOOD ___ PTT-35.2 ___
___ 03:25PM BLOOD Glucose-231* UreaN-31* Creat-1.7* Na-136
K-4.4 Cl-98 HCO3-24 AnGap-18
___ 03:25PM BLOOD ALT-12 AST-24 AlkPhos-71 TotBili-1.0
___ 03:25PM BLOOD Lipase-19
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.05*
___ 03:10PM BLOOD CK-MB-2 cTropnT-0.04*
___ 03:25PM BLOOD Albumin-3.8
___ 06:00AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.4*
___ 06:00AM BLOOD Cyclspr-134
___ 03:30PM BLOOD Lactate-1.8
___ 03:25PM URINE Color-Straw Appear-Clear Sp ___
___ 03:25PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
___ 03:25PM URINE RBC-4* WBC-4 Bacteri-NONE Yeast-NONE
Epi-4
___ 03:25PM URINE CastHy-1*
LABS ON DISCHARGE
___ 07:28AM BLOOD WBC-9.0 RBC-2.87* Hgb-8.9* Hct-27.5*
MCV-96 MCH-31.0 MCHC-32.4 RDW-16.0* Plt ___
___ 07:28AM BLOOD Plt ___
___ 05:22AM BLOOD ___ PTT-35.8 ___
___ 05:22AM BLOOD Plt ___
___ 07:28AM BLOOD Glucose-163* UreaN-29* Creat-1.6* Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
___ 07:28AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.9
___ 04:50PM URINE Color-AMBER Appear-Hazy Sp ___
___ 04:50PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
___ 04:50PM URINE RBC-11* WBC-6* Bacteri-FEW Yeast-NONE
Epi-14 TransE-<1
___ 04:50PM URINE CastHy-46*
___ 04:50PM URINE Mucous-RARE
MICRO
___ 6:00 am Immunology (CMV)
**FINAL REPORT ___
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.
___ 12:14 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ AT 9:37AM
ON
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 11:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
IMAGING
CHEST (PORTABLE AP) Study Date of ___
1. A moderate left pleural effusion has enlarged since ___. 2. Normal bowel gas pattern on included views
of the abdomen.
CT ABD & PELVIS W/O CONTRAST Study Date of ___
1. Fat stranding around the transverse and descending colon.
Although not well distended there is suggestion of wall
thickening in these regions concerning for colitis. No
intraperitoneal free air or signs of bowel perforation.
2. Partially visualized large left pleural effusion and small
pericardial effusion.
3. Right basilar ground-glass opacities, potentially due to
atelectasis
although infection or aspiration are possible.
ECG ___
Sinus rhythm. Left atrial abnormality. Poor R wave progression,
likely a
normal variant. Compared to the previous tracing of ___ the
findings are similar.
Brief Hospital Course:
HOSPITAL COURSE: ___ T1DM c/b ESRD s/p living relative kidney
transplant ___ on immunosuppresion, recently increased dosing,
CAD+AS s/p CABGx3 and AVR w/ mech valve ___, p/w diffuse
abdominal cramping, diarrhea, nausea and vomiting, found to have
C.diff colitis, responded to flagyl, with resolved diarrhea.
ACTIVE ISSUES:
#C diff colitis: Presenting w/abdominal cramping, with mucous
and blood mixed with stool, as well as nausea/vomiting; denies
recent abx, but has been in ECF s/p AVR last month. CT abd
showed signs of colitis at transverse and descending colon. On
flagyl, BMs decreased in frequency, nausea/emesis resolved, she
remained afebrile (though on immunosuppresion) with resolving
leukocytosis on flagyl.
# ESRD s/p living relative kidney transplant ___ - ___ 1.5 at
baseline on admission and 1.5 today. Recent concern for
rejection w/ recently increased immunosuppression regimen
(cyclosporine). Continued home CycloSPORINE (Neoral) MODIFIED
100 mg PO Q12H, Azathioprine 50 mg PO DAILY, and PredniSONE 5 mg
PO DAILY in the hospital.
# Acute on chronic anemia with LGIB ___ colitis - H/H stable,
near baseline, and hemodynamically stable. She had an active
t&s, PIVs, and was treated for colitis as above. No further
intervention was required.
# CAD+AS s/p CABGx3 and AVR ___, INR therapeutic. Home
aspirin, metoprolol, statin, warfarin were continued (dose
adjusted per worksheet while on flagyl). She was discharged with
close PCP follow up for INR monitoring while on flagyl. Home
lasix was briefly held in the setting of C.diff colitis, and
resumed prior to discharge.
CHRONIC ISSUES:
#Hypertension: continued home meds of metoprolol, valsartan
# T1DM - BS 144 on admission. Home insulin pump was functional
and reviewed by ___.
# GERD - continued Omeprazole 20 mg PO BID
TRANSITIONAL ISSUES:
- CONTINUE FLAGYL FOR TWELVE MORE DAYS FOR TOTAL 14 DAY CORUSE
ENDING ON ___
- CBC, CHEM 10, INR and CYCLOSPORINE level check on ___
- CT abdomen/pelvis noted " Partially visualized large left
pleural effusion and small pericardial effusion," the former of
which was also noted on subsequent chest x-ray. Since she was
breathing comfortably, no drainage was performed in hospital.
Monitor on an outpatient basis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
4. Omeprazole 20 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
7. Bisacodyl ___AILY:PRN constipation
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. Docusate Sodium 100 mg PO BID
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. Metoprolol Tartrate 25 mg PO TID
13. Polyethylene Glycol 17 g PO DAILY
14. Sucralfate 1 gm PO QID
15. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
16. ___ MD to order daily dose PO DAILY16 MECH valve
17. Estradiol Transdermal Patch (estradiol) 0.025 mg transdermal
twice weekly
18. Multivitamins 1 TAB PO DAILY
19. Azathioprine 50 mg PO DAILY
20. PredniSONE 5 mg PO DAILY
21. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
22. Valsartan 40 mg PO DAILY
23. Ondansetron 4 mg PO Q4H:PRN nausea
24. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Azathioprine 50 mg PO DAILY
5. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Metoprolol Tartrate 25 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. Ondansetron 4 mg PO Q4H:PRN nausea
13. PredniSONE 5 mg PO DAILY
14. Sucralfate 1 gm PO QID
15. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
16. Vitamin D 1000 UNIT PO DAILY
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q8 Disp #*36
Tablet Refills:*0
18. Bisacodyl ___AILY:PRN constipation
19. Docusate Sodium 100 mg PO BID
20. Estradiol Transdermal Patch (estradiol) 0.025 mg transdermal
twice weekly
21. Furosemide 20 mg PO DAILY
22. Polyethylene Glycol 17 g PO DAILY
23. Valsartan 40 mg PO DAILY
24. Warfarin 1 mg PO DAILY16 MECH valve
25. Insulin Pump SC (Self Administering Medication)
Basal rate minimum: 0.45 units/hr
Basal rate maximum: 0.1 units/hr
Bolus minimum: -- units
Bolus maximum: -- units
Target glucose: 80-180
26. Outpatient Lab Work
Please get CBC, INR, Chem 10, and cyclosporine level at your
PCP's office ___ Dr. ___.
27. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #*4
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Clostridium Difficile Infection
Aortic Valve Replacement
End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with diarrhea that was found to be
due to an infection with 'clostridium difficile' or ' c diff'.
You were treated with antibiotics and you improved. Please
ensure good hand hygiene at home and continue antibiotics for a
total of two weeks.
Followup Instructions:
___
|
10528629-DS-17 | 10,528,629 | 27,601,599 | DS | 17 | 2143-10-24 00:00:00 | 2143-10-24 21:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ Stage IIB breast CA on chemo ___ C3D1 dd-AC, C4
held on ___ due to fever) presenting with fever and cough.
Fevers for the last 2 days (Tmax 102-104) with nonproductive
cough, post-tussive non-bloody emesis, and dyspnea. Her symptoms
have been persistant since ___ when she was seen by her
outpatient oncologist. CTA was negative for PE which was
performed d/t complaints of dyspnea. Ground glass opacities were
seen. She received IV hydration. However she has continued to
spike fevers. Denies nausea but is persistantly having post
tussive emesis. Tessalon pearls are helping. Respiratory panel
is pending. Denies any ill contacts.
Past Medical History:
PMH/PSH:
mildly elevated BP
elevated LDL
chronic headache
Social History:
___
Family History:
Family History:
She has a maternal cousin who was diagnosed with breast
cancer in her early ___, and is now alive and well. There is
another cousin or perhaps a second cousin who is alive and well
in her ___ and at some point had breast cancer, but she did not
know the details. Both of her parents were heavy smokers and
had
lung cancer. However, they die from other causes. Her father
passed away from COPD. Her mother passed away from a ruptured
aneurysm.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1, 110/68, 98, 18, 99%RA
GEN: NAD
HEENT: PERRL, EOMI, slightly dry MM, oropharynx clear, no
cervical ___: CTAB, no wheezes, rales or rhonchi.
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, motor grossly intact
DISCHARGE PHYSICAL EXAM:
T 98.0 (Tmax 99.1) HR 112 (93-112) BP 100/62 RR 19 95% RA
GENERAL: Middle aged women with evidence of hair loss. Sitting
up in bed; appears comfortable.
SKIN: no rashes
HEENT: EOMI, MMM
NECK: nontender supple neck, no LAD including no submandibular
or supraclavicular lymphadenopathy.
CARDIAC: RRR no murmurs
LUNG: CBTA. No crackles/wheezes.
ABDOMEN: Soft, nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact.
Pertinent Results:
ADMISSION LABS:
___ 01:00AM BLOOD WBC-7.0 RBC-3.31* Hgb-10.2* Hct-29.5*
MCV-89 MCH-31.0 MCHC-34.7 RDW-16.2* Plt ___
___ 01:00AM BLOOD Glucose-118* UreaN-8 Creat-0.8 Na-134
K-3.6 Cl-101 HCO3-22 AnGap-15
___ 01:00AM BLOOD Calcium-8.6 Mg-2.2
___ 02:01AM BLOOD Lactate-0.7
DISCHARGE LABS:
___ 05:54AM BLOOD WBC-5.9 RBC-2.93* Hgb-9.0* Hct-26.1*
MCV-89 MCH-30.7 MCHC-34.5 RDW-16.8* Plt ___
___ 05:54AM BLOOD Glucose-99 UreaN-4* Creat-0.6 Na-139
K-3.6 Cl-104 HCO3-25 AnGap-14
___ 05:54AM BLOOD LD(LDH)-321*
___ 01:00AM BLOOD LD(___)-356*
___ 05:54AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
___ 02:01AM BLOOD Lactate-0.7
___ 01:05PM BLOOD B-GLUCAN-PND
IMAGINING:
CXR ___ IMPRESSION: No evidence of focal pneumonia. MIld
diffuse prominence of lung markings is compatible with the
nonspecific ground glass opacities identified on the ___lbeit likely accentuated by underpentrated technique.
___: CTA:
IMPRESSION:
1. No evidence of a pulmonary embolism or acute aortic injury.
2. Bilateral pulmonary nodules as described above. A followup
chest CT is
recommended in 3 months to assess for interval change. There is
also bilateral hilar and borderline mediastinal adenopathy which
require followup given the patient's history of breast cancer.
3. Bilateral nonspecific ground-glass opacities which may be
due to
air-trapping or a resolving infectious or inflammatory process.
4. 4.3 x 3.5 cm fluid collection in the right breast soft
tissues, likely representing a post-surgical seroma.
___: Echo:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and 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
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
___ w/ Stage IIB breast CA on chemo presenting with fever and
cough, with ___ chest CT showing ground glass opacities and no
PE. Ddx pneumonia, likely viral or atypical vs bacterial
including dx of PCP. No h/o CHF. CXR consistent with ground
glass opacities. PCP was entertained; ambulatory sat was normal,
expectorated suptum for PCP was negative. Bd glucan was pending
upon discharge. However, given her clinical improvement the most
likely cause of her symptoms is viral. She was continued on a
course of cefpodoxoine/azithromycin given she was started in
house and unclear if this was attributing to her recovery.
Tessalon perals and Guaifenesin-CODEINE for comfort.
She was anemic during the course of her hospital stay. She had
no active signs or symptoms of bleeding and remained
hemodynamically stable. However, this should be followed-up as
an outpatient.
She tolerated a PO diet and had adequate pain control by
discharge.
Transitional issues:
-------------------
[ ] continue to monitor cough and fever for resolution
[ ] recheck CBC and trend anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. cranberry extract-vit C 250-60 mg oral prn cold
3. Ibuprofen 400 mg PO Q8H:PRN headache
4. Ranitidine 150 mg PO DAILY
5. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN rash
6. Prochlorperazine ___ mg PO Q6H:PRN nausea
7. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Prochlorperazine ___ mg PO Q6H:PRN nausea
4. Ranitidine 150 mg PO DAILY
5. cranberry extract-vit C 250-60 mg oral prn cold
6. Ibuprofen 400 mg PO Q8H:PRN headache
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN rash
8. Azithromycin 250 mg PO Q24H Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
9. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*4 Tablet Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Outpatient Lab Work
Please have a CBC drawn on ___ to be fax to Dr. ___
office at ___. ICD-9 code ___
Discharge Disposition:
Home
Discharge Diagnosis:
Lower respiratory illness
Stage IIB breast
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 due to your fevers and cough.
You remained afebrile here in the hospital and your cough was
treated with cough syrup and tessalon pearls. This most likely
cause of your symptoms is a virus since you are continuing to
recover.
Please have your blood count check at your follow-up appointment
on ___ with Dr. ___.
Followup Instructions:
___
|
10529000-DS-11 | 10,529,000 | 29,759,172 | DS | 11 | 2197-01-03 00:00:00 | 2197-01-03 19:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right shoulder pain
Major Surgical or Invasive Procedure:
Open Reduction and Internal Fixation of Right Humerus
History of Present Illness:
___ yo M PMH UC and anklylosing splodylitis presenting
complaining of fall and shoulder pain. Patient states he was
walking the dog when he tripped and fell with his arm
outstretched on his left shoulder. He endorses intermittent left
hand and arm paresthesias which have resolved. He denies LOC.
Past Medical History:
Ankylosing spondylitis, ulcerative colitis, asthma
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, A&Ox3
RUE
Patient in sling
Fires EPL/FPL/FDP/FDS/EDC/DIO
SILT radial/median/ulnar
palp radial pulse, wwp distally
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have proximal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF humerus, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight-bearing in the right upper extremity. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY Duration: 2 Weeks
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*14 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID PRN Disp
#*28 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 capsule(s) by mouth ___ capsules q4 Hr Disp
#*60 Capsule Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tablet by mouth BID PRN Disp #*28 Tablet
Refills:*0
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Mesalamine ___ 2400 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Fracture and dislocation of Right Humerus
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:
-Non-weight bearing in sling until follow up in clinic
-Range of motion as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10529284-DS-16 | 10,529,284 | 27,605,595 | DS | 16 | 2137-12-05 00:00:00 | 2137-12-05 12:28:00 |
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:
Left occipital crani/ gross total resection of BT ___
History of Present Illness:
Mr. ___ is an ___ year-old male transferred from OSH with a
left occipital mass with edema. Mr. ___ states that he has
felt confused and noticed some word-finding difficulties. He
also had a difficult time driving his car. His daughter noticed
some confusion as well and brought him to the hospital today. At
the OSH, he underwent a head CT which showed a left occipital
mass with vasogenic edema. He also underwent a CT of the abdomen
and pelvis. He received a loading dose of Dexamethasone prior to
transfer to ___. Today he notes a generalized sensation of
confusion and word-finding difficulties. He denies diplopia,
blurred vision, nausea or vomiting. He denies headaches.
Past Medical History:
Type II DM; Hypertension; Hyperlipidemia
Social History:
___
Family History:
He has a sister with colon cancer.
Physical Exam:
On admission:
T: 98.0 BP: 145/68 HR: 83 RR: 16 O2Sats 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and "hospital" when provided
choices. Not oriented to city or time.
Language: Speech with frequent pauses and word-finding
difficulties.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Decreased hearing. + bilateral hearing aids.
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 bilaterally.
Toes downgoing bilaterally.
+ dysmetria bilaterally.
Handedness: Right.
On discharge:
A&Ox3 (self, ___, PERRL, EOMI, Face symmetrical
Full motor t/o, Dysmetria improved.
Incision cd&i, with sutures in place.
Pertinent Results:
___ CT TORSO W/CONTRAST; OUTSIDE FILMS READ ONLY
1. 15 mm spiculated nodule in the right upper lobe concerning
for malignancy.
2. Multiple other smaller nodules as described above. If prior
studies exist for comparison it could be helpful, otherwise
recommend close attention on followup.
3. Nodules in the left adrenal gland are incompletely
characterized but
concerning for metastases given the clinical situation.
___ MRI head with contrast
Left occipital lobe 4.3 cm parenchymal peripherally enhancing
mass with
associated surrounding edema and left lateral ventricular and
sulcal
effacement likely secondary to metastasis. No other suspicious
lesions are noted.
MR HEAD W/ CONTRAST ___
Essentially unchanged left occipital lobe ring-enhancing mass
lesion,
associated with vasogenic edema and effacement of the sulci as
can detail
above, no new lesions are identified since the most recent
examination.
Fiducial markers are in place.
CT HEAD W/O CONTRAST ___
Status post left occipital craniotomy with resection of the
underlying
occipital lesion. Trace amount of hemorrhage in the resection
cavity. No
significant mass effect.
MR HEAD W & W/O CONTRAST ___
IMPRESSION:
1. Postsurgical changes from left occipital craniectomy and
resection of a posterior parietal mass as described above. There
is a curvilinear focus of enhancement in the anterior lateral
surgical bed, which may represent residual tumor.
2. Interval development of acute infarct of the left occipital
lobe, adjacent to the surgical bed.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
8:02 AM
IMPRESSION:
1. Evolving infarct of the left occipital lobe as seen on prior
MR.
2. Expected postoperative changes with no evidence of new large
hematoma.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service for further
management and evaluation of his left occipital brain mass. The
patient was started on Keppra 500mg BID for seizure prophylaxis.
He was also ordered for his home medications while work-up was
completed for possible metastatic disease. A CT chest, abdomen
and pelvis was performed showing multiple lung nodules (RUL most
concerning for metastatic disease) and a left adrenal gland
nodule. A MRI of the head with contrast was ordered to further
evaluate the brain mass. Neuro-oncology and neuro-radiation
services were asked to see the patient for their feedback on the
patient's treatment plan.
On ___ Dr. ___ spoke with family. MRI done completed and
reveals shows solitary left occipital lesion. RN called with
concern of swollen, red L ankle. With ? of gout, uric acid
level sent and was found to be normal. Ankle improved
thereafter.
On ___ Patient received 1 unit prbc for Hbg < 7. Lasix 20mg
given after. Neurologically stable.
On ___ Family has made decidion they would like to proceed with
OR for tumor resection.
On ___ He was started on Keflex ___ QID for concern of
celluitis of LLE. Patient was preopped for surgical procedure
tomorrow.
On ___ The patient was taken to the OR for a craniotomy and
resection of a tumor. Post operatively he was transferred to the
icu extubated for close monitoring. ID recommended dermatology
consult for LLE cellulitis. Post op head CT showed normal post
op changes. On post op examination, patient was intact.
On ___, patient remained intact. He is currently treated with
cefazolin for cellulitis on L ankle and patient reports marked
improvement in pain. Erythema was improved as well on exam. ID
recommended changing to keflex ___ QID until ___. His foley
was removed and he was evaluated by ___. He was also transferred
to the floor. Decadron taper was started.
On ___, patient remained stable on examination. ___ continued
to evaluate patient and determined that he requires rehab. Heme
onc was consulted and recommended outpatient follow for staging.
He awaits discharge to rehab.
On ___, The patient had new complaints of intermittent bright
light in vision field. The patients keppra was increased from
500 mg BID to 1 gram BID. The patient's NCHCT stable. Dr ___
___ neuro oncology and recommendations were to have the patient
on 6 mg po qd until follow up. The patients serum BUN was
elevated at 32 and the patient was given 250 cc normal saline
bolus.
On ___, the patient remained neurologically and hemodynamically
intact. He was discharged to rehab in stable conditions.
Medications on Admission:
Januvia 100mg PO daily; Amlodipine 5mg PO daily; HCTZ 12.5 PO
daily; Lisinopril 20mg PO daily; Zoloft 25mg PO daily; Iron,
unknown dose; Simvastatin 20mg PO daily; Pioglitazone 15mg PO
daily; Embrel weekly
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Cephalexin 500 mg PO Q6H
Continue to take until ___.
4. Dexamethasone 6 mg PO DAILY
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO BID
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. Glucose Gel 15 g PO PRN hypoglycemia protocol
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. LeVETiracetam 1000 mg PO BID
Continue to take until instructed otherwise.
12. Lisinopril 20 mg PO DAILY
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery.
14. Sertraline 25 mg PO DAILY
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
16. Simvastatin 20 mg PO QPM
17. Senna 8.6 mg PO BID:PRN constipation
18. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Occipital Mass
Discharge Condition:
Alert & oriented x3 (self, ___, year). Full motor t/o,
Dysmetria improved.
inturpted non disolvable sutures
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with non-dissolvable sutures then you
must wait until after they are removed to wash your hair. You
may shower before this time using a shower cap to cover your
head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Pepcid), as
these medications can cause stomach irritation. Make sure to
take your steroid medication with meals, or a glass of milk.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10529502-DS-17 | 10,529,502 | 20,748,724 | DS | 17 | 2165-01-16 00:00:00 | 2165-01-16 23:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hand swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date:
___
Time: 2330
_
________________________________________________________________
PCP: ___ does not have a PCP. ___ would like to have a PCP at ___.
.
_
________________________________________________________________
HPI:
----
The patient is a ___ year old male with h/o depression, PSA-
alcohol, intra-nasal cocaine/tobacco, multiple sexual partners
who presents with recurrent hand cellulitis. ___ first developed
a swollen red L hand 3 weeks ago which was treated with po abx
in the setting of bed bug bites. ___ was treated with po abx. ___
then developed L hand swelling in the setting of another bed bug
bite. ___ was hospitalized at ___ for IV abx and d/c'ed 6 days
ago on an 8 day course of bactrim and keflex. ___ was taking
these abx when ___ developed L hand swelling again. No
fevers/chills. ___ denies any other trauma to the hand and does
not report using IV drugs.
Patient lost his job today at a ___ because of missing
time from work secondary to illness.
___ has chronic shortness of breath and intermittent chest pain.
___ becomes short of breath when bending over to tie his shoes.
___ also has a strip of chest pain in the front of his Left
chest.
In ER: (Triage Vitals:4 98.7 113 150/86 16 99% )
Meds Given: vancomycin
Fluids given: NS
Radiology Studies: none
consults called: none
.
PAIN SCALE: ___ with active and passive motion
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [X] All Normal
Eyes: [X] All Normal
RESPIRATORY: [+ ] Shortness of breath [? ] Dyspnea on
exertion
CARDIAC: [+] Chest Pain
GI: [X] All Normal
GU: [x] All Normal
SKIN: [+]swollen L hand
MS: [+ ] Jt swelling
NEURO: [x] All Normal
ENDOCRINE: [X] All Normal
HEME/LYMPH: [X] All Normal
PSYCH: [ +] Depressed secondary to job but [-]Suicidal
Ideation
[X]all other systems negative except as noted above
Past Medical History:
- past psych dx: depression, childhood ADD
- past med trials: prozac
- no past psych hospitalizations
- no past suicide attempts
- hx of cutting himself "everywhere with anything that was
available" for several years
- no hx of violence towards others
- chronic bronchitis
- Poly substance abuse
Social History:
___
Family History:
Mother with depression. Paternal aunt completed suicide.
PGF died of an MI in his ___. Mother - alcoholism. F- healthy.
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: AVSS
Gen: NAD, well-appearing male, slightly disheveled
HEENT: anicteric, EOMI
CV: RRR, normal S1, S2, no murmurs, rubs or gallops
Pulm: CTAB/L, good air movement
Abd: soft, NT, ND, NABS, no rebound/guarding
Ext: warm, well perfused, no clubbing, cyanosis or edema.
notable swelling of left hand, wrist, forearm, but FROM
(active/passive), peripheral pulses intact
Skin: many small excoriations over body, mainly on upper torso,
upper extremities. Streaky erythema on left hand, forearm.
Neuro: AAOx3, fluent speech
Psych: appropriate, calm, interactive, slightly flat affect
Pertinent Results:
Labs:
___ 07:23PM BLOOD WBC-11.9*# RBC-5.19 Hgb-15.5 Hct-47.3
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.0 Plt ___
___ 01:15PM BLOOD WBC-8.9 RBC-5.13 Hgb-15.5 Hct-47.5 MCV-93
MCH-30.3 MCHC-32.7 RDW-12.9 Plt ___
___ 06:50AM BLOOD WBC-9.8 RBC-4.90 Hgb-14.7 Hct-45.2 MCV-92
MCH-29.9 MCHC-32.4 RDW-13.0 Plt ___
___ 07:23PM BLOOD Glucose-105* UreaN-18 Creat-1.0 Na-139
K-4.3 Cl-102 HCO3-25 AnGap-16
___ 06:50AM BLOOD Glucose-113* UreaN-11 Creat-0.9 Na-139
K-4.2 Cl-104 HCO3-28 AnGap-11
___ 06:50AM BLOOD ___ PTT-29.6 ___
___ 07:23PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:51AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:23PM BLOOD CK(CPK)-74
___ 07:51AM BLOOD CK(CPK)-54
___ 07:23PM BLOOD Calcium-9.7 Phos-4.1 Mg-2.3
___ 06:50AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
___ 06:55AM BLOOD HIV Ab-NEGATIVE
___ 07:46PM BLOOD Lactate-1.9
___ 07:23PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 04:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
blood cultures x 2 sets (___): no growth to date, final
results pending
HIV VL (___): pending at time of discharge
.
Imaging:
PA/lat CXR (___):
IMPRESSION: Normal chest radiograph.
.
Left hand and forearm x-ray (___):
There is no evidence of fracture, lytic or sclerotic lesions,
appreciable
radiographical soft tissue swelling, or radiopaque foreign body
demonstrated.
No lytic or sclerotic lesions worrisome for infection or
neoplasm are seen.
.
Brief Hospital Course:
___ y.o. M with h/o PSA, multiple sexual partners who presents
with recurrent hand cellulitis in the setting of bed bug bites.
.
# Cellulitis - Pt had just been treated twice in the past month
for upper extremity cellulitis of the upper extremities at OSH,
most recently treated for the same LUE cellulitis, DC'ed to home
on Bactrim/Keflex, but with progression of symptoms after
discharge to home. ___ was placed on IV Vancomycin on admission
and then also seen by Ortho-Hand, who felt that surgical
intervention was not warranted. Unasyn was added to his abx
regimen, and supportive care, including elevation was
emphasized. Plain films did not show any evidence of
subcutaneous air. His symptoms improved significantly, with the
swelling and erythema nearly completely resolved on day of
discharge. ___ is being sent home with a course of PO
antibiotics, with Bactrim and Augmentin, to complete a total of
a 10 day course of antibiotics. His blood cultures obtained on
admission remained negative. ___ did have a mild leukocytosis
which resolved. The presence of bedbugs in his home environment
with excoriated bed bug bites due to scratching likely
contributed to his initial and recurrent cellulitis. We
recommended to him to have the bed bugs eradicated by a
professional, obtain a new mattress, or to stay with his parents
until his cellulitis resolves completely.
.
# Depression - stable mood, denied any suicidal ideation or
recent suicide attemps. Pt was continued on his home Effexor.
.
# Episode of Chest Pain with Shortness of Breath
-on review of systems, pt endorsed episode of chest pain with
associated shortness of breath, which resolved spontaneously.
However, ___ does have distant h/o cocaine use (denied recent use
on this admit, had negative urine and serum tox screens) and hx
of grandfather with MI in his ___, ___ had an EKG and 2 sets of
cardiac biomarkers, with a benign EKG and negative cardiac
biomarkers. ___ also had a clear CXR. ___ did not have any
additional episodes of similar symptoms and had stable vital
signs on this admission.
.
# HIV screening
-pt requested an HIV test given prior history of multiple sexual
partners, although ___ denied any recent high risk HIV exposure
in the past 3 months. A HIV Ab was negative, and the HIV viral
load is currently pending. ___ denied any symptoms c/w acute HIV
infection.
.
.
Transitional Issues:
1. Will need to establish PCP ___. Pt currently deciding
whether to establish care at ___ vs f/u with his parent's PCP.
Provided pt with ___ number to call for appointment. Unable to
arrange prior to discharge as pt being discharged on weekend.
Also provided pt with contact information for ___
___.
2. Will need f/u of his cellulitis as ___ completes course of
antibiotics.
3. Will need to have the final results of his blood cultures
followed-up.
4. Will need to have HIV viral load followed-up.
.
Medications on Admission:
effexor 225 mg daily
Discharge Medications:
1. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO twice a
day for 9 days.
Disp:*36 Tablet(s)* Refills:*0*
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
3. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain: do not exceed 4grams total in 1 day.
.
4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with recurrent cellulitis of your
left arm/hand, after recent admission at an OSH for similar
complaint, failing oral antibiotics. You were placed on IV
antibiotics and also seen by the Orthopedic Hand Surgeons. Your
symptoms improved significantly on IV antibiotics. The presence
of bed bugs is likely contributing to your infection, we
recommend that you eliminate bed bugs from your home. You will
need to complete a course of oral antibiotics. Please take your
medication as prescribed below.
.
You do not have a PCP at this point in time. We discussed
having your PCP care established here, which you are
considering, and will call tomorrow to schedule an appointment
if you decide to establish care here. Other options that were
suggested, which you are open to as well, include establishing
care at the ___, or establishing care with your
parents' PCP. You were agreeable to these suggestions.
.
Followup Instructions:
___
|
10529587-DS-21 | 10,529,587 | 29,709,200 | DS | 21 | 2124-02-19 00:00:00 | 2124-02-19 17:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vioxx / Wellbutrin / Percocet
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea
Major Surgical or Invasive Procedure:
Left ureteral stent placement, cystoscopy
History of Present Illness:
Patient is a ___ female w/ history of nephrolithiasis
requiring intervention (seen by Dr. ___, h/o diverticulitis
requiring ex-lap who notes worsening abdominal pain in the
setting of vomiting. She states that yesterday evening she began
feeling generally unwell, tried to remain hydrated but began
vomiting while driving home (forcing her to pull over). She has
remained with significant emesis, nausea and anorexia with
associated vague RLQ and abdominal pain. She notes additional
fever, malaise and headache which has driven her to ED.
Subsequent workup revealed obstructing left ureteral stone,
infected urine and fever to 102. Urology consulted for
concerning
obstructing stone in setting of UTI.
Past Medical History:
Problems
LUMBAR DISC DISEASE
GASTROESOPHAGEAL REFLUX
THYROID CANCER
ANXIETY
? ACROMEGALY
DIVERTICULOSIS
NEPHROLITHIASIS
BLADDER CANCER
HYPERTENSION
SEASONAL ALLERGIES
SLEEP APNEA
ARTHRALGIA - MULT JOINTS
HYPERCALCIURIA
Surgical History
LAMINECTOMY
KNEE REPLACEMENT
BLADDER CANCER
THYROIDECTOMY
NEPHROLITHIASIS
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother HEART DISEASE
Sister LUPUS
Sister PEMPHIGUS
Physical Exam:
___ NAD AAOx3
Abdomen is soft nt nd
No flank pain bilaterally
Extremities are WWP without significant edema
No IWOB, No access musc use
Pertinent Results:
___ 06:25AM BLOOD WBC-12.8* RBC-3.12* Hgb-9.9* Hct-28.4*
MCV-91 MCH-31.6 MCHC-34.7 RDW-15.6* Plt ___
___ 01:10PM BLOOD WBC-18.6*# RBC-4.12* Hgb-12.6 Hct-37.8
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.3 Plt ___
___ 06:25AM BLOOD Glucose-146* UreaN-15 Creat-1.1 Na-135
K-3.3 Cl-101 HCO3-24 AnGap-13
___ 01:10PM BLOOD Glucose-135* UreaN-18 Creat-1.1 Na-136
K-3.4 Cl-98 HCO3-27 AnGap-14
___ 08:10AM BLOOD WBC-8.7 RBC-3.28* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.8 Plt ___
___ 06:25AM BLOOD Glucose-146* UreaN-15 Creat-1.1 Na-135
K-3.3 Cl-101 HCO3-24 AnGap-13
Brief Hospital Course:
The patient was admitted to Dr. ___ service from
the ___ ED after unfergoing urgent ureteral stent placement,
left, for obstructing left ureteral stone in the setting of UTI.
She was subsequently admitted to monitor for fevers, urosepsis
and concerning signs or symptoms. Initially she was taking IV
pain control, and IV fluids. She was with foley catheter
initially which was subsequently discontinued on POD2 and the
patient voided without issue. Through POD2 she continued to
spike intermittent fevers while being treated with broad
spectrum IV antibiotics.
By the time of discharge through POD3, she was voiding without
difficulty, and her pain was less severe upon arrival to the
floor. She no longer had fevers and rigors. She was tolerating a
regular diet. Her nausea resolved with reduction in the amount
of narcotic pain medications administered. She was given
Toradol and Flomax to help facilitate passage of stone/ ureteral
stent comfort. At discharge, patient's pain well controlled with
oral pain medications, she was converted to oral antibiotics and
she was tolerating regular diet, ambulating without assistance,
and voiding without difficulty.
Culture data was negative to date and this will be followed up
by the primary team.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Atenolol 25 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
6. esomeprazole magnesium 40 mg oral BID
7. Ascorbic Acid ___ mg PO Frequency is Unknown
8. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q4hrs
Disp #*15 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever>100
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*1
7. Phenazopyridine 100 mg PO TID Dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*8 Tablet Refills:*0
8. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
9. Ascorbic Acid ___ mg PO DAILY
10. esomeprazole magnesium 40 mg oral BID
11. Furosemide 20 mg PO DAILY
12. Vitamin D 0 UNIT PO DAILY
13. Citalopram 20 mg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Cetirizine 10 mg PO DAILY Allergies
16. Cefpodoxime Proxetil 400 mg PO Q12H
Take unless directed otherwise by urology team.
RX *cefpodoxime 200 mg 2 tablet(s) by mouth Q12 hrs Disp #*40
Tablet Refills:*0
17. Oxybutynin 5 mg PO TID bladder spasm
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*20 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Obstructing left ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool
softener, NOT a laxative, and available over the counter. The
generic name is DOCUSATE SODIUM. It is recommended that you use
this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER:
-Please refer to the provided nursing instructions and handout
on Foley catheter care, waste elimination and leg bag usage.
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-Follow up in 1 week for wound check and Foley removal. DO NOT
have anyone else other than your Surgeon remove your Foley for
any reason.
-Wear Large Foley bag for majority of time, leg bag is only for
short-term when leaving house.
Followup Instructions:
___
|
10529619-DS-9 | 10,529,619 | 28,734,899 | DS | 9 | 2139-06-29 00:00:00 | 2139-06-29 12:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / sympathohimedics / polymixins
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The HPI is composed of information gathered from his outpatient
notes and the ED documentation. Mr. ___ is currently confused
and unable to recall any details from today.
Mr. ___ is an ___ year old male with a history of DMII, CAD,
a-fib/flutter on warfarin and follicular lymphoma diagnosed in
___ who presents after weakness and rhythmic jerking of his
arms and legs at his chemotherapy appointment today prior to
infusion.
No bladder/bowel incontinence. Not tonic-clonic movements but
"shaking" as described by son. No chest pain, shortness of
breath, abdominal pain, no dsyuria or polyuria.
I was able to reach his son, ___ tonight who states he's had
a urinary tract infection "for a long time" but was unable to
detail if he had been treated. He stated his dad had a lot of
issues holding his urine, but Mr. ___ daughter in law often
took care of him and she recently passed away.
A call to Mr. ___ son ___ was unanswered and a voicemail
was left to call the floor as he's listed in ___ as a person to
contact.
Vital signs on arrival: 98.9 90 105/60 18 95%
Transfer vitals: 98.6 90 104/53 22 94 2L NC %
Lines: 20g right arm
Fluids: unknown
Given MEDS: Levofloxacin 750mg IV, Ciprofloxacin 400mg IV
Studies: CT head showed changes consistent with prior imaging,
without evidence of mass lesion. CXR shows chronic changes.
Review of Systems:
(+) Per HPI
(-) Denies fever, headache, neck stiffness. Denies chest pain or
tightness, palpitations, lower extremity edema. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, melena,
hematochezia. Denies dysuria. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY: PER ___ notes
"Heme Hx: ___ yrs. man was diagnosed as at least stage III low
grade follicular lymphoma in ___. Right inguinal LN biopsy at
___ on ___ showed follicular lymphoma, grade I/III,
predominantly follicular pattern, CD20+, Ki67 ___. He was
treated by Dr. ___ at ___ from ___ to ___.
He completed 6 cycles of R-CVP with improved mediastinal,
axillary, retroperineal and inguinal adenopathy. He was
followed by Dr. ___ ___. CT a/p at ___ in ___
showed stable small retroperitoneal LNs. He fell down 12 steps
on ___ and had left hip fracture. He was admitted to
___. CT a/p on ___ accidentally showed a
large amorphous soft tissue mass extending from above the
proximal sigmoid colon along the retroperitoneum to the left
renal pelvis tracking along the superior mesenteric vein and
ureter. There is no hydronephrosis or bowel obstruction. There
is a 2cm aortocaval LN beneath the level of the renal arteries.
Ill-defined probable right inguinal adenopathy measures at least
3cm in diameter. CT suggested lymphoma is uspectd until proven
otherwise; given the lack ofobstruction, carcinoma is less
likely. CT neck on ___ showed a 3.5x2.5x1.7cm mass above
the right carotid bifurcation which appears to represent a
prominent internal jugular vein. Right inguinal mass biopsy was
performed on ___ which revealed minute fragments of lymphoid
tissue with sclerosis. Flow cytometry analysis is
non-diagnostic (insufficient cellularity). He is on coumadin
for Afib. ___ doppler at ___ on ___ showed DVTs
in the left upper femoral, common femoral and deep femoral
veins. CT PE protocol on ___ revealed no evidence of PE and no
adenopathy. An IVC filter was placed. He didn't recall the
right inguinal biopsy or the IVC filter placement. He has left
hip pain due to fracture and takes oxycontin and oxycodone. He
uses a wheelchair due to hip fracture. He denies urinary or BM
incontinence. He is in ___ SNF.
Interval Hx: He is here for follow up. He is accompanied by
his son, ___. He noted the right cervical LN is less painful
and the pain is intermittent. He c/o increased fatigue. Denies
significant N/V/D. He is able to feed himself. He spends most
of his time on bed or couch. Not able to walk around. High
fall risk."
PAST MEDICAL HISTORY:
DM type 2
GLAUCOMA - PRIMARY ANGLE-CLOSURE, UNSPEC
OSTEOARTHRITIS
ESOPHAGEAL REFLUX
POSITIVE PPD
DYSPNEA
Colonic Polyp
MELANOMA
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
HYPERTENSION - ESSENTIAL
CARDIOMYOPATHY
GASTROINTESTINAL BLEEDING - LOWER
URINARY URGENCY
___ Esophagus
Major Depression
Pulmonary embolism
Atrial flutter
A-fib
S/P total knee replacement right ___
Advance directive on file - HCP
Social History:
___
Family History:
One daughter died of colon cancer
Physical Exam:
Vitals: T:98.7 BP:103/58 HR:99 RR:16 02 sat:96% 2.5L
General: Elderly male in NAD, confused. Very slow to respond to
questioning, but alert.
HEENT: Dry MM, EOMI, anicteric sclear
Neck: No JVD, no bulky adenopathy
CV: irregularly irregular, ___ SEM
Lungs: Crackles and decreased breath sounds at the left base,
otherwise clear
Abdomen: Soft, NT, ND, NABS
GU: condom catheter
Ext: Without edema, good pulses, warm
Neuro: confused, no cog wheeling, slow to respond, but alert and
appropriate with answers if prompted several times, can't recall
details of today
DISCHARGE EXAM:
Vitals: T:98.5 bp 154/60 HR 66 RR 16 SaO2 97 RA 24h I/O 2400
/ unknown (incontinent)
General: Elderly male in NAD, interactive, alert
HEENT: MMM, EOMI, anicteric sclear
Neck: No JVD,
CV: irregularly irregular, ___ SEM
Lungs: mildly decreased breath sounds at the left base,
otherwise clear; improved from admission
Abdomen: Soft, NT, ND, NABS
Ext: Without edema, good pulses, warm
Neuro: AOx3, uses wheelchair to ambulate otherwise no focal
deficits
Psych: cooperative, calm
Pertinent Results:
Admission Labs:
___ 01:53PM BLOOD WBC-12.4* RBC-3.97* Hgb-10.6* Hct-33.9*
MCV-85 MCH-26.6* MCHC-31.1 RDW-14.5 Plt ___
___ 01:53PM BLOOD Neuts-78.6* Lymphs-10.6* Monos-8.7
Eos-1.8 Baso-0.4
___ 01:53PM BLOOD Glucose-145* UreaN-35* Creat-1.5* Na-145
K-4.8 Cl-101 HCO3-26 AnGap-23*
___ 01:52PM BLOOD Lactate-1.8
___ 07:20AM BLOOD WBC-12.0* RBC-3.26* Hgb-9.3* Hct-28.2*
MCV-86 MCH-28.5 MCHC-33.0 RDW-14.6 Plt ___
___ 07:25AM BLOOD WBC-11.6* RBC-3.82* Hgb-10.6* Hct-32.7*
MCV-86 MCH-27.7 MCHC-32.3 RDW-14.7 Plt ___
___ 07:25AM BLOOD Neuts-84.8* Lymphs-8.1* Monos-4.3 Eos-2.5
Baso-0.3
___ 07:20AM BLOOD Glucose-129* UreaN-31* Creat-1.3* Na-143
K-4.4 Cl-104 HCO3-29 AnGap-14
___ 07:25AM BLOOD Glucose-182* UreaN-25* Creat-1.1 Na-143
K-4.0 Cl-104 HCO3-28 AnGap-15 ___ 07:25AM BLOOD Calcium-9.4
Phos-3.0 Mg-1.8
___ 07:20AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-PENDING EMERGENCY WARD
.
___ 05:25PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 05:25PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:25PM URINE RBC-9* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
.
CXR ___
FINDINGS: AP upright and lateral views of the chest were
provided. There is atelectasis at the left lung base which
likely also is associated with small effusion as seen on prior
CT-PET. Coarsened reticular nodular markings within the lungs
likely represent chronic change. No pneumothorax is seen. The
cardiomediastinal silhouette is stable. No free air below the
right hemidiaphragm.
IMPRESSION: Coarsened markings likely reflect chronic disease
with left basal atelectasis and small effusion again noted.
Head CT ___
FINDINGS: There is no evidence of intra- or extra-axial
hemorrhage.
Moderately dilated lateral, third and fourth ventricles
including the temporal horns of the lateral ventricles does not
appear to be significantly changed from FDG-PET imaging of ___. Extensive periventricular white matter hypodensities
likely reflect sequelae of chronic small vessel ischemic
disease. There is no evidence of edema or midline shift.
Basilar cisterns are patent and there is preservation of
gray-white matter differentiation. No fracture is identified.
Paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Globes are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Moderately dilated ventricles is consistent with
hydrocephalus, relatively unchanged from ___.
Brief Hospital Course:
Mr. ___ is an ___ year old male with a history of DMII, CAD,
a-fib/flutter on warfarin and follicular lymphoma diagnosed in
___ who presents after weakness and seizure-like jerking at his
chemotherapy appointment.
#UTI: UA is grossly positive. There was no initial culture data
to direct therapy; however, he was given Cipro in the ER and had
symptomatic improvement, so was continued on Cipro with
resolution of his acute encephalopathy. He will need treatment
for at least 7 days as he is complicated and has some compromise
of the left collecting system from his retroperitoneal LAD as
documented on CT in Atrius system ___ will write for a
total of 14 days to ensure resolution.
#Toxic metabolic encephelopathy - this was attributed to his UTI
as it resolved after antibiotics. There was slight concern
initially for possible CNS involvement of his malignancy, but
since it resolved so quickly, this is much less likely. His
myoclonic jerking resolved as well.
___: Likely related to the involvement of his collecting system
as detailed above. Recent baseline of 1.0. He initially had Cr
of 1.5 which normalized close to baseline at 1.1. Out of
courtesy for his outpatient providers, ___ renal ultrasound was
preformed to help determine if he may need a nephrostomy in the
future. The results of which are pending at the time of
discharge.
#Lymphoma: Currently being treated by ___. Did not receive
treatment of Rituxan the day of admission, so he should
follow-up to see the frequency of future treatments. The At___
oncologist consultant, Dr. ___ the patient while
he was admitted to the hospital.
#A fib on Coumadin - the patient did not receive Coumadin on
either night he was in the hospital since he was placed on
Cipro. He should resume Coumadin on the evening of discharge
and have his INR checker per rehab MD.
> 30 minutes were spent with D/C activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Acetaminophen 650 mg PO Q8H:PRN pain
4. Senna 2 TAB PO BID constipation
5. Polyethylene Glycol 17 g PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Citalopram 20 mg PO DAILY
8. Mirtazapine 45 mg PO HS
9. Gabapentin 400 mg PO HS
10. Omeprazole 20 mg PO BID
11. Warfarin 1.5 mg PO DAILY16
12. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
13. Lorazepam 0.5 mg PO HS:PRN insomnia
14. Ondansetron ___ mg PO Q8H:PRN nausea
15. Prochlorperazine 10 mg PO Q6H nausea
16. Acyclovir 400 mg PO Q12H
17. Allopurinol ___ mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Omeprazole 20 mg PO BID
3. Acyclovir 400 mg PO Q12H
4. Allopurinol ___ mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Ondansetron ___ mg PO Q8H:PRN nausea
7. Docusate Sodium 100 mg PO BID
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 2 TAB PO BID constipation
11. Ciprofloxacin HCl 500 mg PO Q12H
end date ___. Gabapentin 400 mg PO HS
13. Lorazepam 0.5 mg PO HS:PRN insomnia
14. Metoprolol Tartrate 25 mg PO BID
15. Mirtazapine 45 mg PO HS
16. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
Hold for sedation or confusion
17. Prochlorperazine 10 mg PO Q6H nausea
18. Warfarin 1.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Acute renal failure
Lymphoma
Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: wheelchair
Discharge Instructions:
You were admitted with confusion caused by a urinary tract
infection.
Followup Instructions:
___
|
10530041-DS-11 | 10,530,041 | 27,271,968 | DS | 11 | 2115-08-16 00:00:00 | 2115-08-17 20:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol / Dilaudid
Attending: ___.
Chief Complaint:
Increased ostomy output
Major Surgical or Invasive Procedure:
___ Ileoscopy
___ PICC line placement by IV team
___ Removal of PICC line
History of Present Illness:
Ms. ___ is a ___ year old lady with a PMH of ulcerative
colitis and rectal cancer s/p proctocolectomy with ileostomy ___
years ago, with increasing ostomy output and weakness. Patient
reports protracted history of increased output since ___, with need to empty bag every ___ hours (previously had
been every 3 hours). Over the past several months, she has
noticed that she's losing weight. In the past two days, she has
had increased frequency of emptying every ___ minutes.
Initially, there was some improvement with starting prednisone.
No blood in the ostomy output, no change in its
consistency/color. She also had been losing 1 pound per day. She
had abdominal cramps, which were relieved when she was started
on prednisone at the beginning of ___. Patient notes that she
has had increased fatigue, and cramps in her legs (patient
thinks consistent with dehydration) over the past few days. She
had chills and exhaustion with a URI in ___, but these
symptoms resolved. Additionally, patient notes increased urinary
frequency, which may be related to aggressive fluid hydration at
home. No dysuria or hematuria.
.
For evaluation of this issue, patient had a small bowel
follow-through study on ___, with some suggestion of
gastroparesis. Dr. ___ has subsequently been adjusting
medications. Initially, he had started prednisone for treatment,
perhaps since symptoms were similar to prior UC flares; this is
now being tapered. Also, he recommended that patient start
metoclopramide.
.
In the ED, initial vs were: T 99.5 BP 134/75 HR 74 RR 16 SaO2
100%. Symptoms improved with IVF. Labs were remarkable for WBC
count of 6.5 with neutrophilic predominance, lactate 1.7. UA
with moderate leuk, no bacteria. Patient was given 2L NS. No
medications given. Vitals on Transfer were T 97.7 BP 112/72 HR
74 RR 18 SaO2 100%RA.
.
On arrival to the floor, patient was comfortable. She was
accompanied by her sister.
.
Review of sytems:
(+) Per HPI, intermittent chills
(-) Denies fever, night sweats, recent weight gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias.
Past Medical History:
-Ulcerative colitis: diagnosed ___ years ago after pregnancy
-Rectal cancer ___: s/p radiation and chemotherapy prior
to low anterior resection converted to abdominal total
proctocolectomy
-SBO in ___: resolved spontaneously
-Pneumonia in ___
-History of variable output per ostomy, evaluated in GI clinic
on ___, started on Reglan for possible gastroparesis
-Lichen sclerosis in vulva with partial vulvectomy
-Anxiety
-last EGD was in ___ at ___
-last colonoscopy was in ___
-patient notes possible oral ulcers about ___ years ago
Social History:
___
Family History:
Crohn's in several second-degree relatives, grandmother with
stomach cancer, CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6 124/68 71 18 100%RA
Weight 46.9 kg
General: Pleasant, thin lady, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear without any
ulcers
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Thin, soft abomen, with stoma on the right side. Stoma
looks pink and healthy. Hyperactive bowel sounds, non-tneder. No
rebound or guarding. No organomegaly.
Ext: Thin, warm, well perfused, 2+ pulses. No clubbing, cyanosis
or edema.
Skin: No rashes, healthy skin around stoma.
Neuro: Alert, awake and oriented x3. Gait intact. ___ strength
in upper and lower extremities.
.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4 114/70 (102-114/58-70) 94 16 98%RA
General: Pleasant, thin, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear without any
ulcers
Lungs: Clear to auscultation bilaterally, with minor expiratory
wheeze at the RUL, no rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Thin, soft abdomen, with stoma on the right side. TTP
in the epigastrum. No guarding. No organomegaly.
Ext: Thin, warm, well perfused, 2+ pulses. No clubbing, cyanosis
or edema.
Neuro: Alert, awake and oriented x3.
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-6.5 RBC-4.00* Hgb-12.9 Hct-38.5
MCV-96 MCH-32.2* MCHC-33.4 RDW-13.4 Plt ___
___ 11:30AM BLOOD Neuts-89.3* Lymphs-7.1* Monos-2.9 Eos-0.3
Baso-0.4
___ 11:30AM BLOOD Glucose-124* UreaN-28* Creat-0.8 Na-137
K-4.0 Cl-101 HCO3-24 AnGap-16
___ 11:30AM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.0 Mg-2.6
___ 11:55AM BLOOD Lactate-1.7
___ 12:45PM URINE Color-Straw Appear-Clear Sp ___
___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
___ 12:45PM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
.
RELEVANT LABS:
___ 07:10AM BLOOD Triglyc-155*
___ 06:00AM BLOOD IgM-63
___ 07:30AM BLOOD IgG-411*
___ 04:49AM BLOOD Cortsol-24.7*
.
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-4.1 RBC-3.43* Hgb-10.6* Hct-34.0*
MCV-99* MCH-31.0 MCHC-31.3 RDW-13.1 Plt ___
___ 07:20AM BLOOD Glucose-99 UreaN-15 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-29 AnGap-11
___ 07:20AM BLOOD Calcium-8.8 Phos-1.7* Mg-2.0
MICROBIOLOGY:
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces
negative for C.difficile toxin A & B by EIA.
OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN.
Cryptosporidium/Giardia (DFA) (Final ___: NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ BLOOD CULTURE Source: Line-PICC: (Pending)
WOUND CULTURE - PICC line (Final ___: No significant
growth.
___ Blood Culture, Routine (Pending):
URINE CULTURE (Final ___: <10,000 organisms/ml.
CYTOLOGY
___ Terminal ileum, biopsy: No diagnostic abnormalities
recognized.
STUDIES:
___ Small bowel follow-through: An initial 25-minute
frontal radiograph demonstrates contrast within the stomach and
duodenum. Notably, the stomach has an elongated vertical course,
spanning from the level of the diaphragm to the level of the
acetabular roofs. There is delayed emptying of the stomach, with
contrast persisting within the stomach beyond three hours. In
addition, there is extended transit time through the small bowel
to the ileostomy. Small bowel loops are normal in caliber and
there are no mucosal abnormalities. There is no evidence of
small bowel fistula.
IMPRESSION:
1. No apparent etiology to high output diarrhea.
2. Prolonged retention of contrast in the stomach and prolonged
small bowel transit time. The former raises the possibility of a
gastric emptying delay, a finding which is best evaluated via a
nuclear medicine gastric emptying scan.
.
___ Ileoscopy: Normal mucosa in the ileum (biopsy). Formed
stool was seen upon intubation of the ileum. Biopsies were taken
and the procedure was aborted.Otherwise normal colonoscopy to
distal ileum.
___ LIVER OR GALLBLADDER US (SINGLE ORGAN): Small amount of
sludge and stone seen within the gallbladder. There are no signs
of cholecystitis. The remainder of the abdomen is unremarkable.
___ CHEST (PORTABLE AP): Cardiomediastinal contours are
normal. New right upper lobe consolidation is consistent with
pneumonia. The left lung is grossly clear. There is no evident
pneumothorax. If any, there is a small right pleural effusion.
___ CHEST (PA & LAT): Pneumonic infiltrate in right upper
lobe area slightly progressing. Round lesion in right lower lobe
area is noted and deserves further followup. Heart size remains
within normal limits and no
configurational abnormality is identified. No evidence of
pulmonary vascular congestion.
Brief Hospital Course:
Ms. ___ is a ___ year old lady with a PMH of ulcerative
colitis and rectal cancer s/p proctocolectomy with ileostomy ___
years ago, with dehydration secondary to increasing ostomy
output and weakness.
ACTIVE ISSUES:
# Dehydration secondary to increased ostomy output: The patient
has an extended history of large volume ostomy output, leading
to a decrease in weight and energy secondary to her GI losses.
There were no recent changes in diet; patient had been
recommended to try low fat, low residue and low sugar, by her
gastroenterologist. Had ileoscopy on this admission with no
noted lesions; biopsy of the terminal ileum revealed no
abnormalities, making IBD of ileum less likely. Differential
diagnosis included short bowel syndrome and pancreatic neoplasm
(i.e. VIPoma), lactose intolerance, small bowel bacterial
overgrowth and chronic pancreatitis. Stool studies were negative
for O&P, giardia/cryptosporidium, shigella, campylobacter,
salmonella, c.diff. NPO challenge to evaluate for hypersecretory
diarrhea showed a significant improvement once pt was NPO.
Therefore, etiology was not secretory in nature, but rather
diet-related. Pt was put on low-residue/lactose free diet and
met with a nutritionist for education on this new diet. Tincture
of opium and reglan were discontinued. She was kept on psyllium
wafers. Her 24hr ostomy output ranged from 500-800cc/day prior
to discharge.
# Sepsis secondary to pneumonia - Pt became febrile in the
afternoon of ___ and that night had hypotension initially
unresponsive to fluids. Her PICC line was pulled and cultured,
urine cultures, blood cultures and CXR were obtained. She was
started empirically on vancomycin and cefepime. She remained
afebrile with normal blood pressures since then. PICC line and
urine cultures were negative. Blood cultures are pending. CXR
showed RUL infiltrate and a round lesion in the RLL. Since pt
remained afebrile, she was switched from vancomycin and cefepime
to monotherapy with levofloxacin. She did well on this prior to
discharge and abx will be continued for a total of 10-day course
(V. 8-day), given her relative immunosuppression with a low IgG
of 411.
# IgG Hypogammaglobulinemia - Due to poor nutrition, pt likely
had low protein. IgG was checked and found to be low at 411. IgM
was low-normal at 63, and IgA was normal at 161. Therefore, she
was treated for with a 10-day course (v. 8-day) for her
pneumonia, given her relative ___.
# Gastritis: During this admission, patient had episodes of
abdominal pain, most consistent with gastritis given epigastric
pain, improved with pantoprazole prior to breakfast, and worse
at night. LFTs, amylase, lipase were normal. No pathology noted
on RUQ U/S. Symptoms were better-controlled on pantoprazole 40
mg PO BID, along with Maalox.
# Ulcerative colitis: Patient with long history of UC, now s/p
total proctocolectomy. Had not been on steroids since the 1990s
until recently, when she was restarted (new-onset Crohn's
possible flare). Prednisone was tapered over the course of
admission and then discontinued. Ileoscopy and biopsy did not
reveal evidence of Crohn's.
# Leg cramps: Severe bilateral cramps overnight during this
admission likely secondary to the dehydration, as once her
ostomy output decreased, her symptoms improved. Though
simvastatin was held during the admission, CK was normal, and so
was restarted upon discharge. Patient without unilateral pain,
swelling, TTP or chest pain that would be concerning for DVT.
# Thrombocytopenia: Platelets were downtrending since
admission. Four T score of 1 (for possible other cause of
thrombocytopenia - pantoprazole). No evidence of DVT.
Subcutaneous heparin was discontinued, and pneumoboots used for
PPX. Her platelets normalized to 220 upon discharge.
CHRONIC ISSUES.
# Anxiety: Well-controlled on scheduled alprazolam TID.
# Lichen planus: Well-controlled. Continued home clobetasol
proprionate cream.
# Hyperlipidemia: Well-controlled. Initially held simvastatin
but continued upon discharge. Discontinued gemfibrozil.
TRANSITIONAL ISSUES:
# Recommend review of radiology report of CXR done on ___ as
it notes round lesion in right lower lobe area and official
report remarks it deserves further followup.
# Recommend ___ levels to see if it is transient given
her poor nutrition.
# Recommend f/u of pending blood cultures.
# CODE: full (confirmed with patient)
# EMERGENCY CONTACT (no official HCP): son ___
___
___ on Admission:
-alprazolam 1 mg PO TID
-gemfibrozil 1200 mg PO daily
-simvastatin 20 mg Po daily
-alendronate 70 mg weekly
-clobetasol proprionate cream twice weekly
-pantoprazole 40 mg PO daily
-tincutre of opium: 10 drops with breakfast/lunch/dinner, 15
drops at bedtime
-Lomotil ___ tabs daily PRN diarrhea/cramps
-Caltrate 1200 mg PO daily
-Centrum Silver PO daily
-melatonin 5 mg PO qHS
-prednisone 10 mg PO BID, now decreasing by 5 mg daily over the
next five days
-metoclopramide 10 mg PO before each meal
Discharge Medications:
1. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. clobetasol 0.05 % Cream Sig: One (1) Appl Topical twice
weekly as needed for lichen planus symptoms.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Caltrate 1200mg PO daily
7. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
8. melatonin 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. psyllium 1.7 g Wafer Sig: Two (2) Wafer PO DAILY (Daily).
Disp:*60 Wafer(s)* Refills:*0*
12. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for abdominal pain.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Dehydration secondary to high ostomy output
Secondary diagnosis:
Ulcerative colitis s/p total proctocolectomy
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 here at ___
___! You were admitted for further
evaluation of high ostomy output. It was likely due to the type
of diet you were eating as your ostomy output dramatically
decreased when we limited your oral intake and changed your diet
to low residue and lactose restricted. You had an ileoscopy to
evaluate your small bowel, and no abnormalities were noted.
Biopsies were taken from this procedure, and these results are
pending.
During your hospital stay, you were found to have a pneumonia.
You were started on an antibiotic for this that you should take
daily until ___.
You were also having leg cramps, but this was likely due to
dehydration because as your ostomy output decreased, your cramps
improved. Your simvastatin was held for several days but will be
restarted at discharge. If you continue to have problems with
leg cramps please discuss whether simvastatin could be
contributing to this with your PCP.
Please note, the following changes were made to your
medications:
1. Start taking levofloxacin for pneumonia
2. Start taking rifaxamin for bacterial overgrowth
3. Start taking psyllium for increased ostomy output
4. Stop taking tincture of opium
5. Stop taking gemfibrozil
6. Stop taking metoclopramide
7. Stop taking prednisone
Followup Instructions:
___
|
10530041-DS-14 | 10,530,041 | 29,794,487 | DS | 14 | 2116-02-08 00:00:00 | 2116-02-08 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol / Dilaudid / ibuprofen
Attending: ___.
Chief Complaint:
weakness, fatigue, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ woman with oligometastatic colorectal cancer, s/p
pulmonary wedge resection ___ of RLL solitary metastasis, s/p
1 cycle of Oxaliplatin and Capecitabine, c/b nausea, diarrhea,
weight loss, and profound fatigue, now with progressive fatigue
and weakness. She was seen by her oncologist on ___, when she
was due to complete her 2-week course of Xeloda, and given these
side effects, her chemotherapy plan was stopped indefinitely
with a plan to re-assess in the future for alternative regimens.
Her symptoms were felt to be due to the chemotherapy, and it was
anticipated that they would improve after several days off
Xeloda. However, since that visit, her weakness and fatigue have
progressed, and she also describes exertional dyspnea and
instability while walking. She also describes occasional chills,
but denies any chest pain, cough, or fevers. She has had
diarrhea and nausea as well, and her ostomy output is very
watery, requiring high doses of Lomotil to control. She has been
taking in fluids to keep up with the diarrhea, and has felt
thirsty, although she is not sure if she has been dehydrated.
She also describes mild abdominal cramping, but no blood in her
stools. She is not sure if she has lost any more weight.
In the ED, initial VS: Temp 97.8 F, HR 114, BP 91/58, RR 16,
SaO2 98% RA. Labs revealed normal CBC/diff, coags, lactate, BNP,
and troponin. Metabolic panel notable for HCO3 17, BUN 25,
glucose 138, but otherwise normal. UA with >1.050 spec ___,
trace protein, 15 hyaline casts, otherwise bland. ECG in sinus
rhythm and unchanged from prior. Chest CTA showed no pulmonary
embolus, mild-moderate centrilobular emphysema. Ambulatory pulse
ox showed stable SaO2 but she became tachypneic to 40,
tachycardic to 120, and had an unstable gait. She is being
admitted to ___. She received ___ L NS IV fluids. VS prior to
transfer: Temp 97.5 F, HR 87, BP 107/63, RR 22, SaO2 99% RA.
ROS: As listed above in the HPI. All other systems are negative.
Past Medical History:
ONCOLOGIC HISTORY:
DIAGNOSIS: Oligometastatic colorectal cancer
CURRENT REGIMEN: Oxaliplatin/Capecitabine
Ms ___ is a ___ year old female with history of Ulcerative
Colitis diagnosed in her ___, intermittently treated with
prednisone during the exacerbations of her disease. To the best
of her knowledge, she has never been treated with
immunomodulatory agents. In ___, her Ob/Gyn felt a rectal
mass. She was diagnosed with rectal cancer, but we do not know
the details of the pathology and the staging at the time of the
diagnosis. The patient received neoadjuvant radiation and
chemotherapy with Xeloda, that she tolerated well, and in ___, she underwent total proctocolectomy with ileostomy.
Following her surgery, she had difficulties with increased stoma
output and did not receive adjuvant chemotherapy because "she
was too weak". She lost significant weight, but for the last
several months her weight has been stable in the mid ___. The
patient has had overactive stoma persistently for several
months, and in ___ she started seeing Dr ___ in the
___ Clinic at ___. Her symptoms were better
controlled after some medication and diet modifications. In
___, she was admitted to ___ for increased ostomy
output, was treated with prednisone taper for possible Crohn's,
but the GI biopsy was negative and the steroids were stopped.
During that admission, she was noted to have pneumonia and a
round lesion in the RLL. A chest CT on ___, confirmed a
1.4 x 1.5 cm RLL nodule with lobulated borders. On ___,
the patient had a non-diagnostic endoscopic biopsy. A PET/CT on
___, confirmed a solitary FDG avid RLL pulmonary nodule. A
brain MRI was notable for a non-specific 6x6x10mm small lesion
in the inferior clivus, and a subsequent CTA of the head ruled
out metastatic involvement. On ___, the patient had a CT
guided biopsy of the lesion; pathology revealed adenocarcinoma
of intestinal origin (positive for CD20 and CDx2 and focally
positive for CK7, negative for TTF-1). On ___, Ms ___
underwent R VATS converted to R thoracotomy, wedge resection of
RLL nodule. Pathology again confirmed metastatic adenocarcinoma.
On ___, the patient had a Port-a-cath placed in
anticipation of chemotherapy initiation.
-___ C1D1 Oxaliplatin/Capecitabine
OTHER PAST MEDICAL HISTORY:
- Ulcerative colitis, diagnosed in her ___ after pregnancy
- Rectal cancer, s/p neoadjuvant chemoradiation, total
proctocolectomy and ileostomy in ___, as detailed above;
she was treated in ___ in ___, resolved spontaneously
- Pneumonia in ___
- Overactive stoma, evaluated in the GI clinic
- Lichen sclerosis in vulva with partial vulvectomy
- Anxiety
- GERD
- Solitary pulmonary metastasis of her rectal adenocarcinoma,
s/p metastasectomy, as above
Social History:
___
Family History:
Crohn's in several second-degree relatives (cousins).
Grandmother had stomach cancer and colostomy (unclear if she
also had colorectal cancer). Mother with breast cancer.
Physical Exam:
Admission PE
VS: Temp 97.6 F, BP 90/60, HR 82, RR 18, SaO2 100% RA
General: chronically-ill thin woman in NAD, comfortable,
appropriate
HEENT: NC/AT, pupils equal, EOMI, sclerae anicteric, dry MM, OP
clear
Neck: supple, no LAD or thyromegaly
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: +BS, soft/ND, mild LLQ tenderness w/o rebound/guarding,
ostomy with liquid stool, no masses or HSM
Extrem: WWP, no c/c/e
Skin: no concerning rashes or lesions
Neuro: ___, CNs ___ grossly intact, ___ proximal weakness in
BUE and BLE, sensation grossly intact throughout
.
Discharge PE
BP stable in the 110's, otherwise VSS
General: AAOX3, NAD
HEENT: MMM, op clear
CV: rrr, no rmg
Lungs: crackles at left ___ base
Abdomen: mild TTP at LLQ, ostomy in place, cdi, active BS
Extremities: trace ble edema in mid shin
Neuro: MS and cN wnl, strength and sensation wnl
Pertinent Results:
___ 05:06PM WBC-4.5 RBC-4.61 HGB-13.8 HCT-39.3 MCV-85
MCH-30.0 MCHC-35.2* RDW-16.3*
___ 05:06PM NEUTS-71.5* ___ MONOS-8.5 EOS-0.7
BASOS-0.6
___ 05:06PM PLT COUNT-335#
___ 05:06PM ___ PTT-30.6 ___
___ 05:06PM GLUCOSE-138* UREA N-25* CREAT-0.9 SODIUM-136
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-17* ANION GAP-16
___ 05:06PM cTropnT-<0.01 proBNP-221
___ 05:06PM LACTATE-1.0
___ 08:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:55PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:55PM URINE HYALINE-15*
ECG: NSR @ 90bpm, NA/NI, no ST-Twave abnormalities, no change
from prior.
IMAGING:
CHEST CTA WITH IV CONTRAST: (prelim report)
The thyroid gland is unremarkable. There is no axillary or
mediastinal lymphadenopathy by CT size criteria. A right-sided
Port-A-Cath terminates in the distal SVC appropriately. The
lungs show a right upper lobe nodular opacity that is unchanged
from a PET-CT from ___. No other nodules, effusions
or consolidations are present. Post surgical changes are noted
in the right lower lobe. Mild bibasilar atelectasis is present.
The airways are patent down to the subsegmental level. The aorta
is normal in caliber throughout. The pulmonary arteries are
patent down to the subsegmental level. No pericardial effusion
is present.
Although this examination was not intended for subdiaphragmatic
evaluation, the partially imaged abdomen is unremarkable.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or
blastic lesions or fractures.
IMPRESSION: No pulmonary embolism.
Cortisol stim test normal
MRI brain -- IMPRESSION: 1. Relatively stable and unchanged T2
and FLAIR hyperintensities involving the inferior bifrontal
lobes, likely consistent with sequelae of encephalomalacia due
to prior trauma. 2. There is no evidence of abnormal
intracranial enhancing lesions to suggest metastatic disease. 3.
Unchanged area of enhancement identified in the clivus,
measuring approximately 7 x 10 mm in size, with no significant
changes since the prior study, possibly consistent with a
nonexpansile hemangioma versus a notochordal remnant, long term
follow-up is advised to demonstrate stability or any further
change.
.
CXR ___
FINDINGS: While opacities in the right lower lobe are
consistent with post
operative changes, these appear to be denser than on prior
exams, arguing for
a superimposed infection. A right-sided Port-A-Cath terminates
in the lower
SVC, possibly extending into the right atrium. Left lung is
essentially clear
with the exception of mild basilar atelectasis.
Cardiomediastinal silhouette
and hilar contours are unremarkable.
IMPRESSION: On top of the post operative changes in the right
lower lobe,
there is likely a superimposed infectious process.
.
___ ielal biopsy
___ ___. ___
Previous biopsies: ___ right lower lobe wedge # 1,
right lower lobe wedge # 2.
___ RLL LUNG BIOPSY (1 JAR).
___ RIGHT LOWER LOBE NODULE, RIGHT UPPER LOBE MASS.
___ GI BIOPSY (1 JAR).
DIAGNOSIS:
Ileum, mucosal biopsy:
Small intestinal mucosa, within normal limits.
.
___ TTE
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Doppler parameters are
indeterminate for left ventricular diastolic function. 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 mildly thickened.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormalities.
.
Brief Hospital Course:
___ woman w/PMHx UC and oligometastatic colorectal cancer s/p
ileostomy and pulmonary wedge resection ___ of RLL solitary
metastasis, s/p 1 cycle of chemo (Oxaliplatin and Capecitabine),
admitted with increased ostomy output and dehydration,
complicated by persistent severe migraine HA and anxiety and
hypotension limiting her ability to work with ___.
# Weakness/fatigue with increased ostomy output and dehydration:
4 days prior to admission, the patient's chemotherapy was
stopped because of these symptoms. On admission, she was found
to have clinical and lab evidence of dehydration. There was
initially some concern for other processes, such as pulmonary
embolism (CTA chest was negative), gastrointestinal infection
(stool studies were negative X 2) and adrenal insufficiency (see
below, ___ stim was normal), but ultimately these symptoms were
attributed to her chemotherapy and pneumonia. Her high ostomy
output was treated with lomotil and Immodium with minimal
improvement -- this was discussed with her outpatient
Gastroenterologist Dr. ___. The inpatient GI team was
consulted and they requested repeat stool cultures which were
negative. They also recommended a fistulogram, which showed no
abnormalities and a ileoscopy which showed no abnormal mucosa
and biopsies were negative. Her diet was restarted as bland and
she was placed on immodium before meals and her ostomy output
improved significantly. It was also noted that the patient was
on gabapentin 300 TID for neuropathic pain. The patient denied
such pain. As a result she was started on a taper of
gabapentin, 300 BID X1 weeek. She should then be switched to
300 QD X1 week and then stopped.
.
# Healthcare associated pneumonia
The patient had persistent hypotension without any obvious
cause. The patient endorses a cough and multiple episodes of
pneumonia in the past. In addition she has abnormal lung
parenchyma from prior metastasis in the RLL. A CXR showed
findings consistent with a superimposed pneumonia in the RLL.
This in addition to a mild cough, leukopenia and relative
hypotension resulted in starting zosyn at 2.25 Q6H. The patient
should receive a total of 10 days for treatment. Last day is
___.
.
# Colorectal cancer: H/o UC, dx with rectal cancer in ___,
s/p neoadjuvant Xeloda, s/p total proctocolectomy with ileostomy
___ no adjuvant chemotherapy was given due to increased
ostomy output and poor performance status. Dx ___ with
bx-proven colorectal adeno ca solitary RLL pulmonary metastasis,
s/p wedge resection ___. Now s/p 1 cycle of
Oxaliplatin/Capecitabin.
Further chemotherapy was put hold given her significant side
effects as above. Her Oncologist was aware of her
hospitalization and saw her intermittently.
.
# Migraine Headaches:
The patient developed a severe headache early in her hospital
stay. It did not respond easily to tramadol and morphine (she
has a Tylenol allergy) and she was resistant to try NSAIDs given
prior stomach upset issues with these. The nature of her
headache seemed to have components of migraine and tension
headaches. A single dose of sumatriptan was given with no
significant effect. Given the severity of her headaches, the
lack of improvement and her history of malignancy, a brain MRI
was performed and was normal. The patient was then trialed on
NSAID's which relieved the patients headaches. The GI team
indicated that NSAID's were contra-indicated in patient with IBD
due to the risk of causing a flare. The Neurology team was
consulted and they thought the patients symptoms were consistent
with migraines and recommended elavil. The patient headaches
improved with this and po and IV narcotics. The patient
tramadol was discontinued due to drug-drug interactions.
Neurology will follow up with the patient as an outpatient
# Anxiety:
The patient was initially continued on her home alprazolam,
lorazepam, mirtazapine. When it seemed that this was a
significant component to her ongoing headaches, Psychiatry was
consulted (after discussion with her outpatient Psychiatrist Dr.
___ and recommended changing to standing clonazepam, lower
dose PRN clonazepam and increased mirtazapine dose to 15. The
patients anxiety was then under better control. An possible
interaction was noted between elavil and mirtazepine but Neuro
and Psyc were ok with continuing these medications for now. If
the patient develops altered mental status or decreased ability
to mentate, please d/c the Elavil.
# Chronic hypotension without tachycardia:
It was not felt this was due to dehydration given her BUN and
Cr, and very good urine output. A cortisol stim test was
normal. She was started on fludrocortisone with some
improvement. When the patient diet was modified, her BP's
normalized to her baseline of SBP 110-120. The patient was also
started on treatment for HCAP and his pressure improved. In the
future, it may be possible to wean off the patients
fludrocortisone. The patient got a TTE in house and it was wnl.
.
# Hypokalemia
The patient had several episodes of hypokalemia associated with
increased ostomy output. The patient was placed on standing
potassium supplementation for GI losses of K. The patient has a
normal renal function.
.
# GERD: She was continued on her home PPI.
.
# Transitional Issues:
-please check patients potassium Q2-3 days until normal on
current supplementation
-follow up with Neurology in ___ weeks for routine headache
follow up, follow up with Psychiatry in ___ weeks for further
evaluation of anxiety
-make PCP follow up when discharged from rehab
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. ALPRAZolam 2 mg PO BID
Extended release version
3. Diphenoxylate-Atropine 2 TAB PO QID
4. Gabapentin 300 mg PO TID
5. Lorazepam 0.5-1 mg PO BID:PRN anxiety
6. Mirtazapine 7.5 mg PO HS
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Pantoprazole 40 mg PO Q12H
9. TraMADOL (Ultram) 50 mg PO TID:PRN pain
10. Calcium Carbonate 600 mg PO BID
11. Multivitamins W/minerals 1 TAB PO DAILY
Centrum
12. Psyllium Wafer 1 WAF PO DAILY
Discharge Medications:
1. Gabapentin 300 mg PO BID
Eventual plan to taper off this medication
2. Mirtazapine 15 mg PO HS
3. Multivitamins W/minerals 1 TAB PO DAILY
Centrum
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q24H
6. Psyllium Wafer 1 WAF PO DAILY
7. Amitriptyline 25 mg PO HS
8. Clonazepam 1 mg PO BID
9. Clonazepam 0.5 mg PO TID:PRN anxiety
10. Fludrocortisone Acetate 0.2 mg PO DAILY
11. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
12. Loperamide 2 mg PO Q8H diarrhea
please give 1 hour before meals
13. Morphine Sulfate ___ mg IV Q6H:PRN severe headache
please use po pain medications first
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN moderate
headaches
15. Piperacillin-Tazobactam 2.25 g IV Q6H Duration: 9 Days
16. Potassium Chloride 20 mEq PO BID Duration: 24 Hours
Hold for K >
17. Sodium Chloride Nasal ___ SPRY NU QID:PRN headache
18. Prochlorperazine 10 mg PO Q6H:PRN nausea or headache
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
20. Calcium Carbonate 600 mg PO BID
21. Vitamin D 400 UNIT PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Chemo-associated increased ostomy output leading to ___ Acquired Pneumonia
Chronic anxiety
Migraine headaches
Chronic hypotension of likely related to pneumonia, increased
ostomy output
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 after recently having received chemotherapy.
The chemo caused you to have increased output through your
ostomy, which led to you being dehydrated. We tested you for
infection in your gastrointestinal tract and found none, so gave
you IV fluids and rehydrated you. With time, Lomotil and
Immodium your ostomy output decreased and you were able to stay
hydrated by drinking fluids by mouth. The GI team saw you in
house and did an endoscopic procedure which did not show any
abnormalities. Your ostomy output was well controlled on a
bland diet and immodium with meals. Unfortunately, you then
developed a severe migraine headache that lasted several days.
We performed a brain MRI because of this, which showed no change
from your prior head imaging and no cause for your new
headaches. We treated you with several pain medications and
Neurology saw you in house and recommended elavil for the short
term. Your headaches improved. As we discussed, we felt your
chronic anxiety was contributing to your headaches, so we had
the Psychiatrists see you in the hospital and they made
adjustments to your anti-anxiety medications and changed you to
klonopin. You also had persistently low blood pressures, without
clear cause. Because of this, we started you on medications to
raise your blood pressure called fludrocortisone. This will
hopefully be able to be tapered off eventually. You were also
found to have a pneumonia. You will be on IV antibiotics for
this for 10 days. You will be transfered to rehab for further
care.
.
Medication changes
-please see next sheet
Followup Instructions:
___
|
10530188-DS-4 | 10,530,188 | 20,660,173 | DS | 4 | 2153-01-05 00:00:00 | 2153-01-06 06:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left buttock pain
Major Surgical or Invasive Procedure:
Drainage of abscess in OR
History of Present Illness:
___ 8 weeks post-partum p/w L perirectal abscess. Patient had
a bleeding hemorrhoid 3 weeks ago and was prescribed
hydrocortisone suppositories. The bleeding resolved shortly
thereafter. ___ days ago she developed L buttock pain and went
to
the ___ urgent care clinic on ___, where she was
found to have cellulitis of the left perirectal and gluteal
skin,
was given ceftriaxone x 1 and sent home with pain medication and
amoxcillin. Since then she has been having worsening pain and
fevers up to 102. Has not had a bowel movement in 48 hours, but
prior had been normal, no diarrhea or constipation. No abdominal
pain, tolerating PO, no nausea or vomiting. No perirectal or
rectal drainage. Is currently breast feeding. Her delivery was
via C-section for nonreassuring fetal HR. CT scan shows
7.2x5.2x3.5cm fluid collection in the left ischioanal fossa with
a possible fistulous connection to the rectum. However, CT is a
poor imaging modality for visualization of fistula tracts. The
abscess is about 3.5cm superior to the gluteal folds. No history
of IBD, no colonoscopy in the past. This is her first perirectal
abscess.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
General-AAOx3, NAD
HEENT-AT, NC, sclerae anicteric
Heart-RRR, normal S1, S2
Lungs-CTA B/L
Abdomen-soft, NT, ND
Perianal ___ in place
Pertinent Results:
___ 06:40AM BLOOD WBC-12.2* RBC-3.79* Hgb-11.0* Hct-33.8*
MCV-89 MCH-29.1 MCHC-32.5 RDW-12.4 Plt ___
___ 10:35PM BLOOD WBC-13.8* RBC-3.99* Hgb-11.6* Hct-35.6*
MCV-89 MCH-29.0 MCHC-32.5 RDW-12.5 Plt ___
___ 10:35PM BLOOD Neuts-80.6* Lymphs-13.7* Monos-4.7
Eos-0.8 Baso-0.3
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-38.2* ___
___ 10:35PM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-98 UreaN-7 Creat-0.7 Na-136 K-3.6
Cl-104 HCO3-25 AnGap-11
___ 10:35PM BLOOD Glucose-103* UreaN-9 Creat-0.9 Na-136
K-3.6 Cl-102 HCO3-21* AnGap-17
___ 06:40AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7
___ CT pelivis w/contrast
IMPRESSION:
Rim-enhancing fluid collection in the left ischioanal fossa,
concerning for
abscess, without supralevator extension. No overt connection to
the rectum is
identified. MRI could be helpful for further characterization,
if clinically
indicated.
Brief Hospital Course:
Ms. ___ came in to the ___ emergency department complaining
of left buttock pain on ___. On anorectal exam an area of
tenderness and slight induration was noticed at the 9 o'clock
position. CT pelvis with contrast was obtained which showed
rim-enhancing fluid collection in the left ischioanal fossa.
Colorectal surgery was consulted for further management of the
fluid collection. A decision was made to take her to the
operating room for incision and drainage of the fluid
collection. The risks and benefits were explained to the
patient. She agreed with the plan and singed the informed
consent. She then taken to the operating room and underwent
examination under anesthesia, drainage of an abscess, placement
of a ___. The procedure went well without complication. She
was extubated in the operating room, and transferred to the
postanesthesia care unit. She remained stable in the PACU and
was transferred to the floor. Her pain was well controlled, she
voided without issues and tolerated regular diet.
On ___, the patient was discharged to home. At discharge,
she was tolerating a regular diet, passing flatus, voiding, and
ambulating independently? She will follow-up in the clinic in
___ weeks. This information was communicated to the patient
directly prior to discharge.
Medications on Admission:
tylenol #3 prn, amoxicillin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Perirectal Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were diagnosed with a perirectal abscess. You had the
abscess drained in the operating room and ___ and ___ rose
drains were placed. You no longer require antibiotics. The
rubber ___ drain (which looks like a flat noodle) will fall
out on its own. The blue ___ will stay in place until you are
healed and will be removed in clinic. You may return home. It is
important that you keep the area very clean. Please shower and
pat the area dry, you should apply a clean pad to your underwear
to catch drainage. You may ___ baths. Please monitor the
area for signs of worsening infection: infection including:
increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please monitor your bowel function: Some
loose stool and passing of small amounts of dark, old appearing
blood are expected however, if you notice that you are passing
bright red blood with bowel movements or having loose stool
without improvement please call the office or go to the
emergency room if the symptoms are severe. If you are taking
narcotic pain medications there is a risk that you will have
some constipation. Please take an over the counter stool
softener such as Colace, and if the symptoms does not improve
call the office. If you have any of the following symptoms
please call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
You will be prescribed a small amount of the pain medication
Oxycodone-Acetaminophen. Please take this medications exactly as
prescribed. Please do not take more than 3000mg of Tylenol
daily. Do not drink alcohol while taking narcotic pain
medication or Tylenol. Please do not drive a car while taking
narcotic pain medication.
You are breast feeding therefore you should be careful if
feeding the baby and taking narcotics. If you do not need
narcotics the baby may be drowsy, best to avoid. Please wait 24
hours after taking the antibiotics to breast feed and 24 hours
after anesthesia. Please call your baby's pediatrician with any
further questions.
Followup Instructions:
___
|
10531372-DS-19 | 10,531,372 | 29,677,890 | DS | 19 | 2115-09-11 00:00:00 | 2115-09-11 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of a.fib, not on coumadin, s/p unwitnessed fall
from bed overnight. Found to have ___, ___, left orbital
fractures.
Evaluated by neurosurgery and plastics in the ED. Per
neurosugery, no intervention. No aggressive operative management
offered after ___ family decided that they wanted the
patient cared for with supportive care only, without aggressive
measures.
INJURIES:
- R SDH 4mm
- L parietal SDH 4mm
- R SAH sylvian fissure
- L anterior, posterior max sinus walls, extending into inferior
aspect of maxillary sinus
- comminuted fracture of left orbital floor
- compression deformities of L1, L5, T10 vertebral bodies,
indeterminate chronicity
Past Medical History:
PMH: CAD s/p CABG, mitral valve replacement, breast CA s/p
lumpectomy and tamoxifen, dementia, fall (admitted ___ w/
SDH), gout, hypothyroid, A-fib (not on coumadin), Alzheimers
PSH: L breast lumpectomy, PEG ___ to ___, R craniotomy for
___ ___, BSO, bilateral cataracts
Social History:
___
Family History:
Son with ___
Mother died of breast cancer in the ___ (pt nor family knows
how old she was)
Physical Exam:
95.7, 82, 140/81, 18, 100RA
no acute distress
oriented to self
left periorbital edema, eyelid edema, facial edema, facial
tenderness
heart and lungs within normal limits
right portacath in chest wall
abdomen soft nontender nondistended
Pertinent Results:
IMAGING:
___ head CT (OSH): R SDH 4mm, L parietal SDH 4mm, R SAH sylvian
fissure, L anterior, posterior max sinus walls, extending into
inferior aspect of maxillary sinus, comminuted fracture of left
orbital floor
___ CT cspine: no evidence of acute cervical fracure. Minimal
retrolistheis of c6-c7 of indeterminate chronicity. partially
image left maxillary sinus fracture.
___: CT torso: compression deformities of L1, L5, T10 vertebral
bodies of indeterminate chronicity. Right sided rib fracture,
likely chronic.
___ 09:50AM GLUCOSE-155* UREA N-21* CREAT-1.5* SODIUM-136
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11
___ 09:50AM cTropnT-0.03*
___ 09:50AM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-1.5*
___ 09:50AM WBC-9.9 RBC-3.02* HGB-9.8* HCT-30.7* MCV-102*
MCH-32.5* MCHC-31.9 RDW-19.2*
___ 09:50AM PLT COUNT-312
___ 09:50AM ___ PTT-25.6 ___
___ 11:00PM URINE HOURS-RANDOM
___ 11:00PM URINE GR HOLD-HOLD
___ 11:00PM URINE COLOR-AMBER APPEAR-Hazy SP ___
___ 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:00PM URINE RBC-<1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:00PM URINE HYALINE-10*
___ 11:00PM URINE AMORPH-RARE
___ 11:00PM URINE MUCOUS-FEW
___ 10:35PM GLUCOSE-132* UREA N-21* CREAT-1.6* SODIUM-137
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
___ 10:35PM estGFR-Using this
___ 10:35PM cTropnT-0.02*
___ 10:35PM ALBUMIN-3.3*
___ 10:35PM DIGOXIN-0.6*
___ 10:35PM PHENYTOIN-17.1
___ 10:35PM WBC-9.7 RBC-3.31* HGB-10.6* HCT-34.0*#
MCV-103*# MCH-32.0 MCHC-31.1 RDW-19.0*
___ 10:35PM NEUTS-82.7* LYMPHS-8.8* MONOS-4.7 EOS-3.5
BASOS-0.3
___ 10:35PM PLT COUNT-392#
___ 10:35PM ___ PTT-26.3 ___
Brief Hospital Course:
Ms. ___ was admitted to the ___ following her fall on
___. Neurosurgery, plastic surgery, and spine were
consulted. Her C-spine was cleared by Dr. ___. A thorough
discussion between Dr. ___ the ___ son and
healthcare proxy took place given the ___ baseline
dementia. He noted that the ___ wishes would be to have
conservative care only at this time which would not include
operative intervention or further imaging studies. Plastic
surgery, neurosugery and orthopedic spine surgery initially saw
the patient in the ED and initially evaluated her but did not
continue to follow after her goals of care were made clear.
Ophthalmology saw the patient during her stay and determined
that her globe is intact and that she has some findings
consistent with glaucoma and would benefit from timolol eye
drops twice daily. She was started on a soft solid diet and
transferred to the floor in stable condition. Her foley was
removed on ___, but she failed to void and it was replaced.
She was able to tolerate modest amounts of PO intake, including
her PO medications. She was gently hydrated with IVF during her
stay. Her foley was removed prior to transfer back to rehab.
Medications on Admission:
docusate 100 prn, colchicine 0.6', digoxin 125', metoprolol
100", vit C, ASA 81, MVI, Fe sulfate 325', Celexa 10',
risperidone 0.25''', allopurinol ___, dilantin 200", zantac
150', Lasix 20", SS insulin, trazodone 50'
Discharge Medications:
1. Tylenol ___ mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
2. oxycodone 5 mg Tablet Sig: .___ Tablet PO Q4H (every 4 hours)
as needed for pain.
3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg PO
Q12H (every 12 hours).
8. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
13. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Unwitnessed fall resulting in subarachnoid hemorrhage, subdural
hemorrhage, multiple facial fractures, findings of vertebral
compression fractures of unknown chronicity
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:
Pain medication for comfort, supportive care for sustained
injuries. Resume all home medications. Foley catheter only if
needed for urinary retention.
Followup Instructions:
___
|
10531660-DS-11 | 10,531,660 | 22,433,327 | DS | 11 | 2203-04-24 00:00:00 | 2203-04-24 23:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right Hand burn
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of recurrent UTIs
and lower urinary symptoms, T2DM, BPH, CAD, h/o low grade
lymphoma, CKD, AFib on warfarin, who is presenting with right
hand redness and pain.
On ___, patient was attempting to fix issue with ___ box at
home. When placing power cord in wall, there was a sudden spark
and 'flame' eruption from cord. Pulled back hand instantly but
did notice some redness along dorsal aspect of right thumb/hand.
Denies electrical shock, chest pain, palpitations and shooting
pain up right hand. Went to PCP but unable to get appointment to
be seen. Attended local pharmacy instead and was given silvadene
to apply topically.
Over the following three days, the patient had no complaints. No
pain, no sensory changes, no paresthesias, no obvious burn.
However awoke on morning of ___ with pain along base of right
thumb. This became progressively worse over the course of the
day, and extended up to mid forearm. Area of erythema also began
to progress from dorsal aspect of right hand to mid forearm.
On ___, the patient awoke with severe pain in his right hand
and a small amount of yellow discharge originating from the
original wound site. He attended a walk in clinic and was given
a
course of Cephalexin for possible cellulitis. However, with no
improvement in his symptoms, he decided to attend ED.
On further questioning, range of motion of thumb is limited by
pain. He has noticed occasional paresthesias at distal right
thumb but not along other fingers. Sensation has remained
unchanged, although he does believe the fingers on his right
hand
feel cooler than on left hand. He denies weakness, fevers,
sweats, and chills.
Pertinent ED course:
X-Ray without fracture or acute process, and Ultrasound without
fluid collection. He was seen by Hand Surgery who recommended
against operative management at present. He was given Vanc/CTX
and IV morphine.
Upon arrival to the floor, the patient reports improvement in
his
pain but still feels he requires more analgesia. Paresthesias
not
present currently and sensation appears normal.
Past Medical History:
- Diabetes Mellitus
- Nephrolithiasis x3
- BPH with lower urinary obstructive symptoms
- CAD medically managed
- Hypertension
- Low grade B-Cell lymphoma
- OSA (no requirement for CPAP for years)
- Gout
- COPD
- Anemia
- Degenerative joint disease
- Atrial fibrillation s/p DCCV ___
- CKD stage 4
- CHF
- Hyperparathyroidism
- PVD
Social History:
___
Family History:
Mother: Died age ___ of ___ Cancer
Father: Died age ___ AMI
Siblings: Brother died ___ Cancer; 3 Sisters one has
thalassemia trait, one died recently of lymphoma
Physical Exam:
Admission Exam:
VITALS: Temp 98.1 BP 167/84 HR 73 RR 18 SaO2 100% Ra
GENERAL: patient sitting comfortably in bed, right hand/forearm
splinted
EYES: EOMI, PERRL, no conjunctival pallor, anicteric sclera
ENT: MMM, good dentition
NECK: supple, non-tender, no LAD, no JVD
CV: S1 and S2 normal, no murmurs/rubs/gallops appreciated
RESP: clear to auscultation bilaterally, no
wheeze/rales/rhonchi,
breathing comfortably with no use of accessory muscles of
respiration
GI: soft, non-tender, distended (at baseline), BS + and normal
MSK: moving all four extremities with purpose, right
hand/forearm
splinted
SKIN: right hand splinted, otherwise no rashes, edema, cyanosis.
Recent procedure with podiatry on left great toe, healing well
NEURO: A/O x3, CN II-XII intact, otherwise grossly intact
Discharge Exam:
VS: 97.5 PO 106 / 56 74 18 98 Ra
GENERAL: patient sitting comfortably in bed, right hand/forearm
splinted
EYES: EOMI, PERRL, no conjunctival pallor, anicteric sclera
ENT: MMM, good dentition
NECK: supple, non-tender, no LAD, no JVD
CV: S1 and S2 normal, no murmurs/rubs/gallops appreciated
RESP: clear to auscultation bilaterally, no
wheeze/rales/rhonchi, breathing comfortably with no use of
accessory muscles of respiration
GI: soft, non-tender, distended (at baseline), BS + and normal
MSK: moving all four extremities with purpose, right
hand/forearm splinted
SKIN: right hand splinted, otherwise no rashes, edema,
cyanosis.
Recent procedure with podiatry on left great toe, healing well
NEURO: A/O x3, CN II-XII intact, otherwise grossly intact,
sensation to right hand, ___ digit intact. Pt having trouble
adducting thumb to ___ and ___ phalange.
Pertinent Results:
Admission Labs:
___ 02:55AM BLOOD WBC-5.7 RBC-4.21* Hgb-12.0* Hct-35.4*
MCV-84 MCH-28.5 MCHC-33.9 RDW-14.2 RDWSD-43.3 Plt ___
___ 02:55AM BLOOD Neuts-69.9 Lymphs-17.8* Monos-8.8 Eos-2.6
Baso-0.7 Im ___ AbsNeut-3.97 AbsLymp-1.01* AbsMono-0.50
AbsEos-0.15 AbsBaso-0.04
___ 02:55AM BLOOD Plt ___
___ 02:55AM BLOOD Glucose-105* UreaN-41* Creat-1.8* Na-136
K-4.0 Cl-102 HCO3-20* AnGap-18
___ 02:55AM BLOOD estGFR-Using this
___ 02:55AM BLOOD HoldBLu-HOLD
___ 03:08AM BLOOD Lactate-1.2
Discharge Labs:
___ 07:30AM BLOOD WBC-4.8 RBC-3.81* Hgb-10.8* Hct-32.4*
MCV-85 MCH-28.3 MCHC-33.3 RDW-14.0 RDWSD-43.7 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-39.3* ___
___ 07:30AM BLOOD Glucose-104* UreaN-45* Creat-1.7* Na-139
K-4.4 Cl-106 HCO3-21* AnGap-16
___ 07:30AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
Micro:
__________________________________________________________
___ 8:26 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
__________________________________________________________
___ 6:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 3:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Imaging/Studies:
___ Imaging CHEST (PORTABLE AP)
Comparison to ___. Lung volumes are normal. Moderate
cardiomegaly
with minimal atelectasis in the retrocardiac lung area. Mild
fluid overload
but no overt pulmonary edema. No pleural effusions. No
pneumonia
___ Imaging US MSK HAND/FINGER RIGH
Focal skin and subcutaneous tissue thickening in the area of
patient's concern
close to the right thumb. Minimally increased vascularity,
likely reactive.
No drainable fluid collection or abscess.
___ Imaging HAND (PA,LAT & OBLIQUE)
-Subtle punctate density in the volar soft tissues of the thumb.
This is of
uncertain significance and could reflect a tiny focus of soft
tissue
calcification versus tiny foreign body.
-No acute fracture or dislocation.
-Diffuse degenerative changes, most notable at the first ___
joint.
Brief Hospital Course:
___ with PMH of DM, UTI's, CAD, who is presenting one week post
an electrical burn to dorsal radial aspect of right hand.
Active Issues:
#Hand Burn
Patient presented one week post an electrical burn to dorsal
radial aspect of right hand, with erythema and skin loss. Hand
neurovascularly intact. No fevers or leukocytosis, no fluid
collection on ultrasound so ?cellulitis. Since patient is having
trouble moving hand, concern for dead muscle tissue. His hand
Ultrasound was negative for abscess and x-ray negative for signs
of infection. Pt was going to surgery ___ but INR 4.5. He was
placed on IV vancomycin while in the hospital. Hand surgery
reassessed and determined that he did not need surgery and
should follow up with them as outpatient. Based on exam, it was
felt that there was no cellulitis, so vancomycin was
discontinued upon discharge. He requires a visiting nurse for
dressing changes. He was seen by occupational therapy as his
hand was splinted/elevated. He was recommended for home OT.
#Diabetes
Patient has a long history of diabetes mellitus which is well
controlled at home as per patient. HbA1c on ___ was 8.0 on
Atrius. On insulin glargine 36IU in ___ and liraglutide 1.2mg in
AM. He was placed on a sliding scale and his sugars were
monitored. He was discharged on his home medications.
#Afib on anticoagulation with supratherapeutic INR
We continued home metoprolol. His warfarin was held for
potential hand surgery; INR was 4.5 ___ and 4.7 on ___.
Patient was not sent home on warfarin due to high INR and he
should go to an ___ clinic in the next ___ days to follow up
with his INR/Warfarin dose.
CHRONIC/STABLE PROBLEMS:
#BPH: We continued his home finasteride and tamsulosin.
#Gout: We continued his home allopurinol.
#HTN: We continued home losartan and metoprolol.
#CKD stage 4: creatinine on admission is 1.8 (at baseline)
==========================================
Transitional Issues:
==========================================
[] Will need INR check in the next ___ days to measure INR,
adjust warfarin as needed
[] PCP and hand surgery follow up
[] Wound care, will require ___ services: silver sulfadiazine
cream + dry gauze over wound, change dressing BID until follow
up
[] Outpatient home OT to prevent stiffness of thumb
[] F/u Blood cx and MRSA swab
INR at discharge: 4.7
# Code status: Full (presumed)
# Contact: ___, niece, cell: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Sildenafil 20 mg PO DAILY:PRN sex
2. Vitamin E Dose is Unknown PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Allopurinol ___ mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Glargine 36 Units Bedtime
8. trospium 20 mg oral DAILY
9. Atorvastatin 40 mg PO QPM
10. Losartan Potassium 50 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Furosemide 20 mg PO DAILY
14. Victoza 2-Pak (liraglutide) 1.2 mg subcutaneous QAM
15. Warfarin 7.5 mg PO 2X/WEEK (MO,FR)
16. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Finasteride 5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Glargine 36 Units Bedtime
7. Losartan Potassium 50 mg PO DAILY
8. Magnesium Oxide 400 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Sildenafil 20 mg PO DAILY:PRN sex
___. Tamsulosin 0.4 mg PO QHS
12. trospium 20 mg oral DAILY
13. Victoza 2-Pak (liraglutide) 1.2 mg subcutaneous QAM
14. Vitamin E 400 UNIT PO DAILY
15. HELD- Warfarin 7.5 mg PO 2X/WEEK (MO,FR) This medication
was held. Do not restart Warfarin until your doctor tells you to
16. HELD- Warfarin 5 mg PO 5X/WEEK (___) This
medication was held. Do not restart Warfarin until your doctor
tells you to
17. HELD- Warfarin 5 mg PO 5X/WEEK (___) This
medication was held. Do not restart Warfarin until your doctor
tells you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Electrical burn to right ___ dorsal webspace.
- Supratherapeutic INR
Secondary Diagnoses:
- Atrial fibrillation
- Chronic Kidney Disease stage IV
- Diabetes Mellitus type II
- Benign Prostatic hyperplasia
- Coronary artery disease medically managed
- Hypertension
- Low grade B-Cell lymphoma
- Obstructive sleep apnea (no requirement for CPAP for years)
- Gout
- Chronic Obstructive Pulmonary Disease
- Peripheral vascular disease
- Nephrolithiasis x3
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for care of the burn on your right hand.
WHY WERE YOU HERE?
===========================================
-You were here so that we could care for the burn on your right
hand.
WHAT DID WE DO FOR YOU?
============================================
-We took images of your hand
-We had surgeons come to see you to see if you needed surgery
-We took care of your wounds
-We stopped your warfarin because your INR was too high
(indicates you may have had too much of the drug in your body)
WHAT DO YOU DO NOW?
=======================================
-You should care for the wound as instructed and call your
doctor if you have more pain, fevers, or redness of the area.
-You should go to your ___ clinic in the next ___ days.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10531667-DS-14 | 10,531,667 | 28,741,015 | DS | 14 | 2137-11-14 00:00:00 | 2137-11-14 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ongoing intermittent headache, ear fullness, vertigo and gait
imbalance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF with HTN, recent admission with hypertensive crisis and R
PCA stroke, with ongoing intermittent headache, ear fullness,
vertigo and gait imbalance.
She was recently discharged from ___ ___ after being admitted
for headache, visual disturbances including blurriness,
confusion and hypertensive emergency SBP >240. During that
admission her HTN was better controlled but she was found on CT
to have a R PCA stroke. This prompted a stroke consult and
stroke risk factor workup including Lipid profile, A1c, Echo,
MRI, neck vascular imaging. A clear etiology was not found but
given the size of her stroke was presumed to be of embolic
origin. She was continued on aspirin and statin but not
anticoagulated given that she did not have afib or clear source
of thromboembolus.
She was discharged home and over the past several days has
experienced intermittent confusion, pounding headache, ear
fullness and dizziness - which appears somewhat positional and
describes as a sense that the world spinning around her. She had
described these symptoms during her admission last week but
there was little concern for ongoing stroke and her difficulties
were
deemed to be peripheral in nature. However, she now describes
the sensation as very intense and limiting her ability to walk
and to maintain her balance.
She states that she has been compliant with her BP medications
since leaving the hospital and denies head/neck injury since her
discharge.
On neuro ROS, the pt endorses headache, vertigo and bilateral
lower extremity parasthesias (chronic), difficulty with gait.
She denies loss of vision, blurred vision, diplopia, dysarthria,
dysphagia. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hypercholesterolemia
Hypertension- since age of ___
Uterine prolapse s/p surgical repair ___ years ago
Varicose veins
s/p right knee joint infection many years ago in ___
Stroke- ___
Social History:
___
Family History:
Brother with HTN and DM2. Mother had MI at ___. Father had HTN,
died at ___ of prostate cancer. Children with HTN and daughter
had surgery on ?pancreas.
Physical Exam:
Vitals: T:98 P: 73 R: 16 BP: 211/99 SaO2: 99%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate story in
___ to the interpretor but only in short sentences.
Attentive, able to name ___ backward without difficulty.
Language is fluent (per interpretor) with intact repetition and
comprehension. Normal prosody. There were no obvious
paraphasic errors. Speech was not dysarthric. Able to follow
both midline
and appendicular commands.
-Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and
brisk. Homonymous field cut in left visual field. III, IV, VI:
EOMI without nystagmus in any direction of gaze. Normal saccades
(but long latency) 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.
-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 flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Able to get up with assitance, romberg postive, did not
attempt walking given her trepidation and complaint of vertigo.
*** DISCHARGE EXAMINATION: Unchanged from prior with
redemonstration of the homonymous left field cut bilaterally,
also slight hyperreflexia in patellar and biceps bilaterally.
Pertinent Results:
___ 08:35PM GLUCOSE-134* UREA N-8 CREAT-0.5 SODIUM-125*
POTASSIUM-3.4 CHLORIDE-90* TOTAL CO2-22 ANION GAP-16
___ 08:35PM estGFR-Using this
___ 08:35PM cTropnT-<0.01
___ 08:35PM WBC-9.4 RBC-4.52 HGB-14.2 HCT-39.3 MCV-87
MCH-31.4 MCHC-36.1* RDW-12.4
___ 08:35PM NEUTS-60.4 ___ MONOS-6.7 EOS-1.2
BASOS-0.9
___ 08:35PM PLT COUNT-316
___ MRI/A IMPRESSION:
1. No evidence of acute ischemia or hemorrhage.
2. Expected further evolution of the large now late-subacute
infarct
involving much of the right occipital lobe, sparing only its
pole, This now demonstrates gyriform early dystrophic
mineralization, presumably related to "pseudolaminar necrosis."
3. Occlusion of the P4 segment of the right PCA, as expected,
with otherwise unremarkable cranial MRA.
___ CT ABDOMEN/PELVIS IMPRESSION:
1. No evidence of malignancy within the abdomen or pelvis. No
CT evidence of pheochromocytoma.
2. Multiple bilateral renal hypodensities, measuring up to 1.2
cm in the left kidney, most compatible with cysts.
___ RENAL ULTRASOUND W/ DOPPLERS IMPRESSION:
1. Normal Doppler evaluation of bilateral kidneys without
evidence for renal artery stenosis.
2. Left upper pole cyst contains a small amount of sediment, but
is otherwise simple in appearance. Bosniak class 2. No follow up
is indicated.
3. Nonobstructing left lower pole stone measuring 1 centimeter
in long dimension.
Brief Hospital Course:
Patient was admitted to ___ for further evaluation of her
hypertension.
NEURO:
NCHCT and MRI were performed which were unremarkable for any
ischemic changes; previous right PCA stroke was redemonstrated
without any further evolution which remained evident upon visual
field testing (Left Hemianopsia). Her symptoms described of
"wooshing", epigastric rising sensation, and vertiginous
sensation, and mild headache seemed to coincide with periods of
anxiety which were treated with Diazepam.
CV:
Blood pressure initially was noted to be elevated to SBP>200
which was managed with dosing of her home medications and
Hydralazine PRN which resulted in control of blood pressure with
transient depression to SBP in ___ which corrected to SBP
130-160s. Medicine consult recommended increasing Hydralazine
to 10mg from 5mg which resulted in BP which remained in the 130s
on discharge. The patient was also discharged with a short
course of diazepam for anxiety exacerbation of what was believed
to be poorly controlled primary hypertension (which the patient
has had a history of for ___ years). HCTZ was added at 12.5mg
daily for better control of blood pressure.
GI:
Bloating resolved over the course of her admission, and
Ranitidine was added for better control of her reflux /
bloating.
ENDOCRINE:
Thyroid Function Tests were within normal levels, and labs with
the exclusion of her initial sodium were within reference
ranges. Cortisol was found to be trivially elevated in the AM
(27.3 vs. top-normal 20); however, the patient was not noted to
have any cushingoid stigmata on examination. At the time of
discharge, Metanephrines remained outstanding although given
normal imaging and control with anti-hypertensives our suspicion
for catecholamine secreting tumor was low.
RENAL:
The patient was noted to be hyponatremic to 125 in the ED, which
on repeat was found to be 134. Her sodium and potassium levels
were both consistently within reference ranges excluding the
first result. We performed US Renal and CT A/P which
demonstrated chronic cortical thinning likely ___ poorly
controlled HTN, but no evident renal artery stenosis, or other
pathology concerning for secretory tumors (Pheo).
ONGOING MANAGEMENT:
- An email was sent to the patient's PCP which detailed the
patient's course as well as our change to her Amlodipine dosage
and initiation of a short course of Diazepam therapy.
- We scheduled an appointment with the PCP for further
management of her Diazepam and Anti-hypertensive regimen.
- Renin/Aldosterone, and Plasma Metanephrines were still pending
at the time of discharge
- Medicine suggested possible w/u of trivially elevated AM
cortisol with either 24-hr Urine Cortisol vs. Dexamethasone
Suppression Test
Medications on Admission:
Amlodipine 5mg PO daily
Lisinopril 40mg PO Daily
Atorvastatin 20mg PO Daily
Toprol XL 25mg PO daily
Aspirin 81mg PO daily
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Lisinopril 40 mg PO DAILY16
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Simethicone 40-80 mg PO QID:PRN abdominal pain
7. Diazepam 2 mg PO Q6H:PRN anxiety
RX *diazepam 2 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
8. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
9. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Crises
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for
further evaluation of your episodes of ongoing intermittent
headache, ear fullness, vertigo and gait imbalance. These
symptoms were found to be in the setting of elevated blood
pressures in to the 200's.
We evaluated you for endocrinologic causes of your elevated
blood pressure including thyroid studies which were negative,
adrenal function studies which were also normal, and tumor
markers which were negative as well. We performed imaging of
the abdomen and pelvis which showed no areas concerning for
masses or lesions.
We increased your medications to account for the elevation in
blood pressure that you experienced. We recommend you continue
on these dosages of medication until you have the opportunity to
follow up with your primary care physicians, Drs. ___
___ for continued management. Please continue to take
your blood pressure on a regular basis.
We also have written you for a short course of Diazepam which
has been helpful with managing your heightened anxiety and
concomitant increases in blood pressure experienced with these
episodes.
Followup Instructions:
___
|
10531667-DS-15 | 10,531,667 | 21,654,431 | DS | 15 | 2139-07-23 00:00:00 | 2139-07-27 17:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dysarthria and left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ right-handed
___ white woman with PMH of embolic-appearing R
PCA-territory stroke in ___ without identified source,
difficult-to-control HTN (with prior hypertensive emergency),
dyslipidemia, who is known to the neurology service from her
previous stroke admission in ___ and follows with Dr. ___ in
stroke clinic, and who now presents with L facial droop and
dysarthria after waking up.
The pt had a brief period of not taking her meds earlier this
month when she ran out of them but they were refilled by her PCP
___ ___ and she has been taking them since.
Over the last few days, the pt has been feeling unwell with some
abdominal pain, diarrhea, subjective fevers and general body
aches. She felt hot & uncomfortable again last night but was
otherwise her usual self. This morning around 7 am, the pt woke
up with severe dysarthria to the point of being incomprehensible
to the husband and a L facial droop. She was able to comprehend
speech, and seemed to be using her arms and ambulating without
major difficulty. The dysarthria started clearing after about 2
hours and at present the pt is much more comprehensible and her
speech is only a little halting. The droop is still present.
On neurologic ROS, no headache/neck stiffness; no
lightheadedness/confusion/syncope/seizures; no
amnesia/concentration problems; no loss of vision/blurred
vision/amaurosis/diplopia; no vertigo/tinnitus/hearing
difficulty; no muscle weakness, no clumsiness; no loss of
sensation/numbness/tingling; no difficulty with gait/balance
problems/falls.
Past Medical History:
- R PCA-territory stroke in ___ without identified source
(including negative TTE w/bubble, tele, 2 weeks ___ of
Hearts)
- difficult-to-control HTN (with prior hypertensive emergency,
negative secondary HTN w/u)
- dyslipidemia
- GERD
Social History:
___
Family History:
Brother with HTN and DM2. Mother had MI at ___. Father had HTN,
died at ___ of prostate cancer. Children with HTN and daughter
had surgery on ?pancreas.
Physical Exam:
ADMISSION EXAM
VS T:98 HR:65 BP:172/78 RR:16 SaO2:97% RA
General: NAD, lying in bed comfortably.
- Head: NC/AT, no conjunctival icterus
- Fundoscopy: unable to perform as pt would close her eyes
whenever approached w/ophthalmoscope.
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
- Neurovascular: No carotid bruits
- Cardiovascular: carotids with normal volume & upstroke;
jugular veins nondistended, no RV heave; RRR, short ___ SEM at
RUSB c/w aortic sclerosis
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Abdomen: nondistended, no tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
radial/dorsalis pedis pulses.
- Skin was without rash, induration or neurocutaneous stigmata.
Intact hair, nails and nail folds.
Neurologic Examination:
Mental Status:
Awake, alert, oriented x 3.
Attention: Recalls a coherent history and converses
appropriately and bidirectionally. No neglect to visual or
sensory double stimulation. Concentration maintained when
recalling months backwards.
Affect: anxious but euthymic
Language: Fluent but hesitant speech and good comprehension.
Minimal dysarthria elicited with ___ tongue twisters, no
dysprosody or paraphasias noted. Follows two-step commands,
midline and appendicular but has difficulty with commands
crossing the midline. High- and low-frequency naming intact.
Intact repetition. Normal reading.
Memory: Needs 3 trials to register ___ objects and recalls ___
at 1 minute, improving to ___ with category cueing and ___ with
multiple choice
Praxis: + bodypart-as-object errors when pantomiming brushing
teeth or hair
Executive function tests: + motor impersistence Luria hand
sequencing easily learned and performed repeatedly.
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light. No
RAPD.
Visual fields full to peripheral motion, tested individually,
and to DSS
[III, IV, VI] The eyes are well aligned. EOM intact w/o
pathologic nystagmus. Horizontal and vertical saccades accurate
and symmetric.
[V] V1-V3 with subjectively decreased sensation to light touch
and pinprick. Pterygoids contract normally.
[VII] L lower facial droop and decreased voluntary activation.
[VIII] Hearing grossly intact to finger rub bilaterally.
[IX, X] Palate elevates in the midline.
[XI] Neck rotation normal and symmetric. Shoulder shrug strong.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor:
Mild L cupping but no pronation or drift. No tremor, asterixis
or other abnormal movements.
Bulk: normal
Tone: normal
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 4+]
Biceps [R 5] [L 5]
Triceps [R 5] [L 4+]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5-]
Finger Flexors [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Extensor Digitorum Brevis [R 5] [L 5]
Sensory: Intact proprioception at halluces bilaterally. No
deficits to cold testing on extremities and trunk.
Cortical sensation: No extinction to double simultaneous
stimulation.
Reflexes
[Bic] [Tri] [___] [Pat] [Ach]
L 3 2 3 2 2
R 2 2 2 2 2
Plantar response flexor on right, ?extensor on left.
Coordination: No rebound. No dysmetria on finger-to-nose and
heel-knee-shin testing. Mild orbiting of LUE w RUE. Finger
tapping on crease of thumb, and sequential finger tapping
symmetric.
Gait& station:
Stable stance without sway. Normal initiation. Narrow base.
Normal stride length and arm swing. Intact heel, toe, and tandem
gait.
**********
Discharge Exam:
VS T97.8 HR54 BP159/75 RR18 SpO2 98% on RA
General: NAD, lying in bed comfortably.
- Head: NC/AT, no conjunctival icterus
- Neck: Supple, no nuchal rigidity. No LAD or thyromegaly.
- Cardiovascular: carotids with normal volume & upstroke;
jugular veins nondistended; RRR, short ___ SEM at RUSB c/w
aortic sclerosis
- Respiratory: Nonlabored, CTA with good air movement
bilaterally
- Abdomen: nondistended, no tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, +peripheral
pulses
Neurologic Examination:
Mental Status:
Awake, alert, oriented x 3.
Attention: Recalls a coherent history and converses
appropriately and bidirectionally. No neglect to visual or
sensory double stimulation. Concentration maintained when
recalling months backwards.
Affect: anxious but euthymic
Language: Fluent speech and good comprehension. Minimal
dysarthria elicited with ___ tongue twisters, no dysprosody
or paraphasias noted.
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light. No
RAPD. Poor accuracy w testing of L visual fields to peripheral
motion
[III, IV, VI] The eyes are well aligned. EOM intact w/o
pathologic nystagmus.
[V] V1-V3 with subjectively decreased sensation to light touch
and pinprick.
[VII] L lower facial droop and decreased voluntary activation.
[VIII] Hearing grossly intact to finger rub bilaterally.
[IX, X] Palate elevates in the midline.
[XI] Neck rotation normal and symmetric. Shoulder shrug strong.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor:
Mild L cupping but no pronation or drift.
Tone: normal[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 4+]
Biceps [R 5] [L 5]
Triceps [R 5] [L 4+]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5]
Finger Flexors [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Extensor Digitorum Brevis [R 5] [L 5]
Sensory:
Intact proprioception at halluces bilaterally. No deficits to
cold testing on extremities and trunk.
Cortical sensation: No extinction to double simultaneous
stimulation.
Reflexes
[Bic] [Tri] [___] [Pat] [Ach]
L 3 2 3 2 2
R 2 2 2 2 2
Plantar response flexor on right, mute on left.
Coordination: No rebound. No dysmetria on finger-to-nose and
heel-knee-shin testing. No dysdiadochokinesia. Forearm orbiting
symmetric. Finger tapping on crease of thumb, and sequential
finger tapping symmetric.
Gait& station:
Stable stance without sway. Normal initiation. Narrow base.
Normal stride length and arm swing. Intact heel, toe, and tandem
gait.
Pertinent Results:
___ 08:25PM CK(CPK)-239*
___ 08:25PM CK-MB-4 cTropnT-<0.01
___ 01:48PM GLUCOSE-109* NA+-142 K+-3.8 CL--103 TCO2-24
___ 01:50PM CREAT-0.6
___ 01:30PM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-69
___ 01:30PM ___ PTT-29.1 ___
___ 01:30PM PLT COUNT-210
___ 01:30PM WBC-7.2 RBC-4.28 HGB-13.6 HCT-40.2 MCV-94
MCH-31.8 MCHC-33.9 RDW-12.8
___ 05:55AM BLOOD %HbA1c-5.8 eAG-120
___ 08:15AM BLOOD Triglyc-70 HDL-43 CHOL/HD-3.3 LDLcalc-86
___ 05:55AM BLOOD TSH-2.2
___ CT head w/o contrast
IMPRESSION:
1. Evolving right MCA infarct in the frontal lobe.
2. No evidence of intracranial hemorrhage.
3. Chronic right PCA infarct.
___ CTA head and neck
IMPRESSION:
1. Re- demonstration of hypodensity in the right frontal lobe
and large area of encephalomalacia in left occipital lobe
consistent with old infarction.
2. The petrous portion of the ICA appears irregular, likely due
to artifact. Otherwise no significant abnormality of the
intracranial vasculature.
___ TTE
No PFO/ASD is visualized by color doppler and saline study.
Normal left ventricular function with mild symmetric left
ventricular hypertrophy. Mild to moderate aortic regurgitation.
Borderline pulmonary artery systolic hypertension. There is
doppler evidence of elevated filling pressures.
Brief Hospital Course:
___ ___ F w PMHx cryptogenic R PCA-territory stroke
in ___ (on home ASA 81mg), HTN (previous ED visits for HTN
emergency), and HLD (on home high dose statin, pravastatin 80mg)
presented w L facial droop and dysarthria upon waking ___
AM. NCHCT showed a R MCA territory infarct. Pt also c/o prodomal
sx (subjective fevers, body aches, and GI distress) in the days
prior to presentation. The pt's deficits improved steadily
throughout her admission. At the time of discharge, she had a
persistent (but improved) L facial droop, some L pronator drift,
minimal dysarthria, and no LUE and LLE clumsiness/ataxia. Stroke
work-up was unrevealing (CTA wnl, Tele monitoring w 1st degree
HB - no episodes of Afib captured, TTE wnl). Etiology of infarct
is likely from a proximal embolic souce given that the patient
also has had a posterior circulation infarct in ___ - stroke
work-up at that time was also unrevealing.
The team considered discharging the patient on coumadin for
empiric anticoagulation for presumed (cardiac) embolic source.
Due to patient medication compliance issues, however, we will
start plavix (and discontinue home ASA) upon discharge.
**************
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 = 86
) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
Medications on Admission:
amlodipine 5 mg daily
HCTZ 25 mg daily
lisinopril 40 mg daily
metoprolol succinate 50 mg daily
pravastatin 80 mg daily
ASA 81 mg daily
citalopram 40 mg daily
ranitidine 150 mg BID
LZP 0.5 mg PRN anxiety, takes daily
APAP XR 650 mg q4h PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Citalopram 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Pravastatin 80 mg PO DAILY
7. Ranitidine 150 mg PO BID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Lorazepam 0.5 mg PO DAILY, PRN anxiety
10. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
right MCA infarct
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 slurred speech and 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:
- high blood pressure
- high cholesterol
- previous stroke
We are changing your medications as follows:
- please stop taking Aspirin
- start clopidogrel 75mg once daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10531678-DS-22 | 10,531,678 | 23,906,569 | DS | 22 | 2160-02-11 00:00:00 | 2160-02-13 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Lipitor / Codeine / Nsaids
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of recent AAA repair 3
weeks ago, T2DM, COPD, CKD, who presents with ER with shortness
of breath and chest pain. She reports SOB and pain at her
incision site for the past few weeks since discharge. She has
also had a dry cough, and some chills this weekend, but that
since improved. She says the chest discomfort is mostly near the
site of the incision. Some discomfort when she takes deep
breaths. She does not feel SOB sitting still, and is not sure
how far she can walk before becoming SOB. She has some abdominal
discomfort near the incision site as well, but no nausea or
vomiting. No recent sick contacts. She has had a poor appetite
and hasn't been eating or drinking much.
Pt was evaluated by ___ on last admission for SOB post op
requiring 2L NC. Last PFTs on file here at ___ (in ___
showed a
mild obstructive defect, however the patient states that she had
continued to smoke and that her PFTs may have worsened. ___
CT abd pelvis didn't show emphysematous changes at the lung
bases. She had been started on steroids for COPD but per pulm
these were discontinued. She was also noted to have a small
pleural effusion and SOB was attributed to her volume status
primarily. Note she was also treated with levoflox by her PCP
___ for multifocal PNA, prior to her admission for AAA repair.
In the ED, initial VS were: pain 6 T 99.8 94 98/56 16 98% 4L NP.
Labs were notable for Cr 1.7 (baseline 1.2-1.4), lactate 2.2,
trop 0.02, CK and MB flat, WBC 16.5 with left shift. She was
placed on 2L NC given initially hypoxic to 88% on RA. She was
noted to have BP drop to systolic ___ when she sat up and placed
her legs down. She was given 2 L NS, with BP's improved in 100s
systolic. Lactate improved to 1.2. She was given
Vanc/Levofloxacin empircally for possible infection (unclear
source per signout, likely HCAP since recently hospitalized),
though she remains afebrile. CTAP showed no PE, intact aortic
repair, and no acute issues. Imaging not suggestive of PNA. She
was seen by Vascular in the ED, and given repair intact they
made no further recommendations. She was given percocet x1,
which helped the discomfort.
VS prior to transfer 97.3 78 114/49 16 97% NP. Pt was recently
admitted from ___ for repair of AAA. This was done
without complications, but hospitalization complicated by mild
volume overload and pneumonia, discharged on Abx.
On arrival to the floor pt feels calm states she has signficant
anxiety regarding her medical conditions. Denies chest pain.
REVIEW OF SYSTEMS:
(+) As above.
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
AAA, HTN, Hypertriglceridemia, Mild COPD/Tobacco abuse, Cervical
polyps, benign, Colon adenoma Oseteopenia, Thalassemia trait,
Varicose veins, Gout, CKD stage 2,
PSH: ectopic pregnancy with tube and ovary excusion,
appendectomy, T & A, cataract
Social History:
___
Family History:
n/c
Physical Exam:
Admission Exam:
VS - Temp 98.8F, BP 128/68, HR 80, R 16, O2-sat 95% on 2L
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, mildly dry MM,
OP clear
NECK - supple, no JVD
LUNGS - resp unlabored, no accessory muscle use, few crackles on
left base, good air movement, no wheezes
HEART - RRR, soft ___ systolic murmur LUSB, nl S1-S2
ABDOMEN - well-healed midline scar, NABS, soft/NT/ND, no masses
or HSM, no rebound/guarding
EXTREMITIES - warm, dry, trace edema at ankles, 2+ DP pulses
SKIN - no rashes or lesions, healed scar midline
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities, gait deferred
Discharge Exam:
VS Tc 97.9 Tmax 97.9 126/78 62 19 96%RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, 2+ pulses palpable bilaterally, no c/c/e
NEURO no facial droop, speech fluent, motor function grossly
normal
SKIN no ulcers or lesions
Pertinent Results:
___ 10:48PM ___
___ 08:57PM LACTATE-1.2
___ 08:45PM cTropnT-0.02*
___ 08:45PM proBNP-618*
___ 01:47PM COMMENTS-GREEN TOP
___ 01:47PM LACTATE-2.2*
___ 01:30PM GLUCOSE-104* UREA N-29* CREAT-1.7* SODIUM-140
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-28 ANION GAP-21*
___ 01:30PM estGFR-Using this
___ 01:30PM ALT(SGPT)-4 AST(SGOT)-14 CK(CPK)-18* ALK
PHOS-91 TOT BILI-0.4
___ 01:30PM LIPASE-19
___ 01:30PM cTropnT-0.02*
___ 01:30PM CK-MB-2
___ 01:30PM ALBUMIN-3.7
___ 01:30PM WBC-16.5* RBC-4.16*# HGB-10.0* HCT-32.3*
MCV-78* MCH-24.1* MCHC-31.1 RDW-16.8*
___ 01:30PM NEUTS-90.0* LYMPHS-4.9* MONOS-3.2 EOS-1.6
BASOS-0.3
___ 01:30PM PLT COUNT-521*#
CXR: ___-
FINDINGS: Single portable AP upright image of the chest was
obtained. There are low lung volumes and resultant bibasilar
atelectasis. Superiorly the lungs are clear bilaterally without
focal consolidation or pulmonary edema. The previously described
right pleural effusion has decreased in size. No pneumothorax.
There are no bony abnormalities. There is no free air below
the right hemidiaphragm. Prominent air filled bowel loops are
located below the left hemidiaphragm.
IMPRESSION: No acute intrathoracic process. Interval decrease
in right
pleural effusion.
CT OF THE CHEST WITH CONTRAST ___: The thyroid gland is
normal and symmetric in appearance. Mediastinal and hilar lymph
nodes are noted though none are greater than 1 cm. The heart
and pericardium is unremarkable without
pericardial effusion. The esophagus is normal. The aorta and
major branches are patent with moderate irregular
atherosclerotic calcified and non-calcified plaque throughout.
The aorta is normal in caliber in the chest.
The trachea and central airways are patent to segmental level.
Moderate
predominantly centrilobular emphysema is noted. Several small
sub-4-mm
nodules are noted bilaterally (3:20, 27, 33, 34). There is no
pleural or
pericardial effusion. No focal consolidation is seen.
Bibasilar atelectasis is noted. The pulmonary arterial tree is
reasonably well opacified to the segmental level without
pulmonary embolus though evaluation of subsegmental arteries is
limited due to bolus timing.
CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: The liver is
normal in
attenuation without focal lesion, intra- or extra-hepatic
biliary ductal
dilatation. The portal and hepatic veins appear patent. The
gallbladder is distended. The pancreas, spleen, and bilateral
adrenal glands are
unremarkable. The kidneys enhance and excrete contrast
symmetrically with a 4.8 cm interpolar region cyst in the right
kidney (3:139). There is no hydronephrosis.
The stomach, small and large bowel are unremarkable with
moderate fecal load. The bowel wall enhances appropriately
without bowel wall thickening or peripheral stranding. There is
no mesenteric or retroperitoneal
lymphadenopathy. There is no free air or free fluid.
Post-surgical changes are seen in the anterior abdominal wall.
There is decreasing amount of right retroperitoneal evolving
hematoma and para-aortic post-surgical fluid.
CT OF THE PELVIS WITH CONTRAST: The bladder, uterus, adnexa and
rectum are unremarkable. There is no free pelvic fluid. There
is no pelvic or inguinal lymphadenopathy.
CTA: The patient is status post repair of ruptured infrarenal
aortic aneurysm with post-surgical changes noted and decreased
surrounding para-aortic fluid. The celiac and superior
mesenteric arteries are patent. The ___ remains occluded at its
origin, but reconstituted by to collateral flow. The ligated
left renal vein is again noted with thrombus within the left
renal vein and collateral flow through the left gonadal vein as
before with perhaps minimal increase in the degree of
thrombosis. The aneurysmal sac is unchanged without evidence of
leak.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion
to suggest osseous malignancy.
IMPRESSION:
1. No central pulmonary embolism, though assessment of
subsegmental vessels is limited due to bolus timing.
2. Status post repair of AAA with unchanged size of infrarenal
aorta and
irregular contour at surgical site as on previous study.
Para-aortic fluid
and retroperitoneal hematoma is decreased.
3. Left renal vein thrombus after surgical ligation is
minimally larger, with unchanged drainage via left gonadal vein.
4. Moderate volume of colonic stool.
5. Patent celiac and superior mesenteric arteries without bowel
findings of ischemia.
6. Sub-4-mm pulmonary nodules for which one-year followup is
recommended per ___ guidelines.
7. Distended gallbladder.
Echo ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
___ y/o F history of AAA repair 3 weeks ago, T2DM, COPD presents
with 3 days of SOB. Who had a CTA of both her chest and abdomen
showing no pulmonary emboli, pneumonia or pleural effusions to
explain the dysnea. It appears to be chronic worsening of the
copd along with a large component of anxiety after the emergent
ruptured aaa repair that she underwent. She otherwise seems to
be improving after this surgery.
# SOB/hypoxia: PE was ruled out, cardic etiology less likely esp
in setting of a normal echo, lower bnp. Pt did not understand
her copd reigmen and on instruction she may receive benefit from
better ___ medical management, unlikely to be copd flare,
more likely progression of COPD since no inc cough, sputum and
only more dysnea. We continued her albuterol/ ipatropium nebs
and advair. She should obtain pfts here due to old pfts in ___.
We stopped steriods (she refused the first dose - so she got
none)and antibiotics for copd flare. Social work for coping/
anxiety with and worsening of sob. Ambulatory sat concerning due
to desat to 84% and she was sent out on home oxygen due to
ambulatory sats of 84% that improved to >90 on 2L NC. He echo
showed high output with inc ef 75% likely related to the
hypoxia.
# Anemia - MCV in high ___, RDW ___. s/p recent surgery, HCT
improved from prior although component of rise likely ___
dehydration
- iron studies consistent with anemia of chronic disease and
reticulocyte count was within normal limits
# Acute on chronic renal failure: Baseline Cr 1.2-1.4, up to 1.7
on admission. Pt with recent poor po intake. Most likely
pre-renal, we avoided nephrotoxins and restarted hctz. Do day
of discharge it had improved to 1.4 on d/c.
# Anemia - MCV in high ___, RDW ___. s/p recent surgery, HCT
improved from prior although component of rise likely ___
dehydration
- checking iron studies
- checking retic count
# Pulmonary nodules: Sub 4 mm pulmonary nodules for which ___ year
follow up is required per ___ society guidelines.
- rec f/u in ___ year
- sent email to pcp
___ issues:
# HTN: continue home regimen
# MED REC - pt is supposed to be on albuterol and advair at home
but refuses to use inhalers. Given ___ would consider taking
pt off atenolol in the future. Holding home clonazepam in favor
of prn ativan here
# Leukocytosis: resolved
Translation Issue:
- f/u pending Bcx ___ (final result is NO GROWTH)
Needs Outpt pul f/u and PFTs
-Sub-4-mm pulmonary nodules for which one-year followup is
recommended per
___ guidelines.
# CODE: FULL Code conf w/ pt
# Emergency CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY Start: In am
2. Amlodipine 2.5 mg PO DAILY Start: In am
hold for sbp<100
3. Clonazepam 0.5 mg PO QHS insomnia
hold for rr<12
4. Gemfibrozil 600 mg PO BID Start: In am
5. Hydrochlorothiazide 12.5 mg PO DAILY Start: In am
hold for SBP,100
6. Tiotropium Bromide 1 CAP IH DAILY
7. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze/sob
8. Nicotine Patch 14 mg TD DAILY
9. Senna 1 TAB PO BID:PRN constipation
10. Docusate Sodium 100 mg PO BID
11. Atenolol 50 mg PO DAILY Start: In am
hold for sbp<100 or hr <60
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4-6 pain
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
hold for sbp<100
3. Atenolol 50 mg PO DAILY
hold for sbp<100 or hr <60
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
inh oral twice a day Disp #*1 Inhaler Refills:*0
6. Gemfibrozil 600 mg PO BID
7. Hydrochlorothiazide 12.5 mg PO DAILY
hold for SBP,100
8. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 ___ patch on skin
daily Disp #*30 Transdermal Patch Refills:*0
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4-6 pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg 1 tablet(s) by
mouth Q4 hr Disp #*30 Tablet Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
11. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze/sob
RX *albuterol sulfate 90 mcg 2 puffs oral Q4 hr Disp #*1 Inhaler
Refills:*0
12. Clonazepam 0.5 mg PO QHS insomnia
hold for rr<12
RX *clonazepam 0.5 mg 1 tablet(s) by mouth Q6 hr Disp #*15
Tablet Refills:*0
13. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
inh daily Disp #*30 Capsule Refills:*0
14. Home O2
2L continuous pulse dose for portability via NC.
Dx: COPD
RA Sat 84%
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Miss ___,
We evaluated you for your shortness of breath. We did a ct scan
that showed you did not have any blood clots, we also treated
you for your COPD including restarting the medications that your
were discharged from at the last time you were in the hospital.
We did an echo of your heart and it was normal. We started you
on home oxygen that will be followed by your primary doctor and
your pulmonlagist. We had the nutritionist come to see you and
they recommened protein foods at each meal (chicken, fish, meat,
eggs, yogurt, beans) and ensure.
1. Take all medications as prescribed. Medication changes: Make
sure to take your advair and spirivia
2. Attend all follow-up appointments listed below.
3. Call your doctor or return to the hospital if you develop
increasing shortness of breath, chest pain, abdominal pain,
fevers, increased cough, increased sputum production or any
other concerning change.
Followup Instructions:
___
|
10531982-DS-3 | 10,531,982 | 21,643,924 | DS | 3 | 2156-05-28 00:00:00 | 2156-05-31 01:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left popliteal artery pseudoaneurysm
Major Surgical or Invasive Procedure:
___ left lower extremity angiogram, anterior tibial stent
___ Open repair left popliteal/anterior tibial injury with
popliteal pseudoaneurysm and compressive hematoma, vein graft,
and removal of stent
History of Present Illness:
The patient is a young female, who underwent an ACL repair, who
was noted to have pain and then on CAT scan, what appeared to be
a pseudoaneurysm of her popliteal artery. We initially tried to
treat this endovascularly with a stent
graft across the anterior tibial where the laceration appeared
to have occurred, but that was unsuccessful. Repeat CT scan
unfortunately did not show significant improvement, so she
presented for operative repair.
Of note, she had pre-existing nerve symptoms in her foot and
calf. She had slightly reduced strength w/ dorsiflexion and
plantarflexion on motor exam.
Past Medical History:
PMH: None
PSH:
- Left shoulder cyst excision ___:
1. Arthroscopic assisted left anterior cruciate ligament
reconstruction using autologous hamstring.
2. Arthroscopic left lateral meniscal repair
Social History:
___
Family History:
Non-contributory
Physical Exam:
Tmax=Tcurr 98.6 HR 89 BP 101/56 RR 18 SaO2 100/RA
General: NAD, A/Ox3
Heart: RRR, no increased work of breathing
Lungs: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended
Wound: CDI, no erythema or induration
Ext: no CCE
Pulses (DP, ___
Right: P,P
Left: P,P
Pertinent Results:
Admission, pre-op CBC
___ 10:08AM BLOOD WBC-5.2 RBC-4.28 Hgb-13.0 Hct-39.0 MCV-91
MCH-30.5 MCHC-33.5 RDW-12.0 Plt ___
Discharge CBC
___ 05:17AM BLOOD WBC-4.5 RBC-3.09* Hgb-9.3* Hct-28.5*
MCV-92 MCH-30.0 MCHC-32.5 RDW-12.6 Plt ___
Brief Hospital Course:
Ms. ___ was admitted to the vascular surgery service on ___,
s/p L ACL reconstruction with autologous hamstring and left
lateral meniscal repair on ___ with increasingly severe
posterior left leg pain for several days.
Intially, she underwent CTA which revealed a pseudoaneurysm of
the L popliteal vs anterior tibial artery. She underwent
stenting on ___ which, unfortunately per LLE angriogram the
following day, did not adequately occlude the pseudoaneurysm
puncture lesion. She was then taken for open repair of the
lesion on ___ which was successful and without complication.
She was discharged on ___ with good pain control on oral
pain medications and excellent mobility, with crutches for
support. She will follow up with us as an outpatient in ___
weeks for staple removal and left lower extremity duplex.
Prior to discharge, Ms. ___ verbalized understanding of all
discharge goals and plans.
Medications on Admission:
TraMADOL (Ultram) 50-100 mg PO Q4-6H:PRN pain
Discharge Medications:
1. TraMADOL (Ultram) 50-100 mg PO Q4-6H:PRN pain
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth qday Disp #*60 Tablet
Refills:*0
5. Acetaminophen 650 mg PO Q6H
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Gabapentin 200 mg PO Q8H
RX *gabapentin 100 mg ___ capsule(s) by mouth q8hr prn Disp #*80
Capsule Refills:*0
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hr
prn Disp #*60 Tablet Refills:*0
10. Ibuprofen 400 mg PO Q6H:PRN pain
11. Milk of Magnesia 30 mL PO Q4H:PRN constipation, give q4
until success w/ BM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left popliteal artery pseudoaneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
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:
___
|
10532095-DS-21 | 10,532,095 | 24,112,824 | DS | 21 | 2186-04-28 00:00:00 | 2186-05-10 02:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sepsis with multi-organ failure.
Major Surgical or Invasive Procedure:
Intubated ___ - ___
Paracentesis ___
Peritoneal pleurex catheter placement ___
History of Present Illness:
This is a ___ M with alcoholic cirrhosis, COPD, hep C,
depression, who presented with shortness of breath and
generalized weakness. He receives most of his care at ___
___. He returned from ___ about a week ago and since
then has had progressive weakness and shortness of breath.
Denied chest pain or pleuritic pain. No melena or bleeding PR.
Had lower extremity edema which is around his baseline as well
as ascites around his baseline. No fever, chills, urinary
symptoms.
On the day of presentation, the patient complained of increased
SOB and weakness and called the ambulance to transfer him to the
hospital. On arrival of EMS he was found in his chair at home
complaining of significant SOB. was started on O2
supplementation. The patient also endorsed problem with thinking
clearly which has started 3 days ago.
In the ED at ___ his vitals were notable for BP
of 93/66 on RA and pulse of 102 in sinus rhythm. His RR was 28.
He was alert and oriented x2 on exam. His abdomen was soft and
distended with ascites. 3+ pitting edema was noted bilaterally
in the lower limbs.
He was given dounebs on arrival since he was tachypnic and
dyspneic. His shortness of breath improved with nebs x2. A CXR
showed left sided pleural effusion with ? PNA vs. collapse and
was started on ceftiaxone, azithromycin. He was also started on
methylpred and given IH albuterol.
His confusion raised the possibility of acute hepatic
encephalopathy given his elevated anomia level of 90. t.bili=
9.4 Dbili= 3.9 AST/ALT: ___ alp:79 INR= 2.4. he was given Vit
K 10mg IV once. He also had elevated Cr concerning for
hepatorenal syndrome. There was a suspicion of SBP but he wasn't
tapped at the OSH.
The patient's bleeding was further investigated and he was found
to have a anemia with unclear baseline. His H&H was low to
___ and his stool was positive for blood. He was started on
octreotide and pantoprazole via IV.
His EKG on presentation did not have new change and he denied
symptoms. However, his trop was elevated to 0.16.
Given the physician's impression of acute respiratory distress,
lactic acid of 3.2, and concern for sepsis and multi-organ
failure, his antibiotics were broadened to Vanc + Zosyn.
The patient require ICU level of care and he was transferred to
the ___ for further management.
In the ED, initial vitals: 97.7 90 99/60 16 90% Nasal Cannula.
Labs were significant for: WBC 10.0, H/H 7.1/22.1, Plt 73 (MCV
117). Na= 127.
Lactate: 2.9.
A paracentesis was performed and was negative for SBP WBC=40.
Blood and urine cultures were taken.
Imaging was significant for: left sided pleural effusion with
collapse vs. PNA.
On arrival to the MICU, the patient was breathing comfortably
and is alert and oriented x2.
Past Medical History:
EtOH cirrhosis c/b esophageal varices, ascites
Suspected COPD
Portal vein thrombosis
hx lower GI bleed
Social History:
___
Family History:
none contributory to the current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================
Vitals: afebrile ___ P:93 R:22 O2:92-95% on 2___
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops ABD: soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly GU:
Foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema SKIN: No lesions.
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
DISCHARGE PHYSICAL EXAM:
====================
VS: 97.4 124/82 102 20 97 2.5L
GENERAL: Ill-appearing, jaundiced, not in distress.
HEENT: +scleral icterus
HEART: Tachycardic, regular, no m/r/g.
LUNGS: Non-labored breathing.
ABDOMEN: Distended, tense, non-tender, +fluid wave, +shifting
dullness. Peritoneal pleurex covered by dressing, CDI,
non-tender.
EXTREMITIES: Warm, pitting edema to thighs.
NEUROLOGIC: Lethargic, oriented x1-2 (person and year, not month
or place), inattentive. PERRL, EOMI, face symmetric, moving all
extremities.
Pertinent Results:
ADMISSION LABS:
====================
___ 04:25PM CALCIUM-9.2 PHOSPHATE-4.2 MAGNESIUM-1.9
___ 12:30PM WBC-11.1* RBC-1.87* HGB-7.1* HCT-22.3*
MCV-119* MCH-38.0* MCHC-31.8* RDW-17.3* RDWSD-75.3*
___ 12:30PM PLT COUNT-78*
___ 04:25PM ___ PTT-43.6* ___
___ 09:27AM LACTATE-3.2*
___ 03:10AM GLUCOSE-102* UREA N-27* CREAT-1.8*
SODIUM-127* POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-23 ANION GAP-16
___ 03:10AM ALT(SGPT)-23 AST(SGOT)-50* ALK PHOS-78 TOT
BILI-8.3*
___ 03:10AM LIPASE-66*
___ 03:12AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG=
___ 03:10AM ALBUMIN-1.9*
___ 03:10AM HAPTOGLOB-<10*
___ 03:10AM WBC-10.0 RBC-1.89* HGB-7.1* HCT-22.1*
MCV-117* MCH-37.6* MCHC-32.1 RDW-17.3* RDWSD-73.5*
___ 03:10AM NEUTS-85.4* LYMPHS-6.4* MONOS-6.2 EOS-1.2
BASOS-0.1 IM ___ AbsNeut-8.49* AbsLymp-0.64* AbsMono-0.62
AbsEos-0.12 AbsBaso-0.01
___ 03:10AM ___ PTT-45.4* ___
___ 12:30PM CK-MB-9 cTropnT-0.14*
___ 03:10AM cTropnT-0.14*
___ 01:50AM BLOOD CK-MB-6 cTropnT-0.14*
___ 03:10AM proBNP-288*
___ 04:26AM ASCITES TOT PROT-0.4 GLUCOSE-115
___ 04:26AM ASCITES TNC-40* RBC-986* POLYS-20* LYMPHS-27*
MONOS-0 EOS-1* MESOTHELI-7* MACROPHAG-45*
PERTINENT LABS:
====================
___ 04:25PM HBsAg-NEGATIVE HBs Ab-Negative HBc
Ab-Positive*
___ 03:09AM BLOOD HBV VL-NOT DETECT
___ 04:25PM HCV Ab-Positive*
___ 04:25PM HCV VL-3.1*
___ 01:41PM ASCITES TNC-73* RBC-2196* Polys-18* Lymphs-12*
Monos-6* Mesothe-2* Macroph-61* Other-1*
___ 01:41PM ASCITES TotPro-0.9
DISCHARGE LABS:
====================
___ 05:07AM BLOOD WBC-5.7 RBC-2.10* Hgb-7.4* Hct-22.8*
MCV-109* MCH-35.2* MCHC-32.5 RDW-22.3* RDWSD-87.7* Plt Ct-80*
___ 10:30AM BLOOD ___
___ 05:07AM BLOOD Glucose-87 UreaN-44* Creat-1.2 Na-130*
K-5.2* Cl-94* HCO3-28 AnGap-13
___ 05:07AM BLOOD ALT-23 AST-63* AlkPhos-87 TotBili-11.1*
___ 05:07AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.9*
MICROBIOLOGY:
====================
PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
Reported to and read back by ___ ___ ___
13:30.
PROPIONIBACTERIUM ACNES. 1 COLONY ON 1 PLATE.
All others negative:
___ CULTURE-FINALINPATIENT
___ CULTURE-FINALINPATIENT
___ CULTURE-FINAL {YEAST}INPATIENT
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINALINPATIENT
___ STAIN-FINAL; RESPIRATORY
CULTURE-FINALINPATIENT
___ SCREENMRSA SCREEN-FINALINPATIENT
___ LAVAGEGRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINALINPATIENT
___ Urinary Antigen -FINALINPATIENT
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINALEMERGENCY WARD
___ CULTUREBlood Culture, Routine-FINALEMERGENCY
WARD
___ CULTUREBlood Culture, Routine-FINALEMERGENCY
WARD
___ CULTURE-FINAL
IMAGING/STUDIES:
====================
___ TTE
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>65%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right ventricle
is not well visualized but systolic function is grossly normal.
The aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a may be a very small pericardial effusion around the
right atrium.
IMPRESSION: Highly suboptimal image quality. A left pleural
effusion is present. Ascites is present. Possible very small
pericardial effusion without overt 2D echo evidence of
tamponade. Globally normal biventricular systolic function.
___ CT Chest
IMPRESSION:
Extensive left and small right pleural effusion. Widespread
right predominant parenchymal opacities, highly suggestive of
extensive pneumonia. Mild coronary calcifications. Extensive
ascites.
___ CT Abdomen/Pelvis
1. No evidence of retroperitoneal hematoma
2. Cirrhotic liver morphology with associated splenomegaly,
splenorenal
varices and moderate volume ascites consistent with portal
hypertension.
3. Nodularity of the omentum could represent loculated ascites,
but soft
tissue deposits can't be excluded. Given the history of
cirrhosis multiphasic MRI is recommended nonemergently.
Indeterminate hypodensities in the liver should also be
evaluated at that time.
___ CXR
Comparison to ___. Decrease in extent and severity of
the
pre-existing right upper lobe and right lower lobe parenchymal
opacities. However, the opacities are still clearly visualized.
Stable atelectasis in the left lower lobe. Stable position of
the feeding tube and the right PICC line.
Peritoneal Cytology ___ & ___:
NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
BRIEF SUMMARY
===================
Patient is a ___ male with EtOH/HCV/HBV cirrhosis who
was initially transferred from an outside hospital to ___ MICU
for hypoxemic respiratory failure though to be due to pneumonia
and decompensated cirrhosis. He was treated with antibiotics and
diuresed. He had acute renal failure which improved with
diuresis and albumin. However, he had persistent evidence of
liver failure including a MELD in the ___. Given that he had
been drinking until admission, he was not felt to be a suitable
candidate for a liver transplant at this time. When we discussed
his poor prognosis and our expectations regarding the length of
his recovery, he preferred to have his care focused on comfort
and wanted to be discharged home. Given this, home hospice
services were arranged. A Pleurx drainage catheter was placed
for palliative drainage of ascites at home.
MICU COURSE
===================
#Hypoxemic respiratory failure secondary to
#Community acquired pneumonia
#Pulmonary edema
#Likely COPD exacerbation
Admitted to MICU on ___ requiring 6L O2 by nasal canula. CXR
with R sided pneumonia, redemonstrated on CT chest ___,
involving all 3 lobes. Treated initially with
vanc/zosyn/azithro. Had worsening encephalopathy, tachypnea, so
was intubated on ___. No organism identified on pan cultures. He
was narrowed to ceftazadime/azithro rapidly to finish 8 day
course. He was diuresed with escalating Lasix doses, and
eventually diuril was added. Pulmonary edema and L pleural
effusion improved. He self-extubated on ___. He was weaned from
high flow via face tent to 5L nasal cannula. Respirations
remained somewhat tenuous with rate ___, but he remained
stable for 3 days with radiographic improvement, and was called
out to floor ___.
#Encephalopathy:
Mr. ___ presented with disorientation and asterixis on
admission, consistent with hepatic encephalopathy. He was seen
by our Hepatologists. He had a diagnostic therapeutic on ___
which showed no signs of SBP. He was treated with lactulose
(both PO and PR) and rifaximin with continued encephalopathy
(pulling at lines, waxing/waning alertness, disorientation).
despite adequate bowel movements. Thus encephalopathy felt to be
largely from delirium ___ prolonged intubation.
#Anemia:
Mr. ___ presented with anemia and an acute drop in his
hemoglobin on this admission. The source of this bleed is not
entirely clear. He had guiac positive, but not melanotic stools.
A EGD showed mild portal HTN gastropathy, no evidence of varices
or bleed. He also had a bronchoscopy which was unrevealing. He
got 2 unites of pRBC during this admission. Had low haptoglobin
on multiple checks but this was after blood transfusion.
Peripheral smear reviewed by heme/onc and neg for schistocytes.
Hgb remained stable between ___.
___:
Patient's creatinine is < 1.0 at baseline. Creatinine 1.8 on
admission. Urine sediment negative for granular casts but showed
significant RBCs and WBCs. Despite this, suspect component of
ATN related to sepsis. Improved with treatment of underlying
pneumonia.
#Decompensated Cirrhosis:
Multifactorial etiology -- alcohol, HCV (Ab positive, low VL),
and HBV (new diagnosis this admission, HBc Ab positive but HBs
Ab/Ag negative). Not a candidate for HCV or HBV treatment.
Decompensated by encephalopathy and ascites. Also with history
of PVT not on anticoagulation. Diagnostic paracentesis negative
for SBP, but low protein so was initiated on SBP prophylaxis
with ciprofloxacin 500mg daily.
#Hypotension
Likely due to cirrhosis with contribution from sepsis. Patient
was initially treated with pressors and then transitioned to
midodrine.
#NSTEMI Type II:
Had troponin elevation on admission, peaked at 0.14.
FLOOR COURSE
===================
Patient was extubated and transferred to the floor but remained
clinically tenuous with persistent liver failure including a
MELD in the ___. After in-depth discussion of patient's poor
prognosis and goals of care, patient opted for discharge to home
hospice. A peritoneal pleurx catheter was placed for palliative
ascites drainage at home.
TRANSITIONAL ISSUES
===================
[] Patient should have his Pleurx catheter drained every ___
days or as needed for comfort.
# HCP: ___ (girlfriend) ___
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Spironolactone 200 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Lactulose 30 mL PO PRN RASS<0
3. LORazepam 0.5 mg PO Q6H:PRN nausea, anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Rifaximin 550 mg PO BID
6. TraMADol 25 mg PO BID:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
7. Escitalopram Oxalate 10 mg PO DAILY
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===========================
Acute hypoxemic respiratory failure
Decompensated cirrhosis with refractory ascites, hepatic
encephalopathy, portal hypertensive gastropathy
SECONDARY DIAGNOSES:
================================
Community acquired pneumonia
Pulmonary edema
Chronic obstructive pulmonary disease
Acute renal failure
Acute blood loss anemia
Hypotension
Non-ST elevation myocardial infarction (NSTEMI), Type II
Alcohol use disorder
Hepatitis C
Hepatitis B
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were transferred to the hospital for respiratory failure and
worsening liver failure. You were treated with antibiotics for
pneumonia and given medicine to help remove fluid from your
lungs. You were able to be taken off the breathing machine
(ventilator) and eventually transferred to the general
hepatology service. Here we continued to try to support your
kidneys and your breathing, but you continued to have problems
from liver failure. We had several discussions about your goals
in regards to your medical care and you made the decision that
you wanted to focus on being comfortable and at home for as long
as possible. For this reason, we are discharging you home with
hospice services as opposed to sending you to a rehab facility.
We had a catheter placed in your abdomen to help with fluid
removal for your comfort.
The home hospice agency will take over your care once you are at
home. You do not need to follow-up with your other doctors
unless ___ a reason to.
We have started you on medications to help prevent infection and
prevent confusion from your liver failure. Your hospice nurse
___ help review the medications with you when you are at home.
It was a pleasure taking care of you and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10532263-DS-4 | 10,532,263 | 20,087,350 | DS | 4 | 2184-10-06 00:00:00 | 2184-10-06 11:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfamethoxazole
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: New onset urinary incontinence
HPI: ___ year old female with a known L1 compression fracture s/p
fall in early ___ presents with concern for worsening
of
the L1 fracture. She has developed worsening pelvic pain over
the
past week as well as several episodes of subjective urinary
incontinence. No weakness. No parasthesias.
Patient denies chest pain, shortness of breath, nausea,
vomiting,
bowel or bladder symptoms.
PMH:
Hypertension
CAD
Anxiety
MED:
Furosemide 20 mg qd
Amiodarone 200 mg qd
K-Dur 10 mEq qd
Metoprolol XR 25 mg qd
Calcium Carbonate
Percocet
Lidocaine patch
ALL: Sulfa
ROS: As above
SH:
Activity Level: Community ambulator
Mobility Devices: none
Occupation: ___
Tobacco: denies
EtOH: denies
Housing: Recently discharged from rehab
PE:
Vitals: 98.3 HR-72 BP-147/79 RR-16 SaO2-97% RA
General: NAD
Mental Status: A&O x3
Soft tissue involvement: none. No tenderness about L ___
Vascular Radial DP ___
R ___
L ___
Sensory UE C5 (Ax) C6 (MC) C7 (Mid finger) C8 (MACN) T1 (MBCN)
T2-L2 Trunk
R intact intact intact intact intact intact
L intact intact intact intact intact intact
Sensory ___ L2
(Groin) L3
(Leg) L4
(Knee) L5
(Grt Toe) S1
(Sm toe) S2
(Post Thigh)
R intact intact intact intact intact intact
L intact intact intact intact intact intact
Motor UE Deltoid
(C5)Ax Biceps
(C6)MC WE
(C6)R Triceps
(C7)R WF
(C7)M FF
(C8)AIN Fing Abd
(T1)U
R ___ 5
L ___ 5
Motor ___ Add
(L2) IP (L3) Quad
(L3) Ham (L4) Ant Tib
(L4/DP) ___
(L5/SG) Peroneal
(S1/SP) ___
(S1-2/T)
R ___ 4 4
L ___ 4 4
Reflexes Biceps
(C5-6) BR
(C6-7) Triceps
(L3-L4)Patellar
(L5-S1) Achilles
R ___ 2 2
L ___ 2 2
Straight Leg Raise Test: pain on Right
Babinski: Downgoing toes bilaterally
Clonus: none
Perianal sensation: intact
Rectal tone: good
Estimated Level of Cooperation: excellent
Estimated Reliability of Exam: good
LAB:
UA: negative
IMAGING:
CT MRI ___: Retropulsed fragment in the canal L1. causing
severe compression of cauda equina
IMPRESSION & RECOMMENDATIONS: ___ year old female w/ known L1
compression fracture who presents with worsening pain and
subjective urinary incontinence and a CT ___ which shows
marked loss of disk height and retropulsion of bony fragments
into the canal.
Past Medical History:
see HPI
Social History:
___
Family History:
see HPI
Physical Exam:
see HPI
Pertinent Results:
___ 10:00AM GLUCOSE-113* UREA N-14 CREAT-0.8 SODIUM-130*
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-27 ANION GAP-12
___ 10:00AM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-1.9
___ 10:00AM NEUTS-78.2* LYMPHS-15.8* MONOS-4.1 EOS-1.5
BASOS-0.4
___ 10:00AM ___ PTT-28.8 ___
___ 01:20AM estGFR-Using this
___ 01:20AM WBC-7.6 RBC-4.07* HGB-12.3 HCT-37.7 MCV-93
MCH-30.3 MCHC-32.7 RDW-13.4
Brief Hospital Course:
Patient was admitted to evaluate new onset urinary incontinence
in the setting of severe cauda equina compression due to
retroplused fractured L1 body. The patient was given a trial of
foley removal. The patient voided well with post void residual
urine < 150 on a bladder scan. Patient is not incontinent. The
motor strength was good enough to ambulate with the help of
walker. Considering the patients age and the risk of surgery and
dubious benefit, the decision to operate was deferred. Also the
configuration of the fracture is not ideal for cement
augmentation. The geriatic service were consulted and their
recommendations for pain management were followed. The Physical
therapy mobilized the patient out of bed with a walker and a
lumbar corset and the patient did well.
Medications on Admission:
see HPI
Discharge Medications:
1. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
6. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
11. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic HS (at
bedtime).
12. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
BID (2 times a day).
13. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for c.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L1 osteoporotic fracture with retropulsed fragment without
neurological defict or urinary incontinence
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:
Activity: As tolerated. You should not lift anything greater
than 10 lbs. You will be more comfortable if you do not sit or
stand for a long time without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o ___ times a day you should go for a walk for ___ minutes
as part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting or bending forward.
- Diet: Eat a normal healthy diet.
- Brace: You have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed. This brace can be donned in the
sitting position.
- - You should resume taking your normal home
medications
Physical Therapy:
No log roll precautions required.
Pt can wear brace in the sitting position.
Pt should not bend forward or lift heavy objects.
Fall risk.
Treatments Frequency:
No surgical wounds
Followup Instructions:
___
|
10532326-DS-20 | 10,532,326 | 20,644,814 | DS | 20 | 2162-11-09 00:00:00 | 2162-11-09 09:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
mutism, unresponsivess; called as CODE STROKE.
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. ___ is currently mute and unable to provide
history; following history obtained from EMS report and medical
records.
Ms. ___ is a ___ year-old woman with PMH significant for
a. fib (on aspirin) and schizophrenia (on seroquel and haldol)
with recent discharge for catatoinc state due to
schizophrenia(mute, unresponsive to commands; at time of
discharge she was able to hold conversation), who presents today
after witnessed fall at ___ station. She was walking at the train
station and around 12:30 ___, was witnessed to go down to her
knees. She was helped to the ground. She was not talking and not
following commands. CODE STROKE called upon arrival to ED.
During recent admission for similar presentation, work-up was
nondiagnostic. CT showed no acute intracranial process. EEG
showed moderate to severe diffuse background slowing; left
hemisphere evaluation limited by artifact but there were no
seizures identified. She had no electrolye abnormalities and a
negative tox
screen. Urine and blood cultures were negative. Psychiatry was
consulted and felt that presentation represented a catatonic
form
of schizophrenia. She was started on lorazepam 1 mg TID and her
mental status was reported to gradually improve; she became more
interactive, though remained disoriented and tangential.
ROS: unable to obtain as patient is mute.
Past Medical History:
-Atrial Fibrillation (on ASA)
-Microcytic Anemia - extensive recent GI wkup at ___ unrevealing
-Schizophrenia - diagnosed age ___
-Eczema
Social History:
___
Family History:
(per OMR): Mother with ETOH abuse, no FH of heart
disease, HTN, DM or malignancy.
Physical Exam:
At admission:
Vitals: P: 117 R: 39 BP: 118/80 SaO2: 97%
General: awake, eyes open, not speaking and not following any
commands. Tardive dyskinesia or lips, tongue.
HEENT: NC/AT, sclera anicteric, MMM
Neck: supple
CV: Irregular, tachycardic, S1S2
Lungs: Clear to auscultation b/l anteriorly
Abdomen: soft, nondistended. +BS
Ext: warm, ___ edema b/l
___ Stroke Scale score was: 18
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 0
3. Visual fields: 2
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 2
6a. Motor leg, left: 1
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 3
10. Dysarthria: 1
11. Extinction and Neglect: 2
Neurologic Exam: eyes open, awake, nonverbal, not responding to
any commands. She initially had a left gaze preference, but this
later resolved. PERRL 4-->3 mm b/l. Not tracking but did look
both left and right. She blinked to threat on the left, but not
the right. Face is symmetric. She was not moving any extremities
spontaneously. Decreased tone RUE. Normal tone in LUE and ___
b/l.
When her left arm was elevated, she was able to maintain it
antigravity with no drift. When her right arm was elevated, it
drifted down rapidly. With regards to lower extremities, she
would not maintain either when lifted antigravity, but when
flexed at knee and feet placed on bed, she would maintain this
position. Grimmaced to noxious stimuli on left, but not on
right.
Reflexes 2+ and symmetric at biceps, triceps, brachioradialis
and
patellae. No ankle jerks. Extensor plantar response b/l.
At discharge:
Neuro: awake, alert. Intermittently oriented to self and month.
Perseverative speech. Intermittently follows simple commands.
Pertinent Results:
___ 01:11PM PH-7.27* COMMENTS-GREEN TOP
___ 01:04PM WBC-10.2 RBC-3.94* HGB-10.1* HCT-33.5* MCV-85
MCH-25.6* MCHC-30.0* RDW-16.9*
___ 01:04PM PLT COUNT-490*
___ 01:04PM ___ PTT-34.5 ___
___ 01:04PM UREA N-16
___ 01:04PM CREAT-0.8
___ 01:11PM freeCa-1.26
___ 01:11PM GLUCOSE-91 LACTATE-2.4* NA+-138 K+-4.3
CL--102 TCO2-25
___ 01:11PM PH-7.27* COMMENTS-GREEN TOP
___ 09:59PM PHENYTOIN-12.7
___ 01:56PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:56PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:56PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ EEG:
IMPRESSION: This is an abnormal routine EEG due to the presence
of
attenuation of left hemisphere activity which is also slower
compared to
the right hemisphere, indicative of diffuse left hemisphere
dysfunction.
No clear epileptiform discharges or electrographic seizures were
seen.
The background was otherwise slightly slow and disorganized
reaching a
maximum of 7 Hz consistent with a mild encephalopathy which
could be
seen in toxic/metabolic disturbances, infections, and medication
effects. The diffuse superimposed beta frequency activity is
most likely
due to treatment with benzodiazepines. Note is made of an
irregularly
irregular cardiac rhythm consistent with the patient's history
of atrial
fibrillation.
___ EEG:
IMPRESSION: There were no clinical seizures during this session.
However, there is a very active interictal epileptic disturbance
over
the left temporal region along with a slow wave focus in that
area
suggestive of a subcortical structural lesion. There is mild
diffuse
background slowing which seemed to improve as the study
progressed into
the following morning.
___ EEG:
IMPRESSION: This prolonged continuous video EEG shows focal slow
waves
over the left temporal region compatible with a structural
lesion along
with paroxysmal interictal epileptiform activity from the same
region.
The background rhythm seemed stable but better developed over
the right
hemisphere and there continues to be a cardiac rhythm
disturbance.
___ EEG:
IMPRESSION: This is an abnormal continuous video EEG because of
focal
left temporal slowing with epileptiform discharges phase
reversing at
F7, indicative of an area of focal epileptogenic cortex as well
as
underlying subcortical dysfunction. The discharges did not
appear
periodic or repetitive to suggest ongoing seizures. There was
one
pushbutton activation for patient hitting the bed rail with her
right
hand but there was no electrographic correlate. The background
remains
low voltage and slow indicative of a moderate to severe
encephalopathy.
No clear electrographic seizures were seen.
ECG:
Atrial fibrillation with rapid ventricular response. Low limb
lead voltage. Late R wave progression. Minor T wave
abnormalities. Since the previous tracing ___ the rate is
faster. Voltage is lower. T wave abnormalities are more
prominent. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 0 74 ___
1 view CXR:
IMPRESSION: Limited due to low lung volumes without definite
signs of
pneumonia or overt CHF.
Head and Neck CTA and CTP with and without contrast:
IMPRESSION:
1. Atypical diffusely decreased mean transit time, increased
volume and
blood flow to the left cerebral hemisphere which could reflect
hyperperfusion.
2. No evidence of infarct or other acute intracranial pathology.
No vascular occlusion.
MRI Head with and without contrast:
IMPRESSION: Subtle hyperintensity in the posterior portion of
the left
thalamus could be due to remote infarct and is not typical for a
neoplastic process. No abnormal enhancement is seen. However,
given the subtle nature of the abnormality, followup study
including coronal T2-weighted images should be obtained in four
to six weeks. No acute infarcts are seen.
CXR - 1 view:
1. Interval placement of a feeding tube, which courses below the
diaphragm
with the tip likely within the stomach. The patient is markedly
rotated to
the right, limiting evaluation of the cardiac and mediastinal
contours.
Overall, however, there is a more focal airspace opacity in the
left mid and lower lung, which may reflect asymmetric pulmonary
edema or an infectious process, less likely atelectasis.
Clinical correlation is advised. Possible layering left
effusion.
Cerebrospinal fluid: NEGATIVE FOR MALIGNANT CELLS.
___ 03:49PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-650*
Polys-41 ___ ___ 03:49PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-700*
Polys-23 ___ ___ 03:49PM CEREBROSPINAL FLUID (CSF) TotProt-44 Glucose-87
LD(LDH)-28
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ yo F with afib and schizophrenia with history of
mutism/catatonia apparently previously treated with ativan,
presents after a fall at T-station following recent discharge,
brought back in and found to have right sided jerking episode in
the ED prior to STATNET. EEG monitoring thereafter showing only
L sided slowing without epileptiform activity. Subsequent MRI
not showing any correlates in that would account for her
seizures.
# Neuro: loaded with phenytoin, and continued on maintanence
phenytoin ___. Started oxcarbamazepine 600mg po bid for
long term seizure control as well. Fluoro-guided lumbar punture
was done (after failed bed side attempts) for first time seizure
work up, which was normal. MRI showed no clear seizure focus.
Ms. ___ was placed on continuous video EEG monitoring,
which showed frequent left temporal spikes, which are likely
contributing to the patient's perseverative speech and receptive
aphasia, however it also is likely related to her schizophrenia
as well.
# ___: Atrial fibrillation with AVR. Continue aspirin.
Cardiology consulted for hard to control RVR. HR better
controlled on metoprolol 150mg TID and digoxin 60mg po qid.
CHADS score 1 - no need for anticoagulation at this time
# Psych: Schizophrenia. Continue home medication olanzapine 20mg
po qhs.
Medications on Admission:
1.metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
2.senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
3.polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
4.aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5.folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6.metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7.haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8.docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9.ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10.diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
11.quetiapine 100 mg Tablet Sig: One (1) Tablet PO twice a day.
12.ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
13.lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day:
Please taper this medication over then next ___ days.
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five (5)
ml PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. phenytoin 50 mg Tablet, Chewable Sig: as directed Tablet,
Chewable PO three times a day: 100mg po qAM, 100mg po qPM, and
150mg po qHS.
8. olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for SBP < 90.
10. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
seizures
schizophrenia
atrial fibrillation with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Neuro: awake, alert. Intermittently oriented to self and month.
Perseverative speech. Intermittently follows simple commands.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of a fall while at a T
stop. In the emergency room you had 2 witnessed seizures. It is
suspected that your fall may have related to seizure activity.
We started 2 antiseizure medicines, phenytoin and
oxcarbamazepine. Please continue these medications. We had
psychiatry see you during your stay, who recommended continuing
your home olanzapine 20mg po nightly. We also had the
cardiologists see you during your stay for your fast heart rate
and atrial fibrillation. Currently your heart rate is controlled
on metoprolol and diltiazem. Please continue these medicines as
prescribed.
Followup Instructions:
___
|
10532326-DS-22 | 10,532,326 | 20,563,201 | DS | 22 | 2163-06-16 00:00:00 | 2163-06-16 10:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Dilantin / Trileptal / Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of afib with RVR presents to the ___ ER
with a 3 day history of nausea, vomiting and abdominal pain.
Patient is a poor historian, however states her abdominal pain
began approximately one month ago. She was seen in the ER on ___
where she underwent a CT of abdomen and pelvis which was
unremarkable for any acute pathology. She states the pain is
intermittent and diffuse and is only brought on by palpation.
She
states the pain has worsened over the past week. She also notes
over the past 3 days she has had increasing nausea and vomiting.
Vomiting is brought on after meals. Her last bowel movement was
yesterday which was described as normal for her. She states she
has difficulty with constipation and denies presence of BRBPR or
melena.
In the ER she was noted to be in afib with RVR with heart rates
as high as 190 and was subsequently started on a Diltiazem gtt.
An NGT was placed which put out approximately 2 liters.
Past Medical History:
-Atrial Fibrillation (on ASA)
-Microcytic Anemia - extensive recent GI wkup at ___ unrevealing
-Schizophrenia - diagnosed age ___
-Eczema
Social History:
___
Family History:
Mother with ETOH abuse, no FH of heart
disease, HTN, DM or malignancy.
Physical Exam:
Upon presentation to ___:
Vitals: T 97.7 P ___ BP 114/74 RR 19 O2 97%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular rate and rhythm, SEM, No G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Distended, mild TTP in the RLQ and right midabdomen, no
rebound or guarding, no palpable masses or hernias
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:05AM GLUCOSE-150* UREA N-29* CREAT-1.2* SODIUM-137
POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-31 ANION GAP-19
___ 11:05AM ALT(SGPT)-11 AST(SGOT)-13 ALK PHOS-232* TOT
BILI-0.5
___ 11:05AM LIPASE-52
___ 11:05AM WBC-12.4* RBC-5.02# HGB-12.1# HCT-38.3#
MCV-76* MCH-24.0* MCHC-31.5 RDW-17.9*
___ 11:05AM NEUTS-74.2* ___ MONOS-4.7 EOS-1.4
BASOS-0.3
___ 11:05AM PLT COUNT-548*
CT abd/pelvis upon admission ___
IMPRESSION: Findings consistent with high-grade small bowel
obstruction with transition in the upper pelvis; no discrete
mass or inflammatory process visualized at the site. Small
amount of free intraperitoneal fluid may be related to
congestion associated with bowel obstruction, although given
patient's history could be secondary to heart failure.
Repeat CT abd/pelvis ___
IMPRESSION:
Overall resolution of the small bowel obstruction with contrast
noted
extending into the ascending colon and stool extending into the
distal sigmoid colon and rectum. No evidence of free
intraperitoneal air. Mild persistent abdominal and pelvic
ascites.
Brief Hospital Course:
Ms. ___ was admitted to the Acute Care Surgery team and
transferred to the ICU for close monitoring of her SBO and afib
w/ RVR. CT showed a high grade obstruction. She was kept on a
diltiazem drip until her heart rate could be better controlled.
She was weaned off the drip and started on IV metoprolol. She
was NPO/IVF and with an NGT in place. Her NG initially put out
2L but the output diminished over the course of the next several
days. She was noted with flatus on HD3 and had a bowel movement
the following day. Once hemodynamically stable she was
transferred to the floor.
Once on the regular nursing unit she progressed slowly in terms
of her bowel function. Her NG outputs continued to decrease but
she was still tender on exam. A repeat CT scan of her abdomen
was done showing resolution of the SBO but large amounts of
stool along her entire colon. After having 2 bowel movements and
no residuals after clamp trial the NG was removed. She was given
a bowel regimen. Sips to clear liquids were started at first and
she was able to tolerate this for 24 hours. A regular diet was
then started and she tolerated this as well.
In terms of her afib with RVR she was noted with intermittent
episodes of HR >160 requiring several adjustments in her beta
blockers. Cardiology was consulted early and several
recommendations were made pertaining to her beta and calcium
channel blockers. Once she was able to take po meds she was
started on her home metoprolol; the diltiazem does given was 60
mg QID and upon discharge this was changed to the sustained
release dose (240mg). Her rate has primarily been in the 90's
with blood pressures in the low 100's and an occasional high
90's systolic.
As for disposition patient will be returning to the nursing home
where she has resided with plans for returning to ___
with her family in the next couple of weeks. This plan was
confirmed with patients' brother/health care proxy. A release of
information form was signed by patient for her records to be
sent to her new providers in ___.
Medications on Admission:
Diltiazem 240 ER Daily, Folic Acid 1', Furosemide
20', Keppra 500'', Metformin 1000'', Metoprolol 25''',
Olanzapine
10', Klor-Con 20', ASA 325', Ferrous sulfate 325'', MVI
Allergies: Bactrim, Dilantin, Trileptal
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Docusate Sodium 100 mg PO TID
hold for loose stools
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. LeVETiracetam 500 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Tartrate 25 mg PO TID
hold for SBP <100
9. Mineral Oil 30 mL PO 2X/WEEK (MO,TH) constipation
hold for loose stools
10. Multivitamins W/minerals 1 TAB PO DAILY
11. OLANZapine (Disintegrating Tablet) 10 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Atrial fibrillation
Constipation
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 blockage in your
intestines that required you to be placed on bowel rest and a
tube placed into your stomach to help remove excess fluid
accumulation. As the symptoms of the blockage resolved foods
were slowly re-introduced into your diet. It is being
recommmended that you eat smaller frequent meals as opposed to
larger meals. It is importnat that you chew your foods
thoroughly to help with ease in digestion.
You were also found to be very constipated when your xrays and
cat scans were reviewed. It is very important that you adhere to
a strict bowel regimen in order to avoid this problem in the
future.
During your hospital stay you were also treated for an irregular
heart rate and required some adjustments to your heart
medications.
After discussions with you and your brother ___ you have
expressed plans to return to ___ to be closer to your
family. From the perspective of the surgical issue that brought
you into the hospital it is fine for you to fly home to ___.
Followup Instructions:
___
|
10532466-DS-12 | 10,532,466 | 26,825,602 | DS | 12 | 2181-03-15 00:00:00 | 2181-03-16 03:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors / Levaquin
Attending: ___
___ Complaint:
Hypoxemic Hypercarbic Respiratory Failure
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Patient is a ___ with PMH of COPD on 4L home O2, 100-pack-year
smoking history, HFpEF, mod/sev TR, mixed aortic valve disease,
and AF on Apixaban presents with several days of dyspnea,
worsening over the past 2 hours.
Of note, She has been admitted multiple times for COPD
exacerbations, CHF exacerbations, PNA, ongoing SOB, and melena.
She was recently admitted from ___ to ___ for worsening
DOE,
and felt to have both CHF exacerbation and COPD exacerbation
which was treated with prednisone 40mg x 5 days,
z-pak/CTX->cefpodoxime,and underwent diuresis. She was
ultimately discharged to rehab. While at rehab, her shortness
of breath worsened, and she was
restarted on a prednisone burst which was then tapered down to a
chronic daily dose of 10 mg daily. She was also felt to be
significantly volume overloaded in rehab with increased weight
and
lower extremity edema. Her diuretics were increased, and she
was also seen in the heart failure clinic where she received an
IV infusion of diuretic. She was discharged to home from rehab
on ___.
On this ED admission, patient reports she was feeling well until
___ night when she developed increased difficulty breathing
with abdominal pain. Breathing was worsened by lying flat. Also
reports 2 days of chills, sneezing, sore throat, and dysuria.
Denies fever. Denies CP, dizziness, wkness, n, v, changes in
bowel habit.
Multiple family members at home with "colds."
Reports the episode feels like prior COPD exacerbations and has
been worsening in the 2 hours prior to ED arrival. Received
albuterol and IV methylpred en route.
In the ED, initial vitals were:
Temp 38.2 HR 125 BP 169/86 RR 25 POx 97%
Exam:
Exam notable for initially ___ word sentences with no retraction
or accessory muscle usage. Lungs with inspiratory wheezing and
diffuse crackles.
ED stay was notable for subtle mental status changes. Found to
be in hypercarbic respiratory failure. Resp therapy was
consulted and placed patient on BIPAP settings: IPAP 12, EPAP 5,
40% FIO2 to which mental status reportedly improved.
Labs significant for:
Lactate 2.4
Hgb 9.2
WBC 5.7
___ 21868
ALT 123
AST 118
Creatinine 1.8
BUN 53
Trop 0.04
VBG pH 7.20 pCO2 77 pO2 38 HCO3 31
Flu Neg
VBG pH 7.28 pCO2 71 pO2 43 HCO3 35
Trop 0.05
Urine Cx and Blood Cx pending
Patient was given:
Ondansetron 4 mg IV ONCE
Metoprolol Tartrate 25 mg PO/NG BID
Torsemide 80 mg PO/NG DAILY
Albuterol 0.5% 10 mL IH QHOUR Start: Today - ___, First
Dose: STAT Continuous
Morphine Sulfate 2 mg IV ONCE MR2
CefePIME 2 g IV ONCE
Vancomycin 1500 mg IV ONCE
Ipratropium Bromide Neb 1 Neb IH ONCE MR2
Albuterol 0.083% Neb Soln 1 Neb IH ONCE MR2
Imaging notable for:
CXR ___:
1. Severe cardiomegaly with mild interstitial pulmonary edema.
Possible small left pleural effusion.
2. Chronic bronchial wall thickening may reflect fluid or
chronic airways disease.
VS prior to transfer:
Temp 97.9 HR 114 BP 115/81 RR 25 POx 99% NIV
On arrival to the MICU, patient endorses improved breathing on
BiPap.
REVIEW OF SYSTEMS: as above
Past Medical History:
CONGESTIVE HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
ATRIAL FIBRILLATION
PFO
STROKE
HYPERTENSION
HYPERLIPIDEMIA
SUPPLEMENTAL OXYGEN
NEEDLE PHOBIA
OSTEOARTHRITIS
ADVANCE CARE PLANNING
ANEMIA
CHRONIC KIDNEY DISEASE
MUSCULOSKELETAL PAIN
CONSTIPATION
AORTIC STENOSIS
AORTIC REGURGITATION
TRICUSPID REGURGITATION
SENSORINEURAL HEARING LOSS
ANEMIA
THROMBOCYTOPENIA
PEDAL EDEMA
FALLS
UPPER GASTROINTESTINAL BLEED
ABNORMAL CHEST XRAY
PULMONARY HYPERTENSION
HEADACHE
FATIGUE
DYSPHAGIA
H/O TOBACCO ABUSE
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization
Physical Exam:
Admission Exam:
========================
VITALS: Reviewed in Metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, Head NC, AT
NECK: supple, JVP >14cm, no LAD
LUNGS: Diffuse crackles bilaterally
CV: irregularly irregular, 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+ pitting edema in b/l ___
NEURO: AO x 3, moving all extremities purposefully
Discharge Exam:
=========================
VITALS: Reviewed in Metavision
GENERAL: Somnolent. Appears comfortable.
HEENT: Sclera anicteric
NECK: supple, JVP >14cm
LUNGS: Diffuse crackles bilaterally, bilateral rhonchi
CV: irregularly irregular, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: 2+ pitting edema in b/l ___
Pertinent Results:
Admission Labs:
======================
___ 10:30AM BLOOD WBC-5.7 RBC-3.24* Hgb-9.2* Hct-31.7*
MCV-98 MCH-28.4 MCHC-29.0* RDW-19.9* RDWSD-71.0* Plt ___
___ 10:30AM BLOOD Neuts-76.6* Lymphs-14.3* Monos-8.0
Eos-0.0* Baso-0.4 NRBC-0.4* Im ___ AbsNeut-4.34
AbsLymp-0.81* AbsMono-0.45 AbsEos-0.00* AbsBaso-0.02
___ 10:30AM BLOOD Plt ___
___ 03:04AM BLOOD ___ PTT-26.1 ___
___ 10:30AM BLOOD Glucose-118* UreaN-53* Creat-1.8* Na-142
K-4.5 Cl-103 HCO3-22 AnGap-17
___ 10:30AM BLOOD ALT-123* AST-118* AlkPhos-57 TotBili-0.5
___ 10:30AM BLOOD Lipase-32
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD cTropnT-0.04*
___ 10:30AM BLOOD Albumin-3.5 Calcium-8.0* Phos-5.0*
Mg-2.8*
___ 01:00PM BLOOD Lactate-2.4*
___ 10:39AM BLOOD ___ pO2-38* pCO2-77* pH-7.20*
calTCO2-31* Base XS--1
___ 03:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:50PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:50PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-1
TransE-<1
___ 03:50PM URINE CastHy-22*
___ 03:50PM URINE Mucous-RARE*
Pertinent Labs:
======================
___ 03:04AM BLOOD ALT-682* AST-692* LD(LDH)-655* AlkPhos-62
TotBili-0.6
___ 01:00PM BLOOD cTropnT-0.05*
___ 03:04AM BLOOD CK-MB-3 cTropnT-0.07*
___ 01:01PM BLOOD CK-MB-3 cTropnT-0.06*
___ 03:04AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:59PM BLOOD Lactate-1.7
___ 12:18PM URINE Hours-RANDOM UreaN-255 Creat-71 Na-<20
Cl-59 Uric Ac-4.5
Micro:
======================
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions..
Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___: NO GROWTH.
___ 10:50AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Imaging:
=====================
CXR ___:
1. Severe cardiomegaly with mild interstitial pulmonary edema.
Possible small
left pleural effusion.
2. Chronic bronchial wall thickening may reflect fluid or
chronic airways
disease.
Liver or Gallbladder US ___:
1. No evidence of concerning focal hepatic lesions.
2. Likely simple hepatic and right renal cysts.
3. Cholelithiasis without acute cholecystitis.
Discharge Labs:
======================
Not applicable. Patient discharged to home hospice. No labs
checked.
Brief Hospital Course:
ASSESSMENT & PLAN: Patient is a ___ with PMH of COPD on 4L
home O2, 100-pack-year smoking history, HFpEF, mod/sev TR, mixed
aortic valve disease, and AF on Apixaban presents with several
days of dyspnea, worsening over the past 2 hours. Admitted to
MICU for management of hypercarbic respiratory failure,
originally requiring BiPAP, now confirmed CMO.
Active Issues:
==============================
#Hypercarbic Respiratory Failure ___ congestive heart failure
Patient presented on ___ significantly fluid overloaded on exam
with diffuse crackles, peripheral edema, and increased BNP
suggesting acute respiratory failure iso CHF exacerbation. She
was given one dose of vancomycin and cefepime and placed on
BiPAP in the emergency department. Antibiotics were d/c'd on
___ given low concern for infectious process. We planned for
diuresis with goal net negative of 1.5L. A foley was placed to
monitor urine output. Despite aggressive diuresis with IV Lasix
boluses and Lasix drip which was then switched to diuril.
Despite receiving diuretics, patient responded minimally with
little change in respiratory and renal function. After an
extensive conversation with the patient and her family, she was
made comfort measures only and all diuresis was stopped. Patient
comfort was maintained with morphine PRN.
#Acute on chronic kidney disease:
Creatinine 1.8 (up from baseline 1.3). ___ include
prerenal, intrarenal, and postrenal causes. Likely prerenal
etiology iso impaired cardiac output, hypoperfusion, and CHF
exacerbation (possible cardiorenal syndrome). Her Kidney
function got worse during the reminder of her hospital stay
#COPD Exacerbation: For her COPD exacerbation, likely ___ acute
worsening of CHF. We continued her duonebs, azithromycin, and
home prednisone. Since her repiratory status was majorly
dictated by her congestive heart failure, medication which were
given per as needed basis were stopped.
#AMS: Likely ___ acute exacerbation of hypercarbia which got
worse during her hospital stay in the setting of rising CO2
levels > 80 mmHg
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 10 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH TID
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q1H:PRN
Wheezing
4. Metoprolol Tartrate 25 mg PO BID
5. Apixaban 2.5 mg PO BID
6. Lovastatin 20 mg oral DAILY
7. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
8. Torsemide 80 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Azithromycin 250 mg PO 3X/WEEK (___)
12. Omeprazole 40 mg PO BID
13. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Hyoscyamine 0.125 mg SL QID
RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) sublingually four
times a day Disp #*8 Tablet Refills:*0
2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN comfort guided
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 20 ml by mouth
q2h Refills:*0
3. Scopolamine Patch 1 PTCH TD Q72H
RX *scopolamine base 1 mg/3 day apply to arm q72h Disp #*2 Patch
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
congestive heart failure
acute kidney disease
COPD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Your were admitted to the hospital with acute shortness of
breath caused by significant heart failure. You were placed on a
machine that helps you breath. Your were also noted to have
worsening kidney failure which did not allow us to take excess
fluids out. Unfortunately your condition got worse and we
shifted our care to focus on elevating your symptoms since your
underlying congestive heart failure progressively worse with no
effective therapy.
Followup Instructions:
___
|
10532466-DS-6 | 10,532,466 | 27,514,452 | DS | 6 | 2180-07-03 00:00:00 | 2180-07-03 14:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
COPD exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o severe COPD (severe FEV1 49% ___ on home 4L O2),
dHF, pulmonary HTN, multivalvular disease, pAF on warfarin(INR
>2 since ___ presented to the ED on ___ with fever
___, hypoxia to "as low as 76%" when off her O2 and CXR
significant for a pneumonia admitted to medicine for COPD
exacerbation and pneumonia.
Patient was recently hospitalized ___ for similar issue
of dyspnea and hypoxia. CXR on admission was negative for
pneumonia, she was treated for COPD exacerbation with duonebs,
advair, mehthylpredinsone transitioned to prednisone and was
given acepella valve to help clear secretions. Patient was
discharged to complete a 5 day course of azithromycin and
prednisone taper 40 mg ___,
30 mg ___, 20 mg ___, 10 mg ___. On discharge,
she was followed by PACT, with check ins on ___ with the
patient using 4L home O2 and feeling. Patient saw PCP ___ ___,
patient was feeling well, 97% on O2 unclear amount, lab check
___ with Cr 1.4 K+ 3.6 INR 2.2.
Per PACT check in, patient was feeling well on ___, had lab
work drawn on ___ that was stable. Patient then developed fever,
increased dyspnea and shortness of breath on ___ that
progressed and patient was taken to ED on ___ by daughter.
Patient is followed at the ___ clinic INR 2.1
___, blood draw after 5 pm results. Cont same regimen,
which is ___ 3 mg, ___ 3 mg, ___ 2 mg, ___ 3 mg,
___ 1.5 mg, ___ 3 mg, ___ 4 mg. Patient did not
take her dose on ___.
In the ED, initial VS were temp 97.1 F HR 80 118/40 RR 19 89%
RA
Exam in the ED:
patient was alert, pleasant, conversant, oriented x3, no
distress, speaking full sentences Lungs diminished, no focal
crackles noted.
Labs were significant for:
Na+ 136 K+ 3.6 BUN 24/Cr 1.5 (baseline Cr 1.3-1.6) FSBG 142
WBC 6.1 hgb 8.9 (stable from ___ plt 163 neutrophils 65%
pH 7.43 pCO2 49
INR 3.0
lactate 1.3
FluA/B
BCx pending
Peak flow 75, 100
CXR Increased bibasilar opacities, concerning for pneumonia
Patient was given
___ 18:42 IH Albuterol 0.083% Neb Soln 1 NEB
___ 18:42 IH Ipratropium Bromide Neb 1 NEB
___ 18:42 PO PredniSONE 60 mg
___ 20:34 IV Azithromycin 500 mg
___ 20:55 IV CeftriaXONE 1g ordered
Transfer VS were temp 98.4F HR 82 106/52 RR 18 98% RA
On arrival to the floor, patient reports that she feels her
breathing improved after nebulizers downstairs
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (FEV1 60%)
HFpEF
Pulmonary HTN
paroxysmal AFib a/c warfarin
HLD
HTN
TIA/STROKE ___, attributed to patent foramen oval
Social History:
___
Family History:
Mom-cancer
Sister- heart
Sister- aneurysm in brain
Brother- COPD
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.5 PO 141/64 R Lying HR 93 RR 20 ___ 4L
GENERAL: NAD, alert, interactive, lying comfortably in bed
HEENT: sclerae anicteric, MMM, PERRL
LUNGS: decreased air entry in left lung, end expiratory wheezes
throughout
HEART: III/VI crescendo/decrescendo systolic murmur that
radiates to carotids, RRR
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP, 1+ pitting edema in ankle to knee, no LLE
pitting edema
NEURO: awake, A&Ox3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.0, HR 98, BP 108/56, RR 20, O2 95% on 4L NC
GENERAL: Well appearing, NAD, NC in place
HEENT: Sclerae anicteric
LUNGS: Scattered expiratory wheezing, good air movement, no
crackles or rhonchi
HEART: III/VI systolic murmur heard throughout, S1, S2.
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: Trace pitting edema in RLE
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10PM BLOOD WBC-6.1 RBC-2.93* Hgb-8.9* Hct-27.6*
MCV-94 MCH-30.4 MCHC-32.2 RDW-16.0* RDWSD-55.8* Plt ___
___ 06:10PM BLOOD ___ PTT-39.4* ___
___ 06:10PM BLOOD Glucose-142* UreaN-24* Creat-1.5* Na-136
K-3.6 Cl-96 HCO3-30 AnGap-14
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-6.7# RBC-2.48* Hgb-7.6* Hct-23.3*
MCV-94 MCH-30.6 MCHC-32.6 RDW-16.0* RDWSD-55.2* Plt ___
___ 06:45AM BLOOD Glucose-119* UreaN-33* Creat-1.7* Na-141
K-4.6 Cl-101 HCO3-27 AnGap-18
IMAGING/STUDIES:
================
CXR ___:
Increased bibasilar opacities, concerning for pneumonia.
Brief Hospital Course:
___ w/ h/o severe COPD (severe FEV1 49% ___ on home 4L O2),
dHF, pulmonary HTN, multivalvular disease, pAF on warfarin(INR
>2 since ___ presented to the ED on ___ with fever
___ and CXR significant for pneumonia
#COMMUNITY-ACQUIRED PNEUMONIA: Fevers at home and CXR w/ new
bibasilar opacities concerning for PNA. Received CTX/azithro in
the ED, dose of vancomycin on arrival to the floor. Stable on
home O2 w/o reported increase in dyspnea or cough. Per IDSA ___
guidelines would qualify as CAP, and no known IV abx in last 90
days so low concern for resistant organisms. Flu negative.
Treated with levofloxacin 750mg q48h, one dose while inpatient,
will complete doses ___ & ___ for total 7 days coverage.
#SEVERE COPD: FEV1 49% with FEV1/FVC ratio 75% with severe
obstructive defect on PFTs from ___. Reduced peak flow in ED.
Followed closely by PACT team and was compliant with inhalers,
nebs, prednisone taper from previous exacerbation ___ with
last dose prednisone 10 mg on ___. PCO2 in ED ___ from VBG,
does not have hx pCO2 retention. No increase in hypoxia,
dyspnea, cough, or sputum production at present. Received
prednisone 60mg in the ED, subsequently treated with 20mg daily
for planned 5 day course given pneumonia.
# CHRONIC DIASTOLIC HEART FAILURE
# AORTIC STENOSIS:
TTE ___ LEVF 62% with LVH, preserved systolic dysfunction,
moderate to severe aortic valve regurgitation and moderate
aortic stenosis. Appeared euvolemic, continued torsemide and
lisinopril
#ATRIAL FIBRILLATION: Rate-controlled on metoprolol. INR
therapeutic since ___. Followed by ___ clinic,
INR on discharge 3.7 likely due to levofloxacin. Dose held day
of discharge, to resume normal weekly dosing ___
#CKD: Baseline Cr 1.3-1.6. Cr 1.7 on discharge, asked to hold
torsemide ___ and then restart
# GERD: Home pantoprazole continued.
# HLD: Home lovastatin held as not formulary and patient had
history of allergy to other statins
TRANSITIONAL ISSUES:
[] Levofloxacin 750mg ___ & ___ for CAP
[] Prednisone 20mg, last day ___ given PNA in patient with
severe COPD
[] Amlodipine decreased to 5mg daily, please monitor BP
[] INR 3.7 ___, warfarin held. Will restart warfarin on ___.
Please check INR ___
[] Hgb 7.6 ___, HDS, no signs of bleeding. Please re-check CBC
with INR ___
[] We instructed the patient to hold one dose of Torsdemide on
___ then restart given slight creatinine bump to 1.7. Please
check ___, home torsemide may need to be adjusted
Billing: > 30 minutes spent coordinating discharge to home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Dyspnea
2. amLODIPine 10 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Pantoprazole 40 mg PO Q24H
5. Torsemide 60 mg PO DAILY
6. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
8. Lisinopril 40 mg PO DAILY
9. Lovastatin 20 mg oral DAILY
10. Milk of Magnesia 30 mL PO DAILY:PRN constiaption
11. Multivitamins 1 TAB PO DAILY
12. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation 2 puffs daily
13. Warfarin 3 mg PO 4X/WEEK (___)
14. Warfarin 2 mg PO 1X/WEEK (MO)
15. Warfarin 4 mg PO 1X/WEEK (FR)
16. Warfarin 1.5 mg PO 1X/WEEK (WE)
17. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
Discharge Medications:
1. Levofloxacin 750 mg PO Q48H Duration: 2 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth q48h Disp #*2
Tablet Refills:*0
2. PredniSONE 20 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Dyspnea
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
8. Lisinopril 40 mg PO DAILY
9. Lovastatin 20 mg oral DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY:PRN constiaption
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation 2 puffs daily
15. Torsemide 60 mg PO DAILY
Please hold one dose on ___. Warfarin 4 mg PO 1X/WEEK (FR)
17. Warfarin 1.5 mg PO 1X/WEEK (WE)
18. Warfarin 3 mg PO 4X/WEEK (___)
Please do not take ___. Warfarin 2 mg PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
Community-acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were having fevers and a chest x-ray showed pneumonia
WHAT HAPPENED IN THE HOSPITAL?
-You received antibiotics to treat your pneumonia
WHAT SHOULD YOU DO AT HOME?
-Please continue taking levofloxacin every other day ___,
___
-Please follow-up with your doctors as listed below
-___ not take your warfarin ___, resume your normal dosing ___
-Please hold your dose of Torsemide tomorrow (___), then
restart on ___
-You will need labs checked ___. We have spoken to your primary
doctor's office about this. If they do not contact you, please
call them at ___
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10532466-DS-7 | 10,532,466 | 23,957,983 | DS | 7 | 2180-07-13 00:00:00 | 2180-07-13 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors / Levaquin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an ___ woman with past medical history for heart
failure with preserved ejection fraction, severe COPD, and
recent
admission for community-acquired pneumonia who presents with
progressive dyspnea.
Of note, patient was admitted at ___ from ___ to ___ for
community-acquired
pneumonia. Patient was treated with ceftriaxone and
azithromycin
which was transitioned to levofloxacin for a 7 day course.
Patient was also treated for severe COPD exacerbation with
administration of 60 mg of done in the ED followed by prednisone
20 mg daily for 5 day treatment course.
Patient presented to the emergency room on ___ with
shortness of breath. At that time she had a chest x-ray that
was
reassuring and not concerning for pneumonia. She was
subsequently discharged from the emergency room. Over the
intervening days she noted progressively worsening shortness of
breath which impacted her ability to ambulate. Patient noted
that she had dyspnea even for walks of short durations that was
significantly debilitating. She also noted one episode of
hemoptysis on the morning ___. Patient denied fever
chills cough chest pain or chest pressure. Of note patient uses
4 L nasal cannula chronically at home. Patient presented to her
primary care physician on the morning ___ at that
time she was noted to be failing at home and out of breath.
Patient was missed her appointments was not evaluated by her
physician was rather sent to the emergency room. Patient's
physician felt as though she had worsening of her chronic
disease
and would need admission for placement versus palliative care
for
end-stage COPD.
In the ED, initial vitals: 98.5 67 98/43 18 93% Nasal Cannula
- Exam notable for:
Cardiovascular: Regular rate and rhythm with systolic crescendo
decrescendo ejection murmur that is early peaking.
GI: Slightly distended abdomen with tenderness in the right
lower
quadrant.
Extremities: Edema in the right lower leg which stated was
chronic in nature.
- Labs notable for:
Creatinine 1.8
Calcium 10.5
Hemoglobin 8.7
- Imaging notable for:
Chest x-ray: No pulmonary edema or focal consolidation. Lungs
suggestive of COPD and dilated main pulmonary artery suggesting
pulmonary arterial hypertension.
- Pt given:
Albuterol neb ×1
Ipratropium bromide neb ×1
Prednisone 40 mg ×1
- Vitals prior to transfer:
84 119/53 19 100% Nasal Cannula
On the floor, patient states she feels well. She denies any
dyspnea at rest. She does state that she continues to be short
of breath with ambulation. Stating that she is short of breath
even with ___ steps. States that at home she is only able to
walk up ___ steps before she becomes short of breath. States
that over the past week or 2 she has been unable to get out of
bed and believe this is due to the shortness of breath. She
does
state that she has been on the shower over this period of time.
Upon questioning patient states that she does not feel that this
is depression and rather feels that this is due to her shortness
of breath. Denies chest pain, palpitations, PND, orthopnea.
Denies abdominal pain, constipation, diarrhea. Denies worsening
lower extremity swelling or calf pain. States that she has been
compliant with her warfarin and confirmed the complicated daily
dosing.
Review of systems:
(+) Per HPI
(-) 10 Point review of systems otherwise negative
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (FEV1 60%)
HFpEF
Pulmonary HTN
paroxysmal AFib a/c warfarin
HLD
HTN
TIA/STROKE ___, attributed to patent foramen oval
Social History:
___
Family History:
Mom-cancer
Sister- heart
Sister- aneurysm in brain
Brother- COPD
Physical ___:
PHYSICAL EXAM:
Vital Signs: 98.1 133 / 63 79 20 95 4l
General: Patient lying in bed comfortably with daughter at
bedside.
HEENT: Extraocular muscles intact, pupils equal reactive to
light. Sclerae anicteric.
Neck: No JVD.
CV: Irregularly regular. ___ Crescendo decrescendo murmur at
the
right upper sternal border. No rubs or gallops.
Lungs: Bilateral wheezing in upper lung fields with good air
movement. Few wheezes in the middle and lower lung fields with
good air movement. No crackles.
Abdomen: Soft, nontender, nondistended. No rebound or guarding.
GU: No foley
Ext: Warm well perfused. Trace edema bilaterally. No calf
tenderness to palpation.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS:
======================
___ 05:55PM BLOOD WBC-6.3 RBC-2.96* Hgb-8.7* Hct-27.5*
MCV-93 MCH-29.4 MCHC-31.6* RDW-16.1* RDWSD-54.6* Plt ___
___ 05:55PM BLOOD Neuts-60.2 ___ Monos-14.7*
Eos-2.1 Baso-0.6 Im ___ AbsNeut-3.78 AbsLymp-1.37
AbsMono-0.92* AbsEos-0.13 AbsBaso-0.04
___ 05:57PM BLOOD ___ PTT-48.0* ___
___ 05:55PM BLOOD Glucose-106* UreaN-36* Creat-1.8* Na-142
K-4.2 Cl-99 HCO3-28 AnGap-19
___ 05:55PM BLOOD Calcium-10.5* Phos-3.5 Mg-2.1
DISCHARGE LABS:
======================
___ 06:10AM BLOOD WBC-5.1 RBC-2.96* Hgb-8.6* Hct-27.5*
MCV-93 MCH-29.1 MCHC-31.3* RDW-15.7* RDWSD-53.4* Plt ___
___ 06:10AM BLOOD ___ PTT-39.5* ___
___ 06:10AM BLOOD Glucose-163* UreaN-39* Creat-1.6* Na-141
K-3.9 Cl-99 HCO3-29 AnGap-17
___ 06:10AM BLOOD Albumin-3.4* Calcium-9.6 Phos-3.9 Mg-2.1
STUDIES:
======================
CXR ___
IMPRESSION:
No pulmonary edema or focal consolidation. Hyperinflated lungs
suggestive of COPD and dilated main pulmonary artery suggesting
pulmonary arterial hypertension.
Brief Hospital Course:
Patient is an ___ year-year-old woman with a past medical history
of diastolic heart failure, severe COPD on 4 L home oxygen, and
recent admission for community-acquired pneumonia who presented
with dyspnea and fatigue. She was initially admitted with a
concern of a COPD exacerbation however upon further discussion
with the patient it was determined that her dyspnea and fatigue
are in fact chronic and at her recent baseline. Her exam was not
consistent with a COPD exacerbation and she had no evidence of a
new infection or failed treatment of her pneumonia.
We discussed the possibility of outpatient pulmonary rehab with
the patient. She will continue these conversations with her
PCP. We also had a long conversation with the patient and 2 of
her 3 daughters about palliative care vs hospice evaluation.
Patient and family declined at this time. She was evaluated by
___ who felt that she did not have any rehab needs.
The only medication that was changed with stopping her calcium
supplements as her calcium was high on admission. Her warfarin
was held on the day of her hospitalization for a
supratherapeutic INR. The ___ anticoagulation management team
was alerted to her admission.
Transitional issues:
[] Outpatient pulmonary rehab referral
[] Consider monitoring calcium levels off supplement
[] Close INR monitoring ACMS to contact patient with next lab
draw
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Dyspnea
2. amLODIPine 5 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Torsemide 60 mg PO DAILY
8. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation 2 puffs daily
9. Milk of Magnesia 30 mL PO DAILY:PRN constiaption
10. Lovastatin 20 mg oral DAILY
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
12. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
13. Warfarin 4 mg PO 1X/WEEK (FR)
14. Warfarin 1.5 mg PO 1X/WEEK (WE)
15. Warfarin 3 mg PO 4X/WEEK (___)
16. Warfarin 2 mg PO 1X/WEEK (MO)
17. Azithromycin 250 mg PO 3X/WEEK (___)
18. Ipratropium Bromide Neb 1 NEB IH Q8H
19. Potassium Chloride 20 mEq PO DAILY
20. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
Discharge Medications:
1. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Dyspnea
3. amLODIPine 5 mg PO DAILY
4. Azithromycin 250 mg PO 3X/WEEK (___)
5. Ipratropium Bromide Neb 1 NEB IH Q8H
6. Lisinopril 40 mg PO DAILY
7. Lovastatin 20 mg oral DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Milk of Magnesia 30 mL PO DAILY:PRN constiaption
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Potassium Chloride 20 mEq PO DAILY
Hold for K >
13. Torsemide 60 mg PO DAILY
14. Warfarin 3 mg PO 4X/WEEK (___)
15. Warfarin 2 mg PO 1X/WEEK (MO)
16. Warfarin 4 mg PO 1X/WEEK (FR)
17. Warfarin 1.5 mg PO 1X/WEEK (WE)
18.Home Oxygen
4L continuous home oxygen
ICD-10: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
============
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with difficulty breathing and
fatigue. We evaluated you and upon further discussion it was
felt that these symptoms were chronic and did not represent a
sudden change in your health. We are discharging you home to
resume your normal medications with the exception of stopping
your calcium supplement because your calcium was high.
You should contact your primary care office as below to schedule
a follow-up appointment in the next 1 week. We think that you
should consider outpatient pulmonary rehab.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10532466-DS-8 | 10,532,466 | 28,585,185 | DS | 8 | 2180-08-06 00:00:00 | 2180-08-07 19:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors / Levaquin
Attending: ___
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
EGD ___ w/ diuelafoy clipping
History of Present Illness:
Ms. ___ is an ___ year old woman with a past medical history of
COPD (on 4L O2 at home), HFpEF, afib on warfarin, HTN, HL, CKD
(baseline Cr 1.6) who presents with worsening shortness of
breath and melena.
The patent reports she has been more short of breath and tired
over the past week. The shortness of breath got progressively
worse on one day before admission to the point where she was
short of breath transferring from bed to a chair. She also had
cramping abdominal pain. Had a loose bowel movement that was
dark brown/black. Has also been complaining of dizziness. Per
the patient's daughter, she has been having loose stools, and
been incontinent of stool, soiling herself for several weeks.
She was seen by her PCP earlier in the week, and her blood count
was low at that time with Hb at 7.9 on ___ from baseline of ___.
She reports worsening fatigue but no lower extremity weakness.
Denies fever, chills, chest pain, vomiting. Endorses nausea.
She has not taken her warfarin for the past two days (last dose
was on ___. She reports that, after she sees her PCP, she
usually receives a phone call and they tell her what dose of
warfarin to take. She never got a phone call, so she has not
taken her warfarin.
Note: she was recently hospitalized ___ for questionable
COPD exacerbation.
Of note, she had similar symptoms in ___. She had an EGD at
that time that showed a punctate bleeding lesion in the
duodenum.
In the ED,
- Initial vitals:
97.7 80 107/44 18 100%
- Exam notable for:
HEENT: pale conjunctiva
Cardiac: RRR
Lungs: mild crackles at the bases
Abdomen: mild epigastric TTP
Rectal: +melena, guiac positive
- Labs notable for:
Hb is 5.5 down from 7.9 on ___
INR 2.3
Cr 1.6
WBC 11.6
- Pt given:
___ 00:18 IV Pantoprazole 40 mg ___
___ 00:18 IV Phytonadione 10 mg ___
1 unit FFP
- Vitals prior to transfer:
98.3 76 102/47 23 100%
On interview, the patient reports no shortness of breath at rest
and confirms the history above. She is not having active melena
since arrival at the ED. Of note she has no chest pain and no
vomiting. She endorses nausea and lightheadedness.
Past Medical History:
GIB ___ Diulafoy
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (FEV1 60%)
HFpEF
Pulmonary HTN
paroxysmal AFib a/c warfarin
HLD
HTN
TIA/STROKE ___, attributed to patent foramen oval
Social History:
___
Family History:
Mom-cancer
Sister- heart
Sister- aneurysm in brain
Brother- COPD
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
General: Patient lying in bed comfortably with daughter at
bedside.
HEENT: Extraocular muscles intact, pupils equal reactive to
light. Sclerae anicteric.
Neck: No JVD.
CV: Irregularly regular. ___ Crescendo decrescendo murmur at
the
right upper sternal border. No rubs or gallops.
Lungs: Bilateral wheezing in upper lung fields with good air
movement. Few wheezes in the middle and lower lung fields with
good air movement. No crackles.
Abdomen: Soft, mild tenderness in the epigastrium and diffuse
lower abdomen nondistended. No rebound or guarding.
Ext: Warm well perfused. Trace edema bilaterally. No calf
tenderness to palpation.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 99.3 121/56 62 19 94Ra
General: AOx3
HEENT: PERRL, EOMI, OP clear, MMM
CV: Irregularly regular/ ___ crescendo decrescendo murmur
loudest RUSB
Lungs: CTAB, no wheezes/crackles
Abdomen: SNTND, +BS
Ext: WWP, no ___ edema
Neuro: CNII-XII grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 11:30PM BLOOD WBC-11.3*# RBC-1.91*# Hgb-5.5*#
Hct-17.8*# MCV-93 MCH-28.8 MCHC-30.9* RDW-17.1* RDWSD-56.8* Plt
___
___ 11:30PM BLOOD Neuts-79.7* Lymphs-11.8* Monos-6.7
Eos-0.9* Baso-0.1 Im ___ AbsNeut-9.01*# AbsLymp-1.34
AbsMono-0.76 AbsEos-0.10 AbsBaso-0.01
___ 11:30PM BLOOD ___ PTT-35.0 ___
___ 11:30PM BLOOD Glucose-150* UreaN-74* Creat-1.6* Na-140
K-3.7 Cl-101 HCO3-27 AnGap-16
___ 11:30PM BLOOD ALT-8 AST-16 AlkPhos-39 TotBili-0.2
___ 11:30PM BLOOD Lipase-48
___ 11:30PM BLOOD Albumin-3.1*
___ 08:50AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2
___ 11:46PM BLOOD Lactate-1.4
IMAGING
========
CXR ___. Retrocardiac opacity projecting over the spine on the lateral
views
consistent with left lower lobe pneumonia superimposed on
chronic pulmonary disease.
2. Dilated main pulmonary artery suggesting pulmonary arterial
hypertension.
3. Cardiac silhouette remains mild to moderately enlarged.
EGD ___
Erosion in the body
Fresh blood seen in the duodenum. After washing, an actively
bleeding Dieulafoy was seen in D2. (endoclip)
Otherwise normal EGD to third part of the duodenum
CXR ___. Left lung volume loss and absence of the left diaphragmatic
contour are most consistent with left lung atelectasis, improved
since ___, likely in the lower lobe. Concurrent pneumonia is
not excluded.
2. Moderate cardiomegaly, unchanged.
DISCHARGE LABS
==============
___ 04:37AM BLOOD WBC-5.3 RBC-2.74* Hgb-8.1* Hct-25.8*
MCV-94 MCH-29.6 MCHC-31.4* RDW-15.9* RDWSD-54.3* Plt ___
___ 04:37AM BLOOD Plt ___
___ 04:37AM BLOOD ___ PTT-79.6* ___
___ 04:37AM BLOOD Glucose-94 UreaN-31* Creat-1.2* Na-143
K-4.3 Cl-104 HCO3-29 AnGap-10
___ 04:37AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.9
Brief Hospital Course:
HOSPITAL COURSE
===============
___ with a PMH of COPD (on 4L O2 at home), HFpEF,
moderate/severe AS, afib on warfarin, HTN, HLD, CKD who presents
with sub-acute SOB and melena found to have significant anemia
requiring transfusions, s/p EGD w/ dieulafoy clipping, bridged
back to warfarin prior to discharge.
ACUTE ISSUES
============
# GIB: Presented w/ melena and SOB I/s/o anticoagulation.
Required 3U pRBCs upon arrival with inappropriate bumps in blood
counts, but remained HDS. EGD ___ demonstrated diuelafoy in
proximal duodenum that was clipped. H/H then remained stable
after procedure. Initially w/ IV PPI BID, transitioned to PO.
Tolerating regular diet well at time of d/c. Discharge Hb stable
at 8.1. Will continue BID PPi outpatient.
# Atrial Fibrillation: CHADS2VASC 7 (high risk) with history of
stroke/TIA. Rate-controlled on metoprolol and on warfarin.
Patient is currently followed in ___ clinic. Pt
bridged back to warfarin w/ heparin gtt (refused to do Lovenox
shots given difficulty with them in the past) after GIB
stabilized as above. INR therapeutic at 2.2 on ___, will
recheck on ___ at clinic.
# Lung consolitation: CXR upon arrival w/ LLL consolidation. WBC
mildly elevated on admission, but then normalized. No
respiratory symptoms different than baseline (COPD). Repeat CXR
___ w/ improved but persistent consolidation. Recheck CXR in
___ weeks.
# Hypoxia: Was successfully weaned down to lower levels of O2 w/
good sats in house. Likely does not need to be on 4L NC at rest
at home as she is now.
CHRONIC ISSUES
==============
# Severe COPD: FEV1 49% with FEV1/FVC ratio 75% with severe
obstructive defect on PFTs from ___. Weaning oxygen as above.
Continued ipratropium nebs, albuterol nebs, Advair,
azithromycin.
# HFpEF (EF 62%)
# Mod-Sev AR/Mod AS: TTE ___ LEVF 62 moderate-severe AR %
with LVH, preserved systolic dysfunction, moderate-severe
AR/moderate AS. Patient appeared euvolemic on exam. Continued
home torsemide, metoprolol. Restarted lisinopril at 20mg daily
(half-home dose)
# Moderate-Severe Pulmonary hypertension: Patient with history
of pulmonary hypertension which was last evaluated by ___ in
___. Likely group 3 in the setting of chronic lung disease.
# CKD: Baseline Cr 1.3-1.6. Remained at baseline.
# GERD: PPI as above
# HLD: Held lovastatin held as not formulary and patient had
history of allergy to other statins, restarted at time of d/c.
# HTN: Halved lisinopril and ___ amlodipine 5mg daily in
setting of UGIB, SBP 110-130s on this regimen, consider
restarting if consistently hypertensive as outpatient.
TRANSITIONAL ISSUES
===================
[] Please check CBC and INR on ___ visit
[] BP meds: amlodipine held at time of d/c and lisinopril halved
to 20mg given normotensive, consider restarting as outpatient as
BPs tolerate
[] Started omeprazole BID for 8 weeks, after which time can
return to daily dosing
[] Ongoing discussions of risks vs benefits of anticoagulation
given 2 major bleeds within several year span vs AF w/ CHADS
VASC 7
[] Patient on 4L NC at home, but w/ good sats on just 2L in
house, pt resistant to decreasing home O2 despite multiple
conversations in house, can try re-addressing with patient
[] LLL consolidation without symptoms of pneumonia, chould
recheck CXR in ___ weeks to monitor
[] Should see cardiology for repeat TTE given history aortic
stenosis
# CONTACT ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Dyspnea
2. amLODIPine 5 mg PO DAILY
3. Azithromycin 250 mg PO 3X/WEEK (___)
4. Ipratropium Bromide Neb 1 NEB IH Q8H
5. Metoprolol Tartrate 25 mg PO BID
6. Milk of Magnesia 30 mL PO DAILY:PRN constiaption
7. Pantoprazole 40 mg PO Q24H
8. Warfarin 1.5 mg PO 1X/WEEK (WE)
9. Warfarin 2 mg PO 5X/WEEK (___)
10. Warfarin 3 mg PO 1X/WEEK (___)
11. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
12. Lisinopril 40 mg PO DAILY
13. Lovastatin 20 mg oral DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Torsemide 60 mg PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth Daily Disp #*30 Capsule
Refills:*0
2. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
5. Advair HFA (fluticasone-salmeterol) 230-21 mcg/actuation
inhalation BID
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Dyspnea
7. Azithromycin 250 mg PO 3X/WEEK (___)
8. Ipratropium Bromide Neb 1 NEB IH Q8H
9. Lovastatin 20 mg oral DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY:PRN constiaption
12. Potassium Chloride 20 mEq PO DAILY
13. Torsemide 60 mg PO DAILY
14. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until told to resume by your PCP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
GI Bleed ___ Dieulafoy
Hypernatremia ___ Poor PO intake
SECONDARY DIAGNOSIS
===================
Atrial Fibrillation
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure with preserved ejection fraction
Chronic Kidney Disease
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for having low blood levels from
passing blood in your stools. You had an endoscopy, which is a
camera that the doctors ___ through your GI tract to find a
source of bleeding. They found a bleeding blood vessel called a
dieulafoy that they clipped and stopped the bleeding.
The cause of these abnormal blood vessels is unknown, but the
bleeding was most likely worsened by your blood thinners.
However, we discussed with you the high risk of stroke that you
have given your A-fib, and advised that it is likely in your
best interest to remain on the blood thinner. Therefore, we
restarted the warfarin once your blood levels remained stable
after your procedure.
You will check in with your PCP on ___ and have your INR and
blood levels checked. You will take omeprazole twice a day for
the next two months to protect your stomach. We reduced the dose
of some of your blood pressure medications.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
10532466-DS-9 | 10,532,466 | 26,248,567 | DS | 9 | 2180-11-28 00:00:00 | 2180-11-29 09:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors / Levaquin
Attending: ___.
Chief Complaint:
dyspnea on exertion, orthopnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is an ___ year old woman with a PMH of COPD (on 4L O2 at
home), HFpEF, afib on warfarin, HTN, HL, CKD (baseline Cr 1.6),
iron deficiency anemia s/p iron infusion, hx GI bleed, who
presents with 1 week worsening dyspnea on exertion and
orthopnea.
She reports that her symptoms are worse with lying down, and
with
exertion (even a few steps to the bathroom). She reports a dry
cough, but denies any sputum production. She denies fever,
chills, palpitations, abdominal pain, chest pain, diarrhea,
constipation. She has not noticed a change in her weight, but
reports eating Red Doritos the past 2 days. She reports taking
all her medicines as prescribed at home. Her daughters also
report increased urgency of urination over the past few days.
She reports unchanged chronic abdominal pain and back pain. She
denies chest pain, fever, chills, abdominal pain, nausea,
vomiting, or dysuria. She reports that the recent difficulty
breathing seems to be similar to her COPD episodes in the past,
except for the cough. She reports that her bowel movements are
more normal compared to ___ episode of melena.
EMS Report: The patient received Combivent x 1, albuterol x 1
and
reported a slight improvement in her symptoms.
In the ED, initial vitals: T 98.4 HR 77 BP 161/75 RR 18 POx
100% 6L NC
- Exam notable for:
Gen: NAD
HEENT: PERRLA, oropharynx clear
Lungs: diffuse inspiratory wheezing, no crackles.
CV: RRR, no murmurs
Abd: soft NTND
Ext: trace edema R>L, WWP
- Labs notable for:
WBC 5.0
Hg 9.0
Plt 128
BUN 31
Cr 1.3
INR 3.0 (therapeutic)
VBG:
pH 7.36 pCO2 63 pO2 59 HCO3 37 BaseXS 7
Urinalysis negative
- Imaging notable for:
CXR ___:
Cardiomegaly and pulmonary vascular congestion. Small bilateral
pleural effusions with additional right basilar opacity which
could be atelectasis though clinical correlation regarding
possibility of infection.
- Pt given:
IH Albuterol 0.083% Neb Soln 1 Neb x2
IH Ipratropium Bromide Neb 1 Neb x2
PO/NG Azithromycin 250 mg
PO Acetaminophen 650 mg
- Vitals prior to transfer:
T 98.5 HR 92 BP 160/74 RR 22 POx 99% 6L NC
On the floor, patient continues to feel short of breath, with
orthopnea. She denies chest pain, urinary symptoms other than
frequency, or fever/chills. She is currently on 6L O2 NC.
Past Medical History:
CONGESTIVE HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
ATRIAL FIBRILLATION
PFO
STROKE
HYPERTENSION
HYPERLIPIDEMIA
SUPPLEMENTAL OXYGEN
NEEDLE PHOBIA
OSTEOARTHRITIS
ADVANCE CARE PLANNING
ANEMIA
CHRONIC KIDNEY DISEASE
MUSCULOSKELETAL PAIN
CONSTIPATION
AORTIC STENOSIS
AORTIC REGURGITATION
TRICUSPID REGURGITATION
SENSORINEURAL HEARING LOSS
ANEMIA
THROMBOCYTOPENIA
PEDAL EDEMA
FALLS
UPPER GASTROINTESTINAL BLEED
ABNORMAL CHEST XRAY
PULMONARY HYPERTENSION
HEADACHE
FATIGUE
DYSPHAGIA
H/O TOBACCO ABUSE
Social History:
___
Family History:
Not pertinent to this admission
Physical Exam:
ADMISSION EXAM
==============
VITALS: T 98.1 BP 157 / 72 HR 90 RR 28 POx 99 RA
General: AAOx3, in mild respiratory distress
HEENT: Sclerae anicteric, MMM, dentures in place, EOMI, PERRL,
neck supple, JVP elevated to mid-neck with head of bed at
60degrees, + hepatojugular reflux (increased to level of
mandible)
CV: Irregularly irregular, normal S1 + S2, holosystolic murmur
at
___ and SEM at ___
Lungs: Tachypneic. Diffuse inspiratory and expiratory wheezes,
diminished breath sounds at the bases, bibasilar crackles
appreciated
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema of the
lower extremities bilaterally.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE EXAM
==============
VITALS: 98.3 158 / 71 72 18 98 5L NC
General: pleasant alert elderly female. sitting upright in bed.
no use of accessory muscles. in mild respiratory distress.
HEENT: Sclerae anicteric, MMM, dentures in place, EOMI, PERRL,
neck supple, +JVD 14cm at 60 degrees. with +AJR.
CV: Irregularly irregular, normal S1 + S2. ___ systolic
ejection
murmur at RUSB with diastolic rumble.
Lungs: Tachypneic. Using accessory respiratory muscles. Diffuse
inspiratory and expiratory wheezes, improved. diminished breath
sounds at the bases.
Abdomen: Soft, non-distended, bowel sounds present,
no organomegaly, diffuse tenderness to palpation, no rebound or
guarding
Ext: warm and dry. 2+ DP pulses palpable bilaterally, trace
pitting edema of the lower extremities bilaterally. +Clubbing of
fingernails.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
ADMISSION LABS
==============
___ 12:10PM BLOOD WBC-5.0 RBC-3.09* Hgb-9.0* Hct-29.6*
MCV-96 MCH-29.1 MCHC-30.4* RDW-20.4* RDWSD-71.7* Plt ___
___ 12:10PM BLOOD ___ PTT-41.6* ___
___ 12:10PM BLOOD Glucose-122* UreaN-31* Creat-1.3* Na-144
K-5.1 Cl-101 HCO3-30 AnGap-13
___ 12:10PM BLOOD proBNP-8406*
___ 07:30AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.3
___ 06:45PM BLOOD ___ pO2-34* pCO2-75* pH-1.32*
calTCO2-2* Base XS--313
___ 10:24PM BLOOD K-3.7
DISCHARGE LABS
==============
___ 05:55AM BLOOD WBC-6.0 RBC-2.96* Hgb-8.5* Hct-27.9*
MCV-94 MCH-28.7 MCHC-30.5* RDW-20.8* RDWSD-71.8* Plt ___
___ 05:55AM BLOOD Glucose-104* UreaN-43* Creat-1.3* Na-150*
K-3.7 Cl-102 HCO3-36* AnGap-12
___ 05:55AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.2
PERTINENT LABS
===============
Trops
___ 07:30AM BLOOD CK-MB-3 cTropnT-0.06*
___ 03:37PM BLOOD CK-MB-3 cTropnT-0.05*
INR
___ 12:10PM BLOOD ___ PTT-41.6* ___
___ 07:30AM BLOOD ___ PTT-42.7* ___
___ 07:42AM BLOOD ___ PTT-40.9* ___
___ 05:35AM BLOOD ___
___ 05:35AM BLOOD ___
URINE LABS
==========
___ 12:13PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:13PM URINE Color-Straw Appear-Clear Sp ___
IMAGING
=======
CXR ___
IMPRESSION:
Cardiomediastinal silhouette unchanged.
Slight interval improvement in CHF findings.
Residual increased retrocardiac density and patchy opacity at
the right base with small right effusion. It is difficult to
fully exclude infection at the lung bases. However, the changes
at the right base could reflect atelectasis and changes at the
left base could be related to cardiomegaly and associated
compressive atelectasis.
CXR ___
IMPRESSION:
Cardiomegaly and pulmonary vascular congestion. Small bilateral
pleural
effusions with additional right basilar opacity which could be
atelectasis
though clinical correlation regarding possibility of infection.
MICROBIOLOGY
============
___ 1:24 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 12:13 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Ms. ___ is an ___ year old woman with a past medical history of
COPD (on 4L O2 at home), HFpEF, A fib on warfarin, HTN, CKD
(baseline Cr 1.6),
iron deficiency anemia s/p iron infusions, history of GI bleed,
who
presents with 1 week of worsening dyspnea on exertion and
orthopnea,
admitted for acute on chronic HF exacerbation and COPD
exacerbation.
ACTIVE ISSUES:
===============
# COPD Exacerbation: GOLD Class III. The patient initially
presented with inspiratory and expiratory wheezes. Her
exacerbation may have been precipitated by an underlying
infection or community acquired pnuemonia. Her CXR on ___
demonstrated atelectasis vs pneumonia. On admission, she was on
5LNC O2 and was unable to ambulate without feeling dyspneic.
Spirometry from ___ showed: FEV1 0.67 (44%), FVC 1.32
(67%), FEV1/FVC 51%, DLCO 42% suggestive of severe obstructive
disease. She was started on Prednisone 40mg daily X 5 days (D1=
___ for her exacerbation. She was also started on Azithromycin
250mg daily X 5 days (D1 = ___ and Ceftriaxone 1g Q 24H daily
(D1 = ___ for suspected infection, which was transitioned to
cefpodoxime for a 7-day course at discharge (through ___. She
improved symptomatically with duonebs and inhalers, and had less
oxygen requirement by the time of discharge to 4L. She will be
scheduled to follow up with pulmonology upon discharge.
#Acute on Chronic HFpEF (EF 55% ___:
#Mod-severe AR and AS:
#HTN: The patient likely had a CHF exacerbation, given her
increasing orthopnea and dyspnea over the past week, +JVD,
elevated BNP to ~800, and CXR ___ with evidence of pulmonary
edema. In addition, her weight was up 6 lb from baseline at the
time of admission. The etiology of her exacerbation is unclear.
However, the patient has moderate-severe AR and moderate-severe
AS, and may have increased salt intake over the past month per
family. Her concurrent COPD exacerbation might have also
contributed to her CHF exacerbation. She denied any new
infections, medication noncompliance, and this was less likely
acute ischemia based on her EKG and negative cardiac enzymes.
She was started on IV diuresis with Lasix 100mg. Of note, the
patient initially was hypertensive with SBP 160s-170s, and
titrated up with afterload reduction using Captopril 75mg TID
(transitioned to 40 mg Lisinopril daily at discharge). She was
also continued on her home metoprolol tartrate BID. After a net
negative of 2.27L, and clinically appeared euvolemic, she was
restarted on her home Torsemide 60mg daily.
# Afib:
#Supratherapeutic INR: CHADS2VASC 7. The patient had a
supratherapeutic INR on ___ and ___ to 4.3. This was likely
due to starting daily azithromycin as well as prednisone. The
patient had one episode of gross hematuria, however it was
likely secondary to trauma. She had no evidence of a GI bleed.
Her Coumadin was held for those days. Her INR the day prior to
discharge was 3.1. We gave her 2 mg the day of discharge (___).
An INR was not processed this day due to lab error, and should
be drawn on ___ with adjustment in dose accordingly.
CHRONIC ISSUES:
===============
# Hypernatremia: Na was elevated to 149 on admission, likely
from insensible losses. She received D5W 100 cc/hr x1L. Her Na
normalized on ___ to 145 with an increase to 150 day of
discharge. We encouraged water intake.
# HLD: Home Lovastatin 20 mg oral QHS (non-formulary) was held.
# CKD: Patient at 1.3 on admission, baseline around 1.3,
discharged at 1.3.
# Iron deficiency anemia s/p iron infusion. History of GIB. She
was continued on omeprazole for GI protection.
=======================
TRANSITIONAL ISSUES:
=======================
MEDICATIONS:
- New Meds: cefpodoxime 200 mg q12h through ___
- Changed Meds: Lisinopril 40 mg PO DAILY (from 20 mg daily)
FOLLOW-UP
- Follow up: PCP, ___, pulmonology
- Tests required after discharge:
- Please check INR on ___ and adjust dose of warfarin as
necessary to maintain INR ___.
- Please re-check sodium on ___. If hypernatremic, continue to
encourage free water intake.
- Please recheck UA in 6 weeks as pt had gross hematuria, or if
any concerning urinary symptoms
OTHER ISSUES:
- Hemoglobin prior to discharge: 8.5
- Cr at discharge: 1.3
- Antibiotic course at discharge: cefpodoxime 200 mg q12h
through ___
- Pt was euvolemic on discharge at weight above. Will need
evaluation within 7 days to determine need for adjusting
diuretic.
# CONTACT: ___ Phone: ___
# CODE: DNAR/DNI; OK FOR NON-INVASIVE VENTILATION
PROGRESS NOTE FOR DAY OF DISCHARGE
I have seen and examined ___, reviewed the findings,
data, and plan of care documented by Dr. ___
___ and agree, except for any additional comments below.
Remainder of the plan per housestaff note.
Check if applies: [x] ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care was greater than
30 minutes.
___, ___ Attending
___ of Hospital Medicine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH TID
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID:PRN
wheezing
4. Metoprolol Tartrate 25 mg PO BID
5. Warfarin 3 mg PO 3X/WEEK (___)
6. Lovastatin 20 mg oral QHS
7. Torsemide 60 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. fluticasone-salmeterol 230-21 mcg/actuation inhalation BID
10. Azithromycin 250 mg PO 3X/WEEK (___)
11. Omeprazole 40 mg PO BID
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
13. Potassium Chloride 20 mEq PO DAILY
14. Warfarin 2 mg PO 3X/WEEK (___)
15. Warfarin 4 mg PO 1X/WEEK (TH)
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. ___ MD to order daily dose PO DAILY16
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
4. Azithromycin 250 mg PO 3X/WEEK (___)
5. fluticasone-salmeterol 230-21 mcg/actuation inhalation BID
6. Ipratropium Bromide Neb 1 NEB IH TID
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID:PRN
wheezing
8. Lovastatin 20 mg oral QHS
9. Metoprolol Tartrate 25 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO BID
12. Potassium Chloride 20 mEq PO DAILY
Hold for K >
13. Torsemide 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
=================
1. Acute Exacerbation of Diastolic Heart Failure
2. Moderate-Severe Aortic Regurgitation
3. Moderate-Severe Aortic Stenosis
4. COPD Exacerbation
Secondary Diagnoses:
===================
1. Atrial Fibrillation
2. Hypernatremia
3. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you were feeling more short of breath.
Please see more details listed below about what happened while
you were in the hospital and your instructions for what to do
after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- You were found to have fluid on your lungs. This was felt to
be due to your heart condition, called heart failure. This
causes your heart to not pump hard enough and fluid backs up
into your lungs.
- You also have stiff and leaky heart valves which made your
extra fluid worse.
-You were given a diuretic medication through the IV to help get
the fluid out.
- You were also found to be wheezing when you arrived, which can
be caused by your lung disease called COPD. You were started on
inhalers, nebulizers (breathing treatments), and antibiotics, in
case you had a lung infection.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Followup Instructions:
___
|
10532674-DS-13 | 10,532,674 | 29,178,834 | DS | 13 | 2182-04-03 00:00:00 | 2182-04-03 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ on 400 mg motrin daily for arthritis and s/p prednisone
taper one month ago for plantar fasciitis who presents with 24
hours of acute onset abdominal pain. She reports that she felt
well until yesterday afternoon when she experienced diffuse
epigastric and mid-abdominal pain associated with dry heaves and
a small amount of bilious emesis. She endorses subjective fevers
and chills but otherwise denies other symptoms. She is moving
her
bowels regularly and denies unintentional weight loss. She has
not had any blood in her stool, abnormal travel or sick
contacts.
Past Medical History:
Past Medical History: colon cancer, hypertension,
osteoarthritis,
plantar fasciitis
Social History:
___
Family History:
nc
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: 101.5 90 119/93 16 99 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: soft, mildly distended, moderately tender to palpation in
epigastrium and mid-abdomen, no masses, no rebound, no guarding
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___
Vital signs: t=98.3, hr=68, rr=18, oxygen sat=99% room air,
bp120/57
General: NAD, skin warm, dry
CV: ns1, s2, -s3, -s4
LUNGS: Clear
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., + dp bil, no calf tenderness bil.
NEURO: alert and oriented x 3
Pertinent Results:
___ 07:00AM BLOOD WBC-4.3 RBC-3.66* Hgb-11.6* Hct-35.1*
MCV-96 MCH-31.8 MCHC-33.1 RDW-12.1 Plt ___
___ 04:25AM BLOOD WBC-4.9 RBC-3.57* Hgb-11.5* Hct-34.8*
MCV-97 MCH-32.1* MCHC-33.0 RDW-12.3 Plt ___
___ 06:50AM BLOOD WBC-5.6 RBC-3.74* Hgb-11.7* Hct-36.6
MCV-98 MCH-31.3 MCHC-31.9 RDW-12.0 Plt ___
___ 10:00PM BLOOD Neuts-92.7* Lymphs-5.6* Monos-1.6* Eos-0
Baso-0.1
___ 07:00AM BLOOD Glucose-113* UreaN-6 Creat-0.5 Na-142
K-3.4 Cl-107 HCO3-25 AnGap-13
___ 04:25AM BLOOD Glucose-117* UreaN-10 Creat-0.6 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
___ 10:00PM BLOOD AST-21 AlkPhos-53 TotBili-0.9
___ 07:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
___: upper GI:
IMPRESSION:
1. No evidence of extraluminal contrast to suggest perforation.
2. Thickened folds in the mid third portion of the duodenum
compatible with inflamed duodenum on CT.
___: upper GI:
IMPRESSION: Delayed passage of contrast through the distal
duodenum,likely secondary to known duodenitis, without evidence
for leak.
Brief Hospital Course:
Admitted to the acute care service with acute onset abdominal
pain. A cat scan done at an outside hospital showed prominent
bowel wall thickening of the third portion of the duodenum and
mural air within the wall of the duodenum, but no definite free
air within the retroperitoneum. The concern was for a perforated
duodenal ulcer. Upon admission, she was made NPO, given
intravenous fluids, and underwent placement of a ___
tube for bowel decompression. She was started on a protonix drip
and intravenous antibiotics. Her electrolytes were closely
monitored and repleted. Serial abdominal examinations were
done.
On HD # 5, she underwent an upper GI study to evaulate the
status of the perforation. No duodenal leak was seen. She was
started on clear liquids with advancment to a regular diet. Her
intravenous fluids were discontinued. Her hematocrit has
remained stable. She is preparing for discharge home with
follow-up with her primary care provider. She has been
instructed to avoid non-steroidals and has been placed on ultram
for management of her arthritic pain.
Of note: patient reported urinary frequency upon discharge.
U/A and culture sent.
Medications on Admission:
Medications: metoprolol 25', prednisone taper x 6 days
(completed
___, motrin 400'
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: please take with
food.
Discharge Disposition:
Home
Discharge Diagnosis:
perforated duodenal ulcer
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 abdominal pain. You
underwent a cat scan which was suggestive of a duodenal ulcer
with perforation. You were placed on bowel rest, given
intravenous fluids, and started on antibiotics. You underwent a
upper GI study to evaulate the healing of the ulcer. The study
showed that you did not have a leak in your bowel. You have
been started on a regular diet. Your vital signs have been
stable and you are preparing for discharge home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Please avoid any non-steroidals which include advil, motrin, and
ibuprofen. You may resume your 81 mg aspirin, but please take
with food
Followup Instructions:
___
|
10533040-DS-15 | 10,533,040 | 26,395,854 | DS | 15 | 2141-05-03 00:00:00 | 2141-05-03 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left shoulder pain, left shoulder acriomoclavicular septic
joint, left shoulder osteomyelitis, Strep anginosus bacteremia
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Patient is a ___ yo male with pmh significant for HTN,
hypothyroidism, cerebral palsy which affects ___ and ___,
gout who presents with severe left shoulder pain that started 2
days ago. He reports that he was at his desk yesterday and
developed acute onset of anterior shoulder pain which gradually
worsened as the day progressed. He notes that pain was worse
when he lift his arm above his head, and it was also tender with
palpation. He had one prior episode similar to this ~ ___ weeks
ago for which he took codeine and the pain improved. He took
codeine and his baseline dose of indamethacin which he takes for
foot arthritis pain, which did not help. He thus came to the
ED.
In the ED, initial vitals were: 99.6 84 157/86 16 100%. His exam
was notable for tender shoulder joint, no step off, no
clavicular tenderness, no elbow or wrist pathology, no skin
changes or overlying rashes. He had a L shoulder xray that
showed no fracture or dislocation and his glenohumeral and
acromioclavicular joint spaces were preserved. Ortho was called
for evaluation and didn't think this was related to septic joint
and there was no need for joint arthrocentesis at this time.
Inflammatory markers were sent, ESR 40, CRP of 146. His WBC was
also elevated at 13.8 (N:85.6 L:6.6 M:6.9 E:0.7 Bas:0.3). He was
given Percocet, dose of indomethacin and transferred to the
floor.
On the floor, his vitals were: 99, 138/99, 73, 18, 98% on RA. Pt
resting comfortable. He denies having any pain at rest and mild
to mod pain with arm motion. He also endorses some mild pain on
his R shoulder which was not as bad as the right and has now
improved. He denies having any fatigue, muscle pain, or any
other joint pain at this time. He denies having any injury or
trauma to his arm. He thinks his shoulder is only very mildly
swollen. His last episode of gout was over ___ year ago, and this
affects his toes.
This morning, he states his pain is much improved from yesterday
with some mild limited range of motion upon abduction and
extension of shoulder. He received a dose of indomethacin and
oxycodone overnight.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied myalgias.
Past Medical History:
Past Medical History:
Cerebral palsy
HTN
Hypothyroidism
Gout
Social History:
___
Family History:
Family History:
Father die of MI at age ___ years. No hx of autoimmune disorder
or any other problem
Physical Exam:
Admission Physical Exam:
Vitals: Tm 99 126/88 79 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,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: shoulder with mild edema anteriorly, not warm to touch, no
erythema, tender to palpation over the AC joint. Full active and
passive ROM limited to about 80 degrees of shoulder joint. Able
to flex, mild pain with extension.
Discharge Physical Exam:
Vitals: 98.5 130/90 62 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: shoulder with edema anteriorly over AC joint, full active
and passive ROM to about 150 degrees of shoulder joint,
unchanged from prior.
Pertinent Results:
Admission Labs
___ 04:55PM GLUCOSE-108* UREA N-16 CREAT-1.0 SODIUM-139
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 04:55PM ALT(SGPT)-12 AST(SGOT)-20 ALK PHOS-85 TOT
BILI-0.7
___ 04:55PM URIC ACID-8.7*
___ 04:55PM CRP-146.1*
___ 04:55PM WBC-13.8*# RBC-4.34* HGB-12.5* HCT-36.2*
MCV-83 MCH-28.7 MCHC-34.5 RDW-13.6
___ 04:55PM NEUTS-85.6* LYMPHS-6.6* MONOS-6.9 EOS-0.7
BASOS-0.3
___ 04:55PM PLT COUNT-266
___ 04:55PM ___ PTT-30.7 ___
___ 04:55PM SED RATE-40*
___ 4:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
THIS IS A CORRECTED REPORT ___.
Reported to and read back by ___ ___
___ 12:05PM.
STREPTOCOCCUS ANGINOSUS (___) GROUP.
PREVIOUSLY REPORTED AS (ON ___. PRESUMPTIVE STREP
BOVIS.
THIS IS A CORRECTED REPORT (___).
Reported to and read back by ___ ___
___
12:30PM. CLINDAMYCIN <= 0.12 MCG/ML.
ERYTHROMYCIN <= 0.25 MCG/ML. Penicillin <= 0.06
MCG/ML.
PREVIOUSLY REPORTED AS (ON ___.
CLINDAMYCIN = 0.12 MCG/ML, ERYTHROMYCIN = 0.25 MCG/ML,
Penicillin
= 0.06 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Reported to and read back by ___. ___
___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
___ ___ M ___ ___BD & PELVIS WITH CONTRAST Study Date of
___ 8:05 ___
IMPRESSION: Asymmetric thickening of the rectal wall with no
signs of fat
stranding or local lymphadenopathy. This thickening might
represent a
contraction of the bowel, still, rectal wall lesion cannot be
excluded.
Rectosigmoidoscopy is recommended.
Findings were submitted to critical communications dashboard by
Dr.
___ at 12:15 pm on ___.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: ___ 1:23 ___
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ TTE (Complete)
Done ___ at 12:05:18 ___ FINAL
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.No
valvular pathology or pathologic flow identified.
© ___ ___. All rights reserved.
Colonoscopy Report
Date: ___ Endoscopist(s): ___, MD
___, MD (___)
Patient: ___
Ref. Phys.: ___, MD
Assisting Nurse(s)/
Other Personnel: ___, RN
Birth Date: ___ ___ years) Instrument: ___-___
(___)
ID#: ___ ASA Class: P2
Findings:
Excavated Lesions A few diverticula were seen in the sigmoid
colon. Diverticulosis appeared to be of mild severity.
Impression: Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Recommendations: Ongoing evaluation for source of bacteremia per
inpatient team. Repeat colonoscopy at age ___ for routine
screening or sooner if new symptoms.
_________________________________
_________________________________
___, MD
___ signed by ___, MD on ___ 3:10:48 ___
___, MD ___ signed by ___, MD (___) on ___
3:10:48 ___
Patient: ___ (___)
MRI of Left Shoulder
IMPRESSION:
1. The findings are suspicious for septic arthritis and
osteomyelitis of the acromioclavicular joint.
2. Rim-rent tear of the supraspinatus tendon.
Discharge Labs:
___ 05:06AM BLOOD WBC-5.9 RBC-4.09* Hgb-11.2* Hct-34.6*
MCV-85 MCH-27.4 MCHC-32.3 RDW-13.3 Plt ___
___ 05:06AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-142
K-3.7 Cl-105 HCO3-29 AnGap-12
___ 05:21AM BLOOD ALT-14 AST-24 AlkPhos-75 TotBili-0.2
___ 05:06AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1 Iron-53
___ 05:06AM BLOOD calTIBC-250* Ferritn-171 TRF-192*
CXR
IMPRESSION: Successful uncomplicated placement of right-sided 4
___
Preliminary Reportsingle-lumen PICC, measuring 51 cm internally
with tip in the distal SVC. The line is ready to use.
___. ___
___. ___
Brief Hospital Course:
##Left Shoulder Pain
The patient's left shoulder pain was initially attributed to a
possible gout attack. However, blood cultures grew ___ bottles
of gram positive cocci, which was later speciated to Strep
anginosus. MRI revealed erosion into both the clavicle and the
acromion, as well as a septic acromioclavicular joint.
Orthopedics was consulted and determined that debridement and
drainage were unnecessary. He was treated with ceftriaxone and
discharged with a PICC for total 6 week course. His pain was
well controlled on indomethacin and oxycodone. Incidentally, MRI
also revealed a torn supraspinatus tendon. He will see
orthopedics in follow - up in two weeks.
##Strep Anginosis Bacteremia
The patient received a work-up to evaluate possible sources of
the Strep anginosus bacteremia. An ABD/PELVIS CT was negative,
noting only mild rectal thickening. Colonoscopy revealed mild
diverticulosis, but was otherwise within normal limits. A
transthoracic echocardiogram to evaluate possible endocarditis
showed no signs of possible bacterial vegetations or
endocarditis. He did not have a fever throughout his stay, and
surveillance cultures were negative for 96 hours prior to
discharge. He will continue a 6 week course of ceftriaxone as
outlined above.
##Hypertension
The patient was mildly hypertensive during his hospital stay,
occasionally running 150s/90s. His home atenolol was continued
for blood pressure control.
Transitional Issues:
Patient needs weekly OPAT labs including CBC w/diff, BMP, LFTs,
ESR, CRP and results faxed to ___
Medications on Admission:
Indomethacin
Sertraline
Levothyroxine (LEVOXYL) 88 mcg Oral Tablet
Atenolol 50 mg Oral Tablet
Codeine
Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*0 Tablet(s)* Refills:*0*
5. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 6 weeks: DAY
1 = ___
FINAL DAY = ___ .
6. indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left acromioclavicular joint septic joint
Left acromion osteomyelitis
Left clavicle osteomyelitis
Strep anginosus bacteremia
Torn rotator cuff/torn supraspinatus tendon
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:
You were brought to the hospital with left shoulder pain. It was
found that you had a bacterial infection in your shoulder joint
and the bones in your shoulder; you are being treated for this
infection with antibiotics. You were evaluated for a possible
source of this bacterial infection, but these studies did not
demonstrate a source. You will need to be on IV antibiotics for
a total 6 week course.
The MRI also showed a rotator cuff tear. We have made an
appointment for you to see our orthopedic specialists within the
next few weeks to help manage this issue.
We made the following changes to your medications:
STARTED Ceftriaxone
STARTED Oxycodone as needed for pain
STARTED Tylenol as needed for pain
STARTED senna and colace as needed for constipation
Followup Instructions:
___
|
10533101-DS-16 | 10,533,101 | 24,102,017 | DS | 16 | 2187-06-23 00:00:00 | 2187-06-24 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a ___ year old male with a past medical history
significant for allergic rhinitis, chronic left shoulder pain
secondary to stable endochondroma, ongoing cigarette and daily
crystal meth use (smoked), erectile dysfunction, who presents
with dyspnea on exertion.
.
Patient was last seen by PCP ___ ___. Patient reports that he
was in his usual state of health until 6 weeks prior, when he
developed mild rhinorrhea and intermittently productive cough
with brown sputum. His symptoms lingered for several weeks but
resolved without further intervention or medical care.
Approximately ___ days prior, patient developed gradual onset
of dyspnea with climbing one flight of stairs. He was previously
physically active without any limitations. He denies any
associated wheezing, chest pain, nausea, vomiting, diaphoresis,
palpitations, feeling faint, weight changes, lower extremity
swelling, PND, or orthopnea. He reports mild constipation. No
recent changes in diet; he consumes large amounts of soda but
denies any thirst or dehydration. He has never had a stress test
or prior cardiac evaluation. He admits to smoking crystal meth
several times a day for the last ___ years.
.
In the ED, initial vitals were T: 98.3, BP: 136/92, P: 115,
O2sat: 100%RA, RR: 16. Labs and imaging significant for a BUN of
29, creatinine of 1.3, BNP of 2302, troponin T of 0.01. Patient
was evaluated by cards attending in the ED and thought to be
volume overloaded with elevated JVD and lower extremity
swelling. A bedside echo was performed and reportedly with
severely depressed LV systolic function without dilation. ECG
demonstrated new T wave inversions in the anterolateral
precordial leads. Chest radiograph was with new cardiomegaly but
without overt pulmonary edema. CTA was performed and
demonstrated no PE. Findings also demonstrated bilateral
bronchial wall thickening suggestive of chronic small airway
disease and prominent nonspecific right hilar lymphadenopathy.
Also noted to have 1.5cm nodule in right lobe of the thyroid.
Patient was given aspirin 325mg PO X 1, lasix 20mg IV X 1 with
2L urine output. Vitals on transfer were T: 97.7, BP: 148/64, P:
104, RR: 18.
.
On arrival to the floor, patient reports that he is feeling fine
without breathing difficulties.
.
Past Medical History:
- chronic mild left shoulder pain secondary to endochondroma of
the L humerus, stable per MRI
- recurrent back pain
- allergic rhinitis
- history of colon polyp ___
- erectile dysfunction
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Per OMR notes,
the patient has a positive family history of leukemia (father
died of "bone cancer" -- ? leukemia) and a brother who received
treatment for ___ lymphoma. His sister had ___
disease, tx led to diagnosis with breast cancer at a young age.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T: 97l3, BP: 126/93, P: 106, RR: 18, O2sat: 97% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm. +Hepatojugular reflex.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Heart sounds soft, RRR, 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 abdominial bruits.
EXTREMITIES: 2+ pitting edema in bilateral extremities to the
knees.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
DISCHARGE PHYSICAL EXAM:
VS: 98.6 98 101/64 (101-114/64-78) 81 (79-97) 18 95%RA
I+O yesterday ___
Gen: A&Ox3, sleeping but arousable, breathing comfortably, NAD
HEENT: NC/AT, EOMI
CV: RRR, nl S1, S2, no S3, no m/r/g, no elevated JVP
Pulm: CTAB
Abd: soft, NT, ND, + BS, no TTP
Extr: no ___ edema, wwp, 2+ ___ pulses
Neuro: A&Ox3, no gross deficits
.
Pertinent Results:
CBC:
___ WBC-10.0# RBC-4.94 Hgb-14.7 Hct-42.6 MCV-86 MCH-29.7
MCHC-34.5 RDW-13.4 Plt ___
___ Neuts-70.3* ___ Monos-5.0 Eos-3.5 Baso-0.5
___ WBC-9.8 RBC-5.49 Hgb-15.9 Hct-46.4 MCV-85 MCH-29.0
MCHC-34.3 RDW-13.5 Plt ___
.
CHEMISTRY:
___ Glucose-106* UreaN-29* Creat-1.3* Na-140 K-4.7 Cl-106
HCO3-25
___ Calcium-8.8 Phos-4.0 Mg-2.1
___ Glucose-93 UreaN-36* Creat-1.3* Na-136 K-4.2 Cl-98
HCO3-28
___ Calcium-9.4 Phos-4.7* Mg-2.1
.
CARDIAC:
___ CK(CPK)-152
___ 06:30AM CK(CPK)-116
___ 02:30PM cTropnT-<0.01
___ 11:35PM CK-MB-7 cTropnT-<0.01
___ 06:30AM CK-MB-6 cTropnT-<0.01
___ proBNP-2302*
.
LIPID PANEL:
___ Triglyc-64 HDL-82 Cholest-205* CHOL/HD-2.5 LDLcalc-110
LDLmeas-119
.
THYROID:
___ TSH-1.3
.
OTHER:
___ %HbA1c-5.8 eAG-120
___ Ferritin-61
___ %HbA1c-5.8 eAG-120
___ HIV Ab-NEGATIVE
.
IMAGING
.
CXR ___ No acute cardiopulmonary process. New cardiomegaly when
compared
to ___.
.
CTA ___. No evidence of pulmonary embolism.
2. Bilateral bronchial wall thickening is suggestive of chronic
small airways disease, although acute bronchitis could also have
this appearance. Prominent right hilar lymphadenopathy is
non-specific and could be reactive, although follow-up CT in 3
months is recommended to assess for resolution.
3. 1.5-cm nodule in the right lobe of the thyroid could be
further evaluated with non-emergent ultrasound, if clinically
indicated.
4. Mild cardiomegaly.
.
TTE ___
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis (LVEF = 15
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Doppler parameters
are most consistent with Grade III/IV (severe) left ventricular
diastolic dysfunction. The right ventricular cavity is dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderately dilated and severely hypokinetic left
ventricle with restrictive inflow pattern consistent with severe
diastolic dysfunction. Moderate right ventricular systolic
dysfunction. Moderate mitral regurgitation. Moderate tricuspid
regurgitation.
.
Cardiac Cath ___
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically significant coronary artery
disease.
The LMCA, LAD, LCx, and RCA were without angiographically
apparent
flow-limiting stenosis.
2. Resting hemodynamics revealed normal right-sided filling
pressure
with RVEDP of 8 mmHg and significantly elevated left-sided
filling
pressure with mean PCWP of 20 mmHg. There was mild pulmonary
arterial
hypertension with PASP of 37 mmHg. There was systemic arterial
normotension with central aortic pressure of 98/67 mmHg.
3. Cardiac output was 4.34 l/min with index of 2.2 l/min/m2
using Fick.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Moderately elevated PCWP.
3. Mild pulmonary arterial hypertension.
Brief Hospital Course:
___ yo M w/ extensive tobacco hx and daily crystal meth use
(smoked), who p/w DOE and cardiac exam findings concerning for
heart failure.
.
# Dyspnea on exertion: Patient presented with worsening dyspnea
on exertion while going up and down stairs. On presentation, CXR
notable for cardiomegaly without pulmonary edema and elevated
BNP. Found to have severe cardiomyopathy on TTE with an EF of
15%. Did not appear grossly volume overloaded on exam so was
diuresed with lasix 20mg IV daily with good response, converted
to 20mg oral lasix at the time of discharge. Pt underwent
cardiac catheterization on ___ which showed slightly elevated
PCWP at 20mmHg and otherwise clean coronary arteries ruling out
ischemic etiology. Viral etiology thought to be possible given
patient's cold-like symptoms prior to his presentation, though
felt to be less likely. Other causes of CMP were worked up with
TSH that was normal. Hemochromatosis and HIV were also
considered but ferritin was normal and HIV Ab was negative.
Thus, most likely etiology of cardiomyopathy in this patient was
felt to be his chronic methamphetamine use which patient
endorses having used twice a day for the past ___ years. He was
started on aspirin and low dose metoprolol after Echo findings
and lisinopril was started upon discharge (initially held in the
setting ___ and hyperkalemia). Patient was offered and
refused additional drug counseling while inpatient.
.
CHRONIC ISSUES
# Right Hilar adenopathy: No acute issue at this point. Will
need to communicate to PCP that this is likely reactive and to
consider follow up CT in 3 months given long smoking history
.
# Right thyroid nodule: Incidental CT finding. TSH was normal.
Will need outpatient work-up.
.
TRANSITIONAL ISSUES
-Follow-up CT in 3 months to assess for resolution of hilar
lymphadenopathy
-Ultrasound of thyroid to assess nodule
-Pt should have aldactone added at follow up appointment if
creatinine and potassium return to normal
Medications on Admission:
sildenafil 50mg PO PRN
multivitamin PO QD
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. sildenafil 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Systolic heart failure, likely methamphetamine-induced
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 shortness of breath
while walking up stairs. An echocardiogram of your heart showed
that it was not pumping well and this was likely what was
causing your symptoms. You underwent a cardiac catheterization
which showed no blockages in your coronary arteries suggesting
your heart failure is likely due to your chronic crystal
methamphetamine use. Our hope is that if you stop using this
drug, your heart function will improve.
.
The following medications were changed during this
hospitalization:
- START metoprolol succinate 12.5mg daily
- START lisinopril 5 mg daily
- START lasix 20mg daily
.
Please weigh yourself daily and call your doctor if you gain
more than 3lbs in one day.
Followup Instructions:
___
|
10533101-DS-17 | 10,533,101 | 25,408,391 | DS | 17 | 2188-01-09 00:00:00 | 2188-01-11 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
combative, then unresponsive
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
___ year old male with history of methamphetamine abuse and
amphetamine-related cardiomyopathy, prior GHB overdose, who was
found combative by police last evening, and later became
obtunded and unresponsive. Per report, patient was found down,
uncooperative with police. Had laceration/hematoma over right
eye. Became less responsive, and was brought to ED for
evaluation. Did not respond to Narcan.
In the ED, initial VS 77 121/100 15 100% on NRB. Was afebrile.
Patient not responsive to voice or sternal rub. FSBS 102. Had
laceration/hematoma over right eye that was sutured and he was
given a tetanus vaccine. Labs notable for normal WBC, Hgb 13.9,
Hct 40.7, Cr 1.5 (baseline 1.0-1.3). Urine tox positive for
amphetamines. Serum tox negative. Was concern for GHB toxicity.
While in the ED, was intubated w/etomidate and succ given.
Started on fent/midaz for sedation. Also received naloxone
again without effect, and 1L NS. Given head trauma, underwent
multiple imaging studies. CT Abd/Pelvis w/contrast showed no
evidence of fracture or any other acute injury in the thorax,
abdomen and pelvis on prelim read. CT C-spine negative for
fracture or malalignment (prelim read). CT Head showed no acute
intracranial process or cranial fracture (prelim read). Patient
admitted to MICU for further evaluation.
On arrival to the MICU, patient's VS 97.5 76 ___ 100% on
vent (CMV w/FiO2 40%, PEEP 5, TV 500, rate 16). Patient
intubated and sedated, but will squeeze fingers and move toes on
command. Of note, patient had ED visit in ___ for GHB
overdose. Was discharged to home after the effects of the drug
dissipated and he recovered spontaneously. Also had admission
in ___ after presenting with DOE. Was found to have
non-ischemic cardiomyopathy w/EF 15%, felt to be possibly
secondary to his chronic methamphetamine use.
Review of systems: Unable to obtain as patient intubated and
sedated.
Past Medical History:
- Amphetamine-related cardiomyopathy (EF ___ on most recent
echo)
- Chronic mild L shoulder pain ___ endochondroma of the L
humerus
- Recurrent back pain
- Allergic rhinitis
- History of colon polyp ___
- Erectile dysfunction
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Per OMR notes,
the patient has a positive family history of leukemia (father
died of "bone cancer" -- ? leukemia) and a brother who received
treatment for ___ lymphoma. His sister had ___
disease, tx led to diagnosis with breast cancer at a young age.
Physical Exam:
ADMISSION EXAM:
Vitals: VS 97.5 76 ___ 100% on vent (CMV w/FiO2 40%, PEEP
5, TV 500, rate 16)
General: intubated, sedated, not opening eyes, but will squeeze
fingers and move toes on command
HEENT: hematoma and laceration over right eyebrown with dried
and fresh blood, sutures in place, PERRL, sclera anicteric,
dried blood in nares bilaterally, MMM
Neck: cervical collar in place, no JVD
CV: regular rate and rhythm, normal S1 + S2, no r/m/g
Lungs: coarse breath sounds bilaterally, otherwise clear to
auscultation, no wheezes/rales/rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley in place draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, moves all four extremities, toes down-going
bilaterally
DISCHARGE EXAM:
General: Alert and oriented x 3, sitting comfortably in bed, NAD
HEENT: hematoma and laceration over right eyebrow, sutures in
place, dressing clean, dry, intact, PERRL, sclera anicteric, MMM
Neck: Supple, no JVD
CV: regular rate and rhythm, normal S1 + S2, no r/m/g
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+O x 3, CN II-XII intact bilaterally, full strength and
sensation throughout
Pertinent Results:
ADMISSION LABS:
___ 01:50AM BLOOD WBC-9.4 RBC-4.50* Hgb-13.9* Hct-40.7
MCV-90 MCH-30.8 MCHC-34.0 RDW-13.0 Plt ___
___ 01:50AM BLOOD ___ PTT-30.4 ___
___ 01:50AM BLOOD ___ 01:50AM BLOOD Glucose-102* UreaN-31* Creat-1.5* Na-140
K-4.0 Cl-102 HCO3-24 AnGap-18
___ 01:50AM BLOOD Lipase-47
___ 01:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:08AM BLOOD Type-ART Temp-36.4 Rates-20/ Tidal V-500
PEEP-5 FiO2-100 pO2-501* pCO2-42 pH-7.40 calTCO2-27 Base XS-1
AADO2-170 REQ O2-38 -ASSIST/CON Intubat-INTUBATED
___ 02:05AM BLOOD freeCa-1.18
___ 02:05AM BLOOD Glucose-98 Lactate-1.2 Na-142 K-4.1
Cl-100 calHCO3-24
___ 02:15AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:15AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:15AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
___ 02:15AM URINE CastHy-12*
___ 02:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS mthdone-NEG
DISCHARGE LABS:
___ 05:26AM BLOOD WBC-7.6 RBC-4.36* Hgb-12.9* Hct-38.7*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.1 Plt ___
___ 05:26AM BLOOD ___ PTT-29.8 ___
___ 05:26AM BLOOD Glucose-127* UreaN-23* Creat-1.0 Na-134
K-4.5 Cl-100 HCO3-28 AnGap-11
___ 05:26AM BLOOD ALT-15 AST-22 AlkPhos-52 TotBili-0.5
IMAGING:
CXR ___:
IMPRESSION: Endotracheal tube 4.6 cm above the carina and
nasogastric tube in appropriate position. Otherwise normal chest
radiographic examination.
CT Head w/o contrast ___:
IMPRESSION: No evidence of contusion, hemorrhage, or
infarction. A large hematoma in the scalp.
CT C-spine w/o contrast ___:
IMPRESSION: No evidence of fracture or malalignment of the
cervical spine. Mild-to-moderate degenerative changes.
Osteophytes at C6-7 and osteophytes and disk protrusion at C5-6
encroach on the spinal canal and likely on the spinal cord.
CT Torso w/contrast ___: No evidence of acute thoracic,
abdominal or pelvic injury.
Brief Hospital Course:
Brief Course:
___ with known history of methamphetamine abuse and prior GHB
overdose, brought to ED after becoming unresponsive, now
intubated, with urine tox positive for amphetamines.
Active Issues:
#Altered mental status: Patient initially
combative/uncooperative, but then became unresponsive requiring
intubation in ED. Given hx of methamphetamine abuse and urine
tox positive for amphetamines, suspect acute intoxication.
Patient also has hx of GHB overdose, and it is possible his
current CNS depression is secondary to another GHB overdose.
Hypotension, bradycardia, hypothermia, and decreased RR often
seen with GHB toxicity not currently present, though patient's
agitation followed by abrupt obtundation is suggestive of GHB
toxicity. Urine and serum tox screens otherwise negative. DDx
includes infectious etiologies, though less likely as patient
afebrile, no leukocytosis, and no clear source of infection (UA
not suggestive of UTI, CXR negative for PNA). No acute
intracranial process on CT. Glucose WNL. Possible other
electrolyte abnormalities, liver dysfunction could be
contrubuting to a toxic-metabolic encephalopathy. Patient was
intubated for airway protection and admitted to the ICU with
close monitoring of hemodynamics. He was noted to be a difficult
intubation and didn't have a cuff leak, so he was started on
dexamethasone upon extubation. Extubation went well without
complications. Patient returned to baseline mental status and
requested to leave. Social work consult was obtained given
substance abuse, but patient was reluctant and decided to leave
without speaking to social work. He was scheduled for follow up
appointment with his PCP.
#Trauma: Patient found with hematoma and laceration over right
eye brow. Possibly related to fall in setting of acute
intoxication. CT head and C-spine negative for acute fracture
or intracranial process. CT torso also negative for acute
injury. Patient will need forhead sutures removed by PCP ___ 1
week.
___: Cr 1.5, up from baseline 1.0-1.3. Patient appears
euvolemic on exam, though pre-renal azotemia in setting of acute
intoxication and possible volume depletion on differential. No
history of hypotension to suggest ATN. After IV fluids his
creatinine improved to 1.0.
#Amphetamine-related cardiomyopathy: EF 15% in ___, but
improved to ___ on most recent echo in ___. Patient
currently appears euvolemic on exam. Metoprolol was continued
while lisinopril was held given ___
Transitional Issues:
1. Code status: Full
2. Communication: Patient
3. Medication changes: None
4. Follow up: PCP for suture removal
5. Pending studies: None
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Amphetamine intoxication requiring intubation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr, ___,
It was a pleasure taking care of you at ___. You were brought
to the hospital because you were found to be combative and not
acting like yourself. Your urine was positive for amphetamines.
Because of your depressed mental state, you were intubated to
help protect your airway and admitted to the ICU for close
monitoring. You did well in the ICU and we were able to take you
off of the breathing machine without trouble.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Also please follow up with your PCP in ___ week to have your
stitches removed.
Followup Instructions:
___
|
10533287-DS-7 | 10,533,287 | 27,574,099 | DS | 7 | 2148-08-24 00:00:00 | 2148-08-25 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ man with no significant past
medical history who presented to urgent care today with RLQ
abdominal pain that has been present but mild for the last ___
days and which acutely worsened at 3AM today. He denies any
associated symptoms, including N/V. A CT scan was obtained from
urgent care that showed evidence of acute appendicitis. He was
treated with Cipro and transferred downtown for surgical
evaluation. He has been NPO since noon today.
Past Medical History:
PMH: denies
PSH: denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: AAOx3
HEENT: No scleral icterus
Cardiac: WNL
Respiratory: Breathing comfortably
Abdomen: Soft, non-tender, no rebound or guarding
Physical examination upon discharge: ___
vital signs: 99.2, hr= 74, bp=118/70, rr=18, oxygen sat 98%
General: NAD
CV: Ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, tender, port sites with DSD
EXT: no pedal edema bil., no calf tenderenss bil
NEURO: alert and oriented x 3
SKIN: mild erythema upper cheeks bil, no macular or vesicular
lesions
Pertinent Results:
___ 05:18PM BLOOD WBC-14.9* RBC-4.94 Hgb-14.6 Hct-42.8
MCV-87 MCH-29.6 MCHC-34.1 RDW-12.4 Plt ___
___ 05:18PM BLOOD Neuts-85.1* Lymphs-9.4* Monos-4.4 Eos-0.3
Baso-0.4 Im ___
___ 05:18PM BLOOD Glucose-119* UreaN-12 Creat-1.0 Na-137
K-4.2 Cl-98 HCO3-27 AnGap-16
___ 05:18PM BLOOD ALT-13 AST-16 AlkPhos-55 TotBili-0.5
___: cat scan of abdomen and pelvis:
Findings compatible with acute appendicitis. No
macroperforation, free air or abscess formation.
Brief Hospital Course:
The patient was admitted to the hospital with right lower
quadrant pain. Upon admission, he was made NPO and given
intravenous fluids. Imaging showed acute appendicitis. In
addition to this, the patient was noted to have a mild elevation
in his white blood cell count. The patient was taken to the
operating room on ___ where he underwent a laparoscopic
appendectomy. The operative course was stable. The patient was
extubated after the procedure and monitored in the recovery
room.
His post-operative course was stable. He resumed a regular diet
and had no difficulty voiding. His incisional pain was
controlled with oral analgesia. The patient was discharged on
the operative day in stable condition. He was instructed to
call and make an appointment with the acute care service for
follow-up. Prior to discharge, the patient had a mild elevation
in his temperature to 100. He was cleared for discharge by Dr.
___. Instructions in post-operative care were reviewed with
the patient prior to discharge.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 mg by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Patient discharged in stable conditions
Full mental status
Ambulates after operation
Discharge Instructions:
Mr. ___, you were admitted to the acute care surgery for
appendicitis. You tolerated the procedure well today on ___ and
will be discharged in stable conditions.
Here are the discharge instructions:
Please continue regular diet, there is no diet restrictions.
However, things to watch out for includes worsening abdominal
pain, nausea, emesis, and inability to keep food down.
Please continue regular daily activities; Hold from activities
with heavy weight lifting (>5lbs). Please avoid contact sports
for a week. After 15 days, you are okay to resume all
activities.
You are allowed to shower tonight. please take off dressing if
there is any dressing on tomorrow. If you see steri-strips
underneath the gauze, those can stay on for 7 days, and will
fall off on its own.
You will be given a prescription for narcotics. Please do not
drive while on narcotics. You should also take stool softners
with narcotics.
Followup Instructions:
___
|
10533554-DS-20 | 10,533,554 | 20,138,184 | DS | 20 | 2177-04-05 00:00:00 | 2177-04-06 17:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___
___ Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Chest tube placement ___, removed ___
History of Present Illness:
___ with h/o DLBCL (s/p chemo and XRT in ___ to L
clavicle, now in remission), AF(on coumadin), ___ (EF 45%)
presenting with vomiting and SOB. Patient was recently
discharged to rehab after a prolonged hospital stay on ___
after undergoing a VATS with thoracic duct ligation followed by
talc pleurodesis for chylothorax.
In the ED intial vitals were: T99.1 P76 BP90/59 RR20 O2 sat 94%
2L. Her baseline BPs range 130-160s. Exam was notable for mild
right dysmetria and dizziness. Neuro was consulted and findings
were thought to be ___ to old infarcts. Labs were notable for
WBC 12.7 (78.6%PMNs), HCT 30.5, PLT 478, INR 2.9, Cr 1.4
(baseline 0.9-1.1), lactate 1.6. Blood and urine cultures were
sent. CXR showed worsening opacification of right hemothorax
concerning for loculated/multiloculated effusion with areas of
consolidation. CT ___ showed nasal sinus congestion, chronic
right occipital and left parietal infarcts unchanged from prior
exam.
Patient was given: Patient was give 2L NS and started on
Vancomycin, Cefepime and Azithryomycin. Neurology was consulted
and felt that her exam findings were consistent with her CT
findings which are old and there was no concern for acute
stroke. Thoracic Surgery was consulted and recommended admission
to medicine and consultation with IP for thoracentesis.
Past Medical History:
-Atrial fibrillation on coumadin
-Mild asymptomatic sCHF: Echo ___: EF 45-50%, inferolateral AK,
___ MR.
-___ "silent MI" per records, sees Dr. ___
-___
-L Subclavian clot - Noted after first cycle of chemotherapy.
Kept port in place so treated with Fondaparinux. Last US on
___ showed resolution of clot.
-OA - Followed by Dr. ___ - s/p steroid injections in past.
-hernia repair
-benign fibroma removed
- Diffuse large B-cell lymphoma(patient of Dr. ___
___ initially, primarily in left neck; 2a chop r and XRT
Recurred in ___ dose of Cytoxan followed by 6 cycles
R-EPOCH-> PET after 5 cycles with no evidence of residual
disease; s/p L clavical XRT ___
Social History:
___
Family History:
Mother and Father died of "old age" at ___ and ___ respectively.
Sister with hypertension, no family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- 98.0 98.2 103/50 81 24 97/2L Pulsus 16.
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, prominent EJ, JVP flat, no LAD
Lungs- Mild expiratory wheezes and prominent upper airway
noises, decreased breath sounds throughout entire R Lung field,
no rales, rhonchi
CV- RRR, distant heart sounds, normal S1 + S2, no murmurs, rubs,
gallops. Distant heart sounds.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley, no paraspinal or CVA tenderness
Ext- 1+ pitting ___ edema bilaterally, warm, well perfused, 2+
pulses, no clubbing, cyanosis
Neuro- CNs2-12 intact, b/l ___ ___, LUE ___, LLE ___, gait not
assessed
LABS: Reviewed, see below
Labs: Reviewed, please see below.
DISCHARGE PHYSICAL EXAM
=======================
VS: T98.5/97.5 BP 126/60 HR 77 RR 18 SaO2 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, prominent EJ, JVP flat, no LAD
Lungs- bibasilar crackles, R>L
CV- RRR, distant heart sounds, normal S1 + S2, no murmurs, rubs,
gallops, intertrigo under breasts bilaterally
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- foley in place draining clear yellow urine
Ext- trace pitting ___ edema bilaterally, warm, well perfused, no
clubbing, cyanosis
Neuro- CN ___ grossly intact, strength 4+/5 ___nd RLE, ___
at LUE and LLE, sensation intact, moving all extremities
LABS: Reviewed, see below
Pertinent Results:
ADMISSION LABS:
===============
___ 06:32PM BLOOD WBC-12.7*# RBC-3.25*# Hgb-9.1*#
Hct-30.5*# MCV-94 MCH-28.1 MCHC-29.9* RDW-16.6* Plt ___
___ 06:32PM BLOOD Neuts-78.6* Lymphs-13.1* Monos-6.1
Eos-1.9 Baso-0.3
___ 06:32PM BLOOD ___ PTT-32.7 ___
___ 06:32PM BLOOD Glucose-80 UreaN-18 Creat-1.4* Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
___ 06:32PM BLOOD ALT-30 AST-23 AlkPhos-77 TotBili-0.2
___ 06:32PM BLOOD TSH-13*
___ 06:32PM BLOOD T4-8.4 Free T4-1.6
___ 07:41PM BLOOD Lactate-1.6
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-2.0*# RBC-2.79* Hgb-8.0* Hct-26.2*
MCV-94 MCH-28.6 MCHC-30.4* RDW-19.4* Plt ___
___ 12:00AM BLOOD Neuts-59 Bands-1 Lymphs-16* Monos-17*
Eos-0 Baso-1 Atyps-3* Metas-2* Myelos-1*
___ 12:00AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD ___ PTT-35.7 ___
___ 12:00AM BLOOD LMWH-0.75
___ 12:00AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-138
K-3.8 Cl-101 HCO3-31 AnGap-10
___ 12:00AM BLOOD ALT-15 AST-12 LD(LDH)-134 AlkPhos-61
TotBili-0.1
___ 12:00AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.4 Mg-2.3
UricAcd-3.9
IMAGING:
========
TTE ___:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with basal inferior/inferolateral
hypokinesis. The remaining segments contract normally (LVEF =
45-50%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. No pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CT ___ WITHOUT CONTRAST ___:
IMPRESSION:
1. No acute intracranial abnormality.
2. Chronic-appearing right occipital and left parietal
infarcts, unchanged from prior study.
3. Near-complete opacification of bilateral sphenoid air cells,
left greater than right, compatible with chronic sinusitis.
Focal areas of high density material suggest either mucoid
inspissation or fungal component.
CT ___ W/O CONTRAST ___: IMPRESSION: No acute intracranial
abnormality. Unchanged chronic appearing infarcts in the left
parietal and right occipital lobe, as well as sequelae of
chronic small vessel ischemic disease.
ECG (___): Sinus rhythm. Low voltage. Possible old inferior
wall myocardial infarction. Right axis deviation. Compared to
the previous tracing of ___ there are no significant
changes. These abnormalities can be consistent with right
ventricular disease or severe chronic obstructive pulmonary
disease.
CXR (___): IMPRESSION: Interval significant increase in
opacity projecting over the right hemithorax worrisome for
worsen loculated/multiloculated pleural effusion with possible
areas of consolidation. Possible trace left pleural effusion.
CXR (___): FINDINGS: Right pigtail pleural catheter is in
place, with interval decrease in size of right pleural effusion
with residual small effusion remaining, and no visible
pneumothorax. Cardiomediastinal contours are stable in
appearance. Interval improvement in heterogeneous opacities in
the right mid and bilateral lower lung regions, as well as
decrease in size of a small left pleural effusion.
Pleural Fluid Cytology (___): PLEURAL FLUID: ATYPICAL.
Numerous lymphocytes, including rare atypical forms (see note).
Note: A majority of the specimen consists of small and
intermediate-sized lymphocytes as well as plasma cells. Rare
atypical, large lymphocytes are present. The overall features
are most consistent with a reactive lymphoid population.
However, the presence of large atypical lymphocytes,
particularly in a patient with a history of large B-cell
lymphoma and recurrent pleural effusions, may merit obtaining a
fresh specimen for clonality analysis by flow cytometry.
CT ___ w/out Contrast ___
IMPRESSION:
No acute intracranial abnormality. Unchanged chronic appearing
infarcts in the left parietal and right occipital lobe, as well
as sequelae of chronic small vessel ischemic disease.
MR ___ w/ & w/out Contrast, MRA Neck and Brain ___
FINDINGS: There is no evidence for acute infarction .There are
confluent
white matter abnormalities which have slightly progressed
compared to the
prior examination and may reflect a combination of small vessel
ischemic
changes and post-treatment changes. There is a chronic right
occipital
infarct. There is no evidence for metastatic disease.
Intracranial flow
voids are maintained.There is an enhancing lesion in the left
frontal
calvarium which appears unchanged compared to the prior
examination and is unlikely to represent metastatic disease.
There is mucosal thickening in the sphenoid sinus on the left.
MRA of the circle of ___ demonstrates patency of the anterior
and posterior circulations. The right A1 segment is relatively
hypoplastic. No aneurysm or high-grade stenosis is seen.
MRA of the neck demonstrates patency of the carotid and
vertebral arteries. The right distal vertebral artery appears
hypoplastic. The right vertebral artery also appears somewhat
irregular in contour which could be related to atherosclerotic
disease. Both carotid arteries in the neck are tortuous but
patent.
IMPRESSION: No evidence for metastatic disease or acute
infarction. Slight progression of chronic white matter changes
could represent progressive small vessel ischemic changes or
prior treatment-related changes.
MICRO:
======
___ 3:44 pm PLEURAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 3:44 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 7:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:03 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
___ unilingual ___ PMHx AFib (on coumadin);
sCHF(LVEF45%); DLBCL s/p chemorads; chylothorax s/p thoracic
duct ligation and pleurodesis (___) who presented with
loculated parapneumonic effusion, found to be malignant effusion
(DLBCL).
ACUTE ISSUES:
=========
# Pleural Effusion: This is a ___ with h/o DLBCL (s/p chemo and
XRT in ___ to L clavicle), AF( admitted on coumadin,
converted to Lovenox), sCHF (EF 45%), chylothorax s/p thoracic
duct ligation (___) and talc pleurodesis (___) originally
presenting with malaise, weakness, vomiting and SOB from rehab;
patient was found to have worsening right hemithorax opacities
and concern for increased right pleural effusion by CXR in ED.
She was empirically started on Vancomycin, cefepime for persumed
pneumonia at that time (treated from ___. Chest tube
for chylothorax was placed on ___ by IP. Patient was
transferred from medicine to thoracics on ___ for mgmt of
chylothorax and chest tube. Chest tube drainage trended down,
and on ___, as there was no drainage, the chest tube was
removed. Patient was on octreotride and diet w/ medium chain
fatty acids (conservative mgmt of chylothorax) while on thoracic
surgery service. Patient was on heparin gtt with plan to bridge
to coumadin, however upon arrival to ___ service on ___
decision was made to start the patient on Lovenox. Patient
afebrile throughout stay on surgery service, hemodynamically
stable. Flow cytometry on chylothorax confirmed DLBCL, thus
patient was transferred to the ___ service for treatment of her
malignancy. Patient was transferred on ___ to ___ service.
Definitive treatment of pleural effusion would be treatment of
her malignancy, thus she was started on chemotherapy for this.
Octreotride and medium-chain-fatty acid diet were discontinued
as effusion was malignant, not chylothorax. Treatment regimen
would be CEPP (cyclophosphamide, etoposide, procarbazine,
prednisone). Chemotherapy started on ___. Patient tolerated
chemotherapy well during her admission. Prior to discharge she
was started on Acyclovir and Bactrim for prophylaxis. She was
discharged to ___ facility ___, and will follow up
for C2 of CEPP with Dr. ___ ___ at 9AM.
# DLBCL: Recurrent. As noted above, flow cytometry on pleural
effusion consistent with recurrent DLBCL. Patient transferred
to ___ service on ___. Started chemotherapy regiment on ___
(CEP - cyclophosphamide, etoposide and procarbazine). She was
discharged to ___ facility ___, and will follow up
for C2 of CEPP with Dr. ___ ___ at 9AM.
# Neuro deficits: Left visual field deficit and right-sided
weakness noted by neuro on ___, likely caused by old strokes
seen on CT per neuro. Per neuro team, does not need additional
antiplatelet therapy on top of her anticoagulation. Recommended
checking lipid panel (wnl) and A1c (wnl), and recommended
carotid dopplers. Also of note, patient with intermittent
dysarthria, per family. Latest episode occurred on ___ -
patient reported feeling light-headed and tongue felt heavy when
sitting up. Of note neuro exam was otherwised unchanged from
prior - CNs intact (tongue protruding midline, palatal
elevation, smile and eyebrow raise symmetric, facial sensation
intact), mild decrease in right-sided strenght that RUE and RLE.
CT ___ on ___ was unchanged from prior, symptoms resolved
within a few hours and upon lying down. Symptoms recurred on
evening of ___, resolved on their own, recurred on morning of
___. There was concern for medication effect as symptoms
seemed to occur soon after receiving beta-blocker, and patient
noted to be bradycardic in ___ during the episodes. Bradycardia
may be causing hypoperfusion resulting in recrudescence of old
stroke symptoms. Also patient very deconditioned, sitting up
may also be causing decreased perfusion, although BPs checked
while sitting up were within normal limitis (SBPs 130s-140s).
MRI ___ and MRA neck ordered, which showed old occipital
infarct, however no new infarcts or inflammatory processes.
Pt's symptoms were thought to be drug effects secondary to
amiodarone vs. metoprolol vs. procarbazine. Procarbazine and
amiodarone were discontinued, and pt's neurologic symptoms
improved.
# ___: Resolved. Etiology likely multifactorial - due to
decreased effective circulating volume in the setting of sCHF
and hypotension on admission. Creatinine was within normal
limits (< 1.0) by discharge and UOP was adequate.
# AF: Patient with history of atrial fibrillation, evidence of
old CVAs on imaging. CHADS 2 = 5. Warfarin was held briefly for
chest tube placement. Patient was then on heparin drip in
anticipation of bridging to warfarin. On arrival to ___
service, decision was made to transition to Lovenox given her
recurrent malignancy. Patient's afib was controlled with home
dose of metoprolol. Amiodarone was discontinued as discussed
above.
# Thyroid Studies: TSH elevated, free t4 normal, difficult to
interpret in setting of acute illness. This should be followed
up on as outpatient to ensure resolution of lab abnormalities
and/or consideration of thyroid supplementation if needed.
# Anemia: Thought secondary to chronic inflammation, likely due
to recurrent malignancy, supported by low transferrin and
elevated ferritin in ___. No signs of acute bleeding, H/H
stabilized at ___. CBC was monitored daily.
# sCHF: Stable. TTE, ___: Mild regional left ventricular
systolic dysfunction with basal inferior/inferolateral
hypokinesis. The remaining segments contract normally (LVEF =
45-50%). Patient's home lasix was held initially on admission
in the setting of hypotension and concern for sepsis. Was
restarted on home lasix dose on ___ floor. At discharge, pt's
weight was 183.8 lbs with no evidence of heart failure or
significant volume overload on exam.
# HTN: Stable. Home ___ was held on admission in setting of
hypotension and concern for sepsis. Her home beta-blocker was
continued given history of AF with difficult to control RVR on
prior admission. Patient's pressures remained adequately
controlled off of her ___. Restarting should be reassessed by
her primary care physician and within parameters of new ___
guidelines.
# Hypotension: Resolved. BP 90/50 upon presentation. Received
antibiotics and 2L NS on arrival to ED given concern for sepsis.
Vancomycin and cefepime were given from ___, but
discontinued after concern for infectious process decreased.
# Dyspnea/Hypoxia: Resolved. Due to malignant pleural effusion
as noted above. Patient was on 2L NC in ED on admission,
satting in mid-90s. On ___ floor patient was s/p chest tube
removal and satting well on RA.
CHRONIC ISSUES:
===========
# GERD: continued on home omeprazole
# CAD: Pt's home statin was held due to concern for
hepatotoxicity in the context of concomitant chemotherapy.
Aspirin was discontinued as patient anticoagulated with Lovenox.
TRANSITIONAL ISSUES:
==============
-Patient will follow-up with Dr. ___ ___ at 9AM for C2 of
CEPP.
-Patient's home ___ held. Pressures remained stable on BB.
Restarting her ___ for hypertension should be reassessed by her
primary care physician and with regards to new ___ guidelines.
-Patient was transitioned from Coumadin to Lovenox. This will
require twice daily injections and patient will need training
and/or ___ help to administer this medication. Recommended that
PCP monitor whether patient is able to remain compliant with
this, otherwise there should be consideration given to
restarting coumadin.
- Amiodarone was discontinued this admission secondary to
neurologic symptoms
- ASA discontinued with pt anticoagulated with lovenox
- Statin discontinued due to cencern for hepatotoxicity with
concomitant chemo
- Pt with mild intertrigo under her breasts bilaterally on
discharge, Miconazole powder started prior to discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Senna 1 TAB PO DAILY:PRN constipation
5. Simvastatin 20 mg PO DAILY
6. Valsartan 160 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 3 mg PO DAILY16
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
11. Aspirin 81 mg PO DAILY
12. Metoprolol Tartrate 25 mg PO TID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Furosemide 40 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Senna 2 TAB PO BID
6. Vitamin D ___ UNIT PO DAILY
7. Acyclovir 400 mg PO Q8H
8. Docusate Sodium 100 mg PO DAILY:PRN Constipation
9. Enoxaparin Sodium 50 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
13. Ascorbic Acid ___ mg PO DAILY
14. Metoprolol Succinate XL 75 mg PO DAILY
15. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
16. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
17. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
18. Ondansetron 8 mg IV Q8H:PRN nausea
19. Prochlorperazine ___ mg IV Q8H:PRN nausea
20. Miconazole Powder 2% 1 Appl TP QID:PRN Intertrigo
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
#DLBCL
#Malignant pleural effusion s/p chest tube placement
SECONDARY
#Dysarthria secondary to amiodarone
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 for
evaluation of shortness of breath, low oxygen levels and
vomiting. You were found to have fluid in your lungs and were
started on antibiotics due to concern for an infection. A chest
tube was placed to remove the fluid from your lungs. Studies
done on this fluid showed that you have had a recurrence of your
lymphoma. A plan was put in place in conjunction with your
primary oncologist, Dr. ___, to begin chemotherapy to
treat your malignancy. This was started on ___. In addition,
you were evaluated by the neurology service due to concern for a
new stroke as you had had some right-sided weakness and slurring
of your speech. A CT scan of your ___ showed evidence of old
strokes but nothing acute. An MRI was also done which had
similar findings. Neurology believed that your symptoms were
the result of amiodarone you were taking for your heart rhythm.
Your amiodarone was discontinued, and your symptoms improved.
Regarding your chronic medical issues, your anticoagulation for
your atrial fibrillation was changed from coumadin to Lovenox
injections. Your were restarted on your home lasix dose while
on the ___ service, you should continue this upon discharge.
You have a follow-up appointment with the oncology service to
address continued managment of your lymphoma. You clinically
improved and it was determined you could be discharged to a
rehab facility. Should you develop worsening shortness of
breath, chest pain, or high fevers, you should seek evaluation
at a medical clinic or your nearest emergency department.
Please follow up with your scheduled hematology-oncology
appointment ___ at 9AM with Dr. ___
Followup Instructions:
___
|
10533554-DS-24 | 10,533,554 | 22,906,098 | DS | 24 | 2180-07-15 00:00:00 | 2180-07-15 18:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of systolic CHF (EF 45%), CAD, atrial
fibrillation, and diffuse large B cell lyphoma presenting with
cough, dyspnea, intermittent chest pain. Patient reports 4 days
of cough with progressively worsening dyspnea. She reports mild
retrosternal chest pain with coughing, no pleuritic pain or pain
with exertion. She reports increased exertional fatigue and
dyspnea, as well as multiple pillow orthopnea during this time
period. Cough is productive. No fevers.
In the ED initial vitals were:
Temp. 99.1, HR 70, RR 18, BP 170/92, 100% NC
Exam notable for:
+ JVD
Crackles bilateral lung bases
Abd soft, nonTTP
3+ bilateral ___
EKG: Sinus rhythm, non-specific ST-T wave changes unchanged from
prior.
Labs/studies notable for:
Normal CBC and chem-7. INR 1.7, trop < 0.01, and proBNP: 7224.
UA pending.
CXR: pulmonary vascular congestion and interstitial edema.
Patient was given:
IV Furosemide 40 mg
PO/NG Acyclovir 400 mg
PO/NG Amiodarone 100 mg
PO/NG Aspirin 81 mg
PO Metoprolol Succinate XL 150 mg
PO Omeprazole 20 mg
PO/NG Valsartan 40 mg
PO/NG Apixaban 5 mg
Vitals on transfer:
Temp. 99.0, HR 66, BP 169/82, RR 18, 100 % RA
On the floor patient stated that her dyspnea started 3 days ago,
accompanied by cough. She produces a clear frothy sputum. She
states that her legs have also started swelling for last few
days. She reports her dry weight as 187 lbs. She denies eating
any recent salty foods and does not have any other clear
exacerbating factors. She endorses dry mouth. She denies any
other cold symptoms like runny nose or sore throat. She denies
fevers, chills, chest pain, palpitations, belly pain, diarrhea
or constipation. Has a bowel movement daily. She states that
she has not walked in ___ years and gets home health aid 6 days a
week for 3 hours daily. She states that she uses a wheel chair;
has chronic bilateral knee pain at baseline.
Speaking to her grand-daughter, the health care proxy, patient
had 6-pillow orthopnea night prior to hospitalization. Also
endorsesed leg edema worsening and coughing in last few days.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-- Presented with a left neck mass in ___. Biopsy at that time
was consistent with diffuse large B-cell lymphoma.
-- Treated with four cycles of R-CHOP, completing in ___
followed by involved-field radiation therapy to the left neck,
which completed in ___. Surveillance scans were negative.
-- In ___, developed shoulder pain and neck pain, treated
conservatively and received physical therapy, but chest CT on
___ showed a destructive lesion of the left clavicle with
associated prominent soft tissue component and pathologic
fracture. Needle core biopsy of the left clavicular lesion on
___ showed involvement by B-cell lymphoma.
-- Received Cytoxan 750 mg/m2 and five days of prednisone at
100mg per day starting on ___. PET/CT on ___
showed FDG-avid disease in the left clavicle with soft tissue
extending along the distal right bronchus intermedius and in the
peripancreatic and right inguinal lymph nodes.
-- Started cycle one of R-EPOCH on ___. Cycle one was
complicated by a left subclavian clot at the site of POC.
Completed six cycles of R-EPOCH on ___.
-- PET/CT on ___ showed increased FDG avidity at the
medial left clavicular lesion (SUV 4.2 from 3.21). One dose of
Rituxan given on ___ followed by concurrent Rituxan and
radiation therapy starting at the end of ___. Completed
involved field radiation therapy from ___ to ___
with a total dose of 3960 cGy. PET/CT post-XRT in ___
showed no evidence of recurrent disease.
-- Maintenance Rituxan given for two weeks every two months
from ___ to ___. Her most recent PET scan from
___ showed no evidence of residual recurrent lymphoma
with no adenopathy noted.
-- Presented as an unscheduled visit in ___ due to concern
for some increasing nodes on the right side of her neck. This
was in the setting of an upper respiratory infection, and at the
time of her visit, these had since resolved. Repeat scans in
___ showed no evidence for lymphoma.
-- In ___, noted for increasing hip and pelvis pain. PET
imaging on ___ showed no increased FDG uptake or
concerning abnormality.
-- Did well until ___ when presented with increasing
dyspnea and admitted. Noted for bilateral pleural effusions with
EF 45% and felt to have exacerbation of CHF in the setting of
atrial fibrillation. Medications adjusted and discharged on
___.
-- Readmitted on ___ with acute dyspnea once again with
worsening pleural effusions. Right pleural effusion was drained
for over 2 liters of chylous fluid. There was concern about her
prior malignancy but work up was negative. CT scan on ___
showed no evidence for malignancy. VATS with thoracic duct
ligation followed by talc pleurodesis for chylothorax. It was
felt that she could at least benefit from palliation of the
effusion, as possibly the prior malignancy had injured her
thoracic duct. Discharged for rehabilitation on ___.
-- Readmitted on ___ for recurrent dyspnea and worsening
effusion. Another chest tube placed. Two concentrated fresh
specimens were obtained for immunophenotyping and for gene
rearrangement which finally confirmed recurrence of her DLBCL.
-- Transferred to the Hematologic Malignancy service and
started on treatment with CEPP with cycle 1 on ___.
-- Discharged to ___ Rehabilitation on ___ as she
was markedly deconditioned. Received her ___ cycle of CEPP on
___. She was transferred to ___ for
further care.
PAST MEDICAL HISTORY:
--DLBCL, recurrent, recently on rituxan now in remission
--Atrial fibrillation on apixaban.
--Hypertension
--H/o inferior MI based on Echo Findings, no prior cath or other
testing
--L Subclavian clot - Noted after first cycle of chemotherapy in
___. Kept port in place so treated with Fondaparinux. Last US
on ___ showed resolution of clot.
--OA of knees. Followed by Dr. ___ - s/p steroid injections
in
past.
--hernia repair
--benign fibroma removed
Social History:
___
Family History:
Mother and Father died of "old age" at ___ and ___ respectively.
Sister with hypertension, no family history of cancer.
Physical Exam:
ADMISSION EXAM
==============
VS: T 98.9 BP 153/86 HR 64 RR 18 SpO2 94% 2L bed weight 91.5 kg
bed wait (dry weight 84.3 kg)
Outs: 1L on arrival
GENERAL: Well developed, well nourished woman in NAD.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP to the mandible w/HOB at 45 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: Bilaterally crackles in all lung fields without rhonci or
wheeze. Normal work of breathing
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
GU: foley in place draining clear urine
EXTREMITIES: Warm, well perfused. 1+ lower extremity edema to
the knees bilaterally.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
==============
VS: afebrile Tm 98.2 BP 110s-140s/60-80s HR ___ SpO2 high
92-94% RA
I/O: 1080/1800
Weight: 91Kg <-91.5 (admission) (dry weight 84.3 kg). Bed
weights so unreliable.
GENERAL: ___ speaking well developed, well nourished woman
in NAD.
HEENT: Normocephalic atraumatic. Sclera anicteric. Dry mucous
membranes
NECK: Supple. JVP about 12 cm at 45 degrees
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: Bibasilar crackles
ABDOMEN: Soft, non-distended, very mild epigastric point
tenderness, No hepato-splenomegaly.
GU: foley in place draining clear urine
EXTREMITIES: Warm, well perfused. Lymphedema bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
=============
___ 04:50AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-136
K-4.8 Cl-98 HCO3-26 AnGap-17
___ 04:50AM BLOOD WBC-10.0 RBC-4.37 Hgb-12.9 Hct-39.3
MCV-90 MCH-29.5 MCHC-32.8 RDW-17.0* RDWSD-55.3* Plt ___
___ 04:50AM BLOOD Neuts-66.9 Lymphs-16.9* Monos-12.5
Eos-2.9 Baso-0.4 Im ___ AbsNeut-6.66* AbsLymp-1.68
AbsMono-1.24* AbsEos-0.29 AbsBaso-0.04
___ 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
___ 06:19AM BLOOD K-4.3
___ 04:50AM BLOOD proBNP-7224*
___ 04:50AM BLOOD cTropnT-<0.01
___ 10:15AM BLOOD cTropnT-<0.01
___ 04:50AM BLOOD ___ PTT-33.5 ___
NOTABLE LABS/MICROBIOLOGY
__________________________________________________________
___ 6:40 am URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
DISCHARGE LABS
===============
___ 07:02AM BLOOD WBC-6.3 RBC-4.08 Hgb-11.9 Hct-37.3 MCV-91
MCH-29.2 MCHC-31.9* RDW-17.0* RDWSD-56.3* Plt ___
___ 07:30AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-138
K-3.8 Cl-95* HCO3-30 AnGap-17
___ 07:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
IMAGING
=======
Left central venous access line is unchanged in location. Heart
size is
mildly enlarged but stable. Pulmonary vascular congestion
interstitial edema
are moderate. Lung volumes are low. No pleural effusion or
pneumothorax.
IMPRESSION:
Findings compatible with cardiac decompensation. No pleural
effusion.
EKG ___: Sinus rhythm, non-specific ST-T wave changes
unchanged from prior.
Brief Hospital Course:
Ms. ___ is a pleasant ___ speaking, wheel-chair bound ___
with history of systolic CHF (EF 45%), CAD, atrial fibrillation,
and diffuse large B cell lymphoma s/p chest XRT and
anthracylcine based chemo presenting with cough, dyspnea,
intermittent chest pain and productive cough found to have acute
systolic heart failure exacerbation.
# Acute systolic heart failure exacerbation: Patient presented
with dyspnea, some chest pain (Troponins x2 negative, EKG
unremarkable, resolved ), cough, BNP > 7000, and interstitial
edema on CXR. CHF exacerbation without clear trigger (no
ischemic event, med indiscretion, or diet changes). Concern for
worsening valvular disease or EF secondary to h/o anthracycline
based therapy and prior radiation. Patient was diuresed with
Foley in place (___) with 40 mg IV Lasix BID and
transitioned to PO torsemide 40 mg daily. Bed weight on
discharge noted to be 91 kg. Metoprolol succinate 150 mg daily
was continued. Valsartan was increased to 120 mg daily. Patient
should have weight check at follow up with consideration of
Torsemide 40 mg BID with weight gain/volume overload. Consider
repeat echocardiogram as well at time of follow up to assess LV
function in setting of known prior chest XRT and anthracycline
based therapy.
#De-conditioning: Patient is immobile/wheelchair-bound at
baseline, however was noted to be further de-conditioned as she
was unable to transfer to chair/wheelchair from bed. ___
recommended Rehab though patient and family preferred discharge
to home. She was set up with ___ services and home ___.
# Right Knee Osteoarthritis: Chronic, stable. Patient was
continued on standing Tylenol in house.
# CAD: H/o inferior MI based on Echo Findings, no prior cath or
other testing. Stable, was continued on aspirin 81 mg daily
# Atrial fibrillation - Patient was in sinus rhythm throughout
hospitalization, was continued on home dose apixaban and
amiodarone.
# GERD: was continued on home omeprazole and received Tums prn.
# Diffuse large B cell lymphoma; In remission, treatment last in
___. Was continued on acyclovir 400 mg BID (patient was on
daily at home). Will need outpatient clarification on whether
dosing should be BID vs daily.
TRANSITIONAL ISSUES:
======================
- dry weight (bed weight) 91 kg
- valsartan increased to 120 mg daily
- consider uptitration of torsemide to 40 mg BID pending follow
up weight and clinic status at next appointment
- please check chem-7 at follow up appointment to ensure stable
renal function
- Consider repeat echocardiogram as well at time of follow up to
assess LV function in setting of known prior chest XRT and
anthracycline based therapy.
- patient discharged with home ___ and services
- please clarify acyclovir dose at follow up hem/onc visit as
patient is only taking 400 mg daily instead of BID
- patient will be followed by ___ PACT post-discharge
_______________________
# Full Code (confirmed)
# HCP: ___ (grand daughter): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Amiodarone 100 mg PO DAILY
3. Amoxicillin 2 g PO ONCE PRN dental procedures
4. Apixaban 5 mg PO BID
5. Benzonatate 100 mg PO BID:PRN cough
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Torsemide 40 mg PO DAILY
9. TraMADol 50 mg PO BID PRN Pain - Moderate
10. Valsartan 40 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Senna 8.6 mg PO DAILY:PRN constiption
14. Acetaminophen 1000 mg PO TID
15. Calcium Carbonate 500 mg PO BID PRN acid reflux
Discharge Medications:
1. Valsartan 120 mg PO DAILY
RX *valsartan [Diovan] 80 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
2. Acetaminophen 1000 mg PO TID
3. Acyclovir 400 mg PO DAILY
4. Amiodarone 100 mg PO DAILY
5. Amoxicillin 2 g PO ONCE PRN dental procedures
6. Apixaban 5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Benzonatate 100 mg PO BID:PRN cough
9. Calcium Carbonate 500 mg PO BID PRN acid reflux
10. Metoprolol Succinate XL 150 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Senna 8.6 mg PO DAILY:PRN constiption
13. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
14. TraMADol 50 mg PO BID PRN Pain - Moderate
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute systolic heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with shortness of breath and were found
to have a heart failure exacerbation. We gave you a medication
intravenously called Lasix that help improve your breathing. We
restarted you on Torsemide, your home water pill, before you
left the hospital. Your weight when you left the hospital was 91
kg or 200 lbs. prior to leaving the hospital. This was a weight
obtained while you were in bed since you are bed bound.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We are in the process of setting up an appointment in Cardiology
clinic in the next week and will contact you with this
appointment time. Our physical therapist worked with you and
recommended rehab but you preferred discharge home with
services.
Please take all of your appointments as prescribed.
It was a pleasure being involved in your care,
Your ___ Team
Followup Instructions:
___
|
10533741-DS-9 | 10,533,741 | 22,196,424 | DS | 9 | 2174-05-12 00:00:00 | 2174-05-20 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Propranolol overdose
Major Surgical or Invasive Procedure:
ECMO
Intubation, extubation
History of Present Illness:
___ is a ___ year-old male with a history of HIV (on Truvada
for PrEP), mood disorder (lamotrigine, oxcarbazepine), alcohol
use disorder, and hypothyroidism (on synthroid) presenting for
evaluation after intentional ingestion of an unknown amount of
propranolol. Unknown time of ingestion, at most 4 hours prior to
arrival.
___ states that he was ___ his usual state of health until
three days ago when he developed myalgias, a subjective fever,
and nonproductive cough. He took an over-the-counter cough
medicine that contained an intoxicating substance, after which
he
felt an uncontrollable desire to consume alcohol. Prior to this
his last drink was more than ___ years ago. He forgot which
brand of cough syrup and is unclear if the syrup contained
dextromethorphan or acetaminophen.
He currently feels very anxious, but denies chest pain, dyspnea,
nausea, vomiting, or diarrhea.
___ is unable to provide further history or review of
systems
due to the severity of his illness. His vital signs on arrival
were notable for a heart rate of 35 bpm; blood pressure of
124/71
mm Hg.
Evaluation ___ the Emergency Department revealed undetectable
ASA,
TCA, and APAP levels, ethanol of 222 mg/dL. At the
recommendation of Dr. ___ was at bedside, ___ received
50 g activated charcoal, 3 gm calcium gluconate, two pushes of
5mg of glucagon. A glucagon drip at 2 mg/hr was started.
Simultaneously a resident (Dr. ___ was inserting a central
line to begin an epinephrine drip.
Physical Exam.
General Appearance: Anxious, alert, appears stated age.
HEENT: NC/AT; PEERL (4 -> 2), EOMI
Neck: No thyroid mass
Cor: Bradycardic, regular; palpable radial pulses
Lungs: CTAB with good inspiratory effort
ABD: S/S/NT
Extremities: No rashes, 2+ reflex at patella, no clonus at ankle
Skin: Warm, not diaphoretic, not dry
___ 03:49PM BLOOD Glucose: 99 mg/dL UreaN: 7 mg/dL Creat:
1.1 mg/dL Na: 137 mEq/L K: 4.3 mEq/L Cl: 97 mEq/L HCO3: 24 mEq/L
AnGap: 16 mEq/L
___ 05:30PM BLOOD Type: ___ pO2: 28 mm Hg pCO2: 50 mm Hg
pH:
7.33 units calTCO2: 28 mEq/L Base XS: -1 mEq/L
A/P
___ is a ___ year-old man on antiepileptic and antiviral
medication presenting for evaluation of intentional ethanol and
propranolol ingestion with an unclear time of ingestion found to
be hypotensive and bradycardic, consistent with propranolol
ingestion with alcohol coingestion and no salicylates or
acetaminophen.
Propanolol ingestions are associated with significant mortality.
[ ] Retry activated charcoal
[ ] Continue glucagon drip, increase to 10 mg/hr if bradycardia
persists
[ ] If bradycardia or hypotension persist after maximum rate of
glucagon and epinephrine, please give boluses of intralipid (1.5
mL/kg) and consult ___ team
[ ] If intralipid does not have sustained effect please place
transvenous pacer and appreciate ___ teams recommendations.
Please do not hesitate to contact the toxicology fellow-on call
or Poison Control 1 ___. (A toxicology fellow also
covers Poison Control)
Addendum:
While ___ Emergency Department, ___ was unable to tolerate
the
activated charcoal because of the nausea induced by the glucagon
drip. He was intubated, on learning that propranolol was
extended release, and given activated charcoal through the NG
tube. ___ continued to be hypotensive despite maximum
glucagon and epinephrine drips and received intralipid. A
transvenous pacer was placed. The ___ team is planning to
cannulate ___ anticipation of ECMO (HR ___ ___.
Addendum by ___, MD on ___ at 8:49 pm:
I confirm that I have examined this patient, reviewed the
fellow's note, and discussed the evaluation, plan of care and
disposition of the patient with the fellow.
PMH: mood disorder, HTN, hypothyroidism
Medications: Truvada, alprazolam, lamotrigine, levothyroxine,
oxcarbazepine, propranolol ER 80 mg, trazodone, zolpidem
Allergies: NKDA
Social history: alcohol use
FHx: non-contributory
ROS: a complete 10 point review of systems was performed and was
negative except per HPI
___ brief patient is a ___ male to the ED status post
intentional propranolol overdose. On arrival, the patient was
bradycardic with a heart rate ___ the ___. He was awake, alert,
and appropriate. He was treated with activated charcoal,
calcium, and glucagon with improvement of his heart rate. While
___ the ED, patient became intermittently unstable. Started on a
glucagon drip with good effect. Treated with one intralipid
bolus
with improvement. Intubated for airway protection. Finished
initial dose of activated charcoal through OGT. Pacer wire
placed
___ ED with good capture. However, patient remains intermittently
unstable and is en route to the cath lab to have sheaths placed
___ preparation for possible ECMO.
Recommend:
- continue glucagon drip at 10 mg/hour
- support with pressors as needed
- continue calcium as needed
- can rebolus intralipid 1.5mL/kg if patient is unstable
- initiate whole bowel irrigation as propranolol is extended
release formulation as long as patient has active bowel sounds
- agree with ECMO evaluation and initiation if patient remains
unstable
Past Medical History:
Bipolar Disorder
Alcohol Use Diorder
Hypothyroidism
Essential Tremor
Social History:
___
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___ FIBROMYALGIA
OSTEOPOROSIS
Father Living CORONARY BYPASS ___
SURGERY
HYPERTENSION
HYPERLIPIDEMIA
MGM Deceased ___
MGF Deceased TOBACCO ABUSE
PGM Deceased
PGF Deceased
Brother Living GLAUCOMA
Comments: No prostate cancer No colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Temp: 99.5 HR: 35 BP: 124/71 Resp: 16 O(2)Sat: 100 Normal
Constitutional: Anxious
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Bradycardic
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, motor/sensory grossly intact
throughout
Psych: Anxious, remorseful
Pertinent Results:
ADMISSION LABS:
================
___ 03:49PM BLOOD WBC-8.6 RBC-4.65 Hgb-13.9 Hct-41.2 MCV-89
MCH-29.9 MCHC-33.7 RDW-13.7 RDWSD-44.3 Plt ___
___ 03:49PM BLOOD Neuts-50.1 ___ Monos-5.8 Eos-0.0*
Baso-0.3 Im ___ AbsNeut-4.29 AbsLymp-3.70 AbsMono-0.50
AbsEos-0.00* AbsBaso-0.03
___ 03:49PM BLOOD ___ PTT-25.6 ___
___ 10:24PM BLOOD ___
___ 10:24PM BLOOD Heparin-1.84*
___ 03:49PM BLOOD Glucose-99 UreaN-7 Creat-1.1 Na-137 K-4.3
Cl-97 HCO3-24 AnGap-16
___ 03:49PM BLOOD ALT-15 AST-18 CK(CPK)-99 AlkPhos-92
TotBili-0.2
___ 10:24PM BLOOD Lipase-12
___ 03:49PM BLOOD CK-MB-1
___ 03:49PM BLOOD Albumin-4.1 Calcium-8.7 Phos-3.9 Mg-2.1
___ 03:49PM BLOOD TSH-2.0
___ 03:49PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 05:30PM BLOOD ___ pO2-28* pCO2-50* pH-7.33*
calTCO2-28 Base XS--1
___ 03:52PM BLOOD Lactate-1.5
___ 05:30PM BLOOD O2 Sat-39
___ 10:42PM BLOOD freeCa-1.47*
DISCHARGE LABS
================
___ 05:37AM BLOOD WBC-6.5 RBC-3.00* Hgb-8.8* Hct-28.5*
MCV-95 MCH-29.3 MCHC-30.9* RDW-14.6 RDWSD-49.1* Plt ___
___ 05:37AM BLOOD ___ PTT-26.2 ___
___ 05:37AM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-142
K-4.6 Cl-108 HCO3-22 AnGap-12
___ 05:37AM BLOOD ALT-27 AST-25 AlkPhos-69 TotBili-0.3
___ 05:37AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
REPORTS
=======
Transthoracic Echocardiogram Report
Name: ___ MRN: ___ Date: ___
22:43
There is SEVERE global left ventricular hypokinesis. Overall
left ventricular systolic function is
severely depressed. The visually estimated left ventricular
ejection fraction is ___. There is
abnormal septal motion c/w conduction abnormality/paced rhythm.
IMPRESSION: Limited emergency study overnight.
Poor/uninterpretable image quality without
doppler. Normal sized left ventricle with severe systolic
dysfunction ___ the setting of visual
dyssynchrony from pacing.
___ TTE
The visually estimated LV EF is 75%. The RV has mild global free
wall hypokinesis. Compared to the prior TTE, the small loculated
pericardial effusion is somewhat larger, but no evidence of
hemodynamic compromise is seen.
___ CTA Chest
IMPRESSION:
1. Allowing for presence of motion artifact, related to
excessive breathing,
there is no evidence of acute central or segmental pulmonary
embolism.
Subsegmental pulmonary arterial vasculature is inadequately
assessed. The
main pulmonary artery is not dilated.
2. Patchy bilateral parenchymal opacities ___ a bat-wing
distribution. On
correlation with the prior radiographs, these opacities
developed sometime
between the radiograph performed on ___ and the
radiographs performed
on ___. There is no associated septal
thickening.
Appearance is non-specific. ___ the appropriate clinical
context, this could
reflect multifocal pneumonia. ___ the absence of clinical
features to suggest
an infectious process, appearance may reflect non-cardiogenic
pulmonary edema,
especially ___ view of the recent propranolol overdose.
Appearance is not
classic for cardiogenic pulmonary edema.
3. Small bilateral pleural effusions, with passive atelectasis.
4. Mediastinal and hilar lymphadenopathy, likely reactive ___
nature.
5. Patient is status-post gastric bypass. The gastric pouch
has herniated
above the level of the diaphragm and is filled with air. No
large air-fluid
levels ___ the esophagus.
MICROBIOLOGY
===============
___ Sputum Culture
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE
GROWTH.
BETA LACTAMASE NEGATIVE.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- 2 I
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- 2 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 4 R
VANCOMYCIN------------ <=1 S
___ Sputum Culture
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. SPARSE
GROWTH.
Presumptively sensitive to ampicillin. Confirmation
should be
requested ___ cases of treatment failure ___
life-threatening
infections..
Brief Hospital Course:
TRANSITIONAL ISSUES
=======================
[] Transferred to inpatient psychiatry on ___, requires
1:1 observation, may not leave AMA
[] Will need ongoing titration of psychiatric medications, plan
to uptitrate lamotrigine
[] Propranolol overdose requiring ECMO, should not be prescribed
beta blockers
[] Stopped labetalol due to overdose, consider primidone for
essential tremor if an ongoing issue
[] If ongoing respiratory issues or concern for swallowing,
consider outpatient video swallow.
[] If ongoing vocal issues, consider follow up with ENT as
outpatient.
[] Will need ongoing resources for alcohol use disorder.
[] T4 noted to be low ___ setting of acute illness, TSH normal,
recommend recheck of TSH/T4 after discharge.
PATIENT SUMMARY STATEMENT
=========================
This is a ___ with a history of bipolar disorder, alcohol use
disorder, hypothyroidism, and essential tremor who was admitted
status post originally admitted with cardiovascular collapse
secondary to severe bradycardia/shock from a propranolol
overdose, requiring VA ECMO (R Fem A- R Fem V) ___ and
intubation, treated for pneumonia and weaned to room air,
medically cleared for discharge to psychiatry.
ACUTE/ACTIVE ISSUES:
===================
#Propranolol overdose s/p ECMO Decannulation
Presented with propranolol overdose complicated by severe
bradycardia and cardiogenic shock. Received activated charcoal,
glucagon, epinephrine gtt, IV lipid emulsion, and temporary
pacing wire. Despite aggressive intervention, he had ongoing
cardiovascular collapse and required ___ (R Fem A- R Fem V) ECMO
___. He was monitored ___ the ICU then transferred to the
floor where he remained hemodynamically stable.
#Bipolar Disorder
#Anxiety
#Aphasic episodes
Presented ___ setting of overdose, with unclear intentions given
varying reports to different providers. History of bipolar
disorder with concern for medication misuse. He was monitored
with 1:1 sitter and followed by psychiatry. He was placed on
___ with plan to transition to inpatient psychiatry once
medically cleared. He had transient episodes of aphasia and
self-described catatonia, during which he was able to follow
simple commands and protect face with arm drop during episodes.
He was treated with Seroquel and Lamotrigine with plan for
uptitration, last increased on ___.
#EtOH use disorder
Longstanding history of heavy alcohol use, with recent relapse
after a ___ year period of sobriety. Last drink ___, required
phenobarb load while ___ ICU.
#Dysphonia
#Post-intubation dysphagia
Per speech and swallow evaluation, c/f impaired vocal fold
movement given prolonged intubation and ECMO. Voice quality
improved after extubation. Should follow up with ENT if symptoms
persist after discharge.
#H. Flu, Strep pnuemoniae Pneumonia
#Shock- Resolved
Was started on antibiotics given leukocytosis on ___ with
Haemophilus influenzae and Strep pneumonia. ___ CTA neg for
thrombus, +opacities c/w multifocal pneumonia. Treated with
ceftriaxone (___) for 7 days with ambulatory O2 sats
> 92% at time of transfer.
#Diarrhea
Had loose stools ___ setting of antibiotics. C diff negative.
Improved with loperamide.
#Pericardical effusion
TTE ___ after ECMO showed small loculated effusion with no
evidence of hemodynamic compromise.
CHRONIC/STABLE ISSUES:
======================
#Intermittent sinus tachycardia
Per review, intermittent sinus tachycardia, with anxiety.
#Thrombocytopenia- resolved
#Anemia- Stable
Thought ___ hemolysis from ECMO. H/H continues to be stable.
Plts WNL. HIT ab: neg
#Hypothyroidism
Per labs ___, TSH WNL and T4 0.8 (lower limit 0.93) --
given recent critical illness, T4 assessment may be unreliable,
and is unlikely to be contributing to current clinical picture.
Continued on levothyroxine.
#PrEP
Continued TruVada
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol LA 80 mg PO DAILY
2. Propranolol 80 mg PO DAILY:PRN Tremor
3. ALPRAZolam 1 mg PO DAILY:PRN Anxiety
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. LamoTRIgine 150 mg PO DAILY
6. Levothyroxine Sodium 175 mcg PO DAILY
7. TraZODone 50-100 mg PO QHS:PRN Insomnia
8. Zolpidem Tartrate 10 mg PO QHS Insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Benzonatate 100 mg PO TID:PRN Cough
3. Fluticasone Propionate NASAL 1 SPRY ND BID
4. GuaiFENesin-Dextromethorphan ___ mL PO Q4H:PRN cough
5. Multivitamins W/minerals Chewable 1 TAB PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. QUEtiapine Fumarate 50 mg PO QHS
8. QUEtiapine Fumarate 25 mg PO Q6H:PRN Agitation
9. Ramelteon 8 mg PO QPM
10. LamoTRIgine 25 mg PO DAILY
11. ALPRAZolam 1 mg PO DAILY:PRN Anxiety
12. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
13. Levothyroxine Sodium 175 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
FINAL DIAGNOSIS
=================
Propranolol Overdose
SECONDARY DIAGNOSES
===================
Bipolar ___ Acquired Pneumonia
Essential Tremor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
- You came to the hospital because you took a dangerous amount
of a medication called propranolol.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- You were given medications to help reverse the effects of the
propranolol.
- You required a machine called ECMO to help oxygenate your
blood, because your heart was not pumping correctly.
- You needed a breathing machine to breath for you.
- You improved, and were able to leave the ICU.
- You were evaluated by psychiatry, who had a meeting with you
and your family. After much discussion, it was decided that you
should be admitted to an inpatient psychiatric facility for
further evaluation and management.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10533811-DS-10 | 10,533,811 | 27,213,617 | DS | 10 | 2136-05-06 00:00:00 | 2136-06-13 20:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
sudden onset of difficulty speaking and right sided numbness,
tingling and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Arrived as Code Stroke
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time (and date) the patient was last known well: (24h clock)
___ Stroke Scale Score:
t-PA given: No Reason t-PA was not given or considered:
resolving
symptoms
___ Stroke Scale score was : 2
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 1
10. Dysarthria: 0
11. Extinction and Neglect: 0
CT not done as already got tPA.
HPI:
This is a ___ year old right handed man with a history of
hyperlipidemia and idiopathic hypertrophic subaortic stenosis
who
presents with sudden onset of difficulty speaking and right
sided
numbness, tingling and weakness today around 12:30.
History primarily obtained from patient's wife, though patient
can contribute some history. This morning the patient was
feeling
well. Around 12:30 he had sudden onset of right arm and leg
numbness, tingling and mild weakness. He noted that he dropped a
glass with his right hand, but was able to walk. He went to his
son's room at that time because he was "feeling nervous" but
apparently didn't say anything to him. At the same time he
noticed that he was having trouble speaking. At 12:50 he texted
his wife (who was out) random letters. She asked what he was
saying and he texted back "help he". She called EMS. His son
gave
him an aspirin at that time.
He was brought to ___ where his blood pressure on
arrival was 180/110, and he was noted to be in afib. NIHSS was 2
for aphasia per tele neuro. His head CT was reportedly normal
and
he was given tPA at 2:20. Weakness and numbness is resolved but
patient and wife report no change in aphasia.
The patient's wife reports that the patient had some left chest
discomfort on ___. Otherwise he has complained of no recent
illnesses. There's no history of prior neuro deficits. They do
not recall being told he has afib on an irregular rythm.
ROS difficult to obtain but patient denies headache, loss of
vision, blurred vision, diplopia, Denies current focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
PMHx:
hyperlipidemia
idiopathic hypertrophic subaortic stenosis
depression
Social History:
___
Family History:
Family Hx: IHSS in father. No CAD, strokes, seizures, migraines
Physical Exam:
Vitals: 98.3 100 117/75 18 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: irregular, systolic murmur
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to hospital, cannot say name
("I'm doing ok"), states date as "defender ___. Able to relate
history without difficulty. Grossly attentive. Language is
fluent at times with some naming difficulty and paraphasias (can
name chair, glove, cannot name hammock, Key is a "cane" feather
is "furder"). Cannot repeat. Fluent with cliche statements eg
"I'm hanging in there" and when describing the stroke card
picture. Answers some questions appropriately but others with
"I'm ok". Normal prosody. Able to read short sentances but not
longer ones. Speech was not dysarthric. Able to follow simple
commands but makes minor mistakes with 3 step commands. There
was
no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted.
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, 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: deferred
.
Discharge exam:
Normal - no residual neurologic deficit
Pertinent Results:
Studies:
WBC 13.5 84 % neut PLT 243
HCT 49.9
___: 11.0 PTT: 27.5 INR: 1.0
Cr 1.1
CT- reportedly normal (cannot view)
MRI Brain
FINDINGS:
The diffusion images demonstrate scattered areas of cortical
slow diffusion
with minimal hyperintensity on FLAIR in the left middle cerebral
artery
inferior division distribution and in the right distal MCA,
distal PCA, or
watershed distribution. These bilateral findings suggesting a
proximal
embolic source for infarction. There is a small amount of
hemorrhage in the
lower posterior left MCA infarction seen on the gradient echo
images.
MRA images of the neck demonstrate tortuous courses of the
internal carotid
arteries bilaterally but no evidence of stenosis or occlusion.
There is no
internal carotid artery stenosis by NASCET criteria.
The intracranial MRA studies appear normal with no evidence of
stenosis or
occlusion. The origins of the great vessels, the subclavian,
brachiocephalic,
and vertebral arteries appear normal.
IMPRESSION:
Bilateral middle cerebral artery distribution infarctions
suggesting a
proximal embolic source.
Repeat Head CT ___ - No interval change, no new hemorrhage
Brief Hospital Course:
___ p/w acute onset aphasia and right arm/leg weakness and
numbness, now found to have bilateral embolic cerebral
infarctions (L MCA, R MCA-PCA watershed) with a history
of IHSS. He has atrial fibrillation which is the likely source
of his embolic strokes, although it is unclear if this is new or
old as he was previously told verbally that he has an irregular
heart rhythm. Apparently, AF is seen in anywhere from ___ of
patients with hypertrophic cardiomyopathy (with IHSS as a
feature).
.
Repeat NCHCT given small GRE signal in L sylvan fissure showed
no significant hemorrhage and a decision was made to start
___ 150 mg BID. We continued his home statin and maintain
normothermia, euglycemia. TTE with bubble study done on ___
showed stable IHSS/HCM and no PFO. ___ and OT consultations were
obtained and he was cleared for discharge to home.
.
TRANSITIONAL ISSUES
# Stroke: Follow lipids (LDL 121 in hospital - atorvastatin dose
not changed) and ___ compliance. Re-check A1c
(pre-diabetic range at 5.7 while in house) and consider starting
metformin if remains within pre-diabetic range.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NexIUM (esomeprazole magnesium) 40 mg oral daily
2. Verapamil SR 240 mg PO Q24H
3. BuPROPion 150 mg PO BID
4. Atorvastatin 40 mg PO DAILY
5. Centrum Silver (multivitamin-FA-lycopen-lutein) 400-250 mcg
oral daily
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. ___ Etexilate 150 mg PO BID
RX ___ etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice per day Disp #*60 Capsule Refills:*3
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Verapamil 80 mg PO Q8H
You were taking 240mg once per day previous, this is the same
dose spread out throughout the day
RX *verapamil 80 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*3
5. NexIUM Packet (esomeprazole magnesium) 10 mg oral daily
You were taking this medication before you were admitted to the
hospital
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral MCA distribution infarctions, Afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted after sustaining a stroke. We found that you
have a heart rhythm abnormality called "atrial fibrillation"
wherein the atria of your heart do not effectively pump,
allowing ___ pools of blood to form and coagulate. These clots
are then pumped out of your heart to your brain, causing stroke.
Because of this, your medication list has changed.
START
- ___ 150mg (1 pill) two times per day
It is extremely important not to miss any doses of ___.
Missing a dose can render you more prone to clotting,
transiently increasing your stroke risk.
You have a follow-up appointment scheduled in clinic with Dr.
___, as listed below.
Followup Instructions:
___
|
10534626-DS-14 | 10,534,626 | 20,344,967 | DS | 14 | 2183-06-09 00:00:00 | 2183-06-09 15:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine-benazepril
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___: ___ Placement
___: ___ retroperitoneal lymph node biopsy
History of Present Illness:
___ with hypertension, hyperlipidemia, past history of DLBCL
previously in remission as of ___, biopsy proven follicular
lymphoma under observation who is admitted for management of
back pain and constipation.
He recently transitioned care to a ___ oncologist, Dr. ___, at
___. He had a visit with her on ___, where he was
noted to have back pain and hematuria. A CT scan for restaging
purposes showed ___ upper abdominal and lower thoracic
adenopathy as well as nodes invading the lower thoracic
vertebrae (T9/T10 and T11/T12). He was prescribed tramadol for
pain management, with good effect. He has also had difficulty
with moving his bowels, last four days prior to admission with
enema. Colace has had no effect. This has made him nauseous, but
no vomiting. Mr. ___ is also experiencing urinary frequency
without incontinence, retention or dysuria. No numbness or
weakness in his legs, stool incontinence, saddle anesthesia.
On arrival to the ED, initial vitals were pain 8 99.2 85 124/72
16 100% RA
- initial labs: U/A with trace blood and protein and few
bacteria, serum chemistries with BUN/Cr ___, WBC 10.4, H/h
13.6/39, plt 233, urine culture pending
- exam documented as "no midline tenderness 5 out of 5 strength
in the hip flexors, hip extensors, quads, hamstrings,
___ sensation intact light touch along all lower
extremity dermatomes feet warm and well perfused, downgoing
Babinski bilaterally, no clonus, stable fast symmetrical gait
normal rectal tone and sensation, no stool in vault"
- the patient received nothing
- consults: ___
- patient was admitted for inpatient MRI and further management
Prior to transfer vitals were 98.3 68 134/56 18 100% RA
On arrival to the floor, patient endorses the above story and
otherwise denies any acute complaints. He denies fevers/chills,
night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and ___ rashes.
Past Medical History:
- Presented with fever, back pain, retroperitoneal, mesenteric
and retrocrural adenopathy
- Initial biopsy nondiagnositc
- Repeat CT-guided core on ___ showed DLBCL
- Lymphoid population composed of atypical cells with larger
cells. Cells were positive for CD20, BCL2, and BCL6 with a
KI-67 positivity of about 90%. Cells were negative for CD3,
CD5, CD10, cyclin D1 and CD30. He had a bone marrow at that
time that was negative.
- ___ PET with hypermetabolic retroperitoneal, retrocrural
and mesenteric nodes with mean SUV 34
- 6 cycles of R-CHOP with Dr. ___ in ___
- Treatment complicated by LUE thrombosis and significant
neutropenia despite Neulasta
- PET in ___ (after ___ cycles R-CHOP) showed resolution of
PET positivitiy
- ___: PET scan showed an SUV of 13.5 in the 15 x 10 mm
retrocrural LN noted on the CT. A 4mm right paratracheal node
demonstrated low level FDG uptake (SUVmax 2.8).
- ___: Pt seen at ___ clinic for the first time.
___ review of history/PE/labs and imaging it was decided to
wait and watch the left crural LN despite high risk of suspicion
as the LN was too small in size and yield of a diagnostic biopsy
would be low. Pt and his wife agreed with the plan.
- ___: PET demonstrated unchanged size of the LN but decrease
in the SUV to 10.5. No other areas concerning for relapse.
- ___ PET-CT scan: ABDOMEN/PELVIS: Ill-defined left
retrocrural lymph node measures approximately 1.7 x 1.1 cm and
is FDG avid, with SUV max 13.4, compared to 1.3 x 1.3 cm and SUV
max 10.3 on prior. Exophytic left upper pole renal lesion
appears similar to prior and remains non FDG avid.
- ___: LN biopsy: Lymph node, retrocrural, needle core
biopsy: Atypical lymphoid proliferation, with combined
morphologic, immunophenotypic and cytogenetic features of
Follicular lymphoma.
PAST MEDICAL HISTORY:
- Hypertension
- Hypercholesterolemia
Social History:
___
Family History:
- His father had an MI, died and at ___ of heart-related
complications.
- Mother died at age ___ she had no major medical problems, had
diverticulitis.
- He has one brother. He is not aware of any medical problems
that he might have.
- He has 2 biological children, although he is not in close
contact with them, and 4 grandchildren, and does not believe
that they have any significant medical problems.
- There are no other cancers or blood disorders in his family.
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: afebrile, vital signs stable from ED
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, Strength full
throughout. Sensation to light touch intact. Gait is normal.
Pain is reproducible to palpation in upper lumbar lesion.
SKIN: No significant rashes.
ACCESS: PIV
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
T98.4 BP:139/72 HR:76 RR:18 O2:95RA
GENERAL: Comfortable appearing man sitting in bed and speaking
to me in no distress
HEENT: Pupils equal and reactive. No scleral icterus or
injection. No oropharyngeal lesions or thrush.
CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4.
LUNG: Clear to auscultation bilaterally without any use of
accessory muscles or evidence of respiratory distress.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness. PICC in RUE.
NEURO: A&Ox3, good attention and linear thought. Grossly normal
limb movements and strength.
SKIN: No significant rashes.
ACCESS: PICC
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 01:27PM BLOOD WBC-10.4* RBC-4.33* Hgb-13.6* Hct-39.0*
MCV-90 MCH-31.4 MCHC-34.9 RDW-12.3 RDWSD-40.4 Plt ___
___ 01:27PM BLOOD Neuts-87.9* Lymphs-3.6* Monos-7.5
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.10* AbsLymp-0.37*
AbsMono-0.78 AbsEos-0.02* AbsBaso-0.03
___ 06:30AM BLOOD ___ PTT-26.9 ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Ret Aut-1.0 Abs Ret-0.04
___ 12:00AM BLOOD G6PD-NORMAL
___ 01:27PM BLOOD Glucose-107* UreaN-15 Creat-1.0 Na-138
K-4.2 Cl-93* HCO3-30 AnGap-15
___ 06:30AM BLOOD ALT-13 AST-19 LD(LDH)-251* AlkPhos-92
TotBili-0.6
___ 06:30AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6 UricAcd-6.1
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 12:00AM BLOOD WBC-9.0 RBC-3.67* Hgb-11.4* Hct-33.5*
MCV-91 MCH-31.1 MCHC-34.0 RDW-12.6 RDWSD-41.5 Plt ___
___ 12:00AM BLOOD Neuts-97.3* Lymphs-1.3* Monos-0.2*
Eos-0.8* Baso-0.1 Im ___ AbsNeut-8.79* AbsLymp-0.12*
AbsMono-0.02* AbsEos-0.07 AbsBaso-0.01
___ 12:00AM BLOOD ___ PTT-25.4 ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-94 UreaN-28* Creat-0.8 Na-143
K-3.6 Cl-102 HCO3-29 AnGap-12
___ 12:00AM BLOOD ALT-54* AST-21 LD(LDH)-178 AlkPhos-62
TotBili-0.9
___ 12:00AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.0 UricAcd-4.4
___ 12:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 12:00AM BLOOD HIV Ab-NEG
___ 12:00AM BLOOD HCV Ab-NEG
===========================
REPORTS AND IMAGING STUDIES
===========================
___ Biopsy
SPECIMEN: LEFT RETROPERITONEAL MASS, CORE NEEDLE BIOPSY.
DIAGNOSIS: DIFFUSE LARGE B CELL LYMPHOMA, GERMINAL CENTER TYPE.
SEE NOTE.
Note: Fragments show a diffuse infiltrate composed of large
lymphoid cells. The cells are large with abundant cytoplasm,
irregular nuclear contours, hyperchromatic nuclei and multiple
prominent nucleoli. By immunohistochemistry, the lymphocytes are
positive for CD10 (>30%), CD20, PAX-5, and strongly for BCL-2.
Only a small fraction stains for BCL-6 and MUM1 (<30%) and cells
are negative for CD30. CD3 and CD5 stain scattered
T-lymphocytes. CD23 highlights focal remnants of the follicular
dendritic meshwork . ___ virus (___) in situ
hybridization is negative. CD68 stains histiocytes. A high
proliferation index is seen by ___ staining, averaging 80%.
Overall, the morphologic and immunophenotypic features are
consistent with a diffuse large B cell lymphoma of germinal
center type by Hansclassifier.
___ Transthoracic Echocardiogram
The left atrium is normal in size. Mild symmetric left
ventricular hypertrophy with normal cavity size, and
regional/global systolic function (3D LVEF = 67 %). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic arch is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2 cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size, and regional/global systolic function. Mild
aortic valve stenosis. Mild pulmonary artery systolic
hypertension.
___ CT Chest with Contrast
IMPRESSION:
Large soft tissue mass extending from the left paravertebral
region along the bilateral retrocrural regions into the upper
abdomen there by a tick cases the descending thoracic aorta
upper abdominal aorta and the celiac axis, concerning for
recurrent lymphoma, could represent transformation to B-cell.
Correlation with biopsy is recommended.
A 2.3 cm mass in the left paraspinal region at the level of the
inferior pulmonary veins also represents part of the same
process.
Small bilateral effusions left greater than right with bibasilar
atelectasis.
___ CT scan
IMPRESSION:
1. ___ extensive upper abdominal/lower thoracic adenopathy
concerning for recurrence of lymphoma since ___.
Representative measurements are as above.
2. Nodes involve the lower thoracic vertebra with resultant
pathologic compression fracture of T12.
3. Tumoral extension into the left T9-T10 and T11-T12 neural
foramina.
4. Involvement of the left pleural space with pleural masses and
small left-sided pleural effusion.
___ Limited MR ___
IMPRESSION:
1. Only limited MR images were obtained only as the patient
self terminated the examination and did not wish to continue.
2. Soft tissue mass along the prevertebral and paraspinal
spaces involving the lower thoracic spine, as detailed above,
infiltrating the T9-T12 vertebral bodies and extending into the
left T9-10, T10-11, and T11-12 neural foramina.
3. No evidence of spinal canal encroachment or stenosis on this
limited examination did not include axial images.
4. Probable pathologic fracture of the T12 vertebral body with
moderate loss of height. No associated bony retropulsion into
the canal.
============
MICROBIOLOGY
============
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Mr. ___ is a highly functional ___ year old man with HTN and
HLD, history of DLBCL s/p CHOP and remission in ___ with
follicular lymphoma dx ___ with obseravation who was admitted
for management of back pain and constipation, with recent CT
imaging suggestive of progressive adenopathy in the thorax and
abdomen as well as invading the lower thoracic vertebrae. Biopsy
of a retroperitoneal lymph node showed diffuse large B-cell
lymphoma and he was started on EPOCH (Cycle 1, Day 1 =
___ and rituximab (C1: ___ that was uncomplicated.
====================
ACUTE MEDICAL ISSUES
====================
History of DLBCL s/p R-CHOP
#Follicular lymphoma
DLBCL dx in ___, s/p 6 cycles R-CHOP with resolution on PET-CT.
In ___, retrocrural LN concerning for recurrence, opted for
observation. In ___, retrocrural LN showed growth. ___ LN
biopsy with aypical lymphoid proliferation, with combined
morphologic, immunophenotypic and cytogenetic features of
follicular lymphoma, though it was a poor sample. Decided to
monitor. Patient presented as an outpatient with refractory back
pain and found to have T-spine invasion of tumor. Biopsy of
retroperionteal lymph node demonstrated diffuse large B-cell
lymphoma and he was started on EPOCH (Cycle 1, Day 1 =
___ and rituximab (___) that was uncomplicated.
Plan is for 6 cycles of EPOCH. He had no evidence of tumor lysis
syndrome or DIC. TTE completed, G6PD normal, HCV negative, HBV
Core, Surface Ab, Surface Ag negative, HIV negative.
- Port placement on ___
- Neulasta on ___ in clinic due to high co-pay for neupogen
# Hypertension
# Volume overload
Patient was taking 25mg HCTZ at home, but would only take
lisinopril 10mg on days where blood pressure on home cuff was
high. Normotensive on admission but became hypertensive to
150's-190's despite increasing antihypertensives. Fluid avidity
likely contributing. Weight peaked at 92 from 87kg on admission.
Hypotensive on ___ in the setting of Lasix, HCTZ, lisinopril,
hydralazine, so he was given 1L fluids and hydralazine was
discontinued. He will discharge on home medications with close
blood pressure monitoring as an outpatient.
- HCTZ 25mg daily
- Lisinopril 10mg daily
# Back pain
# Progressive adenopathy
Recent CT imaging concerning for progressive lymphoma with lytic
invasion. This at least partially responsible for his back pain.
ED exam without neurologic compromise. MRI T/L spine with
contrast limited due to early termination but does not show any
evidence of cord compression, and no evidence on exam either, so
MRI was not repeated. Received 100mg prednisone on two days
preceding EPOCH with improvement in pain. His back pain
completely resolved by day 4 of EPOCH cycle 1. He was frequently
independently walking the floor during hospitalization.
# Constipation
Presented with refractory constipation with no bowel movement in
a week. Despite aggressive oral bowel regimen including
lactulose, constipation resolved only after enema. By discharge
he was having regular bowel movements.
# Urinary frequency
Patient presented with several days of waking up more frequently
at night to urinate. No dysuria, U/A unremarkable. No indication
for antibiotics despite culture resulting in alpha
streptococcus, which is likely a skin contaminant. He did have
gross hematuria at presentation, so this should not be confused
with chemo side effect should it recur.
# Hyperlipidemia
- Hold simvastatin given chemo
===================
TRANSITIONAL ISSUES
===================
[ ] Patient was continued on home ASA 81mg at discharge. This
should be discontinued if any concern for bleeding.
[ ] Fluconazole not started on discharge, can be addressed by
outpatient provider.
[ ] Will need continued close monitoring of blood pressure given
hypertension while inpatient
- ___ Meds: Bactrim SS daily, Acyclovir 400mg twice daily
- Stopped/Held Meds: Simvastatin held
- Changed Meds: None
- Discharge weight: ___: 89.5kg (197.31 pounds)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
4. Lisinopril 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth Twice Daily Disp #*60
Tablet Refills:*0
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. HELD- Simvastatin 20 mg PO QPM This medication was held. Do
not restart Simvastatin until your doctor tells you to
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
DIFFUSE LARGE B CELL LYMPHOMA, GERMINAL CENTER TYPE
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 bad back pain.
- A CAT scan showed that your lymphoma may be worsening and
pressing on your spine.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We did an MRI that showed your spinal cord wasn't affected.
- We biopsied the tumor and found that it was a high grade
(aggressive) lymphoma
- You got one cycle of chemotherapy and did very well
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Carefully review the attached medication list as you have ___
medications.
- Review the warning signs below and call your doctor or go to
an emergency department right away if you have any concerns.
- Continue to stay active as much as you are able to.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10534626-DS-20 | 10,534,626 | 21,764,459 | DS | 20 | 2183-10-20 00:00:00 | 2183-10-19 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
amlodipine-benazepril
Attending: ___.
Chief Complaint:
Left incarcerated inguinal hernia
Major Surgical or Invasive Procedure:
Left incarcerated inguinal hernia repair ___.
___ tube placement ___.
History of Present Illness:
Pt noted a "lump" in the shower after doing yard work on
___. The pain has been constant, ___ in intensity,
and located in the L groin alone. He reports he pain is worse
with movement and position changes, and feels
better after bowel movements. He presented with this issue to
his ___ clinic, where he underwent a CT abdomen/pelvis
showing an incarcerated
hernia containing fat. In light of this, he was subsequently
sent to the ED for evaluation. Upon arrival, he was also found
to have a L pleural effusion.
Past Medical History:
Transformed diffuse large B cell lymphoma
NTH
HLD
afib
DVT
CAD
Social History:
___
Family History:
- His father had an MI, died and at ___ of heart-related
complications.
- Mother died at age ___ she had no major medical problems, had
diverticulitis.
- He has one brother. He is not aware of any medical problems
that he might have.
- He has 2 biological children, although he is not in close
contact with them, and 4 grandchildren, and does not believe
that they have any significant medical problems.
Physical Exam:
Admission Physical exam
Vitals: 98.0 88 122/67 18 100% RA
General: no acute distress
Heart: WWP
Resp: breathing comfortably on room air
Abd: soft, nontender, nondistended. Non-reducible left inguinal
hernia, mildly tender to palpation, no overlying skin changes
Discharge Physical Exam
Vitals: T:97.7 BP:94 / 60 HR93 RR:18 O2sat:96% Ra
General: NAD, laying comfortably in bed
CV: RRR, Normal S1, S2
Pulmonary: Clear to auscultation bilaterally. mild tenderness to
palpation on left hemithorax where chest tube was.
Abdominal: soft, non-tender, non distended. incision wound is
clean, dry, well approximated and is mildly tender to palpation
Extremities: warm and well perfused
Pertinent Results:
___ 11:40PM GLUCOSE-109* UREA N-10 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
___ 11:40PM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.4
___ 11:40PM WBC-14.8* RBC-2.74* HGB-9.9* HCT-30.4*
MCV-111* MCH-36.1* MCHC-32.6 RDW-15.6* RDWSD-63.9*
___ 11:40PM PLT COUNT-129*
___ 06:19PM POTASSIUM-4.4
___ 06:19PM MAGNESIUM-1.6
___ 06:19PM WBC-7.8 RBC-2.55* HGB-9.4* HCT-28.9* MCV-113*
MCH-36.9* MCHC-32.5 RDW-15.9* RDWSD-66.2*
___ 06:19PM PLT COUNT-117*
___ 02:04PM OTHER BODY FLUID PH-7.46
___ 01:00PM PLEURAL TOT PROT-2.7 GLUCOSE-104 LD(LDH)-74
CHOLEST-56 proBNP-2551
___ 01:00PM OTHER BODY FLUID IPT-DONE
___ 01:00PM PLEURAL TNC-162* RBC-608* POLYS-41* LYMPHS-8*
MONOS-3* EOS-1* MESOTHELI-2* MACROPHAG-45*
___ 10:25AM URINE HOURS-RANDOM
___ 10:25AM URINE UHOLD-HOLD
___ 10:25AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:07AM LACTATE-1.0
___ 12:55AM GLUCOSE-111* UREA N-15 CREAT-0.8 SODIUM-140
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
___ 12:55AM estGFR-Using this
___ 12:55AM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.9
___ 12:55AM WBC-7.6 RBC-2.51* HGB-9.1* HCT-28.1* MCV-112*
MCH-36.3* MCHC-32.4 RDW-16.1* RDWSD-66.1*
___ 12:55AM NEUTS-81.2* LYMPHS-4.3* MONOS-12.7 EOS-0.3*
BASOS-0.8 IM ___ AbsNeut-6.18* AbsLymp-0.33* AbsMono-0.97*
AbsEos-0.02* AbsBaso-0.06
___ 12:55AM PLT COUNT-141*
___ 12:55AM ___ PTT-53.6* ___
___ 12:00PM GLUCOSE-103* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12
___ 12:00PM ALT(SGPT)-13 AST(SGOT)-14 LD(LDH)-165 ALK
PHOS-70 TOT BILI-0.5
___ 12:00PM TOT PROT-5.5* ALBUMIN-3.7 GLOBULIN-1.8*
CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-2.0
___ 12:00PM WBC-8.0 RBC-2.80* HGB-9.9* HCT-30.6* MCV-109*
MCH-35.4* MCHC-32.4 RDW-15.9* RDWSD-65.0*
___ 12:00PM NEUTS-79.5* LYMPHS-5.6* MONOS-13.3* EOS-0.1*
BASOS-0.9 IM ___ AbsNeut-6.37* AbsLymp-0.45* AbsMono-1.07*
AbsEos-0.01* AbsBaso-0.07
___ 12:00PM PLT COUNT-181
Brief Hospital Course:
The patient presented to the Emergency Department on ___.
The patient referred a painful left inguinal bulge and had a CT
abdomen/pelvis scan that showed an incarcerated hernia
containing fat. Due to an incidental left pleural effusion,
interventional pulmonology was consulted for placement of a left
pigtail chest tube which drained 2L of serous fluid. Following
this, the patient was taken to the operating room for left
incarcerated inguinal herniorrhaphy. There were no adverse
events in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation. On ___, his pain was
well controlled, he was tolerating a regular diet, voiding
without difficulty, and ambulating. Prior to discharge, the left
pigtail catheter was removed by interventional pulmonology.
After a period of observation to ensure no change in respiratory
status (he remained comfortable on room air), he was discharged
home.
Medications on Admission:
1. Acyclovir 400 mg PO Q12H
2. Enoxaparin Sodium 120 mg SC Q24H
3. Metoprolol Tartrate 25 mg PO Q6H
4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth Q6 Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
Disp #*10 Capsule Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Enoxaparin Sodium 120 mg SC Q24H
5. Metoprolol Tartrate 25 mg PO Q6H
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left inguinal incarcerated hernia.
Left pleural effusion.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ on
___ and underwent a Left incarcerated inguinal hernia repair
___ and a chest tube placement for a pleural effusion. You
are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
General Surgery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience 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:
___
|
10534626-DS-23 | 10,534,626 | 22,302,888 | DS | 23 | 2184-08-07 00:00:00 | 2184-08-07 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine-benazepril
Attending: ___.
Chief Complaint:
abdominal pain, dyspnea
Major Surgical or Invasive Procedure:
Right and left sided cardiac catheterization ___
TEE with cardioversion ___
History of Present Illness:
___ yo M w/ stage IIIB DLBCL (dx ___, most recently s/p EPOCH
x6
cycles in ___, Afib and DVT on Xarelto, HFrEF (EF 40%
___,
chronically recurrent L pleural effusion w/ PleurX catheter in
place, who presents for dyspnea.
In terms of recent history, ___ was discharged on ___ after
a
3 day admission for similar symptoms. During that admission, he
required TPA to be instilled by IP on ___. He was stable at home
for a few days, and then over the last day started to develop
increasing dyspnea and orthopnea accompanied with cough
productive of scant beige/clear sputum. ___ states sputum
production has not worsened, but cough worse. ___ without
any
hemoptysis. These symptoms were associated with decreased
drainage from 200-300 cc/d to 30 cc/d (done by home ___.
No fevers, chills, hemoptysis. Denies chest pain, abdominal
pain,
nausea, vomiting, or diarrhea.
He last took his Xarelto day prior to admission.
___ has a history of L recurrent pleural effusion dating
back
to ___, cytology has been negative for lymphoma x4. Etiology
thought to be malignancy-related vs allergic(eosinophilia in
pleural fluid) vs CHF. Tunneled pleural catheter placed ___,
followed by Dr. ___ in ___ clinic, with unclear etiology of
recurrent effusion.
In the ED, initial vitals were: 97.4F, HR 81, BP 152/110, RR18,
100% RA
Exam was notable for irregular heart sounds, crackles
bilaterally, absent lung sounds at L lung base. PleurX in place
over LLL, no erythema or exudate. RUE with stable swelling, LLL
with stable 1+ pitting edema, no calf tenderness.
Labs were notable for:
UA negative
Lactate wnl
Negative trop
CBC: 5.3>12.___.5<159
BMP wnl
Studies were notable for:
CXR ___:
No substantial interval change in size of small to moderate left
pleural effusion which is partially loculated with left basilar
chest tube in place. Associated left basilar opacity may reflect
compressive atelectasis, as seen previously.
CXR ___:
Unchanged partly loculated left pleural effusion with subjacent
opacities. New ill-defined opacities in the right lower lung
could reflect layering pleural fluid or possibly pneumonia.
- The ___ was given: Metoprolol Succinate XL 25 mg,
Simvastatin 20 mg
IP was consulted and is following. Recs below.
On arrival to the floor, ___ states that the drain has not
been draining since last hospitalization discharge. He was told
that the chemotherapy made him "leaky" and prone to the
recurrent
pleural effusions. He otherwise, feels well. He clarifies that
he
sometimes has mild intermittent orthopnea. He states he's able
to
walk for 30min and do about 15min of work outside. He feels a
little nauseous. No vomiting or diarrhea.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Large B Cell lymphoma ___
DVT (both left and right arms, also occlusive thrombus in the
right subclavian, axillary, and basilic veins)
Hypertension
Hypercholesterolemia
Atrial fibrillation
PSH: L inguinal hernia repair ___
Social History:
___
Family History:
- His father had an MI, died and at ___ of heart-related
complications.
- Mother died at age ___ she had no major medical problems, had
diverticulitis.
- He has one brother. He is not aware of any medical problems
that he might have.
- He has 2 biological children, although he is not in close
contact with them, and 4 grandchildren, and does not believe
that they have any significant medical problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp: 97.5 (Tm 97.5), BP: 153/101 (132-153/93-101),
HR:
105 (95-105), RR: 18, O2 sat: 96% (95-96), O2 delivery: Ra, Wt:
202.1 lb/91.67 kg
**100cc of clear yellow fluid from chest tube
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Irregularly irregular rhythm, normal rate. Audible S1
and S2. ___ Systolic ejection murmur. No rubs/gallops.
LUNGS: Decreased lung sounds on left side. No wheezes, rhonchi
or rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis. R leg with 1+ pitting edema
around ankles, L leg pitting edema up to knees. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAMINATION: '
===============================
24 HR Data (last updated ___ @ 802)
Temp: 97.5 (Tm 97.5), BP: 133/84 (97-133/62-84), HR: 75
(61-75), RR: 18, O2 sat: 98% (96-98)
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. JVP 7cm.
CARDIAC: Normal rate and regular rhythm. Audible S1
and S2. ___ Systolic ejection murmur over the cardiac apex. No
rubs/gallops.
LUNGS: Decreased lung sounds on left side with crackles. No
wheezes, rhonchi or rales. No increased work of breathing. L
pleurx c/d/I - to water seal draining serous fluid
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis. R leg with 1+ pitting edema
around ankles, L leg pitting edema up to knees. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:50AM BLOOD WBC-5.3 RBC-4.09* Hgb-12.8* Hct-39.5*
MCV-97 MCH-31.3 MCHC-32.4 RDW-15.5 RDWSD-54.5* Plt ___
___ 11:50AM BLOOD Neuts-84.3* Lymphs-5.8* Monos-8.5
Eos-0.4* Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-0.31*
AbsMono-0.45 AbsEos-0.02* AbsBaso-0.03
___ 07:50AM BLOOD ___ PTT-31.3 ___
___ 11:50AM BLOOD Glucose-104* UreaN-14 Creat-0.9 Na-139
K-4.5 Cl-106 HCO3-29 AnGap-4*
___ 11:50AM BLOOD cTropnT-<0.01
___ 11:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
___ 12:33PM BLOOD Lactate-1.1
DISCHARGE LABS:
===============
___ 04:42AM BLOOD WBC-4.8 RBC-4.09* Hgb-12.4* Hct-39.6*
MCV-97 MCH-30.3 MCHC-31.3* RDW-15.5 RDWSD-54.5* Plt ___
___ 04:42AM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-142
K-4.8 Cl-103 HCO3-28 AnGap-11
___ 04:42AM BLOOD Phos-3.5 Mg-2.0
PERTINENT LABS:
===============
___ 11:50AM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD cTropnT-<0.01
___ 01:15PM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:56AM PLEURAL TNC-365* RBC-1136* Polys-13* Lymphs-47*
Monos-9* Meso-11* Macro-20*
___ 07:56AM PLEURAL TotProt-1.1 Glucose-114 LD(LDH)-37
Cholest-11 ___
___ 07:58AM PLEURAL TNC-306* RBC-9063* Polys-1* Lymphs-83*
Monos-15* Other-1*
___ 07:58AM PLEURAL TotProt-0.9 Glucose-65 LD(___)-69
Albumin-0.8 Cholest-11 proBNP-4386
___ 04:44AM BLOOD TSH-3.0
MICROBIOLOGY:
=============
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
PLEURAL FLUID CYTOLOGY FROM ___: NO EVIDENCE OF MALIGNANT
CELLS
====================================
IMAGING:
========
CXR - ___
No substantial interval change in size of small to moderate left
pleural
effusion which is partially loculated with left basilar chest
tube in place. Associated left basilar opacity may reflect
compressive atelectasis, as seen previously.
CT SCAN - ___
1. Left PleurX catheter terminates in the posterior pleural
space. Small left.
pleural effusion has decreased in size from prior, with
associated pleural
thickening. New locules of pleural gas and small anterior
pneumothorax.
2. Simple moderate right pleural effusion has increased from
prior.
3. Few new peripheral patchy opacities are seen in the right
upper lobe,
which could be infectious or inflammatory nature.
CXR - ___
Lungs are low volume with a stable small left pleural effusion
with
subsegmental atelectasis in the left lung base. Parenchymal
opacity in the
right midlung could also represent atelectasis.
Cardiomediastinal silhouette
is stable. No pneumothorax. Left-sided chest tube remains in
place.
CXR - ___
-Slight interval worsening of small to moderate left pleural
effusion with adjacent compressive atelectasis.
-Mild pulmonary vascular congestion, unchanged.
TTE - ___
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is normal left ventricular
wall thickness with a normal cavity size. Overall left
ventricular systolic function is severely depressed secondary to
global hypokinesis with inferior akinesis. The visually
estimated left ventricular ejection fraction is 25%. There is no
resting left ventricular outflow tract gradient. Tissue Doppler
suggests an increased left ventricular filling pressure (PCWP
greater than 18 mmHg). Normal right ventricular cavity size with
low normal free wall motion. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch is mildly dilated with a normal descending aorta
diameter. The aortic valve leaflets are moderately thickened.
There is low flow/low gradient SEVERE aortic valve stenosis
(valve area 1.0 cm2 or less). There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is moderate mitral
annular calcification. There is moderate to severe [3+] mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The pulmonic valve
leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is moderate [2+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
severe left ventricular systolic dysfunction with
moderate-to-severe mitral regurgitation
Compared with the prior TTE (images reviewed) of ___ ,
mitral regurgitation is increased, left ventricular ejection
fraction is decreased, and severe low flow/low gradient aortic
stenosis now present.
TEE - ___
There is mild spontaneous echo contrast in the body of the left
atrium and in the left atrial appendage. No thrombus/mass is
seen in the body of the left atrium/left atrial appendage. The
left atrial appendage ejection velocity is mildly depressed. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium/right atrial appendage. The right atrial appendage
ejection velocity is normal. There is
no evidence for an atrial septal defect by 2D/color Doppler.
Overall left ventricular systolic function is depressed. There
are simple atheroma in the aortic arch with simple atheroma in
the descending aorta to 37 cm from the incisors. The aortic
valve leaflets (3) are severely thickened. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
Aortic valve stenosis cannot be excluded. There is a centrally
directed jet of mild [1+] aortic regurgitation. The mitral valve
leaflets are moderately thickened
with no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve. No abscess is seen. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/ vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild [1+]
tricuspid regurgitation. EMR ___-P-IP-OP (___) Name:
___ MR___ Study Date: ___ 15:25:00
p. ___
IMPRESSION: Mild spontaneous echo contrast but no thrombus in
the left atrium and left atrial appendage. No spontaneous echo
contrast or thrombus in the body of the left atrium/right
atrium/ right atrial appendage. Depressed LV systolic function.
Calcified aortic valve with mild aortic regurgitation. Mild
mitral regurgitation. Mild tricuspid regurgitation.
RIGHT AND LEFT SIDED CARDIAC CATHETERIZATION - ___
Elevated left heart filling pressure.
Moderate pulmonary hypertension.
Most significant coronary artery disease in the proximal LAD
(eccentric 70% stenosis)
Minimal gradient across aortic valve
Brief Hospital Course:
SUMMARY:
Mr. ___ is a ___ gentleman with history of stage
IIIB DLBCL (dx ___, most recently s/p EPOCH x6 cycles in
___, Afib and DVT on Xarelto, HFrEF (EF 40% ___,
chronically recurrent left pleural effusion with PleurX catheter
in place, presents for dyspnea in setting of reaccumulated
effusion in setting of clogged PleurX and new right pleural
effusion.
ACUTE/ACTIVE ISSUES:
==================
# Dyspnea:
# Recurrent left effusion:
# Right pleural effusion:
___ with shortness of breath on presentation but able to
maintain sats on room air. CXR in the ED showed persistent L
pleural effusion with partial loculation with new right pleural
effusion without evidence of pulmonary edema. Less likely
empyema or pneumonia given lack of fever and negative CXR. Left
pleurX was found to be clogged, with drainage improved following
administration of tPA. A right chest tube was inserted by
interventional pulmonology team on ___ and removed on
___. Pleural fluid was found to be transudative with pro-BNP
initially in 10 K range. It is noteworthy that all pleural fluid
cytology samples were negative in the past and current admission
(x4). ___ underwent TTE (see below) and was found to have
heart failure with new reduced ejection fraction (EF). ___
breathing improved after drainage of pleural fluid and was sent
home with capped left pleurX.
# HFrEF
# CAD
Bilateral pleural effusion that is transudative with pro-BNP in
the 10,000s. ___ with known global systolic dysfunction on
TTE in ___ with EF of 40%. TTE from ___ showed further
reduction in EF to 25% with low flow, low gradient AS and mild
to moderate MR. ___ underwent right and left-sided cardiac
catheterization on ___. There was an eccentric 70% stenosis
in the proximal segment of the LAD that was not intervened upon.
As for pressures, RA: 4 mmHg, PA mean 37 mmHg and PCWP 22mmHg
with minimal gradient across the aortic valve. Etiology of new
reduced EF is not clear but thought to be multifactorial
secondary to chemotherapy and tachycardia mediated (AF with
rates in the 100s) vs. CAD. ___ was given boluses of IV
lasix 20 with good response. ___ was transitioned to to oral
lasix 20mg daily, and spironolactone 25mg daily. Simvastatin was
changed to atorvastatin, and he was started on aspirin for CAD.
We decreased home lisinopril 10mg twice daily to 10mg daily. He
was instructed to monitor daily weight, and call PCP or
cardiologist if it increases by more than ___ pounds.
# Atrial fibrillation - CHADS2VASC 6 (age, CHF, DVT, HTN):
___ underwent successful TEE cardioversion on ___ with
conversion to NSR. ___ was started on amiodarone load of
400mg BID (___). After this week, he should take 400mg
once daily for 1 week (___), and then he should take 200mg
once daily. ___ was discharged on home rivaroxaban 20mg
nightly per his home regimen, and instructed not to miss any
doses given his recent cardioversion and risk of stroke.
CHRONIC/STABLE ISSUES:
======================
# Hyperlipidemia:
- simvastatin was switched to atorvastatin 40mg
# HTN: meds as above
# h/o DLBCL: Transformed from low grade lymphoma. Received 6
cycles R-EPOCH (completed on ___. EOT PET demonstrated a CR.
No signs or symptoms of disease recurrence currently in clinical
remission.
CORE MEASURES:
==============
CODE STATUS: FULL
HEALTH CARE PROXY:
Name of health care proxy: ___: wife
Phone number: ___
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 91.76 kg(202.29 lb)
DISCHARGE Cr: 1.0
DISCHARGE H/H: 12.4/39.6
DISCHARGE K: 4.8
CHANGED MEDICATIONS:
-- Decreased lisinopril from 10mg BID to 10mg daily
-- Decreased metoprolol succinate 25mg BID to 12.5mg BID
NEW MEDICATIONS:
-- Amiodarone (400mg BID till ___ 400mg QD till ___
200mg QD starting ___ onwards)
-- ASA 81 -- Atorvastatin 40mg daily
-- Furosemide 20mg daily
-- Spironolactone 25 mg dialy
DISCONTINUED MEDICATIONS:
-- Simvastatin
# Recurrent pleural effusion:
[] CXR in 6 weeks
# HFrEF:
[] New EF of 25%
[] Consider switching lisinopril to entresto
[] TTE after being optimized on GDMT
# Atrial fibrillation (currently on NSR):
[] Continue amiodarone loading dose till ___
[] Switch to 400mg daily on ___ through ___
[] Switch to 200mg daily starting ___
On the day of discharge, he denies CP, SOB, N/V, abdominal pain,
___ edema. A comprehensive 10 point ROS was obtained and
otherwise negative.
>30 minutes were spent in discharge related activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO BID
2. Metoprolol Succinate XL 25 mg PO BID
3. Simvastatin 20 mg PO QPM
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
5. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day ___ #*5
Tablet Refills:*0
2. Amiodarone 400 mg PO ONCE Duration: 1 Dose
RX *amiodarone 400 mg 1 tablet(s) by mouth once a day ___ #*7
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day ___ #*60
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day ___ #*60 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Nightly ___ #*60
Tablet Refills:*0
6. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day ___ #*60
Tablet Refills:*0
7. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth once a
day ___ #*60 Tablet Refills:*0
8. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day ___ #*60
Tablet Refills:*0
9. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate [Kapspargo Sprinkle] 25 mg 0.5 (One
half) capsule(s) by mouth ___ #*60 Capsule
Refills:*0
10. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day
___ #*60 Tablet Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Bilateral pleural effusion
Heart failure with reduced ejection fraction
SECONDARY DIAGNOSES:
===================
Atrial fibrillation
Hyperlipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because you had shortness of breath
and was found to have fluid accumulation around your lungs.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were found to have fluid around your lungs, called pleural
effusion.
- You left pleurx was found to be clogged and was opened
successfully.
- You have right chest tube to drain fluid around your lungs.
The chest tube was removed on ___.
- The likely cause for accumulation of fluid is your poor
cardiac function.
- You have ultrasound cardiac imaging of your chest, called
surface echocardiography, which showed further decrease in your
cardiac function.
- You underwent cardiac catheterization of your heart to
identify the etiology of your heart failure.
- You were found to have some coronary artery disease but we did
not intervene on that lesion.
- You underwent cardioversion, electric shock of your heart to
revert back to normal rhythm, as your abnormal rhythm was
thought to cause your heart failure.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Please show up to your appointments as listed below.
- Please take your amiodarone as follows:
-- Amiodarone 400mg twice a day till ___
-- Amiodarone 400mg once a day till ___
-- Amiodarone 200mg once a day starting ___
- If you gain 3 lbs in 2 days or 5 lbs in one week, please take
an extra pill of lasix and contact your doctor or come to the
emergency department.
- Please contact your doctor or come to the emergency department
if you experience palpitations, chest pain, leg swelling,
shortness of breath, increased work of breathing, or any
concerning symptoms.
We wish you speedy recovery!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10534687-DS-7 | 10,534,687 | 26,819,322 | DS | 7 | 2146-12-08 00:00:00 | 2146-12-09 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Vision changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year-old man with hx of HTN,
DM, afib (not on AC) who presents with 3 days of vertigo and
vision changes. He was in his usual state ___ until 3 days
ago when he had sudden vertigo "out of nowhere". Described as
room spinning. Associated nausea, vomiting, feeling off
balanced.
Episodes come and go, but have been getting more frequent over
the past 3 days. Developed intermittent headache at this time as
well. Described as frontal, worse with cough/valsalva, worse
with
laying down, wakes him from sleep.
3 days ago he also started complaining of vision changes. The
peripheral vision is blurry and has spinning wheels in it. This
is constant since 3 days ago. He also has constant "gears" in
his
central vision.
He does give a hx of episodes of vertigo in the past, he thinks
his doctor told him he may have a Meniere's disease.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
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 diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
DM
afib (not on AC)
Social History:
___
Family History:
mother had a stroke at age ___
Physical Exam:
Physical Exam:
Vitals:
Temp: 95.9 HR: 93 BP: 181/102 Resp: 18 O2 Sat: 98
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt was able to
name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation to both
finger
counting and finger wiggle. Fundoscopic exam performed, revealed
crisp disc margins with no papilledema.
III, IV, VI: EOMI without nystagmus. Normal saccades. Had an
episode of vertigo while I was in the room, left beating
nystagmus on left gaze.
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 Gastroc
L 5 ___ 5 ___ 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick. 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: deferred due to vertigo
Discharge Exam:
Physical Exam:
Vitals:
Temp: 98.4 BP: 135 / 89 HR: 86 RR: 18 O2: 98 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt was able to
name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. VFF to confrontation to both
finger
counting and finger wiggle.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ 5 ___ 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick. 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: deferred due to vertigo
Pertinent Results:
TTE ___ - Suboptimal image quality. Thickened calcified mitral
valve chordae and mild to
moderate mitral annular calcification but no thrombus, PFO, mass
identified. Normal
biventricular systolic function. Mildly dilated ascending aorta.
No prior study available for
comparison.
MRI-B, MRA- neck ___. Subacute infarction in the right
occipital cortex.
2. A few scattered subcortical and periventricular white matter
T2/FLAIR
hyperintensities nonspecific though likely sequela of chronic
small vessel
disease. Small area of encephalomalacia in the right frontal
lobe.
3. A 2 cm long segment of occlusion of the distal V4 segment of
left vertebral
artery with reconstitution distally just before the basilar
artery, likely
from collateral flow.
4. Focal areas of moderate stenosis in the left M2 branch and
proximal basilar
artery. Areas of mild/moderate narrowing involving the right
vertebral
artery, bilateral P2 segments of the PCAs and supraclinoid ICAs.
5. No evidence of dural venous sinus thrombosis.
6. Patent neck vasculature. Approximately 40% narrowing of the
proximal right
ICA by NASCET criteria.
CTH ___ -
1. No acute intracranial hemorrhage, large territorial
infarction, or evidence
of intracranial mass or mass effect. No fractures.
2. Moderate to heavy atherosclerotic calcification of the
bilateral carotid
siphons.
___ 08:50PM BLOOD WBC-10.0 RBC-5.55 Hgb-16.2 Hct-46.4
MCV-84 MCH-29.2 MCHC-34.9 RDW-12.8 RDWSD-38.4 Plt ___
___ 08:50PM BLOOD Neuts-82.3* Lymphs-10.3* Monos-6.4
Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.26* AbsLymp-1.03*
AbsMono-0.64 AbsEos-0.01* AbsBaso-0.03
___ 08:50PM BLOOD Plt ___
___ 08:50PM BLOOD ___ PTT-27.6 ___
___ 08:20AM BLOOD Glucose-237* UreaN-14 Creat-0.9 Na-139
K-3.4* Cl-102 HCO3-24 AnGap-13
___ 08:50PM BLOOD ALT-<5 AST-76* AlkPhos-70 TotBili-0.8
___ 08:50PM BLOOD Lipase-41
___ 08:50PM BLOOD cTropnT-<0.01
___ 08:20AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.8
___ 12:25AM BLOOD Cholest-180
___ 08:20AM BLOOD %HbA1c-11.4* eAG-280*
___ 12:25AM BLOOD Triglyc-192* HDL-37* CHOL/HD-4.9
LDLcalc-105
Brief Hospital Course:
TRANSITIONAL ISSUES:
[] Started on Glipizide, as well as Insulin, and an increased
dose of Metformin, due to poorly controlled diabetes mellitus.
Mr. ___ is a ___ year old gentleman with
hypertension, diabetes, atrial fibrillation not on
anticoagulation who is admitted to the Neurology stroke service
with visual changes secondary to an acute ischemic stroke in the
occipital pole. His stroke was most likely secondary to an
embolic event given the location, appearance, and previous
diagnosis of Atrial Fibrillation. He was started on
anticoagulation with Apixaban. His deficits improved greatly
prior to discharge and the only notable weakness was in the
peripheral visual fields. He will continue rehab as an
outpatient. Of note, he did endorse symptoms of vertigo,
diaphoresis, and malaise on presentation. Initial blood glucose
was over 300, with significant glycosuria. There was no
indication of ketoacidosis. We feel his vertigo and diaphoresis
were most likely related to symptomatic hyperglycemia.
His stroke risk factors include the following:
1) DM: A1c 11.4%
2) Mild intracranial atherosclerosis - mild atherosclerotic
calcifications of the cavernous internal carotid arteries
3) Hyperlipidemia: well controlled on Atorvastatin 40 with LDL
105
4) Obesity
An echocardiogram did not show a PFO on bubble study
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed ââ¬â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =105 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A apixaban
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. glyBURIDE-metformin ___ mg oral BID
Discharge Medications:
1. Apixaban 5 mg PO/NG BID
2. Atorvastatin 40 mg PO QPM
3. GlipiZIDE 10 mg PO BID
4. Glargine 15 Units Bedtime
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. amLODIPine 10 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lantus Solostar Pen: 15U QHS
11. Humalog Insulin Sliding Scale
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of visual changes
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
diabetes, high blood pressure, atrial fibrillation
We are changing your medications as follows:
INCREASE metformin dose
ADD Glipizide
ADD Insulin
ADD Atorvastatin
ADD Apixaban
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10534761-DS-6 | 10,534,761 | 25,267,618 | DS | 6 | 2120-07-27 00:00:00 | 2120-07-27 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim / IV Dye, Iodine Containing Contrast Media / clams /
mollusks / shellfish derived / shrimp / erythromycin base
Attending: ___.
Chief Complaint:
Recurrent diverticulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old female with history of sigmoid
diverticulitis s/p open sigmoid colectomy in ___,
presenting with a 3-day history of abdominal pain. Patient
describes her pain as stabbing, constant, with occasional waves
in which it becomes severe, located over her mid-abdomen and
left
lower quadrant, exacerbated by oral intake. Pain has gradually
worsened since it was first noticed three days ago.
Concomitantly, she endorses nausea and a single episode of
non-bloody, bilious emesis, as well as chills with no known
fevers. She reached out to her PCP earlier today, who advised
patient to present to our ED for further evaluation.
Her last bowel movement was yesterday, of normal consistency but
darker than usual and accompanied by lower abdominal discomfort
upon defecation. She denies changes in bowel habits (once every
___ days). Patient denies sick contacts or recent travels. She
denies dysuria or changes in urinary habits.
Past Medical History:
Past medical history:
Hypertension, hyperlipidemia, small bowel obstruction requiring
bowel resection and multiple subsequent episodes managed
non-operatively, chronic back pain, irritable bowel syndrome,
ectopic pregnancy s/p right salpingectomy, migraines,
depression,
chronic bronchitis
Past surgical history:
Right salpingectomy for ectopic pregnancy, cesarean section
(___), small bowel resection for small bowel obstruction (___ -
___, spinal fusion/laminectomy L4-L5 (___), bilateral
shoulder
surgery, right bunionectomy and hammer toe surgery
Social History:
___
Family History:
Brother ___
Father ___ heart disorder
Mother ___ Onset; heart disorder
Other Hypertension; lung cancer [OTHER]; thyroid disease
[OTHER]
Sister Alive ___ Onset
Physical Exam:
Admission Physical Exam:
Vital signs - 98.5 85 130/84 97% RA
Constitutional - In no acute distress
Cardiopulmonary - RRR, no murmurs. Non-labored breathing on room
air
Abdominal - Soft, non-distended, mildly tender over left lower
quadrant with no rebound or guarding
Extremities - Warm and well-perfused. No edema
Neurologic - Alert and oriented x 3. No deficits
Anorectal - No lesions on inspection or digital rectal
examination. Guaiac negative
Discharge Physical Exam:
Vitals: 24 HR Data (last updated ___ @ 818)
Temp: 98.2 (Tm 98.2), BP: 123/85 (113-146/82-88), HR: 76
(76-97), RR: 16 (___), O2 sat: 100% (97-100), O2 delivery: RA
GENERAL: Well appearing, NAD, AOx3
HEENT: EOMI, MMM, no scleral icterus
CV: RRR
PULM: nonlabored breathing
ABD: Soft, mildly tender in LLQ with no rebound or guarding,
non-distended
Ext: Intact, appropriate strength
Pertinent Results:
Lab Results
___ 06:28AM BLOOD WBC-4.3 RBC-4.32 Hgb-11.7 Hct-36.9 MCV-85
MCH-27.1 MCHC-31.7* RDW-14.4 RDWSD-44.9 Plt ___
___ 06:28AM BLOOD Glucose-109* UreaN-4* Creat-0.8 Na-142
K-4.3 Cl-104 HCO3-28 AnGap-10
___ 06:28AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
CTAP ___
IMPRESSION:
Acute diverticulitis of the sigmoid colon, uncomplicated.
Brief Hospital Course:
Ms. ___ is a ___ year-old female with history of sigmoid
diverticulitis s/p open sigmoid colectomy in ___,
presenting with a 3-day history of abdominal pain.
She had a CT Abdomen/Pelvis which demonstrated demonstrating
wall thickening and
surrounding inflammatory changes of the sigmoid colon consistent
with diverticulitis. She was admitted to the Acute Care Surgery
service and made NPO with IVF and IV ciprofloxacin/Flagyl.
On ___, the patient's diet was advanced to clears which was
well-tolerated. She was transitioned from IV
ciprofloxacin/flagyl to PO augmention. On ___, the patient's
diet was advanced to regular without issues. In this context,
she was deemed ready for discharge. Her pain was
well-controlled, and she was eating, voiding, ambulating, and
passing flatus/having bowel movements without issues. She will
be discharged on Augmentin to complete a two week course of
antibiotics. She will follow-up in acute care surgery clinic for
further post-operative care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pulmicort (budesonide) 180 mcg inhalation BID
2. Simvastatin 20 mg PO QPM
3. amLODIPine 2.5 mg PO DAILY
4. Escitalopram Oxalate 5 mg PO DAILY
5. Famotidine 20 mg PO BID
6. diclofenac sodium 1 % topical DAILY
7. Diazepam ___ mg PO Q6H:PRN muscle spasm
8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
9. OxyCODONE (Immediate Release) 7.5 mg PO QHS:PRN Pain -
Moderate
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. Famotidine 20 mg PO BID
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 #*20 Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Diazepam ___ mg PO Q6H:PRN muscle spasm
4. diclofenac sodium 1 % topical DAILY
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
6. Escitalopram Oxalate 5 mg PO DAILY
7. Famotidine 20 mg PO BID
8. OxyCODONE (Immediate Release) 7.5 mg PO QHS:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
10. Pulmicort (budesonide) 180 mcg inhalation BID
11. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation of abdominal pain and were found to have recurrent
diverticulitis. You were evaluated by the acute care surgery
team and were admitted to the hospital for bowel rest, IV
fluids, and IV antibiotics. You are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10534781-DS-16 | 10,534,781 | 28,286,260 | DS | 16 | 2124-09-21 00:00:00 | 2124-09-21 17:45:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
T10-11 fractures
Major Surgical or Invasive Procedure:
___ T9-T12 fusion
History of Present Illness:
Eu critical ___ is a ___ year old male presenting to ___ ED
s/p fall from 18ft ladder. +LOC and he is amnesic to events.
head
CT negative. C/o severe ___ mid back pain. No radicular
symptoms
or weakness. No urinary or fecal incontinence. He was admitted
to the Spine floor with plans for surgical intervention over the
next few days.
Past Medical History:
PMHx:
- insulin dependent diabetes
Social History:
___
Family History:
Family Hx:
- noncontributory.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: BP: 143/79 HR: 103 R: 15 O2Sats: 96%
Gen: uncomfortable male in cervical collar.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch bilaterally.
No Hoffmans.
No clonus.
Rectal exam normal sphincter control per ED.
PHYSICAL EXAMINATION ON DISCHARGE:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trap Deltoid Bicep Tricep Grip
Right5 5 5 5 5
Left5 5 5 5 5
IP Quad Ham AT ___ ___
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Surgical Incision:
[x]Clean, dry, & intact. Closed with staples.
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
___ is a ___ male s/p ___ fall from ladder with
T10/T11 fractures, admitted to neurosurgery spine floor ___.
#T10-T11 Fractures
He underwent a ___ medical work-up. He was taken to
the operating room on ___ and underwent T9-T12 fusion with Dr.
___. Procedure was uncomplicated but he did have 2L blood
loss. He received 2units pRBC. JP drain was left
intraoperatively and removed on POD#5. He was evaluated by
physical therapy, who recommended discharge home with services.
#Anemia
Procedure was complicated by 2 liter blood loss. He received 2
units PRBC's. On POD#1 he remained tachycardic despite IVF with
H/H drop to 9.1/26.8 (pre-op 13.1/40.0). He was transfused
additional 2units pRBC for symptomatic acute blood loss anemia.
On POD#2 Hct improved to 31.1. GI was consulted for hematemesis
as below.
#Hematemesis
The patient experienced hematemesis overnight on ___ and
underwent an upper GI diagnostic endoscopy on ___ which showed
esophagitis. He was started on PPI, which he should remain on
for 6 weeks. GI did not recommend follow-up as symptoms
stabilized.
#Urinary retention
Foley was placed for urinary retention. Catheter was removed on
___ and he is voiding without difficulty.
#IDDM
The patient is an Insulin dependent diabetic and he was
continued on home Lantus with sliding scale.
Medications on Admission:
Medications prior to admission:
- lantus 20 qHS
- humolog sliding scale
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY constipation
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*60
Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H Duration: 6 Weeks
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*90 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY constipation
7. Senna 17.2 mg PO BID
8. Glargine 40 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9.Rolling Walker
Dx: T10/T11 fracture
___: 13 months
Prognosis: Good
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Thoracic spine fractures
Acute blood loss anemia
Esophagitis
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:
Spinal Fusion
Surgery
· Your incision is closed with staples. You will need staple
removal ___ days postoperatively.
· Do not apply any lotions or creams to the site.
· Please keep your incision dry until removal of your staples.
· Please avoid swimming for two weeks after staple removal.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· No contact sports until cleared by your neurosurgeon.
· 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.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10534781-DS-17 | 10,534,781 | 20,456,008 | DS | 17 | 2124-10-01 00:00:00 | 2124-10-01 17:07:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH T1DM who had a recent fall s/p T9-T12 fusion
(___) who presented today for staple removal and c/o sudden
onset right-sided abdominal pain. He reports that after the fall
he had occasional "twinges" in the right side but when he woke
up
this morning the pain was intense, described as sharp/stabbing,
constant, does not radiate, with no exacerbating factors, that
is
made worse when he tries to take a deep breath. He has never had
this abdominal pain before, and had no pain prior to the fall.
He
has never had abdominal surgery before. Of note, he recently
started taking oxycodone and several stool softeners for his
back
surgery. Denies chest pain, SOB, N&V, changes in appetite,
dysuria, or hematuria.
Past Medical History:
insulin dependent diabetes
Social History:
___
Family History:
Family Hx:
- noncontributory.
Physical Exam:
Admission Physical Exam:
========================
VITALS: T98.4, BP139/80, HR108, RR18, 93% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. EOMI, PERRLA
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: +BS, TTP to right upper and lower quadrant, soft,
guarding, no rebound tenderness, not peritoneal, negative psoas
sign
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. No erythema or tenderness
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOX3, CN grossly intact, moving all extremities
equally.
Discharge Physical Exam:
========================
VITALS: 24 HR Data (last updated ___ @ 005)
Temp: 98.3 (Tm 99.7), BP: 120/76 (115-147/65-83), HR: 98
(96-106), RR: 18, O2 sat: 95%, O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. EOMI, PERRLA
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness. Surgical
incision over mid-back and lower back appears c/d/i
ABDOMEN: +BS, soft, nontender, no guarding, no rebound
tenderness
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. No erythema or tenderness
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOX3, CN grossly intact, moving all extremities
equally.
Pertinent Results:
===============
ADMISSION LABS:
___
___ 01:55PM BLOOD WBC-19.9* RBC-4.17* Hgb-12.1* Hct-36.9*
MCV-89 MCH-29.0 MCHC-32.8 RDW-13.1 RDWSD-42.1 Plt ___
___ 01:55PM BLOOD Neuts-88.7* Lymphs-5.5* Monos-4.6*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-17.69* AbsLymp-1.10*
AbsMono-0.92* AbsEos-0.06 AbsBaso-0.05
___ 01:55PM BLOOD Glucose-135* UreaN-11 Creat-0.7 Na-135
K-5.0 Cl-95* HCO3-25 AnGap-15
___ 01:55PM BLOOD ALT-48* AST-26 AlkPhos-212* TotBili-0.5
___ 08:27PM BLOOD GGT-65*
___ 01:55PM BLOOD Lipase-9
___ 08:27PM BLOOD cTropnT-<0.01 proBNP-25
___ 01:55PM BLOOD CRP-53.8*
___ 07:45PM URINE Color-Straw Appear-Clear Sp ___
___ 07:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
========================
PERTINENT INTERVAL LABS:
========================
___ 10:06AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 02:30PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE
===============
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-10.2* RBC-3.70* Hgb-10.6* Hct-32.8*
MCV-89 MCH-28.6 MCHC-32.3 RDW-13.0 RDWSD-42.3 Plt ___
___ 07:00AM BLOOD Neuts-74.6* Lymphs-11.4* Monos-11.2
Eos-1.7 Baso-0.5 Im ___ AbsNeut-7.63* AbsLymp-1.17*
AbsMono-1.15* AbsEos-0.17 AbsBaso-0.05
___ 07:00AM BLOOD Glucose-130* UreaN-7 Creat-0.7 Na-137
K-4.8 Cl-95* HCO3-28 AnGap-14
___ 07:00AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.0
================
IMAGING STUDIES:
================
CT ABD/PELVIS (___):
1. No evidence of an acute fracture.
2. Interval spinal fixation with posterior rods and pedicle
screws from T9
through T12. Of note, there is persistent mild posterior
translation of T11 relative to T10.
3. Small right pleural effusion and trace left pleural effusion,
new compared to ___.
CTA CHEST (___):
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bibasilar atelectasis and small pleural effusions.
RUQ U/S (___):
Normal abdominal ultrasound.
X-RAY TSPINE (___):
Unchanged appearance of posterior spinal fusion hardware with an
unchanged
moderate T11 vertebral body compression fracture.
X-RAY LSPINE (___):
Mild lower lumbar facet arthropathy, otherwise unremarkable
lumbar spine
radiographs.
=============
MICROBIOLOGY:
=============
__________________________________________________________
___ 8:42 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
__________________________________________________________
___ 8:42 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):
__________________________________________________________
___ 9:15 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:45 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 1:55 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:27 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ with PMH T1DM who had a recent fall s/p T9-T12 fusion
(___) who presented today for staple removal and reported
right-sided abdominal pain, numbness, and fevers.
# Viral gastroenteritis:
# Fevers/chills:
# Abdominal pain/numbness:
Patient reported acute onset RUQ> RLQ abdominal pain, with
fevers/chills (Tmax 102 on ___. No N/V though does report loose
stools in the setting of a bowel regimen post-operatively at
home. Pain constant and pleuritic, not associated with meals or
relieved with bowel moevments. No evidence of DKA with no
ketones in urine or anion gap. EKG/trops/BNP negative for
cardiac etiology. CT abd pelvis without evidence of
pancreatitis, biliary pathology, obstruction, peritonitis, or
appendicitis. No evidence of infection at previous spine surgery
site per neurosurgery. No growth to date on blood/urine
cultures. No evidence of rib fracture. CTA negative for PE, but
notable for small bilateral atelectasis and effusions. Effusions
likely related to recent intubation/deconditioning from surgery
and component of pleurisy may be contributing to RUQ pain. No
evidence of pneumonia on CTA or CXR. Of note, he does have
esophagitis found on EGD last admission and per patient has not
been taking prescribed PPI. Could also have component of
gastritis/PUD, so PPI was started this admission with sucralfate
PRN. However, most likely etiology for abdominal pain and fevers
is viral gastroenteritis, as workup has otherwise been
unremarkable as above. Patient treated supportively with Tylenol
for fevers and IV fluids as needed. Abdominal pain and numbness
has now improved and patient afebrile x 24 hours prior to
discharge. WBC count has also downtrended. Norovirus, C.Diff,
and influenza all tested and resulted negative.
# Leukocytosis:
# Thrombocytosis:
Increased WBC, platelet count, and CRP. Most likely in the
setting of viral infection as above. WBC and platelet count now
down-trending. Will plan to repeat CBC at PCP appointment within
1 week of discharge.
# IDDM:
Blood sugars relatively well controlled on home regimen
(100-200s) during hospitalization. Continued home Glargine 40U
at bedtime and ___ Humalog with breakfast, lunch, dinner, and
at bedtime.
TRANSITIONAL ISSUES:
====================
[] PCP follow up within 1 week of discharge
[] Repeat CBC at PCP follow up to ensure continued down-trend of
leukocytosis and thrombocytosis
[] Follow up fecal cultures pending though likely negative
[] Follow up with neurosurgery as scheduled ___
##CODE: Full (confirmed)
#CONTACT: ___
Relationship: OTHER RELATIVE
Phone: ___
Other Phone: ___
> 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY constipation
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY constipation
6. Pantoprazole 40 mg PO Q12H
7. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
Discharge Medications:
1. Sucralfate 1 gm PO QID:PRN abdominal pain
RX *sucralfate 1 gram 1 tablet(s) by mouth Four times a day Disp
#*30 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Bisacodyl 10 mg PO DAILY:PRN Constipation
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 17.2 mg PO BID:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
8. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
==================
Likely Viral gastroenteritis or other viral illness
Secondary diagnoses
===================
T1DM
Vertebral Fracture (T10-11)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had abdominal pain, diarrhea, and
fevers.
What happened while I was in the hospital?
- You underwent CT scan of your abdomen, which was normal. You
also had X-rays of your back to look at your surgery site.
- The neurosurgery team evaluated you and looked at your scans.
Your surgery site looks normal, without evidence of
complication. Please follow up with the neurosurgeons as
scheduled.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10534781-DS-19 | 10,534,781 | 28,969,270 | DS | 19 | 2124-11-01 00:00:00 | 2124-11-02 15:49:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Guided Drainage of paraspinal abscess ___
History of Present Illness:
Mr. ___ is a ___ y/o man with history
of DMI with recent T9-T12 fusion c/b abscess s/p washout on
prolonged antibiotic course now presenting with abdominal pain,
found to have recurrent paraspinal abscess.
The patient suffered a fall in ___ and underwent T9-T12 fusion.
He subsequently presented from clinic with purulent drainage
from
wound, and found to have MSSA paraspinal abscess s/p washout and
on prolonged antibiotic course with cefazolin/rifampin. He has
had persistent pain in the right upper quadrant region/right
flank since his discharge that has not responded much to
oxycodone of tizanidine. The pain in his abdomen increased in
the
2 days prior to admission, and he began to notice a hot, tender
bulge at the site that was most prominent when he is standing.
He
denies any fevers but does report chills. No nausea, vomiting,
diarrhea. No increase in his back pain. No numbness, tingling,
weakness, loss of bowel or bladder function.
In the ED, initial VS were: 8 98.6 115 113/88 17 99% RA
Exam notable for: Per NSGY note:
- Abd: Large, soft, non-tender, nondistended. Slightly
asymmetric
on right flank, no palpable masses.
- Cranial Nerves II-XII grossly intact.
- Motor: Normal bulk and tone bilaterally. No abnormal
movements,
tremors. Strength full power ___ throughout.
ECG: NSR at 96 bpm, LAD, NI, no acute ischemic changes
Labs showed: BMP wnl, WBC 6 H/H 12.___ plt 456; CRP 6.9;
lactate
1.8
Imaging showed:
- CT A/P:
1. No evidence of diaphragmatic injury. No soft tissue
abnormality was noted to correspond to area of palpable
abnormality in the right anterolateral abdominal on exam.
2. There is a 9.2 cm fluid collection with rim enhancement
posterior to the T12 vertebral body in the subcutaneous tissues
extending inferiorly to the L3 level concerning for an abscess
with bone graft migrated into the collection and a sinus tract
to
the skin.
Consults: Neurosurgery: No acute neurosurgical intervention
Patient received:
___ 20:33 IV Morphine Sulfate 4 mg
___ 20:33 SC Insulin 4 Units
Also reportedly received 1 dose of antibiotics while in the ED
that is not documented in the dashboard
Transfer VS were: 97.9 89 125/80 16 100% RA
On arrival to the floor, patient reports that he continues to
have mild right side pain that is worst when standing. He tells
me that he took his morning rifampin and 2 doses of ceftaz today
already; he is due to his evening ceftaz and has not yet taken
his nighttime Lantus. He is discouraged that he has not been
able
to recover.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
-DMI (diagnosed at age ___
-T10-11 laminectomy, evacuation of epidural hematoma
-T9-T12 fusion (___) c/b MSSA paraspinal abscess
-Right arm ORIF
Social History:
___
Family History:
Brother with diabetes
No family history of recurrent infections
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 139 / 81 109 18 98 Ra
GENERAL: Lying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Soft, TTP in right upper quadrant and right flank; no
clear palpable mass
EXTREMITIES: No peripheral edema; mild midthoracic spinal
tenderness
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN II-XII tested and intact; right pupil approx 1
mm smaller than left but equally reactive; sensation and
strength
intact in bilateral lower extremities
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0753 Temp: 97.9 PO BP: 124/80 HR: 97 RR: 18 O2 sat:
95% O2 delivery: Ra
GEN: Lying in bed in NAD
HEENT: MMM.
NECK: no JVD.
HEART: RRR, nl S1 S2, no murmurs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABD: Soft, TTP in right upper quadrant and right flank; small
soft tissue swelling at right anterior lateral abdominal wall,
slightly tender in LLQ.
EXT: No peripheral edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN II-XII tested and intact; right pupil approx 1
mm smaller than left but equally reactive; sensation and
strength
intact in bilateral lower extremities
SKIN: JP drain in place from spinal site, dressing in tact, dry,
clean. serousanginous drainage from JP site
Pertinent Results:
ADMISSION LABS:
================
___ 03:00PM BLOOD WBC-6.1 RBC-4.66 Hgb-12.9* Hct-40.0
MCV-86 MCH-27.7 MCHC-32.3 RDW-13.4 RDWSD-41.7 Plt ___
___ 03:00PM BLOOD Neuts-65.1 ___ Monos-6.0 Eos-3.6
Baso-0.7 Im ___ AbsNeut-3.98 AbsLymp-1.49 AbsMono-0.37
AbsEos-0.22 AbsBaso-0.04
___ 03:00PM BLOOD Glucose-314* UreaN-11 Creat-0.6 Na-135
K-4.8 Cl-96 HCO3-27 AnGap-12
___ 03:00PM BLOOD ALT-14 AST-19 LD(LDH)-177 AlkPhos-187*
TotBili-0.2
___ 03:00PM BLOOD CRP-6.9*
MICRO:
======
___ 1:42 pm ABSCESS Source: paraspinal abscess.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood cultures: pending
IMAGING:
========
CXR ___:
PA and lateral views of the chest provided. Right upper
extremity access PICC line terminates in the mid SVC, unchanged
from prior. Partially visualized thoracic spinal hardware is
again noted right sided pleural effusion has resolved with only
minimal residual atelectasis in the lower lungs. No signs of
pneumonia or edema. Cardiomediastinal silhouette appears stable
and normal. No acute osseous abnormality seen. No free air
seen below the right hemidiaphragm.
CT AP ___:
1. No evidence of diaphragmatic injury.
2. No findings at the site of right upper quadrant palpable
abnormality.
3. Rim enhancing fluid collection deep to the incision line in
the low back is concerning for an abscess.
Rib Films ___:
1. No signs for acute cardiopulmonary process.
2. No displaced rib fracture.
3. Laxity of the right lateral abdominal wall muscles with some
extension of retroperitoneal fat laterally. This may account
for the patient's symptoms.
MRI T/L Spine ___:
1. Status post spinal fusion from T9-T12 level without signs of
intraspinal abscess, hematoma, spinal cord compression or
abnormal signal within the spinal cord.
2. Small 2.4 x 1.6 x 7.4 cm fluid collection extending from the
spinous
process of T12 inferiorly with associated adjacent soft tissue
enhancement
could be postoperative in nature but associated infection cannot
be excluded on MRI appearances alone and clinical correlation
recommended. Overall this is unchanged from the abdominal CT of
___.
DISCHARGE LABS:
================
___ 05:21AM BLOOD Neuts-59.2 ___ Monos-8.5 Eos-5.6
Baso-0.7 Im ___ AbsNeut-3.49 AbsLymp-1.50 AbsMono-0.50
AbsEos-0.33 AbsBaso-0.04
___ 05:21AM BLOOD Glucose-170* UreaN-16 Creat-0.6 Na-138
K-4.5 Cl-99 HCO3-25 AnGap-14
___ 05:21AM BLOOD ALT-13 AST-16 AlkPhos-167* TotBili-<0.2
___ 05:21AM BLOOD Calcium-9.1 Phos-5.3* Mg-1.9
___ 05:21AM BLOOD CRP-9.1*
Brief Hospital Course:
Patient Summary for Admission:
===============================
Mr. ___ is a ___ with history of DMI with recent
T9-T12 fusion c/b abscess s/p washout on prolonged antibiotic
course who presented with abdominal pain, found to have
recurrent paraspinal abscess requiring ___ drainage ___ with
no growth subsequently on culture. Abdominal pain was evaluated
and felt to be secondary to some abdominal wall laxity
demonstrated on rib imaging, and potentially neuropathic. MRI
completed while inpatient ___ was without discitis. Pain
control was achieved through Oxycodone and Gabapentin.
# PARASPINAL ABSCESS: Patient recently s/p fusion ___ c/b MSSA paraspinal abscess, s/p washout, on IV abx (week
3) who presented ___ with right sided abdominal pain. CT AP
completed ___ demonstrated recurrent 9.2 cm fluid collection
with rim enhancement posterior to the T12 vertebral body in the
subcutaneous tissues extending inferiorly to the L3 level
concerning for recurrent abscess. Patient underwent ___ guided
drainage with drain placement. Preliminary cultures were without
growth. Additionally patient underwent MRI T and L spine ___
to evaluate for evidence of discitis which was negative for
discitis, however did demonstrate a persistent fluid collection.
As a results, the drain was left in place at time of discharge,
with plan to remove once drainage stopped. ID was consulted and
patient continued his previous antibiotic regimen of Cefazolin
and Rifampin with current end date of antibiotics scheduled for
___.
# ABDOMINAL PAIN: Patient notably with right sided abdominal
pain since ___ with previous extensive work up
including CTPE, CT AP, RUQ/US and infectious stool studies which
were negative. CT AP completed ___ was without acute
intrabdominal process, LFTS were reassuring and lipase WNL.
Given chest wall tenderness dedicated rib series completed which
demonstrated some abdominal wall laxity without rib fracture.
MRI T/L spine was completed ___ to evaluate for discitis or
nerve compression which could be contributing to abdominal pain
although no obvious cause on MRI of abdominal pain. Given
potential neuropathic component of pain, Gabapentin was
initiated and up titrated to 200mg TID while inpatient. Patient
continued his home Oxycodone 10mg Q6H but home Tizanidine was
held in favor of Gabapentin initiation. Patient will be
evaluated in the chronic pain clinic for ongoing medication
titration.
CHRONIC ISSUES:
==================
# DMI: Continue Lantus plus ISS, patient carb counts and
utilized Humalog for short acting coverage. Blood sugars
elevated to 300 at times during admission without evidence of
DKA. He will require close follow up on discharge for further
management.
# GERD: Continued pantoprazole.
TRANSITIONAL ISSUES:
====================
[]Drain placed by ___ ___ in place at time of discharge, ___ to
monitor for continued drainage and contact ___ once drainage has
stopped. Once LESS THAN 10cc/ml for 2 days in a row, please have
the ___ call Interventional Radiology at ___ at ___
and page ___. This is the Radiology fellow on call who can
assist you.
[]If drain is no longer draining, consider an ultrasound of area
to confirm appropriate drain placement prior to removal.
[]Repeat imaging of paraspinal fluid collection should be
pursued as needed by outpatient Infectious Disease and Primary
Care Providers.
[]Final blood cultures and abscess cultures from admission
pending at time of discharge and will be followed up by
Infectious Disease team.
[]Blood sugars elevated at times to 300 while inpatient without
evidence of DKA. Ongoing titration of Lantus dosing required at
PCP follow up
[]Patient discharged on 200mg TID, this dose should be adjusted
as tolerated by Chronic Pain clinic.
[]Tizanidine was held during admission as patient denied benefit
and Gabapentin was initiated.
[]Antibiotic course currently with end date ___ given no growth
in paraspinal cultures. Patient follows with OPAT and has home
___ services for medication administration.
[]Consider referral to outpatient ___ for abdominal wall
strengthening given laxity noted on imaging, provided OK per
post-op neurosurgical recommendations. Likely after drain
removal.
Medication Changes:
-New Medications: Gabapentin 200mg TID
-Changed Medications: None
-Held Medications: Tizanidine 4mg PO QID PRN
Code Status: Full Code
HCP: ___
___: girlfriend
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
2. Rifampin 450 mg PO Q12H
3. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Pantoprazole 40 mg PO Q12H
5. CeFAZolin 2 g IV Q8H
6. Tizanidine 4 mg PO TID:PRN Muscle spasm
7. Acetaminophen 1000 mg PO Q8H
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times daily
Disp #*168 Capsule Refills:*0
2. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 1000 mg PO Q8H
4. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every
eight (8) hours Disp #*57 Intravenous Bag Refills:*0
5. Docusate Sodium 100 mg PO BID
6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
7. Pantoprazole 40 mg PO Q12H
8. Rifampin 450 mg PO Q12H
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. HELD- Tizanidine 4 mg PO TID:PRN Muscle spasm This
medication was held. Do not restart Tizanidine until you see our
Chronic pain service
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Paraspinal Abscess
History of T9-T12 fusion
Abdominal pain, unclear etiology
Type 1 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ as your site of care.
Why was I admitted to the hospital?
-You were admitted to the hospital because of your abdominal
pain.
-You were also admitted because of a fluid collection found by
your spine.
What was done for me while I was in the hospital?
-We looked for additional causes of your abdominal pain with
imaging of your ribs and spine.
-We found some weakness in the wall of your abdomen.
-Our pain doctors ___ and we started medication to
help with nerve related pain.
-Because of the fluid accumulation near your spine, our
Interventional Radiology placed a drain to remove the fluid.
-An MRI did not show infection in the bones of your spine.
-You continued your antibiotics and were seen by our Infectious
Disease team.
What should I do when I leave the hospital?
-Please continue taking your antibiotics as prescribed.
-You will follow up with your outpatient providers as detailed
below.
-If you notice worsening back or abdominal pain, new fevers or
chills please return to the emergency department.
We wish you the best,
Your ___ treatment team
Followup Instructions:
___
|
10535384-DS-15 | 10,535,384 | 24,245,974 | DS | 15 | 2156-06-19 00:00:00 | 2156-06-19 10:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck pain, intermittent left leg weakness and unsteady gate for
3 weeks
Major Surgical or Invasive Procedure:
DECOMPRESSION, FUSION, MASS REMOVAL C6-T1
History of Present Illness:
___ h/o HTN, gout presents in transfer with MRI concerning for
cervico-thoracic cord compression. He reports the onset of neck
pain, intermittent left leg weakness and unsteady gate 3 weeks
ago. This occurred soon after a golf outing. He had a
radiofrequency therapy targeting his C-spine ___ years ago.
Patient denies numbness, tingling, saddle anesthesia, loss of
bowel or bladder function. He takes a baby ASA daily but no
other blood thinners.
Past Medical History:
Gout
HTN
Right meniscus repair
Achilles tendon repair 1980s
Social History:
SH: Former smoker, occasional alcohol. Denies illicit drug use.
Physical Exam:
Last 24h:No acute events overnight. Feels well this morning.
PE:
VS98.2 PO 138 / 78 R Lying 61 18 97 3L
NAD, A&Ox4
nl resp effort
RRR
Incision c/d/I, HVAC 55cc, c-collar in place
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT
T2-L1 (Trunk)
SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
___: Negative
Clonus: No beats
Pertinent Results:
___ 06:06AM BLOOD WBC-10.4* RBC-3.38* Hgb-11.3* Hct-31.4*
MCV-93 MCH-33.4* MCHC-36.0 RDW-11.6 RDWSD-38.6 Plt ___
___ 06:25AM BLOOD WBC-3.7* RBC-4.21* Hgb-14.1 Hct-38.5*
MCV-91 MCH-33.5* MCHC-36.6 RDW-11.4 RDWSD-37.8 Plt ___
___ 11:10AM BLOOD WBC-6.6 RBC-4.30* Hgb-14.3 Hct-38.5*
MCV-90 MCH-33.3* MCHC-37.1* RDW-11.4 RDWSD-36.3 Plt ___
___ 11:10AM BLOOD Neuts-68.4 ___ Monos-6.8 Eos-0.5*
Baso-0.5 Im ___ AbsNeut-4.52 AbsLymp-1.54 AbsMono-0.45
AbsEos-0.03* AbsBaso-0.03
___ 06:06AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 11:17AM BLOOD ___ PTT-29.8 ___
___ 11:10AM BLOOD Plt ___
___ 04:19AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___:19AM URINE RBC-2 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-0
___ 4:19 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Report not finalized.
Assigned Pathologist ___, MD
___ in only.
PATHOLOGY # ___
SOFT TISSUE, SIMPLE EXCISION FOR TUMOR
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.Hospital course was otherwise unremarkable.On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
Allopurinol
Carvedilol
HCTZ
Lisinpril
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 5 mg PO Q8H:PRN shoulder/neck spasm and pain
may cause drowsiness
RX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp
#*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: discontinued Oxycodone
please do not operate heavy machinery, drink alcohol or drive
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Spinal canal mass, C7-T1.
2. Spinal stenosis, C6-C7.
3. Spinal cord compression.
4. Cervicothoracic myelopathy.
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:
Posterior Cervical Fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Cervical Collar / Neck Brace:You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks.You may remove the collar to take a
shower.Limit your motion of your neck while the collar is
off.Place the collar back on your neck immediately after the
shower.
Wound Care:Mepilex Ag applied on ___. This
dressing may stay in place for ___ days. If this dressing comes
off; a dry dressing may be placed until follow up. Keep covered
until follow up. If the incision begins to drain at any time,
please call the ___.
You should resume taking your normal home
medications
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in narcotic
prescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
C-collar at all times
Treatments Frequency:
Mepilex Ag applied on ___. This dressing may stay in place for
___ days. If this dressing comes off; a dry dressing may be
placed until follow up. Keep covered until follow up. If the
incision begins to drain at any time, please call the spine
center.
Followup Instructions:
___
|
10535897-DS-4 | 10,535,897 | 24,862,837 | DS | 4 | 2127-05-14 00:00:00 | 2127-05-14 13:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening low back pain and urinary retention
Major Surgical or Invasive Procedure:
ALIF L3-S1
XLIF L1-L3
Posterior laminectomy and fusion L1-S1
History of Present Illness:
___ yo female patient with history of previous cervical fusion
and chronic low back pain, as well as, diabetic neuropathy. She
presents today as a transfer from ___ where the presented
complaining of worsening low back pain over the past few month.
The pain had become so bad recently it has made it difficult to
ambulate. Additionally she complains of BLE pain radiating to
the left, greater than, right leg and BLE paresthesias from the
knees to the feet. She also reported history of intermittent
urinary incontinence and retention and appears to have UTI.
Lumbar MRI reveals scoliosis and diffuse degenerative changes
within the lumbar spine worst on the right at L4/5 and L5/S1.
She was admitted for pain control and further work up of her
back pain.
Past Medical History:
DM,GERD, diabetic nephropathy, osteoarthritis, cervical
spine stenosis, cervical fusion
Social History:
___
Family History:
N/A
Physical Exam:
Exam on admission:
PHYSICAL EXAM:
O: T:98.8 BP:150 /83 HR: 76 R: 20 O2Sats: 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ bilaterally EOMs: intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, proprioception bilaterally
Reflexes: B T Br Pa Ac
Right: 2+ throughout
Left: 2+ throughout
Propioception intact
Toes downgoing bilaterally
Rectal exam: decreased sphincter tone
On Discharge:
***
Pertinent Results:
Lumbar MRI ___
1. Extensive multilevel degenerative changes throughout the
lumbar spine, as described above, worst at L4-5 resulting in
severe spinal canal stenosis, severe right and moderate left
neural foraminal stenosis.
Lumbar CT ___
1. Extensive multilevel degenerative changes with severe bony
vertebral canal stenosis at L4-L5.
2. Right convex scoliosis of the mid-lumbar spine and left
convex scoliosis of the lower lumbar spine.
3. No evidence of acute fracture.
CT C-SPINE W/O CONTRAST Study Date of ___ 4:56 ___
IMPRESSION:
1. Cervical fusion changes status post ACDF of C4 through T1 as
described
above. Osseous fusion of the C4 through T1 vertebral bodies is
noted with
fusion of the left C4 through C6, left C7-T1 and right C4-C5
facets.
2. Unchanged 4 mm anterolisthesis of C7 on T1 from recent
outside hospital
MRI. No evidence of acute osseous or hardware fracture. No
significant
perihardware lucencies identified.
3. Cervical spondylosis resulting in multilevel moderate to
severe bilateral neural foraminal narrowing as described above.
MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 6:00 ___
IMPRESSION:
1. Multilevel degenerative and postsurgical changes throughout
the cervical spine, worse at C7-T1, resulting in moderate to
severe spinal canal and bilateral neural foraminal stenosis.
Short segment of high signal within the spinal cord at this
level is likely secondary to myelomalacia from chronic stenosis
in the absence of trauma.
2. High signal in the C5 vertebral body with no abnormal signal
extending into the adjacent discs, likely secondary to bone
graft material.
Chest xray ___:
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia. Cervical spinal fusion device is in place.
___ 11:00AM BLOOD WBC-9.1 RBC-3.62* Hgb-10.5* Hct-31.8*
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.3 RDWSD-45.2 Plt ___
___ 04:44AM BLOOD WBC-8.9 RBC-3.10* Hgb-9.1* Hct-27.9*
MCV-90 MCH-29.4 MCHC-32.6 RDW-14.2 RDWSD-46.2 Plt ___
___ 11:00AM BLOOD Plt ___
___ 04:44AM BLOOD Plt ___
___ 01:22AM BLOOD ___ PTT-26.8 ___
___ 11:00AM BLOOD Glucose-159* UreaN-9 Creat-0.4 Na-133
K-3.5 Cl-93* HCO3-24 AnGap-20
___ 04:44AM BLOOD Glucose-148* UreaN-7 Creat-0.4 Na-133
K-3.5 Cl-94* HCO3-27 AnGap-16
___ 12:02AM BLOOD CK(CPK)-195
___ 06:03PM BLOOD CK(CPK)-215*
___ 12:02AM BLOOD CK-MB-2
___ 06:03PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:46AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.4*
___ 04:44AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.3*
___ 05:45AM BLOOD VitB12-553
___ 12:50PM BLOOD %HbA1c-10.3* eAG-249*
___ 05:45AM BLOOD TSH-0.85
Brief Hospital Course:
On ___, the patient was transferred to ___ after presenting
with worsening low back pain and intermittent urinary retention
and incontinence. MRI revealed diffuse degenerative disease
with scoliosis and sever stenosis. Additionally the patient
complains of BLE numbness and tingling in a stocking
distribution in the BLE. Sagittal views of her cervical spine
revealed previous C4-C7 fusion and posterior decompression and
apparent adjacent segment degenerative disease at C7/T1 with
possible signal change. Dr ___ will speak with orthopedics
about possible surgery for her lumbar spine.
On ___ the patient remained neurologically stable. She denied
pain on morning exam. She continued on Bactrim for a UTI and was
voiding appropriately with no incontinent episodes of urine or
stool. A post void residual was performed and she was found to
have 14 cc of urine in her bladder and was not retaining urine.
The patient worked with physical therapy.
On ___, the patient remained neurologically stable. He back pain
is well controlled. She is voiding appropriately without
incontinence of bowel or bladder. She continues with
paresthesias in her bilateral lower extremities. Decreased
sensation is more prominent distally. Physical therapy is
recommending rehab. Dr. ___ 45 minutes at the bedside
speaking with the patient and four of her family members about
the spine surgery she will need to prevent progression of her
scoliosis and spinal stenosis. The plan is for Dr. ___
orthopedics to speak with the family as well regarding the
surgery to take place as early as this weekend. Her Mg was 1.4
and was repleted. She recognizes urge to void and is voiding on
commode however has some urinary retention. She was bladder
scanned for 600cc. Voided 300cc. PVR 300cc. We are monitoring
her output and PVRs with bladder scanning q6h. She required
straight cath x1 for PVR 600 overnight.
On ___, the patient remained neurologically stable. A chest xray
was ordered for pre-op testing and was negative. Her Bactrim
will complete this evening and a repeat UA/UC has been ordered
for tomorrow. Dr. ___ has reviewed the surgical plan with her
and she is having phase 1 of 3 of her surgical procedures on
___.
On ___:
1. Anterior fusion, L3-S1.
2. Anterior spacers x 3.
3. Anterior instrumentation.
4. Autograft, bone morphogenic protein, and allograft.
On ___:
1. Anterior fusion L1-L3.
2. Anterior spacers x 2.
3. Autograft and allograft.
On ___:
1. Total laminectomy of L1, L2, L3, L4, and L5.
2. Osteotomies at L2, L3, L4, and L5.
3. Multiple thoracic laminotomies.
4. Fusion T10 to S1.
5. Instrumentation, T10 to S1.
6. Autograft.
7. Epidural catheter placement.
___ yo female admitted to ___ on ___ with 3 days of back pain
and chronic urinary incontinence without recent falls or trauma.
She was transferred from OSH for
further work-up. Cervical and lumbar stenosis noted on imaging
and neurosurgery was consulted for management of spinal
impairments.Recommended surgical intervention. Pt u/w anterior
fusion of L3-S1, spacer placement, autograft bone morphogenic
protein and allograft on ___. Medicine consulted for assist in
management of altered mental status/delirium (likely
multifactorial), tachycardia (?hypovolemia vs. SIRS reaction vs.
PE), and HAP (pt initiated on abx). She returned to the OR on
___ for ___ part of staged fusion with anterior fusion of
L1-L3, spacer placement, and autograft/allograft. Again returned
to OR on ___ for ___ part of staged fusion with total
laminectomy L1-L5, osteotomy L2-L5, multiple thoracic
laminotomies, fusion
T10-S1, autograft and epidural placement. While in ___, pt with
EBL < 1.5L; she required 4 units of PRBC, 2 units of FFP
___. Transferred to ___ post-op for hemorrhagic
shock. APS consulting and recommending hold on initiating
epidural infusion while pt is hemodynamically unstable. She
required pressor support (has sinced weaned) and was extubated
on ___. Post-extubation, pt w/ reported chest pain. EKG without
ischemic changes. Epidural and hemovac discontinued ___.
Received 1 unit of PRBC for post-op anemia on ___. Pt remained
in
ICU until ___. Since admission to the floor, has worked with
___ who are now recommending Rehab.
Delirium: improving, maintain sleep/wake cycles, continue
trazadone, pain control with Tylenol and tramadol. avoid
opiates, encourage mobility.
Thrombocytopenia:will need to repeat CBC as outpatient.
Diabetes:started glargine
Asymtomatic Bacteruria:Stopped cipro
Mild interstitial pulmonary edema:satting well on RA, monitor as
outpatient
Rehab Stay is expected to be less than 30 days.
Medications on Admission:
Magnesium oxide, omeprazole, Tylenol, ASA, Colace, Neurontin,
metformin, nitrostat, nortriptyline, oxycodone 5 ___, miralax,
senna, simvastatin,
tramadol
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain/fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using REG Insulin
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Mineral Oil ___ mL PO DAILY:PRN constipation
11. Nystatin Oral Suspension 5 mL PO QID:PRN thrus
12. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
13. Senna 8.6 mg PO BID
14. Metoclopramide 10 mg PO QIDACHS reflux
15. Omeprazole 20 mg PO DAILY
16. Simvastatin 20 mg PO QPM
17. TraMADol ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth q6h prn Disp #*28
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Lumbar scoliosis and stenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Spinal Fusion
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
*** You must wear your brace at all times when out of bed. You
may apply your brace sitting at the edge of the bed. You do not
need to sleep with it on.
*** You must wear your brace while showering.
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.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10536146-DS-3 | 10,536,146 | 20,222,479 | DS | 3 | 2176-02-07 00:00:00 | 2176-02-08 08:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine / Demerol / Fentanyl
Attending: ___.
Chief Complaint:
s/p mechanical fall with left orbit blowout, left max sinus fx,
left ___ rfx, left humerus proximal fx, 3mm right SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of CVA, falls, presents
following a fall with head strike but no LOC. Patient reports
getting out of bed and falling from standing. She was getting
out of bed fell and knocked her head against the wall. She could
not lift herself off the ground because her right arm was in too
much pain. She was bleeding out of her nose. Pt denies LOC,
changes in vision, nausea, and headache. She also denies
dizziness, lightheadedness, vertigo, or gait instability at the
time. Of note, patient had a colonoscopy at ___ yesterday
afternoon (negative, random bx was taken).
Further, pt has a h/o of various falls (x4 over the past year)
including the most recent this past ___. She uses a cane to
ambulate when out of the ___ but rarely uses it in the ___.
Past Medical History:
Past Medical History:
Significant for coronary artery disease,
hyperlipidemia, hypertension, history of a glucose intolerance;
however, does not take meds according the patient, GERD, chronic
kidney disease, history of Schatzki ring, cerebral aneurysm of
bleed, eczema, history of IBS, diverticulosis, thyroid nodules,
history of vertical zoster, urinary incontinence.
Past Surgical History:
Cholecystectomy, tonsillectomy, mastoid
resection, tracheotomy in childhood, appendectomy, carpal tunnel
surgery, history lens implants, cataract surgery, also tubal
ligation.
Social History:
___
Family History:
Family Hx: The patient states that mother and sister with
history of cancer, history of diabetes, heart disease, sister
with melanoma.
Physical Exam:
Admission Physical Exam:
Vitals: T96.2 72 132/92 18 98% RA
General: well-appearing and in NAD
HEENT: L orbital hematoma; good range of motion and no neck
tenderness
Cardiac: RRR; no M/R/G
Lungs: CTA (auscultated anteriorally)
Back: NT; no CVA tenderness
Abdomen: soft, NT/ND; BS+
Extremities: no ___ edema
Discharge Physical Exam:
Vitals - T 98.3 / HR 95 / BP 148/88 / RR 18 / O2sat 97%RA
General: comfortable, NAD
HEENT: L orbital hematoma improving, PERRLA/EOMI, vision intact,
moist mucous membranes
Neck: good range of motion and no neck tenderness
Cardiac: RRR; no M/R/G
Lungs: CTAB, mild left chest wall TTP
Back: NT; no CVA tenderness
Abdomen: soft, NT/ND; BS+
Extremities: LUE in sling, warm and well-perfused, no edema
Neuro: A&OX3, sensorimotor function intact in all 4 extremities
Pertinent Results:
Lab Results:
___ 04:26AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-139
K-3.6 Cl-100 HCO3-24 AnGap-19
___ 06:30AM BLOOD Glucose-130* UreaN-13 Creat-0.9 Na-140
K-3.4 Cl-102 HCO3-24 AnGap-18
___ 07:30AM BLOOD Glucose-129* UreaN-20 Creat-1.0 Na-138
K-3.1* Cl-101 HCO3-23 AnGap-17
___ 02:36AM BLOOD Glucose-145* UreaN-22* Creat-1.0 Na-141
K-3.4 Cl-101 HCO3-25 AnGap-18
Imaging Results:
CT HEAD W/O CONTRASTStudy Date of ___ 2:49 ___
IMPRESSION:
1. No significant interval change in the known right posterior
subdural
hemorrhage.
2. No new or enlarging hemorrhage.
3. Partially visualize known left orbital fractures as
described, better
visualized on recent maxillofacial CT.
CT CHEST W/CONTRASTStudy Date of ___ 6:09 AM
IMPRESSION:
1. Minimally displaced left first rib and comminuted proximal
left humerus
fractures. No additional acute fractures.
2. No intrathoracic traumatic injury.
3. 3.8 cm right thyroid mass
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRASTStudy Date of
___ 2:56 AM
IMPRESSION:
1. Acute comminuted left orbital inferior wall fracture in close
proximity to
the inferior rectus muscle to be correlated clinically for
entrapment.
2. Questionable left maxillary sinus medial and possible lateral
wall
fractures.
3. Preseptal left periorbital and left facial edema with
hematomas.
4. Hemorrhage opacifies the left maxillary sinus
CT C-SPINE W/O CONTRASTStudy Date of ___ 2:56 AM
IMPRESSION:
1. Dental amalgam and ear piercing streak artifact, and motion
limits study.
2. No fracture or traumatic malalignment of the cervical spine.
3. Question minimally displaced left first rib fracture versus
volume
averaging artifact.
4. Please see concurrently obtained maxillofacial and head CT
for description
of cranial and maxillofacial structures.
5. Known thyroid goiter, better visualized on ___ prior
thyroid
ultrasound.
6. Grossly stable multilevel degenerative changes.
CT HEAD W/O CONTRASTStudy Date of ___ 2:55 AM
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Left orbital blowout fracture in close proximity to the
inferior rectus
muscle. Please note that inferior rectus muscle entrapment is
not excluded on
the basis of this examination. Recommend correlation with
physical exam.
3. Acute fracture of the lateral wall of the left maxillary
sinus.
4. Left periorbital and facial soft tissue edema with areas of
hematoma.
5. 3 mm right hemisphere subdural hemorrhage.
6. Please see concurrently obtained maxillofacial CT for
description of
maxillofacial structures.
7. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
CHEST (SINGLE VIEW)Study Date of ___ 2:19 AM
IMPRESSION:
No intrathoracic acute process.
HUMERUS (AP & LAT) LEFTStudy Date of ___ 2:16 AM
IMPRESSION:
Acute comminuted left proximal humerus fracture.
___ 04:45AM BLOOD WBC-10.3* RBC-5.03 Hgb-14.3 Hct-43.0
MCV-86 MCH-28.4 MCHC-33.3 RDW-14.2 RDWSD-43.7 Plt ___
___ 05:05AM BLOOD WBC-10.9* RBC-5.07 Hgb-14.2 Hct-43.1
MCV-85 MCH-28.0 MCHC-32.9 RDW-13.9 RDWSD-42.8 Plt ___
___ 02:36AM BLOOD Neuts-84.6* Lymphs-8.5* Monos-5.6
Eos-0.1* Baso-0.3 Im ___ AbsNeut-14.28* AbsLymp-1.43
AbsMono-0.95* AbsEos-0.02* AbsBaso-0.05
___ 04:45AM BLOOD Plt ___
___ 02:36AM BLOOD ___ PTT-30.4 ___
___ 04:45AM BLOOD Glucose-140* UreaN-22* Creat-1.0 Na-139
K-3.5 Cl-102 HCO3-23 AnGap-18
___ 05:05AM BLOOD Glucose-147* UreaN-17 Creat-0.9 Na-137
K-3.4 Cl-103 HCO3-24 AnGap-13
___ 04:45AM BLOOD Calcium-10.1 Phos-3.6 Mg-2.0
___ 2:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 3:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ PMHx of CVA who presented after a mechanical fall with
headstrike without loss-of-consciousness. She was pan-scanned in
the Emergency Room and found to have a Left orbital fracture,
maxillary-sinus fractures, left 1st rib fracture, left proximal
humerus fracture, and 3mm subdural hematoma on the right. She
was admitted to the Acute Care Surgery Service for observation.
She was monitored with Q4H neuro checks and continued to be
A&OX3 and neurologically intact.
Plastic Surgery was consulted for the facial fractures and
recommended a CT maxillofacial which detected large mildly
displaced and comminuted left orbital floor fracture, no
evidence of entrapment. Their recommendation was to follow-up in
clinic w/ Dr. ___ in ___ days once the periorbital edema
resolves to determine timing for surgical fixation. During her
hospital course she had ice packs to affected area and
bacitracin ointment BID to affected area per Plastic Surgery
recommendations. Ophthalmology was consulted for the
___ injuries and determined that there were no vision
changes or entrapment and recommended routine outpatient
ophthalmology. Orthopedics was consulted for the acute
comminuted left proximal humerus fracture and recommended LUE
sling and non-weight-bearing until follow-up in clinic in 2
weeks. Neurosurgery was consulted for the 3mm Right subdural
hematoma and recommended a repeat Head CT 12 hours after the
initial scan, which was obtained and demonstrated no changes.
The patient remained neurologically intact throughout her
hospital course. She tolerated a regular diet and her pain was
controlled with tylenol and tramadol. She worked with Physical
Therapy and Occupational Therapy which recommended discharge to
rehab if 24-hr supervision at home cannot be arranged. The
patient was discharged to a rehabilitation facility on ___ in
stable conditions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Oxybutynin 5 mg PO BID
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. amLODIPine 5 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Omeprazole 20 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Bacitracin Ointment 1 Appl TP BID
3. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
may d/c after patient ambulatory
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Ondansetron ODT 4 mg PO Q8H:PRN nausea
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
hold for increased sedation, resp. rate <8
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
11. ALPRAZolam 0.25 mg PO TID:PRN anxiety
12. amLODIPine 5 mg PO DAILY
13. Atorvastatin 20 mg PO QPM
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Omeprazole 20 mg PO BID
17. Oxybutynin 5 mg PO BID
18. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until 1 week after your initial injuries
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Comminuted left orbital floor fracture, no evidence of
entrapment
Periorbital edema
Acute comminuted left proximal humerus fracture
3mm right subdural hematoma
Left 1st rib nondisplaced 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:
Dear Ms. ___,
It was a pleasure taking care of you here at ___. You were
admitted after a mechanical fall that resulted in left-sided
facial fractures, left upper arm fracture, left 1st rib
fracture, and a small right-sided subdural hematoma. You were
admitted to the Acute Care Surgery Service for monitoring.
Plastic surgery was consulted for your facial fractures and
recommended follow-up in 1 week after discharge to discuss
optimal timing of surgical repair once the edema has resolved.
You were evaluated by the Ophthalmology service which
recommended routine outpatient Ophthalmology follow-up. You were
also evaluated by the Orthopedics department for your left arm
fracture for which they recommended nonoperative management and
left arm in sling until follow-up in 2 weeks. Your pain was
controlled with tylenol and tramadol here at the hospital and
you worked with Physical Therapy and Occupational Therapy, which
have both cleared you for home. You are now ready for discharge
home. Please follow the below instructions for a safe and speedy
recovery:
Rib Fractures:
* Your injury caused left first 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).
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10536200-DS-11 | 10,536,200 | 26,782,165 | DS | 11 | 2152-06-28 00:00:00 | 2152-06-29 13:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall, left rib fractures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ with history of mild dementia
attributed to atypical ___ disease, aphasia and diabetes
who presented from ___ following an unwitnessed fall with
subsequent rib fractures.
Per patient's family, patient reportedly fell on the morning of
___ in his closet after losing his balance. Patient typically
needs assistance with walking and sometimes gets up on his own.
This morning, walked to closet and tripped on scale, no LOC or
light headedness. He fell and hit his left ribs on the side of a
chair. His health aid came in and was able to lift him but due
to ongoing rib pain, he presented to the ED. Patient denies LOC,
head strike. Per his family, his mental status was at baseline.
Patient initially presented to ___. Labs at ___
notable for WBC 8.9 with 80% polys, normal chemistries. Patient
had head CT scan which revealed no evidence of bleed. CT chest
revealed several broken ribs on left as well as a right axillary
fluid collection. Given his rib fractures, patient was
transferred to ___ for trauma evaluation and pain control.
IN the ___ ED, initial vitals: 98.5 96 156/80 18 94%. Patient
was seen by ACS and was admitted to ___ for pain control. This
afternoon, medicine asked to consult on patient for medical
issues and possible transfer to medicine given resolution of
acute trauma issues. It was decided that patient appropriate for
transfer to medicine for further management.
On evaluation of patient, patient reports he feels well without
pain.
Past Medical History:
IDDM (last A1C 6.3% ___
Aphasia (? with atypical parkinsons vs dementia)
Hyperlipidemia
Hypertension
spinal stenosis
OSA
Depression
peripheral neuropathy
GERD
Benign Prostatic Hypertrophy
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Vitals: 97.9; 156/67; 69; 18; 97/RA
General: Well appearing, sitting up in bed with family at
bedside, dysarthric
HEENT: MM slightly dry, difficulty opening mouth fully
Neck: Supple
CV: ___ systolic murmur at RUSB, regular rate and rhythm
Lungs: bibasilar crackles, otherwise CTAB, although poor air
movement and inspiratory effort
Abdomen: mildly distended, soft, nontender
GU: No foley
Ext: WWP, no peripheral edema
Neuro: Oriented to ___, not clear on location,
EOMI, PERRL, slowed speech, only ___ word answers with delay
Skin: No rashes appreciated
PHYSICAL EXAM ON DISCHARGE:
Vitals: 98.7 ; 128/70; 78; 20; 96/RA
General: Well appearing, no acute distress, eyes open, eating
breakfast, answeting questions with yes/no repsonses
HEENT: PERRL, face symmetric
Neck: Supple
CV: ___ systolic murmur at RUSB, regular rate and rhythm
Lungs: clear to auscultation on anterior anteriorly, although
poor air movement and inspiratory effort
Abdomen: nondistended, soft, nontender
GU: No foley
Ext: WWP, no peripheral edema
Neuro, moving all extremities, negative babinski B/L, difficult
to asess for cogwheel rigidity (patient resists despite
insistence on keeps limbs resting).
Skin: No rashes appreciated
Pertinent Results:
LABS ON ADMISSION:
========================
___ 05:50AM BLOOD WBC-7.3 RBC-4.23* Hgb-13.3* Hct-38.4*
MCV-91 MCH-31.5 MCHC-34.7 RDW-13.3 Plt ___
___ 05:50AM BLOOD Glucose-160* UreaN-19 Creat-0.8 Na-140
K-3.1* Cl-102 HCO3-25 AnGap-16
___ 05:50AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.5*
IMAGING:
========================
VIDEO SWALLOW ___
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of
obstruction. There was no gross aspiration. There was
penetration with thin
liquids and nectars.
IMPRESSION:
Penetration with thin liquids and nectars. No gross aspiration.
MRI C-SPINE ___
FINDINGS:
Evaluation is mildly limited due to motion artifact.
There is minimal anterolisthesis of C3-4, unchanged from ___. There
is no acute change in alignment. Vertebral bodies are normal in
height. There
is no evidence of bone marrow, ligamentous, or paravertebral
edema. There is
diffuse desiccation and height loss of the intervertebral discs.
There is no
epidural hematoma. Evaluation of spinal cord signal is limited
by motion
artifact.
C2-3: There is a small central disc protrusion which does not
contact the
spinal cord. There are left facet osteophytes but no neural
foraminal
stenosis.
C3-4: There is a central disc protrusion indenting the thecal
sac but not
contacting the spinal cord. There uncovertebral and facet
osteophytes causing
mild bilateral neural foraminal stenosis.
C4-5: There is a central disc protrusion indenting the thecal
sac but not
contacting the spinal cord. There are uncovertebral and facet
osteophytes
causing severe right and moderate left neural foraminal
stenosis.
C5-6: There is a disc osteophyte complex indenting the thecal
sac but not
contacting the cord. There are uncovertebral and facet
osteophytes causing
moderate right and severe left neural foraminal stenosis.
C6-7: There is a central and right paracentral disc protrusion
indenting the
thecal sac but not contacting the spinal cord. There are
uncovertebral and
facet osteophytes causing severe right and mild to moderate left
neural
foraminal stenosis.
C7-T1: There is no significant spinal canal stenosis. There are
uncovertebral
and facet osteophytes causing moderate bilateral neural
foraminal stenosis.
There are disc bulges at T1-2 through T3-4 that do not contact
the spinal
cord.
There is a focus of T2/STIR hyperintensity in the dorsal
subcutaneous fat of
the upper back that corresponds to a nonspecific ossification on
the prior CT
(series 12, image 8).
There is a well-defined, lobulated, T2 hyperintense structure
medial to the
right glenohumeral joint extending to the right axilla,
partially visualized
on the present exam, but previously seen on the CT chest from ___
and demonstrated to be cystic on the ultrasound from ___.
IMPRESSION:
1. No evidence for acute traumatic injury.
2. Multilevel degenerative disease. Disc protrusions indents
the thecal sac
at multiple levels but do not contact the spinal cord.
Evaluation of cord
signal is limited by motion artifact.
3. Uncovertebral and facet osteophytes cause significant neural
foraminal
stenosis at multiple levels.
4. Lobulated cystic structure medial to the right glenohumeral
joint and
extending into the right axilla, incompletely imaged but
recently visualized
on the preceding chest CT and right axillary ultrasound.
Musculoskeletal
etiology is suspected, but this could be better assessed by a
shoulder/chest
wall MRI with and without contrast, if clinically warranted. A
lymphocele or
seroma may also be considered if there has been recent
intervention.
CT Head without contrast ___ (___): No acute intracranial
process. Moderate atrophy.
CT Chest w/o Contrast ___ (___): Nondisplaced left-sided
rib fractures as described. No associated pneumothorax or
hemothorax. Incidentally noted right axillary fluid collection
which could be evaluated with elective ultrasound. No
subdiaphragmatic injury or acute pathology.
U/S L AXILLA ___
IMPRESSION:
5.2 x 2.6 x 5.0 cm fluid collection in the right axilla.
Correlate with any history of instrumention, as findings may
represet a lymphocele or seroma; a lymphatic malformation may be
considered particularly if there has been no history of trauma
or surgery. Findings do not appear likely to represent a labral
cyst, although the possibility is difficult to exclude
completely.
LABS ON DISCHARGE:
========================
___ 04:50AM BLOOD WBC-5.5 RBC-4.16* Hgb-12.9* Hct-38.2*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.5 Plt ___
___ 04:50AM BLOOD Glucose-103* UreaN-14 Creat-0.7 Na-141
K-3.7 Cl-106 HCO3-28 AnGap-11
Brief Hospital Course:
Mr. ___ is an ___ with history of mild dementia
attributed to atypical ___ disease, aphasia and diabetes
who presented from ___ following an unwitnessed fall with
subsequent rib fractures.
ACUTE ISSUES:
===========================
# S/p mechanical fall: Per patient's son, who is a neurologist,
extensive workup had been performed and patient likely has
history of atypical ___ disease with shuffling gait and
walks with a walker at home. Cervical spinal stenosis could also
be causing gait abnormality, although this less likely. CT chest
at OSH showed nondisplaced left-sided rib fractures with no
associated pneumothorax or hemothorax. MRI neck completed at
request of patient's son who is a neurologist, MRI did not
reveal spinal stenosis or cord compression. Fall precautions
were taken, and patient was evaluated by pt. Patient was
discharged home with srvices for home safety eval and home
health aides.
# Acute metabolic encephalopathy: On admission patient lethargic
and confused most likely related to fall and narcotic use. As he
improved he did exhibit sundowning at night likely due to
hospital setting and atypical ___ disease/mild dementia
contributing. He was given Haldol and Zyprexa for pulling at his
lines and was more somnolent the next day. Lidocaine patch was
started in attempt to decrease his narcotic use. Delirium
precations were taken, and patient's mental status improved.
# Aspiration: Patient's family reported that his swallowing was
at baseline during this admission and that he works with speech
therapy at home. Although he has dysphagia, he did not aspirate
with proper precautions tolerated a regular diet. Video swallow
cleared him for mechanical soft, thin liquidf diet.
# Rib Fractures: Patient was started on a lidocaine patch and
standing 1000mg tylenol q8h to reduce narcotic use. He was given
oxycodone for breakthrough pain. He use the incentive
spirometry. He was trasnitioned to tylenol, lidocaine, and
tramadol prn on time of discharge.
# Right Axilla Fluid collection - Incidentally noted right
axillary fluid collection on CT chest. Right axillary US showed
likely lymphocele or seroma; a lymphatic malformation may be
considered particularly if there has been no history of trauma
or surgery.
# BPH/urinary retention: Patient has history of BPH. Of note,
patient voided as frequently in hospital as he has done at home
___ X daily, more frequiently during day, often 300-400 cc),
but repeatedly had elevated bladder scans (ranging from
500cc-800cc) though was asymptomatic. Patient's highest post
void residual was 1000 cc in am of ___, though patient
subsequently urinated 400 cc urine 1 hr after this scan and
remained asymptomatic. Patient was started on tamsulosin in
house for BPH and asx urinary retention, and will f/u with
urology as outpatient to determine if any management is needed
for urinary retention.
CHRONIC ISSUES:
=========================
# Diabetes: Insulin dependent, poorly controlled, complicated.
On glipizide and lantus at home. Decreased lantus to 16u qam
from 22u given poor PO with aspiration risk. Glipizide was held
inpatient, and patient was placed on ISS.
TRANSITIONAL ISSUES:
=========================
- Continue speech therapy at home and aspiration precautions
(ground diet, thin liquids)
- Fall precautions: should consider bed/chair alarm at home
- Continue lidocaine patch and tylenol (standing), tramadol
(prn) for pain.
- f/u with urology as outpatient to determine if any management
is needed for urinary retention. Dischagred on tamsulosin 0.4 mg
daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. Duloxetine 30 mg PO BID
5. GlipiZIDE 5 mg PO BID
6. Glargine 22 Units Breakfast
7. Omeprazole 20 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Milk of Magnesia 30 mL PO Frequency is Unknown
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. Duloxetine 30 mg PO BID
5. Glargine 22 Units Breakfast
6. Milk of Magnesia 30 mL PO PRN constipation
7. Omeprazole 20 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
11. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) place one every morning over
chest Disp #*30 Patch Refills:*0
12. GlipiZIDE 5 mg PO BID
13. Durable medical equipment
Hospital bed
Diagnosis: ICD-9 ___ disease 332.0
Length: Lifetime
14. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth every night Disp
#*30 Capsule Refills:*0
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth
every 6 hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Left rib fractures
Secondary diagnoses:
Delirium
Diabetes
Aspiration
Right axiallary fluid collection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
transferred here from ___ for rib fractures after you fell.
A CT scan of your head did not show any bleeding, but the CT
scan of your chest did show rib fractures and a collection of
fluid next to your right armpit. We obtained an ultrasound to
better evaluate that collection of fluid, and it showed that it
was likely from the trauma or a collection of lymph. You also
had a MRI which showed your cervical stenosis on your spine,
however it showed no acute fractures. During your stay as well,
we started you on a medication to help your urinate.
While you were here, we treated your pain and had our physical
therapists work with you.
We wish you all the best!
Your ___ team
Followup Instructions:
___
|
10536248-DS-2 | 10,536,248 | 20,100,310 | DS | 2 | 2181-12-20 00:00:00 | 2181-12-20 12:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Simvastatin
Attending: ___.
Chief Complaint:
increased seizure frequency
Major Surgical or Invasive Procedure:
na
History of Present Illness:
___ is a ___ male with a PMHx of epilepsy
followed by Dr. ___ who presents with increased seizure
frequency of his typical semiology (lip smacking and right arm
clenching/flexion lasting ~60 seconds).
He was in his USOH until ___ at 8:30pm or 9:00pm at which time
he was sleeping; at that time, his wife observed lip smacking,
clenching his right fist, and flexion of his right elbow at the
elbow and wrist. He said, "She's not there." This lasted just
over a minute, and then the patient was back at baseline. He did
not lose consciousness, and he "vaguely" remembers the event.
This represents his typical semiology, except his wife notes
that
it was a little longer than usual (usually less than a minute).
The following day, while awake, he had 8 more seizures from
9:30am to 2:00pm. No LOC or feeling of lost time. Eyes are
closed
or straight head and there is no eye deviation or eyes rolling
up, no head version, no limb shaking, no incontinence, no tongue
biting, no drooling, and no aura.
Of note, he was diagnosed with epilepsy ___ years ago. His
typical
semiology is described above. He had one lifetime seizure with
loss of consciousness and whole body shaking prior to being
started on an phenytoin. He was treated for years with
phenytoin,
but this was discontinued in ___ in the setting of
poor balance and an elevated level to 35. He was switched to
Keppra 2g ER daily. In ___, he had ___ seizures in a day,
and his Keppra was increased to 2.5g daily. In ___, he had
3
seizures in a week; the neurologist on call Dr. ___
recommended an increase to 3g daily. However, the patient did
not
do this because he wanted to be seen by Dr. ___. He has
had
no further seizures until yesterday. He feels that his seizure
frequency has been the same on Keppra vs Dilantin up until
yesterday.
His only trigger is flashing lights, but he has not been exposed
to these recently. No recent illnesses, truamas, missed Keppra
doses, or sleep deprivation. He sleeps ___ hours a night and
then
naps for an hour during the day, and he wakes up no more than
once a night.
Chronologic Seizure History:
Spell types:
1. lip smacking and right arm clenching/flexion lasting ~60
seconds
2. LOC with whole body shaking (once ___ years ago)
AEDs trialed previously
Phenytoin
Current AEDs:
Keppra 2.5g ER daily
Diagnostics:
- MRI summary: no seizure focus identified in ___
- EEG summary: EEG suggestive of left temporal focus (see
Diagnostics)
Positive: bilateral leg weakness which, on clarification, refers
to legs feeling tired after exertion. He denies difficulty
getting out of a chair, lifting his feet, or bearing weight.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus, and hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal numbness, and
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
Positive: DOE
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:
BELL'S PALSY
CERVICAL SPONDYLOSIS ___
HYPERLIPIDEMIA
SEIZURE DISORDER
COLONIC ADENOMA
ADVANCE CARE PLANNING
MOLST form provided to patient- full code
LUTS
OSTEOARTHRITIS
knees
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ STROKE
Father ___ ___
Brother Living ___ ___ DISEASE
Comments: No history of seizures
Physical Exam:
Admission exam:
Physical Exam:
Vitals: T: 99.2F P: 93 R: 18 BP: 118/79 SaO2: 98RA ___ 98
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity.
Pulmonary: no WOB.
Cardiac: RRR, nl.
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. No adventitious movements, such as tremor, noted.
No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Discharge exam:
unchanged. non-focal
Pertinent Results:
___ 05:56PM BLOOD WBC-8.7 RBC-4.85 Hgb-14.7 Hct-42.5 MCV-88
MCH-30.3 MCHC-34.6 RDW-13.2 RDWSD-42.2 Plt ___
___ 05:56PM BLOOD ___ PTT-27.8 ___
___ 05:56PM BLOOD Glucose-105* UreaN-21* Creat-0.9 Na-138
K-4.5 Cl-102 HCO3-22 AnGap-19
___ 05:56PM BLOOD ALT-28 AST-31 AlkPhos-71 TotBili-0.6
___ 05:56PM BLOOD Lipase-41
___ 05:56PM BLOOD cTropnT-<0.01
___ 05:56PM BLOOD Albumin-4.6 Calcium-9.7 Phos-3.5 Mg-2.2
___ 05:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MRI seizure protocol:
1. No acute intracranial abnormality including hemorrhage,
infarct, or
enhancing lesion.
2. Moderate global atrophy and scattered areas of white matter
signal
abnormality in a configuration most suggestive of chronic small
vessel
ischemic disease.
3. Otherwise no definite epileptogenic focus identified.
Brief Hospital Course:
___ is a ___ male with a PMH of epilepsy who
presented with increased seizure frequency of his typical
semiology (lip smacking and right arm clenching/flexion lasting
~60 seconds) without a clear trigger. infectious workup was
unrevealing. repeat MRI showed Moderate global atrophy and
scattered white matter flair hyperintensities. The patient was
taking 2500mg of keppra XR which we switched to 1500mg keppra
BID. The patient tolerated this well without further seizures.
He was noted to have some desaturations overnight raising the
concern for sleep apnea as a trigger for his worsening seizures.
[ ] Sleep clinic follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Keppra XR (levETIRAcetam) 2500 MG oral DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. LevETIRAcetam 1500 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
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 neurology service because of an
increase in your seizure frequency. We did not find a clear
cause but you did very well on an increased dose of your seizure
medication. Please follow up with neurology as planned.
Thanks you,
___ neurology team
Followup Instructions:
___
|
10536658-DS-19 | 10,536,658 | 28,992,497 | DS | 19 | 2156-05-30 00:00:00 | 2156-05-30 21:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma and alcohol intoxication
Major Surgical or Invasive Procedure:
Intubation in the Emergency Department
History of Present Illness:
___ from OSH s/p assault with frontal bone fractures and
___ transferred from an OSH for further management of
his frontal bone fracture. Most of the hx obtained from Mom in
the ___ as patient was agitated. The patient reportedly drank 15
beers the night prior to admission and got in a fight ( the
circumstanes are unclear). The neighborhood kids ran to call
the patient's mom, and she found him bloody and on the floor at
that time she called an ambulance and presented to the OSH.
At the OSH patient received Ancef and had a CT head which was
signficant for no ICH, and maxillofacial CT showed a
non-displaced right frontal bone fracture and pnemocephalus.
Upon arrival, the patient's GCS 10 (2,3,5) and he was very
agitated, requiring intubation. He received fentanyl/versed
___
In the ___, initial vitals: T 98.3, BP 108/43, P 82, RR 16, 97%
RA
Exam in the ___ was notable for contusions/abrasions to right
frontal bone, right zygoma. Scalp laceration (midline, near
hairline) closed with 3 staples at OSH. Pupils pinpoint
(received fentanyl), mild ecchymosis over right eye lid but
minimal edema, no subconjunctival hemorrhage.
Labs notable for WBC 16.0 and serum EtOH of 153 his other tox is
negative. He was evaluated by neurosurgery who recommened no
neurosurgical interventions at that time. He was subsequently
evaluated by plastics who recommened Augmentin for prevention of
meningitis and sinus precautions.
Upon arrival to the floor, patient was complaining of neck pain
___ sharp but not radiating and made worse with movement. He
denied any headache, change in vision, dizziness, or
paresthesias. He reported vomitting x 2 after extubation after
drinking some juice. He does not recall any of the events from
last night. He denies any tremors or hallucinations. Denies
any hx of etoh withdrawl in the past. His last drink was 1 day
prior to admission.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
PMHx: Asthma
All:Ceclor ( hives)
Medications prior to admission: albuterol PRN
Social Hx: ___
FAMILY HISTORY: mother and father with previous hx of etoh
abuse.
Past Medical History:
Asthma
Social History:
___
Family History:
Mother and father with previous hx of etoh abuse.
Physical Exam:
Admission Physical Exam:
VS - Temp 98.1F, BP 111/36 , HR 56 , R16 , 100 % RA
GENERAL - drowsy but arousable with multiple brusies on face in
NAD HEENT - staples anterior midline of scalp, slight depression
middle frontal bone, ecchymoses right periorbital area,
contusions on R. fronal bone. no subconjunctival hemorrhage
PERRL , EOMI, sclerae anicteric, MMM, OP clear
NECK - in C-collar
LUNGS - CTA bilat, no r/rh/wh
HEART - nl S1 S2 no M/R/G
ABDOMEN - NABS, soft/NT/ND, no masses, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - multiple bruises on face
NEURO - drowsy, Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar function is intact
Discharge Physical Exam:
Vitals: T.98.1 BP 148/49 ( 111-148/56-84) P 53 ( 56-93) R 20 O2
sat 99% on RA
GENERAL - awake, multiple brusies on face in NAD
HEENT - staples anterior midline of scalp, slight depression
middle frontal bone, ecchymoses right eye lid, no
subconjunctival hemorrhage PERRL , EOMI, sclerae anicteric,
MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh
HEART - nl S1 S2 no M/R/G
ABDOMEN - NABS, soft/NT/ND, no masses, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - multiple bruises on face
NEURO - drowsy, Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar function is intact
Pertinent Results:
___ 06:26AM TYPE-ART RATES-16/ TIDAL VOL-500 PEEP-5 O2-50
PO2-209* PCO2-48* PH-7.26* TOTAL CO2-23 BASE XS--5 -ASSIST/CON
INTUBATED-INTUBATED
___ 08:27AM PO2-151* PCO2-44 PH-7.30* TOTAL CO2-23 BASE
XS--4
___ 05:30AM WBC-16.0* RBC-4.42* HGB-13.8* HCT-41.1 MCV-93
MCH-31.1 MCHC-33.4 RDW-12.7
___ 05:30AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
ALT(SGPT)-24 AST(SGOT)-39 LD(LDH)-238 ALK PHOS-82 TOT BILI-0.3
___:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:58PM LACTATE-2.3*
___ 06:17 White Blood Cells 11.1
DIFFERENTIAL
Neutrophils 68.9 50 - 70 %
Lymphocytes 23.5 18 - 42 %
Monocytes 5.0 2 - 11 %
Eosinophils 2.3 0 - 4 %
Basophils 0.4 0 - 2 %
BASIC COAGULATION ___, PTT, PLT, INR)
Platelet Count ___ K/uL
IMAGING:
Imaging from OSH was reviewed and the following findings were
confirmed (uploaded on ___:
CT head: No ICH.
CT C-spine: No fracture/dislocation.
Maxillofacial CT: Non-displaced right frontal bone fracture
through anterior and posterior table also involving the frontal
sinus and right superior ethmoid air cells. Tiny Pneumocephalus.
___ Chest X-Ray
Confirmed placement of ET tube (5.3cm above carina). No focal
consolidation, pleural effusion, or pneumothorax.
Cardiomediastinal silhouette was normal. No displaced fractures.
Urine Culture: Negative
___ 05:30AM
Brief Hospital Course:
___ year old male presented from OSH s/p trauma with frontal bone
fractures in the setting of alcohol intoxication. Upon arrival
to the ___ ___, pt was intubated due to GCS of 10 (2,3,5),
combative behavior, and agitation. Pt was later extubated due to
improved mental status. He remained restrained due to agitation
and restlessness in the setting of post alcohol intoxication. Pt
was transferred to medicine floor for continuing monitoring in
the possible scenario of alcohol withdrawal. He was transferred
extubated and unrestrained and was overall sedated.
Active Issues:
# Non-displaced right frontal bone fracture s/p trauma
The patient was admitted to the medical floor for observation
and medical management of his frontal bone fracture, as plastics
and neurosurgery warranted no surgical intervention at this
time. On admission the patient denied any headache, and his
neuro exam was non-focal. He was placed on sinus precautions
and received pain control with PRN morphine.. Per plastic
surgery he was started on Augmentin for prevention of
meningitis, and will complete a 7 day course He is to follow up
with plastic surgery 2 days after discharge. He is to also
follow up with Dr. ___ Neurosurgery in 1 month with a
non-contrast head CT.
# Alcohol intoxication- The patient initially presented to the
___ ___ with an etoh level of 153 and was extremely agitated
necessitating intubation. He was subsequently extubated in the
___ and was extremely drowsy on admission to the floors.Although
the patient denied a history of alcohol withdrawal he was placed
on the ___ protocol given his agitation and concern for
possible withdrawal. He scored an 11 and 2 on CIWA, but did not
require any diazepam. He did not exhibit any signs of active
withdrawal during his hospital course. He denied any tremors or
hallucinations during his hospital stay and his cerebellar
function was intact on neurological exam. He was seen by social
work prior to discharge, who provided emotional support for the
patient and his mother regarding reactions to trauma and
victim's compensation.
#Neck Pain
On admission the patient complained mostly of neck pain, located
on the lateral aspects of his neck bilaterally. His was
transferred to the floors with a C-collar, which was cleared by
the trauma service. His pain was made worse with rotation of
the head bilaterally with no midline point tenderness on exam,
only neck muscle tenderness. His findings were most consistent
with a muscle spasm or whiplash injury. A C-spine x-ray from
the OSH reported no cervical fracture/dislocation, which was
reassuring. During his hospital course his pain was controlled
with morphine. Given the persistent neck pain he was sent home
with a soft collar and a 7 day course of Naproxyen.
# Emesis -During the hospital course the patient had
approximately 3 episodes of post-prandial emesis. The patient
reports a remote history of GERD when he was younger for which
he took protonix, unclear as to why he stopped. He reports
having similar episodes of emesis when experiencing reflux
symptoms. It is unclear if his nausea and vomiting were related
to recurrent GERD or possibly side effect from the morphine.
There was less concern for possible increased intracranial
pressure, as all episodes of emesis were post-prandial, and the
patient had no focal deficits on neurological exam. He was able
to tolerate lunch prior to discharge with out vomiting. He is
to follow up with his PCP after discharge for reevaluation of
his GERD and the potential need for a PPI or H2 blocker.
Inactive Issues:
# Asthma: Well controlled on albuterol inhaler
Transitional Issues:
-Follow up with Plastic Surgery Team this ___ in Clinic
___ with Dr. ___ at 3pm (___)
-Follow up with Dr. ___ in one month with non
contrast head CT
-Follow up with PCP (___) for ___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
Day 1 ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*11 Tablet Refills:*0
2. Naproxen 500 mg PO Q12H:PRN pain
RX *Naprosyn 500 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis- frontal bone fracture
Secondary Diagnosis- alcohol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was pleasure participating in you care at ___. You were
transferred to our hospital afer being assualted and were found
to have a frontal bone fracture and alcohol intoxication. You
fracture did not require surgery and you were given medicine to
control you pain. We will give you a soft collar that you can
wear for your neck pain as well as naproxen for pain control.
We also recommend you sleep with you head elevated to 30
degrees, avoid blowing your nose, and avoid drinking out of
straws for the next month. You have appointments to follow up
with your primary care doctor, plastic surgery and neurosurgery
after discharge.
Followup Instructions:
___
|
10536738-DS-22 | 10,536,738 | 20,949,614 | DS | 22 | 2171-06-22 00:00:00 | 2171-06-23 09:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
R hand weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w PMHx of HTN, HLD, DM2, and prior CVA
who presents to ___ ED after waking up this morning at 6AM
with
new right hand weakness.
Ms. ___ states that she was in her usual state of health last
night when she went to sleep and did not notice any problems
with
her right hand. She did have a stroke in ___ that left her with
some weakness of the right arm and leg, but she reports that
those issues were stable. When she awoke this morning (___) at
6AM and began to go about her morning routine, she felt
significant weakness in her R hand - well beyond her baseline.
Specifically, she had difficulty holding a cup for coffee cup,
buttoning her clothes, and combing her hair. She tried to text
her daughter, but had significant difficulty doing so with her
right hand. She eventually switched to using her left hand, and
was able to compose a logical message. Ms. ___ then made an
appointment with her PCP at ___. She was sent to ___ ED for
further evaluation from her PCP's office.
Ms. ___ reports that the only significant changes from baseline
that she noticed this morning was weakness in her hand and an
"odd" sensation "like wires" in her right forearm. She does not
believe that she had any new weakness in her right shoulder or
right leg. She denies difficulty with speaking or understanding
what was being said to her. She denies difficulty with her bowel
or bladder. She denies any new associated HA, neck pain, or arm
pain. She does not believe that she slept in an odd position
last
night.
She did recently return from a trip to ___, but has been in
her usual state of health with no fevers, CP, SOB, or other
illnesses.
Currently, Ms. ___ states that the function of her right hand
is
improving "a little bit" but is not yet near her baseline.
Past Medical History:
- CVA in ___
- sx: right arm and leg weakness -> continues to have residual
weakness but does not use assistive devices for walking and is
able to write without difficulty
- HTN
- HLD
- DM2 with diabetic neuropathy
- sleep apnea, not currently using CPAP machine ("it's broken")
- chronic lower back pain
- osteoarthritis
- thyroid nodule
Social History:
___
Family History:
- Denies MI or CVA at a young age
- Mother with HTN, HLD, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T98.5 HR70 BP177/89 RR18 Sat99%RA
GEN - obese woman, pleasant and cooperative, NAD
HEENT - NC/AT, MMM
NECK - short and thick; supple, full ROM
CV - RRR
RESP - normal WOB
ABD - obese, soft, NT, ND
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Neurologic Examination:
MS - brightly awake and alert; attentive to examiner, able to
recite MOYB quickly and accurately; speech is fluent with normal
prosody; she is able to name all objects on the stroke card
except for the feather; reading intact; repetition intact;
comprehension intact for 1 and 2 step commands as well as
grammatically complex commands; no evidence of visual neglect;
no
R-L confusion
CN - [II] PERRL 3->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch
bilaterally. [VII] No facial movement asymmetry with forced
eyelid closure or volitional smile. There does appear to be
?decreased wrinkling over R forehead. [VIII] Hearing intact to
voice. [IX, X] Palate elevation symmetric. [XI] SCM and
Trapezius
strength ___ bilaterally. [XII] Tongue midline with full ROM.
MOTOR - Normal bulk and tone. Very mild RUE pronator drift and
orbiting around the RUE. Left side is full power. Ride side
power
is as follows: Delt/tri/bi 4+, ECR 4-, FEx 4-, Ffl 4+, IO 4-;
IP/Ham/Quad 4+, TA 4, Gas 5
SENSORY - Reports decriment to LT over RUE, ~75% of normal.
Reports decriment to PP over R hand ~75% of normal. Reports
decreased PP over RLE ~90% of normal.
REFLEXES -
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2 0
R 2+ 2+ 2+ 2+ 0
Plantar response mute bilaterally.
+Pectoralis jerk bilaterally.
COORD - No dysmetria with finger to nose B/L.
GAIT - Circumduction with RLE; per patient, this is her baseline
gait.
===============================================
DISCHARGE PHYSICAL EXAM:
T 97.5 BP: 120-164/61-79 HR: ___ RR: ___ O2 sat: 100 RA
NAD, raspy voice, respirations unlabored, RRR
MS: Alert, interactive, speech fluent, no dysarthria
CN: EOMI, no nystagmus, right nasolabial fold flattening but
smile symmetric, V1-V3 sensation intact
Motor: Left full strength except IP which is ___.
Right as follows:
Delt Bic Tri ECR FEx Fflex IP Quad Ham TA Gas
5 ___ 4- 5 4+ 5 5- 5 5
Right pronator drift
Sensation intact to light touch
Finger-nose-finger normal. Heel-to-shin normal. Bilateral
finger-tap decreased.
Pertinent Results:
ADMISSION LABS:
___ 01:05PM BLOOD WBC-5.6 RBC-4.44 Hgb-13.3 Hct-38.6 MCV-87
MCH-30.0 MCHC-34.5 RDW-13.0 RDWSD-40.4 Plt ___
___ 01:05PM BLOOD Neuts-47.4 ___ Monos-6.4 Eos-3.0
Baso-0.5 NRBC-0.4* Im ___ AbsNeut-2.67 AbsLymp-2.38
AbsMono-0.36 AbsEos-0.17 AbsBaso-0.03
___ 01:15PM BLOOD ___ PTT-28.1 ___
___ 01:15PM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-140
K-4.5 Cl-102 HCO3-26 AnGap-17
___ 01:05PM BLOOD ALT-22 AST-52* AlkPhos-81 TotBili-0.5
___ 01:05PM BLOOD Lipase-51
___ 01:15PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:05PM BLOOD Albumin-4.6 Calcium-9.7 Phos-3.5 Mg-2.3
___ 01:15PM BLOOD %HbA1c-8.2* eAG-189*
___ 06:40AM BLOOD Triglyc-266* HDL-47 CHOL/HD-4.0
LDLcalc-89
___ 01:15PM BLOOD TSH-1.3
___ 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___:
No acute intracranial process based on a mildly motion limited
exam.
CTA HEAD AND NECK ___ (PRELIM):
1. Patent circle of ___.
2. No evidence of internal carotid artery stenosis by NASCET
criteria.
3. Short segment occlusion of the right vertebral artery at its
origin with distal reconstitution.
CXR ___:
No acute cardiopulmonary process.
MRI BRAIN ___ (PRELIM):
1. No acute infarct or intracranial hemorrhage.
2. Nonspecific T2/FLAIR subcortical and periventricular white
matter
hyperintensities, commonly seen in the setting chronic
microangiopathy in a patient of this age.
TTE ___:
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. The estimated right atrial pressure is ___ mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No intracardiac source of thromboembolism
identified. Mild symmetric left ventricular hypertrophy with
preserved biventricular systolic function. Mild mitral
regurgitation. Normal pulmonary artery systolic pressure.
DISCHARGE LABS: NONE
Brief Hospital Course:
Ms. ___ is a ___ year-old F with a PMHx of HTN, HLD, DM2,
and prior CVA with residual right sided weakness who presents
with acute onset new right hand weakness with a likely MRI
negative stroke.
# Right hand weakness: The patient's exam was concerning for
possible new weakness in the right wrist, finger extensors and
thumb abductor. She does also have some right sided weakness in
an upper motor neuron pattern, which is likely chronic based on
prior documented exams. Her MRI does not show evidence of acute
infarct but because her symptoms were persistent and new, this
was thought to be an MRI negative stroke. She did have a CTA
head and neck which showed patent anterior circulation
vasculature but a short segment of occlusion of the right
vertebral artery at its origin with distal reconstitution. The
patient reports she takes her medications most of the time. She
was continued on home aspirin 325mg and Rosuvastatin 40mg
nightly. She was evaluated by occupational therapy who
recommended outpatient OT. She was monitored on telemetry but
remained in NSR without evidence of afib. She had a TTE which
showed no evidence of clot or PFO, but elongated left atrium.
The etiology of the stroke was thought to be small vessel
disease secondary to her multiple uncontrolled risk factors,
including hypertension, hyperlipidemia and diabetes. Her HbA1c
was 8.2. A cholesterol panel was checked: LDL 89, HDL 47, and
triglycerides 266. Per the PCP's notes, she has issues with
medication non-compliance. She was counselled on the importance
of medication compliance and a heart healthy diet. She will
follow-up with her PCP and neurologist as an outpatient. She
also received a prescription for outpatient occupational
therapy.
# HTN: Patient is on multiple blood pressure medications per
Atrius records but is unsure of her home regimen. In reviewing
her medications with her pharmacy, it seems she has not filled
clonidine or lisinopril in a few months. During the
hospitalization, she was continued on home amlodipine and half
her dose of labetolol to allow for permissive hypertension. She
will continue on her home medications at discharge with plan to
bring her pill bottles to her next PCP appointment to confirm
what she is and is not taking at home.
# OSA: Patient was continued on CPAP while inpatient.
# Non-insulin dependent Diabetes-Mellitus: Patient's HbA1c 8.2.
She takes Exenatide as well as metformin at home. She was
continued on insulin sliding scale while inpatient. She was seen
by the diabetes service and counselled on diabetes management
but no changes to her home regimen were made.
Transitional issues:
- continue to address HTN, DM
- Fenofibrate added to statin regimen: monitor for myalgias
- CPAP machine broken, will need this addressed as outpatient
- continue to address compliance: per pharmacy, has not filled
lisinopril since ___ and clonidine since ___
- outpatient OT for right hand weakness
- left thyroid nodule measuring 2x2 cm seen on CTA.
- HCP: none chosen
- Code: presumed Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 40 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Prazosin 1 mg PO QHS
4. Labetalol 200 mg PO BID
5. Amlodipine 10 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY
8. CloniDINE 0.3 mg PO BID
9. Lisinopril 40 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
11. Aspirin 325 mg PO DAILY
12. exenatide microspheres 2 mg subcutaneous 1X/WEEK
Discharge Medications:
1. Outpatient Occupational Therapy
Occupational therapy
Right hand weakness secondary to ischemic stroke
2 session/week x 6 weeks or more
Evaluate and treat
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. CloniDINE 0.3 mg PO BID
5. Fluoxetine 40 mg PO DAILY
6. Labetalol 200 mg PO BID
7. Rosuvastatin Calcium 40 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
9. Fenofibrate 145 mg PO DAILY
RX *fenofibrate micronized 145 mg by mouth daily Disp #*30
Tablet Refills:*2
10. exenatide microspheres 2 mg subcutaneous 1X/WEEK
11. Lisinopril 40 mg PO QHS
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Prazosin 1 mg PO QHS
14. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute ischemic stroke, MRI negative
Secondary diagnosis:
Diabetes mellitus
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with right hand weakness and concern
for stroke. Your MRI did not show any evidence of stroke but
because your exam was changed with weakness in the right hand,
we feel that you did have a stroke. The stroke was most likely
due to uncontrolled diabetes, high blood pressure and high
cholesterol. You were continued on aspirin and rosuvastatin. You
were started on Fenofibrate to help lower your cholesterol. You
were seen by the diabetes doctors who did not want to make any
changes to your current regimen at this time. Please continue to
take all medications as prescribed. Please bring all your pill
bottles to your next PCP ___. You will be starting a new
medication for your cholesterol called: Fenofibrate. If you
experience muscle aches and pains that are different, severe on
concerning, please call your primary care physician right away
as this may be a side effect of the medication. You will
follow-up with your primary care physician who will refer you to
neurology for further management.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
10536742-DS-20 | 10,536,742 | 23,703,739 | DS | 20 | 2188-01-12 00:00:00 | 2188-01-15 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
En bloc left colectomy with resection of the
psoas fascia.
History of Present Illness:
___ yo M w/ PMH of cecal diverticulitis s/p Lap R colectomy 05',
Ex lap and SBO 08' By Dr. ___ @ ___. He was free of
symptoms
until ___ when he presenting with uncomplicated
diverticulitis treated conservatively with ___, since then he
has
experienced additional 4 episodes on ___ and ___.
He is presenting to the ED today with 1 day of LLQ pain, PCP
started ___ treatment with augmentin and flagyl, no improvement
of the symptoms. Worsening abdominal pain with PO intake. Denies
fever, nausea and diarrhea. No recent colonoscopy.
Past Medical History:
Recurrent Diverticulitis
Past Surgical History:
s/p Lap R colectomy ___, Ex lap and SBO ___
Social History:
___
Family History:
No hx of Colon cancer or diverticulitis
Physical Exam:
On admission:
No acute distress
Vitals: 98 90 125/86 16 100%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, focally TTP LLQ, no rebound or
guarding,
no palpable masses. Midline laparotomy scar, no hernia palpated
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
On discharge:
AFVSS
Gen: alert, pleasant, NAD
HEENT: mmm
CV: rrr
Abd: incision c/d/i w staples in place. soft, appropriately
tender, nondistended. jp serosanguinous, pulled
Ext: no ___, wwp
Pertinent Results:
___:15PM ALT(SGPT)-119* AST(SGOT)-40 ALK PHOS-63 TOT
BILI-0.8
___ 12:15PM GLUCOSE-89 UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-18
___ 12:15PM WBC-10.4 RBC-5.01 HGB-16.3 HCT-45.4 MCV-91
MCH-32.5* MCHC-35.9* RDW-13.3
___ 12:15PM NEUTS-70.7* ___ MONOS-5.7 EOS-0.9
BASOS-0.5
___ 12:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
CT Abdomen (___)
IMPRESSION:
Acute uncomplicated diverticulitis along a segment of the
descending colon. An underlying mass cannot be entirely
excluded and colonoscopy is recommended once the acute symptoms
subside, if not performed recently.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
___ presented to the ED on ___ with LLQ abdominal pain
and a CT scan consistent with diverticulitis. He had previously
had a right colectomy for cecal diverticulitis. He has now had
essentially continuous diverticulitis for the last 6 months with
at least 5 hospitalizations and courses of intravenous
antibiotics,
which rapidly recurred with ceasing antibiotics. He was taken to
the OR on ___ for a left colectomy with resection of the
psoas fascia. In the OR, a mass was discovered in the
descending colon which was densely adherent to the psoas fascia
near the level of L3. An en bloc resection was performed
assuming that the patient had a tumor with penetration into the
abdominal wall. The specimen was taken to pathology for which
it was thought to be a fibrotic abscess rather than a tumor.
Resection margins were marked on the retroperitoneum awaiting
final pathology. Post-operatively, he was given a dilaudid PCA
for pain control. He was initially doing well, however he
developed shortness of breath on post-operative day one, for
which an xray was performed. The xray did not demonstrate an
acute process. An ABG on room air was performed which
demonstrated respiratory alkalosis. Due to his absence of pain,
lack of hypoxia, negative imaging, and reported sense of
anxiety, his breathlessness was presumed to be due to anxiety.
He had a normal white blood cell count. His dyspnea improved
without intervention and he continued to be pain free. He was
discharged on ___.
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet,delayed release (___) by mouth
daily Disp #*20 Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*75 Tablet Refills:*0
3. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth daily Disp #*20 Capsule
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*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:
___
|
10536763-DS-20 | 10,536,763 | 26,389,140 | DS | 20 | 2179-11-28 00:00:00 | 2179-11-28 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ G3P2 at 23w5d by 23w3d US and unknown LMP presents with
persistent nausea, vomiting and inability to tolerate PO since
___. Was initially seen on ___ in ED for
nausea/vomiting after a night of drinking alcohol and found to
be
23w3d pregnant by US. Transferred to OB triage with reassuring
evaluation.
Today, presented to ED with persistent nausea/vomiting.
Transferred to OB Triage for evaluation. States nausea and
vomiting has persisted since last visit. Has vomited ___ times
today and unable to tolerate PO. Denies abdominal pain, fever,
chills, sick contacts, diarrhea. Reports constipation with last
BM 5 days ago.
Of note, patient had not yet had first prenatal visit.
Past Medical History:
POBHx: G3P2
- G1: ___ SVD boy at 40wks, 7 lbs 14oz. No GDM.
- G2: ___ SVD boy at 41wks. 8 lbs c/b GDMA1
PGynHx: Denies history of STD's, abnormal paps, uterine
procedures or instrumentation.
PMHx: depression, anxiety (self-dc'd meds prior to first
pregnancy, denies depression/SI today).
PSHx: none
Social History:
___
Family History:
Not contributory
Physical Exam:
Upon arrival
General: NAD, comfortable
Cardiac: RRR
Pulm: CTAB
Abdomen: soft, nontender, nondistended, no rebound or guarding
Extremities: No edema, nontender
SVE: Deferred
Upon discharge
No acute distress
RRR no m/r/g
CTAB
ABD S/NT/ND
Pertinent Results:
___ 01:58PM PLT COUNT-166
___ 01:58PM NEUTS-78.3* LYMPHS-12.0* MONOS-9.4 EOS-0.1
BASOS-0.3
___ 01:58PM WBC-9.2 RBC-3.89* HGB-12.1 HCT-36.0 MCV-93
MCH-31.0 MCHC-33.5 RDW-13.1
___ 01:58PM CALCIUM-8.6 PHOSPHATE-2.8
___ 01:58PM LIPASE-24
___ 01:58PM ALT(SGPT)-49* AST(SGOT)-52* LD(LDH)-165 ALK
PHOS-64 TOT BILI-1.1
___ 01:58PM GLUCOSE-84 UREA N-11 CREAT-0.5 SODIUM-140
POTASSIUM-2.8* CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
___ 04:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:35AM URINE HOURS-RANDOM
___ 05:55AM ALBUMIN-3.4* CALCIUM-7.9* PHOSPHATE-1.5*
MAGNESIUM-1.9
___ 05:55AM GLUCOSE-101* UREA N-8 CREAT-0.4 SODIUM-135
POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-24 ANION GAP-11
___ 10:35AM HCV Ab-NEGATIVE
___ 10:35AM HIV Ab-NEGATIVE
___ 10:35AM TSH-0.92
RUQ U/S showed cholelithiasis with no evidence of cholecystitis
Brief Hospital Course:
Ms. ___ was admitted into the antepartum service for
observation given evidence of transaminitis with no obvious
source. Her RUQ showed cholelithiasis but no evidence of
cholecystitis. She had normal Tbili and negative Hep C and HIV
testing. Her liver enzymes were trended in house and became
stable prior to discharge. She was given anti-emetics and placed
on maintenance IV fluids until she was able to tolerate a
regular diet. She had TORCH titers and bile acids ordered to
evaluate for unusual causes of transaminitis. She was discharged
in good condition and was asked to follow up at ___
for routine prenatal care.
Medications on Admission:
Prenatal vitamins
Discharge Medications:
1. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth q6hrs Disp #*30
Tablet Refills:*2
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q6hrs Disp #*30 Tablet
Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
suspected viral transaminitis
Blood work up still pending
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted into the ___ service for work up fo
nausea, vomiting and transaminitis
* You have been stable with no emesis and tolerating oral intake
so the team feels that you are safe to discharge home
Followup Instructions:
___
|
10536920-DS-17 | 10,536,920 | 29,122,379 | DS | 17 | 2125-08-29 00:00:00 | 2125-09-03 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
aspirin
Attending: ___
Chief Complaint:
fascial dehiscence
Major Surgical or Invasive Procedure:
___: Exploratory Laparotomy, Repair Fascial Dehiscence
History of Present Illness:
___ year old male who is s/p cystectomy with ileal conduit on
___ presenting with continuous leakage of fluid from his
midline incision. DDx: fascial dehiscence vs. wound
infection/seroma vs. intra-abdominal fluid collection
Past Medical History:
DM II, on metformin
HTN
Kidney stones
PSH:
Kidney stone removal
TURBT
Social History:
___
Family History:
FH: No family history of GU malignancy
Physical Exam:
Gen: NAD, pleasant, articulate
resp: no tachypnea
Abd: Binder in place; no evidence of hernia/dehiscence; surgical
dressing down.
___ has been removed.
urostomy w/ yellow uop.
Extrem: Without deformity. wearing scds. no l/e e/p/c/d.
Pertinent Results:
___ 09:30AM BLOOD WBC-9.7 RBC-3.10* Hgb-9.0* Hct-28.9*
MCV-93 MCH-29.0 MCHC-31.1* RDW-14.0 RDWSD-47.5* Plt ___
___ 05:46AM BLOOD WBC-9.7 RBC-3.39* Hgb-10.0* Hct-31.5*
MCV-93 MCH-29.5 MCHC-31.7* RDW-14.0 RDWSD-47.8* Plt ___
___ 06:35AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-30.7*
MCV-94 MCH-29.6 MCHC-31.6* RDW-14.2 RDWSD-48.8* Plt ___
___ 09:30AM BLOOD Glucose-151* UreaN-23* Creat-1.5* Na-137
K-4.8 Cl-101 HCO3-23 AnGap-13
___ 05:46AM BLOOD Glucose-145* UreaN-24* Creat-1.5* Na-141
K-5.1 Cl-102 HCO3-22 AnGap-17
___ 06:35AM BLOOD Glucose-153* UreaN-25* Creat-1.6* Na-140
K-5.0 Cl-103 HCO3-22 AnGap-15
___ 06:35AM BLOOD Calcium-8.2* Mg-1.6
___ 4:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. ___ was admitted with high grade micropapillary bladder
cancer s/p cystectomy ileal conduit ___. Readmitted on ___
with fascial dehiscence and wound infection and taken to the
operative theatre on ___ where he underwent wound washout,
fascial freshening and primary repair. His postoperative course
was not complicated. His diet was gradually advanced and he was
given appropriate perioperative antibiotics. He was on Cefazolin
for E. Coli UTI and maintained on insulin sliding scale while
inpatient. Nystatin creams/powders were added for his
intertriginal rash/infections and he was screened by ___ for
intervention (not needed). With improvement in his pain control
and gait, he was discharged over the weekend to home with ___
services and a plan for one week follow up. All of his questions
were answered.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Cephalexin 500 mg PO Q6H
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
6. amLODIPine 5 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Medications:
1. Miconazole Powder 2% 1 Appl TP TID:PRN rash
RX *miconazole nitrate [Anti-Fungal] 2 % Apply to groins three
times a day Disp #*85 Gram Refills:*3
2. Acetaminophen 1000 mg PO TID
3. amLODIPine 5 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
fascial dehiscence, post-operative, abdominal incision
intertiginal yeast infection
acute kidney injury (creatinine rise to 1.6)
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:
-Please also refer to the instructions provided to you by the
Ostomy nurse specialist that details the required care and
management of your Urostomy
-You will be sent home with Visiting Nurse ___
services to facilitate your transition to home, care of your
urostomy, Lovenox injections, etc.
-Lovenox is an injection that you will use once daily to reduce
your risk of dangerous blood clot. Please follow the provided
instructions on administration and disposal of syringes/needles
("sharps").
-Resume your pre-admission/home medications except as noted.
Always call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor
-___ reduce the strain/pressure on your abdomen and incision
sites; remember to log roll onto your side and then use your
hands to push yourself upright while taking advantage of the
momentum of putting your legs/feet to the ground.
--There may be bandage strips called steristrips which have
been applied to reinforce wound closure. Allow these bandage
strips to fall off on their own over time but PLEASE REMOVE ANY
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may
get the steristrips wet.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
For pain control, try TYLENOL (acetaminophen) FIRST, then
ibuprofen, and then take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that may
be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > ___ F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
10536920-DS-18 | 10,536,920 | 21,271,900 | DS | 18 | 2125-09-06 00:00:00 | 2125-09-06 13:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
aspirin
Attending: ___
Chief Complaint:
Hypoglycemia
Left ureteral stone
UTI
Major Surgical or Invasive Procedure:
___: Placement of an ___ percutaneous nephrostomy tube.
History of Present Illness:
Experienced AMS on ___ presented to ___ found to have BS
of 48 and left ureteral kidney stone causing moderate to sever
hydronephrosis. Preliminary Culture data is isolating ___.
Past Medical History:
DM II, on metformin
HTN
Kidney stones
PSH:
Kidney stone removal
TURBT
Social History:
___
Family History:
FH: No family history of GU malignancy
Physical Exam:
N: Alert and Oriented, NAD, VSS
Resp: LSCTA bilaterally
CV: RRR, no CP
Abd: ___ appliance changed in hospital. Stoma is pink and
protruding, appliance is intact with secure with ostomy belt.
His Left PCN insertion site is intact with minimal drainage,
dressing changed and is draining to gravity. Midline abdominal
incision staples removed, incision is reinforced with
steri-strips. Dressing is C/D/I.
___: No edema, no calf pain, no redness
Pertinent Results:
___ 05:35AM BLOOD WBC-11.7* RBC-3.51* Hgb-10.1* Hct-32.7*
MCV-93 MCH-28.8 MCHC-30.9* RDW-14.5 RDWSD-49.5* Plt ___
___ 05:35AM BLOOD Glucose-231* UreaN-22* Creat-1.4* Na-133*
K-5.0 Cl-96 HCO3-25 AnGap-12
___ 05:46AM BLOOD ALT-127* AST-125* AlkPhos-286*
TotBili-0.2
___ 05:46AM BLOOD Albumin-2.7*
___ 05:46AM BLOOD %HbA1c-6.1* eAG-128*
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Mr. ___ is admitted to urology service with hydronephrosis from
a left ureteral kidney stone. On ___ a Left PCN tube was
placed to decompress his kidney.
Of note he has a history of muscle invasive bladder cancer and
is now status post robotic radical cystectomy with ileal conduit
creation from ___. With an Exploratory laparoscopy and
fascial dehiscence repair on ___.
His PCN tube was placed by ___ which was uneventful. See
separately dictated note. He was transferred to the floor.
He was discharged on Fluconazole for a ___ UTI. His first
dose was given here with a prescription for 6 more days. The
ostomy nurse specialist changed the ___ appliance before
discharge and he will go home with ___ services for care of the
___ and Left PCN tube.
Post-operative follow up appointments were discussed and the
patient was discharged home with visiting nurse services to
further assist the transition to home with ostomy and PCN care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
3. Docusate Sodium 100 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
6. Enoxaparin Sodium 40 mg SC DAILY
7. amLODIPine 5 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Miconazole Powder 2% 1 Appl TP TID:PRN rash
Discharge Medications:
1. Fluconazole 200 mg PO Q24H ___ UTI Duration: 6 Days
Your first dose was given today. Start this prescription
tomorrow ___
2. Senna 17.2 mg PO HS
3. Acetaminophen 1000 mg PO TID
4. amLODIPine 5 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Miconazole Powder 2% 1 Appl TP TID:PRN rash
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Altered Mental status
1.4 cm proximal left ureteral stone
s/p left PCN tube placement
UTI
Discharge Condition:
NAD, AVSS, Alert and Oriented
RMQ ___ stoma is pink and protruding, left flank
nephrostomy is intact and secure, dressing is clean, dry and
intact. Staples removed on ___, Abdominal incision is
approximated by steri-strips.
Urine from ___ and PCN is clear yellow.
Bilateral lower extremities are warm, dry, well perfused. There
is no reported calf pain to deep palpation. No edema or pitting
Discharge Instructions:
-You will be sent home with resumption of your Visiting Nurse
___ services to facilitate your transition to
home, care of your ___, left PCN tube dressing changes,
Lovenox injections, etc.
- Complete your Lovenox is an injection that you will use once
daily to reduce your risk of dangerous blood clot. Please follow
the provided instructions on administration and disposal of
syringes/needles ("sharps").
-Keep the PCN tube clean and dry, do not shower with tube in
place.
-Resume your pre-admission/home medications except as noted.
**DO NOT TAKE your Glimepiride 2mg.
***RESUME your Metformin 1000 mg twice per day.
***Check your finger sticks more frequently to avoid a
hypoglycemic episode. Continue to check your finger sticks
before every meal and before bedtime. As we discussed take your
evening Metformin before dinner. Not at bedtime.
***You may not have your full appetite back, but you MUST
remember to eat small frequent meals.
Always call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor
-___ reduce the strain/pressure on your abdomen and incision
sites; remember to log roll onto your side and then use your
hands to push yourself upright while taking advantage of the
momentum of putting your legs/feet to the ground.
--There may be bandage strips called steristrips which have
been applied to reinforce wound closure. Allow these bandage
strips to fall off on their own over time but PLEASE REMOVE ANY
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may
get the steristrips wet.
-UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing
products and supplements that may have blood-thinning effects
(like Fish Oil, Vitamin E, etc.). This will be noted in your
medication reconciliation.
IF PRESCRIBED (see the MEDICATION RECONCILIATION):
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
For pain control, try TYLENOL (acetaminophen) FIRST, then
ibuprofen, and then take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-You may take sponge baths but do NOT immerse your incisions or
PCN tube in water or take tub baths
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
FOLLOW-UP
-Follow up in ___ days for ostomy check and post discharge
evaluation.
-Call your urologist to schedule/confirm your follow up
appointment (if not listed below) and if you have any questions.
Followup Instructions:
___
|
10537300-DS-13 | 10,537,300 | 25,318,662 | DS | 13 | 2154-03-17 00:00:00 | 2154-03-17 15:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
___
WBC-11.2* RBC-2.26* Hgb-6.4* Hct-21.2* MCV-94 MCH-28.3
MCHC-30.2* RDW-16.1* RDWSD-55.1* Plt ___
___
WBC-14.1* RBC-3.31* Hgb-9.6* Hct-30.5* MCV-92 MCH-29.0
MCHC-31.5* RDW-16.1* RDWSD-53.2* Plt ___
___
Neuts-84.5* Lymphs-6.8* Monos-7.2 Eos-0.6* Baso-0.2 Im ___
AbsNeut-11.78* AbsLymp-0.95* AbsMono-1.00* AbsEos-0.09
AbsBaso-0.03
___
___ PTT-29.1 ___
___
Glucose-99 UreaN-11 Creat-0.7 Na-143 K-4.1 Cl-102 HCO3-24
AnGap-17
___
ALT-7 AST-43* AlkPhos-90 TotBili-0.3
___
LD(LDH)-1273*
___
Lipase-23
___
proBNP-398*
___
Albumin-3.1* Calcium-9.4 Phos-4.2 Mg-1.8
___
calTIBC-196* Hapto-438* Ferritn-329* TRF-151*
___
TSH-0.67
___
Lactate-1.8
___ 5:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS HOMINIS.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
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 in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS HOMINIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0240.
GRAM POSITIVE COCCI IN CLUSTERS.
___ 5:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS HOMINIS.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
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 in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS HOMINIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ (___) @___
(___).
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
MRSA screen negative
Blood cx on ___ NGTD
CTPA ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
segmental level without filling defect to indicate a pulmonary
embolus. The
thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. The heart and great vessels are within
normal limits.
Small pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: A large, necrotic appearing nodal
conglomerate
encompassing the majority of the left axilla spans approximately
9.7 x 8.0 cm
in greatest axial ___. No right axillary
lymphadenopathy. An enlarged
node or nodal conglomerate at the sternal notch measures
approximately 4.2 x
2.7 cm (2:25), exerting mass effect on adjacent structures,
causing rightward
displacement of the trachea, which remains patent, and narrowing
the left
brachiocephalic vein. Multiple other enlarged, necrotic
appearing mediastinal
nodes measure up to 4.2 x 2.7 cm. There is no hilar
lymphadenopathy.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: A pulmonary nodule within the right middle lobe
measures 1.0 cm
(3:132). Linear opacities within the bilateral lower lobes
likely reflect
atelectasis or scarring. The airways are patent to the level of
the segmental
bronchi bilaterally.
BASE OF NECK: Aside from the aforementioned findings, the
visualized portions
of the base of the neck show no abnormality.
ABDOMEN: The study is not optimized for evaluation of the
subdiaphragmatic
structures. Within this limitation, the included portion of the
upper abdomen
is unremarkable.
SOFT TISSUE: A large, lobulated mass within the left breast
spans
approximately 14.1 x 13.6 cm, likely extending into the skin,
with diffuse
overlying skin thickening, compatible with known inflammatory
breast cancer.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
2. Large, lobulated left breast mass, measuring up to
approximately 14.1 cm,
with diffuse overlying skin thickening, compatible with known
inflammatory
breast cancer.
3. Necrotic appearing left axillary and mediastinal
lymphadenopathy, which
exerts mass effect on adjacent structures, causing rightward
displacement of
the trachea, which remains patent, and narrowing the left
brachiocephalic
vein, are concerning for metastatic disease.
4. 1.0 cm right middle lobe pulmonary nodule, also concerning
for additional
metastasis.
5. Small pericardial effusion, which could be related to
underlying
malignancy.
EKG ___ with sinus tachy and low voltage
Brief Hospital Course:
___ yo F with hx of PTSD here with symptoms related to her left
sided inflammatory breast cancer.
Transitional issues
[ ] she has follow up with her atrius PCP and palliative care
[ ] At___ onc will arrange for chemo
[ ] monitor for left sided neck vein compression
[ ] monitor respiratory status
- suspect based on CTPA that both are from mass effect
# locally advanced inflammatory grade 3 invasive ductal
carcinoma of left breast with metastases
she has had progressive disease despite neoadj THPx4 and ddACx3.
Per Dr. ___ patient is not a surgical candidate now and
unless she has a substantial response to further systemic
treatment.
She was initially scheduled for carboplatin therapy, but it has
been challenging to manage her breast cancer given her psych
issues namely her PTSD and denial.
She was tachycardic here to the 120s in sinus and short of
breath. Given her malignancy, ruled out PE with CTPA. Did show
mass effect on trachea and sublclavian vein as in report.
Her shortness of breath is likely manifest by mass-effect of
axillary and mediastinal lymphadenopathy causing rightward
displacement of the trachea (which remains patent).
She also has mildly dilated external jugular on the left which
can be correlated to the mass effect on the subclavian vein seen
on the CTPA. Would monitor for vein compression.
On discharge, her HR were 90-low 100s sinus, normal SPO2 on RA,
and breathing comfortably.
#) Leukocytosis
# Superimposed soft tissue infection
# Coag negative staph blood stream infection:
Here with ___ bottles from ___ with Staph hominis. Has
completed vancomycin for uncomplicated coag negative staph
infection. (2 bottles from within 24 hrs positive = 5 days of
therapy (through ___.
Was put on doxycycline 100 mg BID for soft tissue infection but
MRSA screen negative, no sensitivities to tetracycline on blood
culture and skin findings mostly related to underlying
malignancy, so stopped prior to discharge.
Patient still have elevated WBC to 14 on discharge despite
completion of ABx for bacteremia.
# Symptomatic anemia: possibly from myelosuppression from
chronic inflammatory state, maybe prior chemo. No evidence of
acute blood loss. Iron studies show at least anemia of chronic
disease but with percent saturation of 5%, concomitant iron
deficiency is possible. She received 2 units of pRBCS while
inpatient with appropriate increase in Hgb from 6 to 9.
# Schizotypal personality disorder/PTSD: increased fluoxetine to
60 mg daily
# Hyperphosphatemia: Mild, likely secondary to tumor burden and
cell turnover. Does not meet other ___ definitions of
tumor lysis syndrome. On Phos restricted diet
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
3. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
4. FLUoxetine 20 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Severe
RX *hydromorphone 2 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
3. MetroNIDAZOLE Topical 1 % Gel 1 Appl TP BID *AST Approval
Required*
RX *metronidazole 1 % apply to breast wound twice a day
Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Naproxen 500 mg PO BID:PRN Pain - Moderate
RX *naproxen 500 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 capsule by mouth once a day Disp
#*10 Capsule Refills:*0
7. FLUoxetine 60 mg PO DAILY
RX *fluoxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*1
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth q6hr Disp #*30
Tablet Refills:*0
9. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth at bedtime Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coagulase negative staph blood stream infection
Skin and soft tissue infection
Breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ with an skin and blood stream
infection. We treated you with antibiotics. We recommend using
any medications you find helpful for the pain.
The reason you had the infection is because of the wound from
the cancer. If we can treat your cancer, we can prevent you from
having infections in the future.
The oncology teams will arrange follow up for you.
Followup Instructions:
___
|
10537376-DS-21 | 10,537,376 | 26,340,211 | DS | 21 | 2151-11-13 00:00:00 | 2151-11-16 07:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
NJ tube out
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o man with no signficant PMH who was discharged on ___
after recent 20-day hospitalization for gallstone pancreatitis
complicated by cholangitis and post-ERCP GI bleed, now
presenting with an episode of bilious emesis with ejection of
NJ Tube. The pt had just been discharged to a rehab facility on
___ and did not feel well starting on ___. He felt nausea and
also felt "clammy," but he denies fever. He had 2 bowel
movements on ___ which he describes as pasty. His stool
guiacs on ___ were reportedly positive. He has had no
diarrhea. On ___ he vomited non-bloody emesis which his wife
said appeared as yellow gatorade, in that it was very yellow and
may have been bilious. His NJ tube, which had been placed on
___, was ejected.
Of note, pt was hospitalized on ___ with severe pancreatitis. He
underwent ERCP on ___ with stones and pus removal. A
sphincterotomy was performed. He developed acute GI bleeding
following ERCP. He also underwent EGD at the OSH. He was seen by
urology for evaluation of scrotal edema and urinary retention,
thought to be due to extensive edema and was diagnosed with
epididymitis. He was started on flomax and a foley catheter was
placed. At the OSH, he developed fevers to 102 with
leukocytosis. In the ___ ICU, a post-pyloric dobhoff was
placed on ___ and he was started on tube feeds. He eventually
defervesced and his cholanigtis was believed to be treated. He
was treated with high-dose PPI for esophatitis and GI bleeding.
During his hospitalization he had significant pain.
Currently, he reports ___ abdominal pain, diffuse but worst in
his LUQ, which he describes as a "pressure" feeling. He also
reports nausea but has not vomited since yesterday. He endorses
fatigue. He denies cough, SOB, chest pain, headache.
Past Medical History:
Gallstone pancreatitis ___ s/p ERCP c/b sphincterotomy bleed
Social History:
___
Family History:
Mother - breast cancer, diabetes, hypertension Father -
testicular cancer, non-Hodgkin's lymphoma
No h/o GI diseases
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.8 96 138/77 16 100% RA.
General: Middle-aged appearing man resting calmly in bed with
his wife next to him
HEENT: ___. EOMI. Sclera anicteric. MMM.
Neck: Neck supple, no lymphadenopathy, no thyromegaly
Lungs: CAB, no w/r/r
CV: RRR, no m/r/g
Abdomen: TTP diffusely but most notable in LUQ. Non-distended,
no masses or hepatosplenomegaly. No rebound tenderness or
guarding. No ___ sign or Turner's sign.
GU: Foley.
Ext: 1+ pitting edema. WWP. Distal pulses 2+.
Skin: Small macular mildly erythematous rash in upper right
thigh.
Neuro: Moves all extremities spontaneously. Alert and oriented.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
___ 12:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 12:30AM GLUCOSE-120* UREA N-9 CREAT-0.6 SODIUM-133
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
___ 12:39AM LACTATE-0.9
___ 12:30AM ALT(SGPT)-32 AST(SGOT)-30 ALK PHOS-132* TOT
BILI-0.4
___ 12:30AM LIPASE-35
___ 12:30AM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-4.6*
MAGNESIUM-2.1
___ 12:30AM WBC-11.0 RBC-3.12* HGB-8.6* HCT-26.3* MCV-84
MCH-27.5 MCHC-32.7 RDW-13.9
___ 12:30AM NEUTS-81.8* LYMPHS-11.2* MONOS-5.4 EOS-0.9
BASOS-0.___bdomen Final Read: CT ABD & PELVIS WITH CONTRAST Study Date
of ___ 2:05 AM
1IMPRESSION:
1. Since the prior study of ___, there has been
significant organization of the fluid in the peripancreatic
area. What is remaining of the pancreatic parenchyma appears to
enhance homogeneously at this time; however, there are areas of
replacement of the pancreas with fluid
collections. A still significant amount of phlegmonous change
is noted in the
mesentery.
2. Partially occlusive distal (i.e. near the spleen) splenic
vein thrombus.
DISCHARGE LABS
Brief Hospital Course:
___ y/o man w/ recent 20-day hospitalization for gallstone
pancreatitis complicated by cholangitis and post-ERCP GI bleed
who presents with an episode of bilious emesis with ejection of
NJ Tube, hospital course complicated by diarrhea.
#Nausea/vomiting: Given fluid surrounding pancreas on CT scan,
pt thought to have pseudo-obstruction in the setting of recent
inflammation, compressing the stomach. Pt's abdominal pain and
n/v signficantly improved after first day of admission. He was
initially on bowel rest and continued on TPN and fluids. After
his narcotic requirement decreased, he was placed on clears
which he tolerated well, and then was advanced to a BRAT diet.
#Diarrhea: Pt had multiple episodes of diarrhea for a few days,
describing it as loose and bilious appearing stools. Likely
related to resolving inflammation/intestinal sloughing in GI
tract, resolved with loperamide. Sent out a c. diff antigen to
r/o c. diff colitis which was negative.
#Splenic vein thrombosis: Partial thrombosis of distal spenic
vein seen on CT scan, which could be a complication of his
pancreatitis. Per night float note, 19% of episodes of acute
pancreatitis are c/b SV thrombosis due to local inflammation
___ et al, J Comput Assist Tomogr, ___. Expect that
splenic vein thrombosis will resolve when pancreatitis resolves
per GI. Did not anticoagulate.
# Gallstone pancreatitis: Pt CT showed multiple organized fluid
collections, likely a result of extensive inflammation from his
recent severe pancreatitis.
# Scrotal edema: Pt developed severe anasarca during first
hospitalization which led to urinary retention, requiring
urology foley placement. His edema seems to have resolved and he
is receiving an adequate amount of fluids, thus we d/c'ed his
foley and monitored, he had no problems urinating. Remains on
tamsulosin, to be reassessed with PCP.
TRANSITIONAL ISSUES:
-Returning home on low fat, low residue diet.
-Continues on Creon for panc insufficiency.
-Continues on tamsulosin, to be reassessed with PCP
-___ on pantoprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PR HS:PRN Constipation
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
3. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN breakthrough
pain
4. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
5. Pantoprazole 40 mg PO Q12H
6. Simethicone 120 mg PO QID:PRN gas pains
7. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
8. Tamsulosin 0.4 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice daily Disp #*60 Tablet Refills:*0
2. Simethicone 120 mg PO QID:PRN gas pains
RX *simethicone 125 mg 1 tablet by mouth three times daily as
needed for gas Disp #*60 Tablet Refills:*0
3. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth once daily Disp #*30 Capsule Refills:*0
4. Creon 12 3 CAP PO TID W/MEALS
RX *lipase-protease-amylase [Creon] 3,000 unit-9,500 unit-15,000
unit 3 capsule,delayed ___ by mouth three times
daily with meals Disp #*270 Capsule Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins & Minerals] 1 tablet(s)
by mouth once daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pseudo-obstruction secondary to recent severe pancreatitis
Discharge Condition:
Mental status: Clear and coherent
Level of Consciousness: Alert and interactive.
Ambulatory status: Ambulatory- independent
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at the ___. You
were admitted because you had an episode of vomiting which led
to the expulsion of your NJ tube. While here, your abdominal
pain improved and you did not have anymore nausea or vomiting
after the first day. Given your preference, we did not replace
your feeding tube and instead you were treated with TPN. You
were eventually started on a clear liquid diet and were able to
tolerate it well, thus we advanced you to a BRAT diet. You
continued to feel well with no abdominal pain, nausea, or
vomiting and we discharged you home.
Followup Instructions:
___
|
10537484-DS-6 | 10,537,484 | 28,946,994 | DS | 6 | 2111-11-13 00:00:00 | 2111-11-14 11:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ R pigtail ( d/c ___
___ washout of hemoperitoneum
___ ___ hepatic angio, gel foam/embolization
History of Present Illness:
Mr. ___ is a ___ year old male status post kick boxing injury
on ___ who presented to ___ emergency department
hypotensive and was found to have a positive ultrasound and
positive CAT scan for liver laceration. The patient was
transferred to ___ for evaluation. The patient received
approximately 2 L of normal saline prior to arrival and no blood
products. The patient complains of diffuse abdominal pain and no
other real injuries.
He denies any headache, nausea, vomiting, neck pain, back pain,
extremity pains. He has no other significant ongoing medical
history.
Past Medical History:
None.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
Constitutional: Pale
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits, no cervical spine
tenderness
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nondistended, diffuse tenderness
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
On discharge: ___
vital signs: t=98.2, hr=73, bp=118/54, oxygen saturation=100%
room air
General: sitting comfortably in chair, NAD
CV: ns1, s2, -s3, -s4\
LUNGS: diminished BS right side
ABDOMEN: soft, non-tender, bloody oozed from lower port site
EXT: no pedal edema bil.
NEURO: alert and oriented x 3, speech clear
Call to Dr. ___ bloody ooze, plan to place suture
prior to discharge
Pertinent Results:
___ 06:30AM BLOOD WBC-12.4* RBC-3.44* Hgb-10.5* Hct-33.7*
MCV-98 MCH-30.4 MCHC-31.0 RDW-14.7 Plt ___
___ 05:50AM BLOOD WBC-10.6 RBC-3.20* Hgb-9.9* Hct-30.9*
MCV-96 MCH-30.8 MCHC-31.9 RDW-14.4 Plt ___
___ 10:45PM BLOOD Neuts-84.3* Lymphs-8.9* Monos-6.6 Eos-0.2
Baso-0.1
___ 03:20PM BLOOD Neuts-87.3* Lymphs-5.4* Monos-7.0 Eos-0.1
Baso-0.1
___ 04:35AM BLOOD ___ PTT-28.7 ___
___ 12:00AM BLOOD ___
___ 01:00PM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-134
K-4.4 Cl-96 HCO3-28 AnGap-14
___ 06:17AM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-134
K-4.5 Cl-99 HCO3-24 AnGap-16
___ 02:15PM BLOOD Glucose-116* UreaN-40* Creat-1.6* Na-135
K-6.7* Cl-100 HCO3-20* AnGap-22*
___ 03:55AM BLOOD ALT-131* AST-39 AlkPhos-117 TotBili-1.3
___ 01:00PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
___ 06:40PM BLOOD Type-ART pO2-134* pCO2-38 pH-7.36
calTCO2-22 Base XS--3
___ 05:08AM BLOOD Lactate-1.2
___ 06:40PM BLOOD Hgb-8.1* calcHCT-24
___ 06:40PM BLOOD freeCa-0.98*
___: trancatheter embolization:
IMPRESSION:
1. Succesful coil and Gelfoam embolization of a single
intrahepatic branch supplying segment ___ demonstrating a
pseudoaneurysm with active
extravasation.
2. Empiric gelfoam embolization of a single hepatic artery
supplying segments V/VI.
3. No residual areas of extravasation on completion angiography
and review of delayed images opacifying the portal vein .
___: Angio: distinct procedural:
1. Right common femoral artery access and arteriography.
2. Celiac artery angiogram.
3. Right hepatic angiography.
4. Selective angiography and Gelfoam and coil embolization of a
bleeding
hepatic branch supplying segment ___ of the liver.
5. Gelfoam embolization of hepatic arterial branch supplying
segment VI.
6. Completion celiac angiography.
___: CTA of abdomen and pelvis:
. Large subcapsular hepatic hematoma has slightly increased
since ___ exam. No definite area of active extravasation
is seen. A punctate focus enhancement on the arterial phase,
adjacent to the right hepatic lobe, is new since prior. This
area persists on delayed phases and retains its shape and
configuration as well as tracks with the blood pool, most
compatible with a small pseudoaneurysm formation.
2. No evidence of pulmonary embolus or acute aortic syndrome.
3. Large amount of hemoperitoneum is unchanged since ___.
4. Moderate bilateral intermediate-density pleural effusions,
right greater than left, have increaed in size since prior.
___: Femoral/vascular US:
1. Patent common femoral artery and veins. No evidence of
pseudoaneurysm formation.
2. Large amount of complex fluid in the abdomen and pelvis
represents
hemoperitoneum better seen on CTA exam of the same date.
___: US of right leg:
No evidence of deep venous thrombosis in the right lower
extremity.
___: Percutaneuos embo:
CONCLUSION: Very small pseudoaneurysm as seen on CT angiogram
on the surface of the inferolateral right lobe of the liver
could not be identified with ultrasound today. The CT scan was
three days ago and it is possible that this small pseudoaneurysm
has thrombosed. If there is further clinical concern, suggest
reassessment with a single-phase CT angiogram, perhaps confined
to the area in question to limit radiation dose.
___: chest x-ray:
Large right pleural effusion has probably increased since
___,
moderate left pleural effusion unchanged. On ___, the
effusions where nonhemorrhagic. Their nature today is unknown.
Severe bibasilar atelectasis is attributable to the persistent
effusions. Upper lungs are clear. Heart is normal size. No
pneumothorax. No free subdiaphragmatic gas.
___: chest x-ray:
FINDINGS: Right pigtail pleural catheter has been placed within
the lower right hemithorax with associated evacuation of the
previously large right effusion. Moderate right lateral and
basilar pneumothorax is new. Improving aeration in right middle
and lower lobes with residual partial atelectasis remaining. On
the left, there is worsening retrocardiac opacity which probably
reflects a combination of atelectasis and effusion, although
coexistent pulmonary infection is also possible.
___: x-ray of the abdomen:
FINDINGS: A non-obstructed bowel gas pattern is visualized.
No free
intraperitoneal air is evident. Within the imaged portion of
the lung bases, bibasilar atelectasis is present as well as
small bilateral pleural effusions.
A pigtail catheter overlies the right upper quadrant of the
abdomen, unchanged in position. Soft tissue density in right
upper quadrant is likely due to liver with known subcapsular
hematoma.
___: chest x-ray:
IMPRESSION:
1. New small right pleural effusion and decreasing right
lateral
pneumothorax.
2. Bibasilar atelectasis with interval improvement on the left.
___: chest x-ray:
FINDINGS: With the pigtail catheter on waterseal, there is no
definite
pneumothorax. The degree of a pleural effusion has decreased.
There is some relatively new opacification at the left base,
consistent with some
atelectatic change and probable effusion
Brief Hospital Course:
Mr. ___ was admitted to the trauma surgical service on
___ with a grade 4 liver laceration, significant
hemoperitoneum and active extravasation. Upon admission, he was
made NPO, and required 4 liters of fluid at which point he was
hemodynamically stable. He was taken directly to
interventional radiology where two branches of the right
hepatic artery were embolized. During the procedure, he received
2 units pRBCs for tachycardia (120's) and hypotension (SBP
90's), after which his HR decreased to the 90's and SBP
increased to 130's He was then admitted to the trauma intensive
care unit where he had serial hematocrits and monitoring of his
vital signs. On HD #3, he was reported to have a drop in his
hematocrit and required 2 units of packed red blood cells. A
repeat CT angio was done which showed no extravasation. On HD
#4, he was doing well and was advanced to a regular diet and
transferred to the surgical floor. His hematocrit had stabilized
and he was hemodynamically stable.
After transfer to the surgical floor, he was reported to have an
increase in his heart rate and reported increased abdominal pain
while ambulating. A CTA was performed which was negative for
pulmonary embolism, but showed a slight increase in the liver
hematoma. There was no active extravasation, but a new punctate
focus of enhancement concerning for a pseudoaneurysm. He was
also reported to have a drop in his hematocrit to 22 and
required 2 units of packed red blood cells. Because of his
hemodynamic status, he was re-admitted to the intensive care
unit for further monitoring. After identifying the
pseudo-aneurysm, the patient was taken to ___ for potential
embolization. The small pseudoaneurysm seen on CT angiogram
could not be
identified with ultrasound and could not be treated
percutaneously and the thought was that the aneurysm was
thrombosed. Serial hematocrits and vital signs were closely
monitored. The patient resumed a regular diet. On follow-up
chest x-ray he was noted to have little progression in the size
of the hemoperitoneum. Because of this, he was taken to the
operating room for a diagnostic laparoscopy and evacuation of
massive hemoperitoneum. The operative course was stable with a
10cc blood loss and evacuation of 1200cc of hemoperitoneum. He
was extubated after the procedure and monitored in the recovery
room. During his post-operative course, he reported increased
shortness of breath and there was concern about increasing
pleural effusion. He was given incremental doses of lasix to
help facilitate his breathing. Interventional Pulmonolgy was
consulted, and based on their findings, placed a catheter into
the right chest fluid collection. They were able to drain 650cc
sero-sanguinous fluid and the patient's respiratory status
improved. The chest tube was placed to suction. On chest tube
day # 4, the chest tube was placed to water seal after chest
x-ray showed a decreased right pleural effusion. The chest tube
was removed on chest tube day #5 and his chest x-ray showed no
pneumothorax.
The patient's vital signs remained stable and he has been
afebrile. He has been tolerating a regular diet and ambulating
without difficulty. He had a small amount of bloody ooze from
the lower laparoscopy site and a dry sterile dressing was
applied. He has maintained an oxygen saturation of 99% on room
air. On HD # 16, he was discharged to his uncle's home. A
follow-up appointment was made with the acute care service.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
4. Senna 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Liver laceration
Hemoperitoneum
right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ after you were kicked in the abdomen. On further
evaluation, you were found to have a liver laceration with
intra-abdominal blood. You first underwent an embolization to
stop the bleeding in your liver. You later required an
operative procedure to wash out your abdomen as it contained old
blood.
During this time, you were found to have bilateral pleural
effusions (fluid around your lungs). You had multiple chest
x-rays to assess their size. You were given a few doses of
diuretics to help you remove that fluid, along with generalized
fluid retention, via urination.
Your pain was treated with narcotic and non-narcotic analgesics.
You have now recovered well and are being discharged with the
following instructions.
Followup Instructions:
___
|
10537974-DS-21 | 10,537,974 | 29,292,627 | DS | 21 | 2195-06-18 00:00:00 | 2195-06-18 15:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Tetracyclines / Sulfa (Sulfonamide Antibiotics) / Amoxicillin
Attending: ___.
Chief Complaint:
headache, brain tumor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ right-handed WF w/PMH of HTN,
dyslipidemia, hypothyroidism, who presents now with several
months of headache and was found to have a tumor on OSH imaging.
She first developed a pressure sensation over her nasal bridge
in
early ___. This has gradually worsened in severity. A few
weeks ago, her ears started aching, and more recently her pain
has begun to radiate behind her ears and her jaw bilaterally
(but
more on the right. Ms. ___ initially thought that this was due
to a sinus headache, and started taking loratadine without much
relief. Of note, she had no other other URI symptoms. Due to
worsening nasal and ear pain, pt began taking amoxicillin about
3
weeks ago, which made her nauseous and feel worse. Two days ago,
she went to see an ENT, who did not see anything wrong with her
ears and ordered head imaging. However, the pain became
intolerable, and pt went to ___ today. A head CT was
performed, which showed a calcified lesion in the right
temporo-occipital cortex suspicious of a meningioma with
surrounding edema. She received dexamethasone 10 mg x 1, and was
transferred here.
Past Medical History:
HTN, dyslipidemia, hypothyroidism
G3P2 w/ 1 miscarriage; no PSH
Social History:
___
Family History:
uncle with "malignant brain tumor"
Physical Exam:
PHYSICAL EXAM on admission:
VS T:98.7 HR:89 BP:142/71 RR:16 SaO2:96%RA
General: NAD, lying in bed comfortably.
- Head: NC/AT and no tenderness to palpation behind ears, no
conjunctival icterus, no oropharyngeal lesions
- Fundoscopy: mild disc blurring b/l
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
-- Cardiovascular: RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Extremities: Warm, no cyanosis/clubbing/edema, symmetric
radial
pulses.
Neurologic Examination:
Mental Status:
Awake, alert, oriented x 3.
Attention: Recalls a coherent history; thought process linear
without circumstantiality or tangentiality. No neglect to visual
or sensory double stimulation. Concentration maintained when
recalling months backwards.
Affect: mildly anxious
Language: Converses appropriately with fluent speech and good
comprehension. No dysarthria, dysprosody or paraphasias noted.
Follows two-step commands, midline and appendicular and crossing
the midline. High- and low-frequency naming intact. Intact
repetition. Normal reading.
Memory: Easily registers ___ objects and recalls ___ at 3
minutes
(with one multiple choice prompt); also easily recalls where 3
objects were hidden in the room without verbal prompts
Praxis: No ideomotor apraxia or neglect w/o bodypart-as-object
or
spacing errors. Pt was able to copy unfamiliar hand
configurations without difficulty.
Executive function tests:
Luria hand sequencing learned after several attempts but then
performed well
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light and
accommodation. No RAPD.
Visual fields full to peripheral motion, tested individually,
and
to finger counting (including DSS) when tested together.
[III, IV, VI] EOM intact, no pathologic nystagmus.
[V] V1-V3 with symmetrical sensation to light touch. Pterygoids
contract normally.
[VII] No facial asymmetry at rest and with voluntary & emotional
activation.
[VIII] Hearing grossly intact to finger rub bilaterally.
[IX, X] Palate elevates in the midline.
[XI] Neck rotation normal and symmetric. Shoulder shrug strong.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor: Normal bulk; normal tone except increased in LLE. No
pronation or drift. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5]
Finger Flexors [R 5] [L 5]
Interossei [R 5] [L 5]
Abductor Digiti Minimi [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Sensory:
Intact proprioception at halluces bilaterally.
No deficits to cold testing on extremities and trunk.
Cortical sensation: No extinction to double simultaneous
stimulation. Graphesthesia intact.
Reflexes
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 2
R 2 2 2 1 2
Plantar response flexor bilaterally.
Coordination: No rebound. No past-pointing when touching own
nose
with finger, with eyes closed. No dysmetria on finger-to-nose
and
heel-knee-shin testing. No dysdiadochokinesia.
Gait& station:
Stable stance without sway. No Romberg.
Normal initiation. Narrow base. Normal stride length and arm
swing. Intact heel, toe, and tandem gait.
Exam on Discharge
Neuro intact
Pertinent Results:
___ Chest X ray
No acute cardiopulmonary radiographic abnormality.
___ CTA head
NECT: 2.2cm hyperdense mass with calcification at the right
temporo-occipital lobe with surrounding edema, probably
originating from the right tentorium, and similar entrapment of
the right lateral ventricle temporal horn compared to CT ___
at 7:46am from ___. no acute intracranial
hemorrhage.
CTA/CTV: COW patent. The mass appears to be supplied by vessels
from right
superior cerebellar and right posterior cerebral arteries. Dural
venous
sinuses are patent. Equivocal 1-mm aneurysm at the right MCA
origin
___ MRI head with and without contrast
1. No acute intracranial abnormality.
2. 2.3 cm extra-axial mass, subjacent to with a small amount of
vasogenic
within the surrounding right temporal lobe. This uniformly
enhancing,
partially calcified lesion represents a meningioma originating
from the right leaflet of the tentorium cerebelli.
3. Slight asymmetric prominence of the temporal horn of the
right lateral
ventricle in comparison to the left, which may, to some extent,
be "trapped" by this mass; however, there is no evidence of
transependymal migration of CSF.
4. Sequela of chronic small vessel ischemic disease in a pattern
seen in
chronic migraineurs (or patients with hyperlipidemia).
Brief Hospital Course:
___, Ms. ___ was admitted to the hospital and underwent a
series of diagnostic test which included a chest x-ray, a CTA of
the brain, and a MRI of the brain with and without contrast.
Imaging showed a 2.2cm hyperdense mass at the right
temporo-occipital lobe with surrounding edema, probably
originating from the right tentorium.
The chest x-ray was negative for any pulmonary processes. She
was started on a steriod with stomach prophlyaxis.
On ___, Ms. ___ met with her neurosurgeon to discuss surgery.
Dr. ___ the patient the option of being discharged home
before her elective surgery. She was discharged home in stable
condition with steriods and seizure prophlyaxis. Follow up with
neurosurgery, after discussion of her case in Brain Tumor
Clinic, was established.
Medications on Admission:
- levothyroxine 50 mcg daily
- triamtarene 37.5-HCTZ 25 1 cap daily
- pravastatin 10 mg daily
- atenolol 12.5 mg daily
- Vit D 1000 u daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atenolol 12.5 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 4 mg 1 tablet(s) by mouth q 12 hours Disp #*28
Tablet Refills:*0
9. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right temporal-occipital lesion
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of headaches. CT and MRI scanning show a
right temporal-occipital mass. As discussed with Dr. ___,
___ will require surgery for resection of the mass, likely next
week. You are now being discharged with the following
instructions:
o Continue to take Keppra until follow up with Dr. ___. This
medication is to prevent seizures.
o You are being prescribed Decadron, a steroid medication, which
is used to reduce inflammation. Continue to take this
medication until follow up with Dr. ___.
o As Decadron can cause stomach irritation, you are being
prescribed Zantac which will help reduce stomach acid. This
medication can be purchased over the counter.
Please contact the Neurosurgery office if you have any questions
or concerns. ___.
Followup Instructions:
___
|
10537974-DS-22 | 10,537,974 | 20,350,424 | DS | 22 | 2195-06-25 00:00:00 | 2195-06-25 13:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Tetracyclines / Sulfa (Sulfonamide Antibiotics) / Amoxicillin
Attending: ___.
Chief Complaint:
Pressure behind her eyes and nasal bridge
Major Surgical or Invasive Procedure:
___ Resection of right supratentorial lesion
History of Present Illness:
Patient is a ___ year old female with known right sided brain
lesion who was planned for resection on ___ and now presents
with increasing pressure behind her eyes and nasal bridge. She
has no ___ complaints at this time.
Past Medical History:
HTN, dyslipidemia, hypothyroidism
G3P2 w/ 1 miscarriage; no PSH
Social History:
___
Family History:
uncle with "malignant brain tumor"
Physical Exam:
On admission:
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. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally
Pertinent Results:
___ MR head without contrast:
Stable 2.3 x 2.2 x 1.8 cm extra-axial dural-based mass along the
right
tentorial leaflet, likely representing a meningioma.
CT Head ___:
Small-to-moderate pneumocephalus and minimal amount of blood
products layering along the surface of the brain at the
resection bed are
expected after surgical procedure. There is no intraparenchymal
hemorrhage or significant mass effect
MRI Brain ___:
IMPRESSION:
Status post resection of right tentorial mass with expected
postoperative
changes.
Brief Hospital Course:
Mrs. ___ was admitted to ___ on under the Neurology service
for further management of her right-sided brain lesion. She was
discharged from that service on ___ with the plans for her
returning later in the week for elective resection of the tumor.
While at home, her headache ("pressure") behind her eyes and
nasal bridge and she presented to the ED on ___. Other than
those symptoms, Mrs. ___ was neurologically stable.
On ___, the patient was taken to the Operating Suite for
planned R craniotomy for resection of the right tentorial mass.
She underwent a function MRI prior to that procedure. She
tolerated the procedure well. For more details of the procedure
please see the OP note in OMR. She was extubated in the
operating room. She was subsequently transfered to ICU for
recovery. Strict SBP <140. Started on dexamethasone 4mg Q6.
Continued Keppra 500mg BID. A head CT was obtained post
operatively which revealed expected post-op changes. She
remained stable overnight into ___. She was then deemed fit for
transfer to the floor and was awaiting MRI. The MRI of her brain
showed post operatively expected changes with expected edema and
no new lesions.
On ___, she remained neurologically and hemodynamically stable.
The plan was to discharge the patient home today but, she became
suddenly nauseous and began to vomit a couple of times. Her
bowel regimen was increased since she has not had a bowel
movement since admission. On examination the patient denied
nausea.
ON ___, she remained stable and was discharged in stable
condition.
Medications on Admission:
Synthroid, triamterene/hctz, pravastatin, atenolol,
cholecalciferol, keppra, decadron, zantac
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Atenolol 12.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
Take while taking narcotic pain medication (oxycodone)
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
8. Pravastatin 10 mg PO DAILY
9. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Dexamethasone 2 mg PO QID Duration: 2 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
then stop
RX *dexamethasone 2 mg 1 tablet(s) by mouth as indicated Disp
#*14 Tablet Refills:*0
12. Dexamethasone 2 mg PO BID Duration: 3 Days
Start: After 2 mg tapered dose
then stop
Discharge Disposition:
Home
Discharge Diagnosis:
Right supratentorial meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Keep your sutures should stay clean and dry until they are
removed. OK to shower, pat dry the when done
-Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
-Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
-Exercise should be limited to walking; no lifting >10lbs,
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.
-DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
-You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; you will not require blood work
monitoring.
- Do not drive until your follow up appointment.
Followup Instructions:
___
|
10538251-DS-9 | 10,538,251 | 29,099,487 | DS | 9 | 2156-08-25 00:00:00 | 2156-08-25 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lovastatin / enoxaparin
Attending: ___
Chief Complaint:
Slurred speech and vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right-handed male with h/o
afib on coumadin, HTN, HLD, CAD s/p 5-vessel CABG, TIA/CVA in
___ s/p R CEA, who was transferred from ___
with concern for vertigo, dysarthria, right-sided weakness and
numbness with abnormal CTA with bilateral vertebral artery
occlusions.
He was in his USOH until last night. He was seen well by his
son around 11:30pm last night. This morning he woke up around
8:45am and felt unsteady with some right leg weakness and right
hand and leg numbness. He also complained of vertigo and
difficulty walking. He called his son who said his speech
sounded slurred so he should go to the ED.
He was taken to ___ where he was elevated by
TeleStroke and found to have an NIHSS 2 for dysarthria and
right-sided sensory changes. He had a NCHCT that was
unremarkable and a CTA that was concerning for bilateral
vertebral artery occlusions noted at different levels. Not a tPA
candidate due to full anticoagulation and mild symptoms. INR at
OSH 2.7.
He lives with his son, gets some help with medication management
and higher level functions, but dresses and showers himself,
cleans around the house. He uses a walker for long distances,
otherwise ambulates independently.
On neuro ROS, he recalls he had a headache a few days ago for
which he had to lay down, but otherwise had been fine this week.
He denies any head trauma, nausea, vomiting, urinary or bowel
incontinence. No loss of vision, blurred vision, diplopia,
dysphagia. No bowel or bladder incontinence or retention.
On general review of systems, the patient 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.
Past Medical History:
Afib on coumadin
HTN
HLD
CAD s/p 5-vessel CABG in ___
TIA/CVA in ___ s/p R CEA
schizophrenia
right bundle branch block,
sick sinus syndrome s/p pacemaker
Social History:
___
Family History:
No known family h/o early strokes
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: T 97.8, HR 60, BP 152/82, RR 18, 92% RA
General: awake, alert, sitting up in bed, NAD
HEENT: NC/AT, wearing glasses, no scleral icterus noted, MMM, no
lesions noted in oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, well perfused
Abdomen: soft, NT/ND
Skin: no rashes or significant lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Patient was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Strength ___ except RLE with 4+/5 strength at IP, quad, ham, TA
and gastroc (baseline per patient from prior leg injury).
-Sensory: No deficits to light touch, pinprick, temperature
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 - 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF.
-Gait: Good initiation. Narrow-based, slightly shuffling gait,
no veering noted.
DISCHARGE PHYSICAL EXAMINATION
Physical Exam:
Vitals: T 98.4 F, BP 178/85, HR 61, RR 22, O2sat 94% on Room Air
General: Awake, alert, and in no acute distress. Wears glasses.
HEENT: Clear oropharynx, MMM
Neck: supple, no thyromegaly, no JVD, decreased ROM
Pulmonary: equal expansion of lungs bilaterally
Abdomen: soft, nontender
Skin: no significant lesions noted
Neurologic:
-Mental Status: AAOX3 (person, place, and full date). Fluency of
language is preserved with intact naming and repetition. Reading
is preserved and speech is dysarthric. Able to follow multi-step
commands, both axial and appendicular. No neglect or apraxia.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm. EOMI with double vision on
sustained leftward gaze (not reproducible on later exam)
V: Facial sensation reduced to light touch and pinprick on the
right side of face (V1 distribution).
VII: No facial droop, facial musculature symmetric.
VIII: Hearing grossly decreased
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild RT pronation w/o
drift. Bilateral action tremor worse on LT than RT. Strength ___
in bilateral upper extremities with the exception of bilateral
interosei ___. RT IP was pain limited, otherwise full. LT IP
was ___.
-Sensory: Decreased sensation to PP over BLE in a stocking
pattern consistent with peripheral neuropathy. Also observed
hyperesthesia over this area.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 - -
R 2 2 2 - -
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF.
-Gait: Walked with the assistance of walker and ___ supervision.
Pertinent Results:
LDL: 64
TSH: 2.8
Hemoglobin A1c: Pending
CTA HEAD AND NECK ___:
1. Complete occlusion of the left V1 and proximal V2 segments
from the origin of the vertebral artery to the level of C6,
where there is reconstitution of flow from collateral vessels.
2. 50% stenosis by NASCET criteria of the proximal left internal
carotid
artery due to partially calcified atherosclerotic plaque.
Otherwise extensive moderate atherosclerotic disease.
3. The great vessels of the head and neck are otherwise patent
without
stenosis, occlusion, dissection, or aneurysm greater than 3 mm.
4. No intracranial hemorrhage or loss of gray-white
differentiation to suggest acute infarction.
5. 4 mm right upper lobe pulmonary nodule (3:61) requires no
further follow-up according to current ___ guidelines.
6. Final read pending 3D reformations.
CT HEAD ___:
No intracranial hemorrhage or large territorial infarct. MRI
would be more sensitive for evaluation of acute infarct.
Brief Hospital Course:
___ is a ___ right-handed man with afib on coumadin,
HTN, HLD, CAD s/p 5-vessel CABG, TIA in ___ s/p R CEA, who was
transferred from ___ with concern for vertigo,
dysarthria, right-sided weakness and numbness with abnormal CTA
with bilateral vertebral artery occlusions. Neurologic exam with
dysarthria, RT facial decreased sensation, and gait instability.
Stroke risk factors notable for LDL 64, A1C pending. INR
therapeutic at 2.5. Repeat NCHCT with no acute findings, however
CTA head and neck with bilateral vertebral artery occlusions
complete at LT V1 and proximal V2 from origin to level of C6.
Transitional Issues:
# Changed ASA from 162mg daily to 81mg daily to reduce risk of
intracranial bleeding
# Will need repeat INR at rehab
# Will need inpatient physical therapy and occupational therapy
# Fluphenazine 10 mg PO BID This medication was held. Do not
restart Fluphenazine until cleared by your PCP
# ___ 5 mg PO DAILY This medication was held. Do not
restart Lisinopril until confirmed with your PCP that you are
taking this med at home
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 64) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
2. Vitamin E 400 UNIT PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Aspirin 162 mg PO DAILY
5. Warfarin 5 mg PO 5MG DAILY EXCEPT ___ TAKES 7.5MG
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Fluphenazine 10 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Metoprolol Tartrate 100 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. Rosuvastatin Calcium 20 mg PO QPM
13. Digoxin 0.125 mg PO DAILY
14. Warfarin 7.5 mg PO 1X/WEEK (___)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Ipratropium Bromide MDI 2 PUFF IH BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO QPM
10. Topiramate (Topamax) 25 mg PO BID
11. Vitamin E 400 UNIT PO DAILY
12. Warfarin 5 mg PO 5MG DAILY EXCEPT ___ TAKES 7.5MG
13. Warfarin 7.5 mg PO 1X/WEEK (___)
14. HELD- Fluphenazine 10 mg PO BID This medication was held.
Do not restart Fluphenazine until cleared by your PCP
15. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until confirmed with your PCP that you
are taking this med at home
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Pontine ischemic stroke secondary to bilateral vertebral artery
occlusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of slurred speech, right
arm/leg numbness, and right leg weakness resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
We imaged your brain and vessels of head and neck which showed
evidence of blockage in two of your major neck vessels. This is
likely due to atherosclerosis. 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:
Smoking
High cholesterol
High blood pressure
We are changing your medications as follows:
Decreasing aspirin to 81mg daily
Continuing rosuvastatin 20mg daily
Continuing warfarin 5mg daily/7.5 on ___
Please take your other medications as prescribed. Please follow
up with Neurology and your primary care physician as listed
below. If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10538480-DS-21 | 10,538,480 | 25,531,322 | DS | 21 | 2172-10-21 00:00:00 | 2172-10-22 07:28:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cephalosporins
Attending: ___.
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Patient is post ERCP
Impression: The scout film was normal.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
Contrast injection revealed a filling defect in the lower third
CBD.
A biliary sphincterotomy was successfully performed with the
sphincterotome.
There was no post-sphincterotomy bleeding.
The sphincterotome was exchanged for a balloon.
The biliary tree was swept with a 9-12mm balloon starting at
the bifurcation.
Small amount of sludge was successfully removed.
No stone was seen.
The CBD and CHD were swept repeatedly until no further sludge
was seen.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
I supervised the acquisition and interpretation of the
fluoroscopic images.
The quality of the fluoroscopic images was good.
Otherwise normal ercp to third part of the duodenum
Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Recommend surgical evaluation for possible cholecystectomy.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call Advanced
Endoscopy Fellow on call ___
History of Present Illness:
HPI(4):
___ p/w jaundice.
Per ED, the patient was admitted to ___ over the
past 48 hours and found to have T bili of 9, elevated LFTs, and
a
large number of gallstones on ultrasound and MRI. She was
discharged AMA this morning because she was told she would need
surgery, and stated she preferred to receive care at ___
___,
and is therefore presenting to the ER here. EKG sinus at 65 with
normal axis, normal intervals, no ST elevation or depression, no
ischemic appearing T-wave inversions. On exam, ED stated
scleral
icterus, moderate jaundice, nontender moderately obese abdomen,
clear lungs
ED attempted to obtain records from ___, which she did
not
come with. Per ED, found to have positive UA, however she is
denying urinary symptoms, we will await culture results before
treating. Discussed with surgery team, they feel patient would
benefit most from review of MRCP, potential ERCP for
decompression, and medical admission. ERCP team contacted.
I reviewed VS, labs, orders, imaging, old records, meds.
___ 01:30PM BLOOD WBC: 9.8 Hct: 38.3 AbsLymp: 3.97*
AbsMono:
0.95* ___: 13.2* ___: 1.2* Plt Ct: 330
___ 01:30PM BLOOD Creat: 0.5 HCO3: 21* ALT: 900* AST: 523*
AlkPhos: 190* TotBili: 8.8* DirBili: 6.9* IndBili: 1.9 Lipase:
27
Albumin: 3.9
___ 01:20PM URINE Appear: Hazy* Protein: TR* Bilirub: MOD*
Urobiln: 2* Leuks: TR* WBC: 12* Bacteri: FEW* AmorphX: RARE*
Mucous: FEW*
___ 1:20 pm URINE
URINE CULTURE (Pending):
Imaging
liver gb US
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. A simple appearing hepatic cyst in the right
hepatic lobe
measures 1.2 x 1.1 x 1.1 cm. There is no focal liver mass. The
main portal
vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 3 mm.
GALLBLADDER: There is cholelithiasis with circumferential
gallbladder wall
edema and trace pericholecystic fluid, though the gallbladder
is
only mildly
distended.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.3 cm.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
Cholelithiasis, gallbladder wall edema, and trace
pericholecystic fluid, findings which can be seen in acute
cholecystitis, though the gallbladder is only mildly distended.
Recommend correlation with outside hospital ultrasound
and MRCP reported in the ___ medical record. If outside
hospital images are provided, an addendum with comparisons
could
be provided.
EKG reviewed - sinus rhythm
I reviewed outpatient notes. Was being treated for depression,
pancix attacks, inability to concentrate, no SI,
I reviewed ERCP note
Impression: The scout film was normal.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
Contrast injection revealed a filling defect in the lower third
CBD.
A biliary sphincterotomy was successfully performed with the
sphincterotome.
There was no post-sphincterotomy bleeding.
The sphincterotome was exchanged for a balloon.
The biliary tree was swept with a 9-12mm balloon starting at
the bifurcation.
Small amount of sludge was successfully removed.
No stone was seen.
The CBD and CHD were swept repeatedly until no further sludge
was seen.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically
and
fluoroscopically.
I supervised the acquisition and interpretation of the
fluoroscopic images.
The quality of the fluoroscopic images was good.
Otherwise normal ercp to third part of the duodenum
Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Recommend surgical evaluation for possible cholecystectomy.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call Advanced
Endoscopy Fellow on call ___
___ d/w patient. She reiterates information above. She noted
jaundice and decreased appetite x2 days. Went to ___ and
had work up as above. MRCP done. She signed to allow for
requisition of paperwork from ___. She denied nausea,a
vomiting, fever, chills, ab pain, diarrhea, constipation.,
dysuria, urinary frequency
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
ASEPTIC MENINGITIS
viral- ___ ___
G8P2M3
___- uncertain ___ C-sections x 2 large babies
Supracervical hysterectomy- ___- ovaries in
TOBACCO ABUSE
DEPRESSION
ADD
Social History:
Social History
Country of Origin: ___
Marital status: Married, # years: ___
Name ___ ___
___:
Children: Yes: 3 children, all girls- ___,3
Lives with: ___ Children
Lives in: House
Work: ___
Tobacco use: Former smoker
Tobacco Use electric cigarrette
counseling offered:
Year Quit: ___
Years Since 5
Quit:
# Packs/Day: 1
# Years Smoked: 14
Pack Years: 14
Alcohol use: Past and Present
drinks per week: 7
Family History:
Family History
Relative Status Age Problem Onset Comments
Mother Living ___ PERSONALITY DISORDER
OCD
PRE-DIABETES
Father Living ___ PRE-DIABETES
Sister Living ___
Sister Living ___ THYROID NODULE
MGM Deceased SCHIZOPHRENIA
PGF Living CORONARY ARTERY premature
DISEASE
PGM THYROIDITIS
Physical Exam:
Admission Physical Exam:
EXAM(8)
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: LUQ TTP, otherwise nondistended
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: jaundice
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:
___ 01:30PM BLOOD WBC-9.8 RBC-4.69 Hgb-11.7 Hct-38.3 MCV-82
MCH-24.9* MCHC-30.5* RDW-18.7* RDWSD-54.0* Plt ___
___ 01:30PM BLOOD ___ PTT-32.6 ___
___ 01:30PM BLOOD Glucose-94 UreaN-4* Creat-0.5 Na-137
K-4.1 Cl-103 HCO3-21* AnGap-13
___ 01:30PM BLOOD ALT-900* AST-523* AlkPhos-190*
TotBili-8.8* DirBili-6.9* IndBili-1.9
___ 08:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 01:40PM BLOOD AMA-PND Smooth-PND
___ 01:40PM BLOOD ___
___ 01:40PM BLOOD IgG-1417
___ 01:40PM BLOOD HIV Ab-NEG
___ 08:10AM BLOOD HCV Ab-POS*
___ 01:40PM BLOOD HEPATITIS C VIRAL RNA, GENOTYPE-PND
Discharge Labs:
AMA, no labs
Brief Hospital Course:
___ woman with history of a spontaneous abortion
complicated by hemorrhage requiring multiple transfusions in the
___ with resultant depression who presented to ___ on ___ with complaints of jaundice for the last
several
days.
ACUTE/ACTIVE PROBLEMS:
# Transaminitis,
# Concern for acute hep C infection: Patient presented with
elevated transaminases with an ALT up to 1000 and a STN to the 6
and 700s, elevated total bilirubin to the eights, and elevated
alk phos. There is initial concern at the outside hospital for
biliary obstruction. She underwent a right upper quadrant and a
MRCP at the outside hospital without evidence of biliary
obstruction. She ultimately left AGAINST MEDICAL ADVICE and
represented to ___ for further evaluation. Here her
right upper quadrant shows a patent portal vein as well as no
intra-or extrahepatic biliary dilation. She underwent an ERCP
on
___ which had a small amount of sludge but no other findings.
Her LFTs are starting to trend down. She recently got a tattoo
approximately ___ weeks ago on her right wrist. Her hepatitis
C
antibody is positive and she has a viral load of log 5.7. HIV
negative.
- Hepatitis C viral load and genotype pending at discharge.
- ___, IgG, AMA pending at discharge.
- Discussed with Liver team post discharge who are trying to
arrange outpatient liver follow-up.
- S/p ERCP so no AC or ASA/NSAIDS for 5 days (4 days post
discharge).
CHRONIC/STABLE PROBLEMS:
# Depression:
- Continued home Wellbutrin, but held home Abilify given risk
for
hepatotoxicity
# ADD:
-Continued home medication
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 2 mg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. dextroamphetamine-amphetamine 20 mg oral BID
Discharge Medications:
1. ARIPiprazole 2 mg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. dextroamphetamine-amphetamine 20 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute hepatitis C virus
Weight loss
Post ERCP for concern of cholecystitis
Discharge Condition:
Worsening jaundice, bleeding, vomiting, poor appetite, weakness,
fatigue, dehydration, shortness of breath, pale skin, chest
pain, fever, headache, diarrhea, nausea, any worrisome symptoms
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are choosing to leave against medical advance. You have
been explained the risks of leaving including worsening
hepatitis, liver failure, bleeding, vomiting, loss of appetite,
worsening jaundice, including unforeseen possible complications
and death. You have also been warned that leaving AMA will
result in not having your full work up completed, may result in
lapses of care, incomplete work up, unevaluated or lost labwork,
and other complications with your care plan as it is written by
a physician who is not your primary hospitalist, and because it
is late, your subspecialities services are on coverage, and not
your primary coverage teams.
As you are leaving against medical advice, please schedule
follow up appointments immediately on discharge with:
Your primary care physician, if you do not have a primary care
physician, please schedule a follow up with ___
___ clinic if possible with doctor ___
or
___ - ___
General surgery clinic if possible with doctor ___
or
___ - ___
You should call the ___ medical record ___ in the
morning tomorrow and requisition all records from this current
stay. If you have pending labs, you should call back the
following day. You should also call back and request a
discussion with your primary attending ___ to determine
if there is any further follow up information you still need
that you do not have. You should also call ___
___'s record department and request all your paperwork,
labs, and imaging from your recent admission. You should bring
all this information with you to all of your follow up
appointments.
If you experience worsening jaundice, bleeding, fever, vomiting,
weigth loss, or any other worrisome symptoms you should return
to the emergency department immediately.
Followup Instructions:
___
|
10538657-DS-22 | 10,538,657 | 21,754,601 | DS | 22 | 2145-11-13 00:00:00 | 2145-11-14 13:19:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Atorvastatin / alprazolam / oxytocin / Demerol /
Codeine / lorazepam / Cyclobenzaprine / narcotic pain medication
/ amiodarone
Attending: ___
Chief Complaint:
SHORT OF BREATH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/hx CAD s/p CABG & multiple PCI dating back ___ years,
chronic afib, sCHF (LVEF ___ s/p AICD implantation ___ who
p/w interval worsening SOB w/minimal exertion at home.
.
She was seen in the ED 2 days ago for similar concerns; EP
adjusted her ICD settings (turned off tracking when she was
noted to be in afib to the 120s); she was then given 50 mg
Toprol XL, 40 mg IV lasix, and sent home. However, she
experienced no interval change, so re-presented to the ED
yesterday evening. No anginal chest pain, no palpitations, but
describes SOB all the time, worst with walking. Can only walk a
few steps at a time. At home she is monitored by CHF NP who
adjusts daily torsemide dosing based upon phoned-in daily
weights, usually 40-60 mg torsemide QD. The morning of admission
she was at her dry weight of 159 so was instructed to take no
diuretics.
.
In the ED yesterday evening, initial VS 97.4 106 132/77 24
98%/RA. EKG demonstrated afib w/incomplete LBBB, nonspecific ST
changes c/w prior. INR therapeutic at 2.6, trop 0.02 (baseline),
Cr 2.5 (bl ~ 2.2), BNP 15674. Cardiology attg recommended
admission to CMED.
.
This morning she continues to feel SOB, even sitting in bed
talking to her daughter. Afraid of becoming SOB walking to
bathroom. Reports intermittent compliance with low salt diet,
and good compliance with 2L fluid restriction. Baseline ___
pillow orthopnea unchanged; no abdominal or leg edema, no cough.
Some fleeting CP & palpitations which are dwarfing (in her mind)
by overwhelming SOB. Also describes intermittent nausea
unchanged recently. Daughter also reports that her mother feels
congested and is awaiting ENT evaluation (scheduled for later
this week) for chronic headaches not relieved by tylenol.
Past Medical History:
* CARDIAC HISTORY:
Systolic congestive heart failure - ___ TTE: EF ___ w/ 2+
MR
NSTEMI ___
.
INTERVENTIONS:
- CABG: ___ LIMA-LAD, SVG-D1, SVG-OM1
- PCI: multiple PCIs, mostly to LAD - most recent cardiac
catheterization in ___ showing widely patent grafts
* ___: NSTEMI s/p coronary atherectomies to LAD/D1 bifurcation
lesion with placment of 2 stents and PTCA to jailed D1
* ___: Elective cath revealed in-stent restenosis and 90%D1
restenosis; PTCRA was performed for in-stent restenosis as
well as kissing balloons to LAD/D1 with residual 20% D1 lesion
* ___: UA with cath/no intervention but LVEDP 38
* ___: Chest pain with diagnostic cath showing widely patent
LIMA-LAD and SVG-D1-OM1. LMCA with 50% stenosis, LAD with 80%
proximal and mid, LCx with 70-80% proximal, and RCA with 80%
ostial lesion. LVEDP severely elevated to 36 mmHg.
* RHC on ___ showed mean wedge of 20 and CO of 2.871 L/min
.
- PACING/ICD:
- ___ Hx NSVT on telemetry in the setting of MI, sustained
T-wave alternans on stress testing (worked up for ICD but none
placed)
- s/p AICD - BiV pacer ___
- Chronic ATRIAL FIBRILLATION
.
Other MEDICAL & SURGICAL HISTORY:
Peripheral vascular disease
Hypothyroidism
Nephrolithiasis (s/p right nephrectomy, creatinine 1.1-1.4
baseline)
Plantar fasciitis
Reflux esophagitis, peptic ulcer disease, GERD
Peripheral neuropathy
s/p right inguinal hernia operations x ___
s/p laparoscopic cholecystectomy ___ ___)
s/p hysterectomy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathy, or
sudden cardiac death.
Physical Exam:
ADMISSION
VS - 97.4 ___ 20 100%/RA 73.3 kg
GENERAL - sitting up on side of bed leaning forward talking
w/daughter, no conversational dyspnea NAD
___ - ___, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no carotid bruits, JVP 7
HEART - irregularly irregular, distant heart sounds,
+holosystolic murmur, no rub
LUNGS - good aeration and expansion, +diffuse rales throughout
ABDOMEN - obese, NABS, soft/NT/ND, no masses
EXTREMITIES - WWP, no c/c/e, 2+ radial pulses, 1+ dps
NEURO - AA&Ox3, CNs II-XII grossly intact, full muscle strength
throughout. Gait slow but stable.
.
DISCHARGE
VS 97.3 115/70 (90-100/70-80s) 81 18 99/RA Wt 69.9
GENERAL - walking around the room carrying on conversation with
neighbor NAD
___ - ___, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, JVP 5
HEART - irregularly irregular, distant S1/S2, no rub
LUNGS - good aeration and expansion, no rales
ABDOMEN - obese, NABS, soft/NT/ND, no masses
EXTR - WWP, no c/c/e, +palpable distal pulses
NEURO - AA&Ox3, CNs II-XII grossly intact, full muscle strength,
gait stable.
Pertinent Results:
ADMISSION LABS
___ 12:20AM BLOOD WBC-9.6 RBC-4.18* Hgb-13.3 Hct-38.3
MCV-92 MCH-31.9 MCHC-34.8 RDW-15.1 Plt ___
___ 12:20AM BLOOD ___ PTT-37.2* ___
___ 11:35PM BLOOD Glucose-170* UreaN-42* Creat-2.5* Na-134
K-5.1 Cl-98 HCO3-17* AnGap-24*
___ 04:20AM BLOOD CK(CPK)-46
___ 11:35PM BLOOD cTropnT-0.02* ___
___ 11:35PM BLOOD Calcium-10.4* Phos-4.7* Mg-2.4
.
URINALYSIS
___ 12:47AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:47AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:47AM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-1
___ 12:47AM URINE CastHy-12*
.
DISCHARGE LABS
___ 07:08AM BLOOD WBC-8.3 RBC-4.80 Hgb-15.4 Hct-43.2 MCV-90
MCH-32.0 MCHC-35.6* RDW-15.3 Plt ___
___ 07:08AM BLOOD Plt ___
___ 07:08AM BLOOD Glucose-144* UreaN-58* Creat-2.4* Na-140
K-3.1* Cl-96 HCO3-27 AnGap-20
___ 07:08AM BLOOD Calcium-10.5* Phos-4.5 Mg-2.2
.
IMAGING
___ CXR
PA AND LATERAL CHEST RADIOGRAPHS: An AICD/pacemaker generator
overlies the left chest wall. The leads appear intact and
terminate in the expected locations of the right and left
ventricles. The lungs are clear. There is no focal consolidation
or pneumothorax. There is no vascular congestion or pleural
effusions. Mediastinal and hilar contours are within normal
limits.
Moderate cardiomegaly, with disproportional enlargement of the
right heart, is unchanged from prior.
IMPRESSION:
1. Unchanged moderate cardiomegaly. Pacemaker/AICD leads intact
and in standard position.
2. No pulmonary edema or consolidation.
.
___ TTE
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 15*-20%). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is dilated with
mild global free wall hypokinesis. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] 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. Severe (4+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. [In the setting of
at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.]
Compared with the prior study (images reviewed) of ___,
the left ventricle appears more dilated. Systolic function is
similar (was OVERestimated on prior). The severity of mitral
regurgitation is severe (was described as moderate on prior but
was probably moderate-to-severe then). Dilated and hypokinetic
right ventricle. There is a pacing/ICD wire in place now and it
appears to be causing increased tricuspid regurgitation (now
severe). Estimated pulmonary pressures are lower although,
again, likely underestimated.
Brief Hospital Course:
___ w/chronic sCHF EF20-25%, chronic afib and recent ICD
placements p/w persistent tachycardia and dyspnea w/minimal
exertion despite ICD adjustment 2d prior to admission, now
admitted for CHF management, with marked clinical improvement
after diuresis and initiation of long-acting nitrate & digoxin.
.
# sCHF w/ EF ___
Volume overloaded on admission exam; concern that her current
flare may represent an exacerbation of an already-declining
baseline cardiac pump function, likely ___ uncontrolled atrial
fibrillation, and possibly also worsening valvular disease.
Noted to be s/p very recent ICD placement for primary
prevention. TTE repeated here shows worsening MR, worsening LV
dilation, and TR 2+ -> 4+. Heart failure medication regimen
modified to be: Metoprolol Succinate XL 100 mg PO DAILY,
Torsemide 60 PO QD, Imdur 30 QD, digoxin 125 mcg QOD (NB: s/p
dig loading 0.25 mcg q12h x 2 doses on ___. Not on an ACEi bc
of chronic renal insuffiency. She was feeling well, euvolemic on
exam, walking around carrying on comfortable conversation with
staff for two days prior to dischargem and for >24h on oral
regimen. Discharge weight 69 kg. Needs f/u TTE while euvolemic
to re-assess TR.
.
# AFIB W/RVR
Chronic issue; here on admission and 2d ago in the ED, EKGs &
telemetry demonstrate poor rate control, HR 100-120 w/frequent
self-limited RVR to 140s. Tachycardia thought to worsen CHF, so
rate control was a major goal at this time. Significant
improvement after dig loading, 0.25 x 2 doses q12 on ___,
with resultant HR baseline ___ on telemetry. She was seen by the
EP consult team who recommended AVJ ablation in ___ weeks.
Coumadin dosing unchanged.
.
# HTN
BP baseline 90-100s, not altered by diuresis or initiation of
nitrate. Hydralazine discontinued, started on imdur + ongoing
diuresis w/torsemide as above.
.
# NAUSEA/VOMITING
Vomited once on ___. Pt has hx of nausea due to abdominal
congestion when volume overloaded. Symptoms resolved w/diuresis.
.
# HX CAD s/p CABG
No anginal chest pain during this admit. Cardiac enzymes at
baseline (MB fraction negative) on admission. Review last cath
report from ___ demonstrating widely patent grafts. Continued
ASA, statin, Coenzyme Q.
.
# HEADACHE
Congestion and headache ongoing x weeks. Pt awaiting outpatient
ENT evaluation. Not responsive to tylenol at home, good response
to fioricet here.
.
# DM2
Onset ___ years ago. BS well-controlled on ISS and a diabetic
diet.
.
# CHRONIC RENAL INSUFFICIENCY
Baseline Cr 2.2-2.5 over the past year. Within baseline at 2.4
on admission, now downtrending. Underlying issue is lack of ___
kidney - s/p nephrectomy for complications of nephrolithiasis.
Cr was monitored closely while diuresing. Discharge Cr 2.4.
.
# Hypothyroidism
Continued synthroid ___ mcg qday.
.
TRANSITIONAL ISSUES
1. CHF - trend weights, adjust torsemide dosing PRN
2. CRD - recheck Cr
3. Hypokalemia - required aggressive repletion while on IV lasix
in-house, discharged on oral potassium but may need dose
adjustment/monitoring
4. Needs follow-up echo when euvolemic to re-assess TR
Medications on Admission:
Pravastatin 20 mg qday
Levothyroxine 100 mcg qday (___)
Aspirin 81 mg qday
Ranitidine 150 mg qday
Metoprolol Succ 100 mg qday
Torsemide (averages 40 mg per day, took 60 on ___, none on
___
Metolazone - intermittent
Coenzyme Q10 100 mg qday
Coumadin 2 mg qday ___ 1 mg per day, else
Hydralazine 10 mg q8h
Metformin (recently stopped by PMD)
Glimepiride 4 mg qday (recently started by PMD)
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAYS
(___).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Imdur 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet
Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO qday ().
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS (___).
10. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS
(___).
11. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
12. glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
13. potassium chloride 10 mEq Tablet Extended Release Sig: Three
(3) Tablet Extended Release PO twice a day.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
14. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO once a
day as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute-on-chronic systolic heart failure, ejection fraction
___
Atrial fibrillation
Chronic renal insufficiency
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital with decompensated congestive
heart failure. ___ were suffering from worsening
shortness-of-breath at home.
Your symptoms improved quickly with a modified set of
medications to control heart failure. We felt your heart failure
progressed due to worsening valve regurgitation, which we saw on
Echocardiogram.
___ should continue limit your fluid intake to 1.5 liters per
day and limit your salt intake to no more than 2 grams total per
day. Please remember to read labels carefully and look out for
hidden sources of salt like prepared & canned foods, crackers,
spice mixes & soy sauce.
We made the following changes to your medications:
HOLD your warfarin dose today
STARTED IMDUR, TAKE 30 MG DAILY
STARTED DIGOXIN, TAKE 125 MCG EVERY OTHER DAY
*INCREASED* TORSEMIDE DOSE, TAKE 60 MG TWICE DAILY
STOPPED HYDRALAZINE
STOPPED METOLAZONE
.
Please review the attached medication list with your doctors at
your ___ appointments (see below for scheduling details).
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10538657-DS-27 | 10,538,657 | 27,000,935 | DS | 27 | 2149-08-22 00:00:00 | 2149-08-25 14:37:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Atorvastatin / alprazolam / oxytocin / Demerol /
Codeine / lorazepam / Cyclobenzaprine / narcotic pain medication
Attending: ___.
Chief Complaint:
Shortness of breath, weight gain, fatigue.
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
___ with a history of systolic congestive heart failure with
reduced EF of 15% on echo from ___, chronic AF, severe MR
___ bioprosthetic mitral valve in ___, severe TR, 3V CAD ___
CABG ___, ___ nephrectomy, hx of VT storm and AVJ
ablation who presented to outpatient ___ clinic with marked
volume overload (reports ___ weight gain). She was
complaining of head congestion (her main complaint with HF
symptomatology) and weakness. She was also complaining of
worsened dyspnea. At baseline she is dependent on help for
personal hygiene, ADLS and is unable to do any physical
activity. She also has chronic diarrhea and a poor appetite with
a drop in her weight from 165-170lbs in ___ to 144-145lbs.
She also reports recent falls and dizziness. She was sent to
___ ED for further evaluation.
In terms of her heart failure, she has failed PO metolazone and
higher doses of home diuretics necessitating the need for
periodic intravenous infusions of Lasix. She gets 120mg IV Lasix
boluses every two weeks.
Of note, she was also recently seen at ___ after a fall
with a head strike resulting in an ecchymotic right eye. NCHCT
was negative.
In the ED initial vitals were: 97.3 HR 80 BP 115.62 RR 22
100%RA.
EKG:
Labs/studies notable for: H&H 9.7/33.4, plts 171, WBC 9.2. INR
2.7. BUN/Cr 47/2.9. Na+132. Anion gap 14. ___ 13648 from
___ in ___. UA neg. CXR shows pulmonary edema, pleural
effusion on R and a small consolidation. Lactate 1.8. She was
started on a Lasix gtt @ 5mg/hr.
Past Medical History:
- Systolic congestive heart failure ___: EF 35%
- Mitral regurgitation ___
- Coronary artery disease, NSTEMI ___ ___ CABG x ___, ___
multiple PCIs, mostly to LAD
* ___: NSTEMI ___ coronary atherectomies to LAD/D1 bifurcation
lesion with placment of 2 stents and PTCA to jailed D1
* ___: Elective cath revealed in-stent restenosis and 90%D1
restenosis; PTCRA was performed for in-stent restenosis as well
as kissing balloons to LAD/D1 with residual 20% D1 lesion
* ___: UA with cath/no intervention but LVEDP 38
* ___: Chest pain with diagnostic cath showing widely patent
LIMA-LAD and SVG-D1-OM1. LMCA with 50% stenosis, LAD with 80%
proximal and mid, LCx with 70-80% proximal, and RCA with 80%
ostial lesion. LVEDP severely elevated to 36 mmHg.
* RHC on ___ showed mean wedge of 20 and CO of 2.871 L/min
- PACING/ICD:
- ___ Hx NSVT on telemetry in the setting of MI, sustained
T-wave alternans on stress testing (worked up for ICD but none
placed)
- ___ AICD - ___ pacer ___
- Chronic atrial fibrillation, on Coumadin
- Peripheral vascular disease
- Diabetes mellitus
- Hypothyroidism
- Nephrolithiasis ___ right nephrectomy, creatinine 1.1-1.4
baseline)
- Plantar fasciitis
- Reflux esophagitis, peptic ulcer disease, GERD
- GI Bleed ___
- Peripheral neuropathy
Past Surgical History:
- ___ CABG x ___
- ___ right nephrectomy
- ___ AICD - ___ pacer ___
- ___ right inguinal hernia operations x ___
- ___ laparoscopic cholecystectomy ___ ___)
- ___ hysterectomy
Social History:
___
Family History:
Father had CHF, died at age ___. Otherwise no signficant family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
Physical Exam on Admission:
T=97.5-98.6, 110s-140s/60s-80s, pulse 80, ___ 95% on RA
Weight on admission: 68.9 (dry weight 71kg but inaccurate due to
recent cachexia)
GENERAL: Elderly female in no acute distress.
HEENT: Normocephalic. R Echymosses over eye. The oropharynx is
benign.
NECK: Supple.
CV: RRR, normal S1/S2, prominent respirophasic S3. JVP improved
from prior, approximately 8-10cm. Faint holosytolic murmur at
tricuspid position.
CHEST: Good respiratory effort, faint bibasilar crackles.
ABDOMEN: Soft and normoactive BS.
EXTREMITIES: warm, 1+ edema to thigh
NEUROLOGIC: AAOx3, non-focal.
SKIN: warm, no rashes.
Psych: appropriate.
=
=
=
=
=
=
=
=
=
=
=
================================================================
Physical Exam on Discharge:
T=97.5-98.6, 114-121/64-67, pulse 80, ___ 95% on RA
I/O:
8H: 220 in, 1300 out
24H: 850 in, 2300 out
Weight: 68.9 (dry weight 71kg but inaccurate due to recent
cachexia)
58.4kg (Discharge)
GENERAL: Elderly female in no acute distress.
HEENT: Normocephalic. R Echymosses over eye. The oropharynx is
benign.
NECK: Supple.
CV: RRR, normal S1/S2, prominent respirophasic S3. JVP improved
from prior, approximately 7cm. Faint holosytolic murmur at
tricuspid position.
CHEST: Good respiratory effort, faint bibasilar crackles.
ABDOMEN: Soft and normoactive BS.
EXTREMITIES: warm, 1+ edema to thigh
NEUROLOGIC: AAOx3, non-focal.
SKIN: warm, no rashes.
Psych: appropriate.
Pertinent Results:
Labs on Admission:
___ 01:15AM BLOOD WBC-9.2 RBC-4.06 Hgb-9.7* Hct-33.4*
MCV-82 MCH-23.9* MCHC-29.0* RDW-24.8* RDWSD-72.6* Plt ___
___ 01:15AM BLOOD Neuts-84.4* Lymphs-4.7* Monos-8.6 Eos-1.1
Baso-0.7 Im ___ AbsNeut-7.77* AbsLymp-0.43* AbsMono-0.79
AbsEos-0.10 AbsBaso-0.06
___ 01:15AM BLOOD ___ PTT-39.3* ___
___ 01:15AM BLOOD Glucose-96 UreaN-47* Creat-2.9* Na-132*
K-4.9 Cl-100 HCO3-18* AnGap-19
___ 01:15AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
___ 01:15AM BLOOD GreenHd-HOLD
___ 07:38PM BLOOD Lactate-1.8
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================================================================
Labs on Discharge:
___ 06:00AM BLOOD WBC-8.4 RBC-4.01 Hgb-9.7* Hct-32.8*
MCV-82 MCH-24.2* MCHC-29.6* RDW-24.9* RDWSD-73.0* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-69* UreaN-19 Creat-1.7* Na-136
K-3.6 Cl-94* HCO3-29 AnGap-17
___ 06:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
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================================================================
Clinical Studies/Imaging:
___: TTE
Conclusions
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 15 %). No masses or thrombi
are seen in the left ventricle. with depressed free wall
contractility. A bioprosthetic mitral valve prosthesis is
present. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.]
Compared with the prior study (images reviewed) of ___,
no clear change (TR remains severe).
___: CXR
IMPRESSION:
1. Increased CHF, compared with ___
2. Increased right pleural effusion with underlying atelectasis.
The
possibility of an early pneumonic infiltrate at the right base
cannot be
entirely excluded.
3. Moderately severe cardiomegaly is grossly unchanged.
Pacemaker/AICD device
again noted.
___: CXR
IMPRESSION:
Mild pulmonary vascular congestion and small right pleural
effusion. Patchy right basilar opacity may reflect atelectasis
however infection cannot be completely excluded.
___: EKG
Ventricularly paced rhythm with likely underlying atrial
fibrillation.
Compared to the previous tracing of ___ the findings are
similar.
Brief Hospital Course:
___ with a history of CAD ___ CABG in ___, severe TR, systolic
congestive heart failure with EF 15% ___, severe MR ___ MVR
with ___ in ___ who presented to infusion clinic with
complaints of worsening dizziness, increased falls, admitted for
acute systolic heart failure exacerbation.
#Acute on chronic systolic heart failure exacerbation: Ms.
___ was admitted with shortness of breath, congestion
symptoms and found to be grossly volume overloaded on exam. She
had a ___ that was 13000 with CXR demonstrating pulmonary
edema. Her admission weight was 68.9kg (dry weight 71kg but
inaccurate due to recent cachexia). Clinically, she had an
elevated JVP to the earlobe, diffuse crackles bilaterally, RRR
with faint holosystolic murmur at the apex, and severe ___
pitting edema to the sacrum. We obtained a TTE that demonstrated
her LVEF was 15% (same as prior), but with right ventricular
contractile function that was further impaired compared to the
past. We started her on a Lasix gtt at 15/hr and decreased it
progressively until she was successfully transitioned to oral
torsemide 40mg BID. She diuresed well during this course with
successful resolution of her shortness of breath and diffuse
peripheral edema. At the time of discharge, her dry weight was
58.4kg. We believe this will be her new dry weight. She was
discharged on Torsemide 40mg BID with PO potassium 20meq daily.
At the time discharge, his cardiac medications included imdur,
hydral, metop XL, amio, dig and torsemide. ___ will follow-up
with Dr. ___ in the outpatient setting.
#Atrial Fibrillation w/ hx of VT storm on Coumadin: Ms. ___
has a ___ pacemaker. An EKG demonstrated that she was
ventricularly paced rhythm with likely underlying atrial
fibrillation. Compared to the previous tracing of ___, these
findings were similar. We continued to titrate her Coumadin to
an INR goal of ___. Her INR remained at goal throughout this
admission. At the time of discharge, her INR was 2.4. We
discharged her on Coumadin 0.5mg daily. She will need to have
her INR checked early next week. Please follow-up on it and
adjust her Coumadin accordingly in the outpatient setting.
#Severe pulmonary HTN: Ms. ___ recently had a RHC that
showed a mean pulmonary capillary wedge pressure was 27 mmHg
with a mean pulmonary artery pressure of 38 mmHg, a
transpulmonary gradient of 11 mmHg and a pulmonary vascular
resistance of three woods units. Cardiac index was less than 2
and her right atrial mean pressure was 16. Per Dr. ___
was not a good candidate for pulmonary vasodilator therapy.
#CAD ___ CABG: We continued her aspirin. Her metoprolol was
initially held in the setting of HF exacerbation but was resumed
at the time of discharge. We had a discussion with her regarding
atorvastatin and she did not want to initiate therapy due to
history of myopathy with the medication.
#Stage V CKD: Ms. ___ has a history of Stage V CKD with a
baseline Cr 2.2-2.9, GFR 13. She is a dialysis candidate but per
renal a fistula may create a steal phenomenon that will worsen
her cardiac condition, hence she has never initiated HD. She was
admitted with a Cr of 2.9, which continued to downtrend as we
diuresed her. She transiently developed metabolic acidosis
during this admission but it subsequently resolved as we
continued to diurese her. At the time of discharge, her Cr was
lower than her most recent baseline (discharge Cr 1.7; previous
baseline 2.2-2.9).
#Catheter-associated UTI: During this admission, Ms. ___
endorsed having urinary symptoms including dysuria, burning and
increased frequency. We removed her foley and analyzed her urine
and it was positive with +bacteria and WBCs, but no culture
results. Due to her symptoms, we decided to treat her with a 7
day antibiotic course. She was started on ceftriaxone and
transitioned to cefpdoxime (to end ___.
#Anemia: Ms. ___ has a history of chronic microcytic,
hypochromic anemia that is most likely ___ to her CKD and iron
deficiency. Her iron deficiency may relate to poor intake and
poor absorption as well as losses from the diarrhea. Per
outpatient renal, to defer iron therapy at this time. Hence we
did not supplement her. Her hgb remained stable between ___.
#CDiff: She has a history of recurrent Cdiff and was previously
on Vanc 500mg BID. We discussed with our inpatient ID team and
they recommended changing her to PO vanc 125mg BID for chronic
suppressive therapy. She remained asymptomtatic and did not have
any acute diarrhea during this admission. She was discharged on
PO Vanc 125mg BID.
#Gout: She has not had any gout flares recently. We continued
her allopurinol renally dosed and resumed her home daily
frequency at the time of discharge as her kidney function
improved.
#Falls: Patient has had multiple falls recently that prompted
admissions to ___. We obtained a ___ evaluation and
they recommended home ___, which she will have.
#Diabetes II: On insulin glargine and at home. We continued her
home lantus and ISS. Her sugars remained at goal.
#Chronic pain: We continued her home gabapentin.
#Hypothyroidism: We continued her home levothyroxine 100 mcg
#Malnutrition: Ms. ___ has had significant weight loss over
the past months. We obtained a nutrition consult who recommended
the following: encouraging smaller, more frequent meals with
emphasis on protein intake; nutritional supplementation with
sugar free carnation instant breakfast w/ whole milk w/ 1pkt
Beneprotein TID.
#Goals of Care: During this admission, extensive discussions
were held with family, Dr. ___ the palliative care team
to discuss further steps given Ms. ___ future medical
goals. Right heart catheterization with potential initiation of
dobutamine was deferred during this hospitalization because of
her improved clinical status with diuretics. However, if she
decompensates in the near future, right heart catheterization
with initiation of dobutamine may be considered. The risks of
dobutamine were discussed including that it is used as a last
resort and can add quality but may in fact hasten death.
Palliative care was involved in discussing resources, including
hospice, that can be used going forward. Hospice care was
deferred at this time but can be considered as a transition
outside the hospital.
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================================================================
TRANSITIONAL ISSUES:
1. Please follow-up regarding her acute systolic heart failure
exacerbation. She was discharged on Torsemide 40mg BID
2. Please check her lytes during the outpatient appointment in 1
week.
3. Her discharge weight was 58.4kg. Please note her previous dry
weight may not be reliable due to her recent weight loss.
4. Statin therapy has been deferred given the minimal benefit
and severe side effect of myalgias she experienced with this
class of medications.
5. Please note that her cardiac meds at time of discharge
include:
-Isosorbide mononitrate
-Hydralazine
-Metoprolol succinate
-Amiodarone
-Digoxin
-PO Potassium
-Torsemide
6. Please follow-up regarding her urinary symptoms. We treated
her for a course of CAUTI with ceftriaxone and switched her over
to oral cefpdoxime for a total of 7 days.
7. After discussion with Dr. ___ from ID, we decreased
her suppressive vanco dose to 125mg BID for her chronic Cdiff.
8. Her creatinine improved with diuresis, and her discharge Cr
was 1.7
9. Please follow-up regarding her chronic anemia, she has been
getting outpatient EPO.
10. Please note we had multiple goals of care meetings with Ms.
___ and she confirmed her code status of DNR/DNI.
11. Discharged on PO potassium
12. As transitional issue consider initiating ACE and
spironolactone.
13. Please note that we had a discussion with her regarding
atorvastatin and she did not want to initiate therapy due to
history of myopathy with the medication.
#Code: DNR, DNI, ___ ICD to remain on.
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Amiodarone 200 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.0625 mg PO EVERY OTHER DAY
5. Gabapentin 300 mg PO QHS
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Warfarin 1 mg PO 3X/WEEK (___)
9. Metoprolol Succinate XL 25 mg PO QHS
10. Torsemide 60 mg PO BID
11. Potassium Chloride 40 mEq PO DAILY
12. Allopurinol ___ mg PO DAILY
13. Warfarin 0.5 mg PO 4X/WEEK (___)
14. vancomycin 500 mg oral BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Amiodarone 200 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.0625 mg PO EVERY OTHER DAY
5. Gabapentin 300 mg PO QHS
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 25 mg PO QHS
8. Potassium Chloride 40 mEq PO DAILY
9. Warfarin 0.5 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. Allopurinol ___ mg PO DAILY
11. Vancomycin Oral Liquid ___ mg PO BID
RX *vancomycin 125 mg 1 capsule(s) by mouth Twice daily Disp
#*60 Capsule Refills:*0
12. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
Take on ___, then stop.
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
13. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
14. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
15. HydrALAzine 20 mg PO Q8H
RX *hydralazine 10 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. acute decompensated systolic congestive heart failure
2. severe tricuspid regurgitation
3. acute on chronic kidney disease
4. pulmonary hypertension
5. catheter-associated urinary tract infection
6. atrial fibrillation
SECONDARY DIAGNOSES:
1. Anemia
2. Diabetes II
3. Chronic CDiff
4. Gout
5. Malnutrition
6. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
after you presented with shortness of breath and weight gain.
You were subsequently diagnosed with an acute heart failure
exacerbation from fluid building up in your body. While you were
here, we started you on a Lasix drip to help get fluid off of
you. We monitored your weights, kidney function, and how much
you were urinating closely. We saw your weight decrease and your
kidney function improve with diuresis during this
hospitalization successfully.
While you were here, we also discussed with Dr. ___ the
best next steps in your care. The ultrasound of your heart
(echocardiogram) continued to show persistent tricuspid
regurgitation (leaky valve) and that the squeezing function of
your heart was very reduced - both of which, unfortunately, are
not new news. Additionally, your pulmonary hypertension remains
severe, and it was decided during our family meeting with Dr.
___ a right heart catheterization was not a good idea at
this time. Because of this, you will likely be hospitalized
again. At that time, dobutamine may be considered based on how
you are doing clinically and also if your heart responds to it -
which we won't know until you undergo cardiac catheterization.
We did not do a cardiac catheterization during this admission
but may benefit from one in the future, again, something that
was discussed with Dr. ___.
For your atrial fibrillation, we continued your Coumadin
titrated to a goal INR of ___. On the day of discharge, your INR
was 2.4. Please note that we are discharging you on Coumadin
0.5mg daily, but that you need to have your INR checked early
next week. The Coumadin dose may need to be adjusted based on
the INR level, but ___ let you know.
Your weight on the day of discharge was 58.4kg. Call Dr. ___
___ or ___ if your weight increases more than 3lbs
in one day.
While you were here, you developed urinary symptoms and we found
you had a urinary tract infection. For this, we started you on
an antibiotic called ceftriaxone and then switched you to an
oral antibiotic called cefpodoxime. Please take this antibiotic
until ___, then you can stop.
For your chronic Cdiff, we continued you on a lower vancomycin
dose (125mg twice daily) per our infectious disease team
recommendations.
It was a pleasure caring for you.
***Please go to ___ and have your labs drawn on ___.
These will be sent to your cardiologist***
We wish you the absolute best,
Your ___ Team
Followup Instructions:
___
|
10538657-DS-30 | 10,538,657 | 29,784,336 | DS | 30 | 2150-01-01 00:00:00 | 2150-01-02 16:51:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Atorvastatin / alprazolam / oxytocin / Demerol /
Codeine / lorazepam / Cyclobenzaprine / narcotic pain medication
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a PMHx ischemic
cardiomyopathy, severe chronic systolic heart failure (LVEF 15%)
on palliative dobutamine, CAD ___ 3V CABG ___, BiV/ICD, chronic
AF and AVJ ablation, severe MR ___ bioprosthetic mitral valve in
___, severe TR, hx of VT storm, ___ nephrectomy, recurrent C.
diff who presents with weakness and is found to have acute on
chronic renal failure and hyperkalemia.
Pt reports that she fell 3 days ago. She went to ___ where
she had a negative head CT. The day prior to presentation, she
reports experiencing total body weakness and cramping pain over
multiple parts of her body. In the evening, she also experienced
chest pain and shortness of breath and felt a sense of impending
doom. She slid out of bed because she was too weak to get up, so
called her family, who brought her in to the hospital. She had
no headstrike or loss of consciousness.
She reports that over the last few days, her weight has been
increasing (from 57.9kg on discharge ___, now 62kg), she has had
worsened orthopnea. She thinks her leg edema is at baseline. Of
note, her potassium level had been checked and low earlier this
week, so potassium supplementation was increased from 60 meq
daily to 80 daily.
She denies fevers, chills, cough, abdominal pain, dysuria,
nausea, vomiting. She endorses pain over her left hip and
shoulder over the sites where she landed when she fell.
In the ED, initial vitals: HR 77; BP 128/58; RR 17; O2 100% RA
Pt was given:
___ 07:55 IV Calcium Gluconate 2 g
___ 08:16 IV DRIP DOBUTamine Started 2.5 mcg/kg/min
___ 08:16 IV Insulin Regular 10 units
___ 08:27 IV Dextrose 50% 25 gm
___ 09:32 PO/NG Acetaminophen 650 mg
___ 09:32 PO/NG Amiodarone 200 mg
___ 09:32 PO/NG Levothyroxine Sodium 100 mcg
We discussed her preferences regarding life sustaining therapy
at length. Quality of life is important for her and she does not
want to be sustained on machines. She saw her father die on
machines and wouldn't want that for herself. She is DNR/DNI. (Of
note, she has an ICD in place which she is OK keeping on.) We
discussed dialysis and she is unsure at this time whether she
would accept dialysis. She is hesitant to take on another
therapy that would further compromise her quality of life. She
wants to discuss this with her children before making a final
decision. Of note, per MOLST from ___, pt is DNR/DNI,
ok for BIPAP, no dialysis, ok to use artificial
nutrition/hydration.
Review of systems: As per above otherwise negative.
Past Medical History:
- T2DM
- Systolic congestive heart failure ___: EF 35%
- Mitral regurgitation ___
- Coronary artery disease, NSTEMI ___ ___ CABG x ___, ___
multiple PCIs, mostly to LAD
* ___: NSTEMI ___ coronary atherectomies to LAD/D1 bifurcation
lesion with placment of 2 stents and PTCA to jailed D1
* ___: Elective cath revealed in-stent restenosis and 90%D1
restenosis; PTCRA was performed for in-stent restenosis as well
as kissing balloons to LAD/D1 with residual 20% D1 lesion
* ___: UA with cath/no intervention but LVEDP 38
* ___: Chest pain with diagnostic cath showing widely patent
LIMA-LAD and SVG-D1-OM1. LMCA with 50% stenosis, LAD with 80%
proximal and mid, LCx with 70-80% proximal, and RCA with 80%
ostial lesion. LVEDP severely elevated to 36 mmHg.
* RHC on ___ showed mean wedge of 20 and CO of 2.871 L/min
- PACING/ICD:
- ___ Hx NSVT on telemetry in the setting of MI, sustained
T-wave alternans on stress testing (worked up for ICD but none
placed)
- ___ AICD - BiV pacer ___
- Chronic atrial fibrillation, on Coumadin
- Peripheral vascular disease
- Diabetes mellitus
- Hypothyroidism
- Nephrolithiasis ___ right nephrectomy, creatinine 1.1-1.4
baseline)
- Plantar fasciitis
- Reflux esophagitis, peptic ulcer disease, GERD
- GI Bleed ___
- Peripheral neuropathy
Past Surgical History:
- ___ CABG x ___
- ___ right nephrectomy
- ___ AICD - BiV pacer ___
- ___ right inguinal hernia operations x ___
- ___ laparoscopic cholecystectomy ___ ___)
- ___ hysterectomy
Social History:
___
Family History:
Father had CHF, died at age ___. Otherwise no signficant family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
===============
ADMISSION EXAM:
===============
Vitals: T: 97.6 BP: 122/64 P: 85 R: 21 O2: 100% on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP mildly elevated
LUNGS: Mild basilar crackles
CV: Regular rate and rhythm, S1/S2, systolic murmur
ABD: soft, non-tender, non-distended
EXT: Warm, well perfused, no clubbing, cyanosis or edema
===============
DISCHARGE EXAM:
===============
VS: T= 98.3 BP=100/52-125/70 HR=80 RR=16 O2 sat=98-100RA
Wt: 58.6kg
GENERAL: older woman in NAD
HEENT: small 2cm lac on back of head with 3 staples, well
healing, no drainage; EOMI, no scleral icterus, MMM
NECK: supple, venous pulsations with TR
CARDIAC: regular, normal S1/S2, systolic murmur
LUNGS: CTAB, normal respiratory effort
ABDOMEN: Soft, NTND. +BS
EXTREMITIES: warm, well perfused, trace edema R>L
SKIN: No rashes
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 06:13PM ___ PO2-34* PCO2-31* PH-7.40 TOTAL
CO2-20* BASE XS--4
___ 05:52PM GLUCOSE-111* UREA N-74* CREAT-3.5*
SODIUM-130* POTASSIUM-5.4* CHLORIDE-98 TOTAL CO2-19* ANION
GAP-18
___ 05:52PM CK-MB-5 cTropnT-0.05*
___ 05:52PM MAGNESIUM-2.4
___ 05:52PM DIGOXIN-1.5
___ 12:23PM ___ PO2-55* PCO2-31* PH-7.33* TOTAL
CO2-17* BASE XS--8
___ 12:23PM LACTATE-2.1* K+-6.5*
___ 12:23PM O2 SAT-82
___ 12:23PM freeCa-1.09*
___ 12:17PM GLUCOSE-216* UREA N-73* CREAT-3.5*
SODIUM-125* POTASSIUM-6.4* CHLORIDE-95* TOTAL CO2-17* ANION
GAP-19
___:17PM ALT(SGPT)-15 AST(SGOT)-31 ALK PHOS-173* TOT
BILI-0.8
___ 12:17PM CALCIUM-9.1 PHOSPHATE-4.4 MAGNESIUM-2.3
___ 12:17PM WBC-9.8 RBC-2.51* HGB-7.7* HCT-25.5* MCV-102*
MCH-30.7 MCHC-30.2* RDW-19.9* RDWSD-73.8*
___ 12:17PM PLT COUNT-150
___ 09:38AM K+-6.7*
___ 12:17PM ___ PTT-42.3* ___
___ 08:00AM LACTATE-3.0* NA+-130* K+-7.6* CL--102
___ 07:50AM GLUCOSE-180* UREA N-75* CREAT-3.4*
SODIUM-127* POTASSIUM-7.5* CHLORIDE-97 TOTAL CO2-15* ANION
GAP-23*
___ 07:50AM estGFR-Using this
___ 07:50AM cTropnT-0.04*
___ 07:50AM proBNP-8598*
___ 07:50AM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-2.3
___ 07:50AM WBC-9.9# RBC-2.63* HGB-8.1* HCT-27.1*
MCV-103*# MCH-30.8# MCHC-29.9* RDW-20.0* RDWSD-75.8*
___ 07:50AM NEUTS-88.8* LYMPHS-4.7* MONOS-5.4 EOS-0.0*
BASOS-0.5 IM ___ AbsNeut-8.79*# AbsLymp-0.47* AbsMono-0.54
AbsEos-0.00* AbsBaso-0.05
___ 07:50AM PLT COUNT-154
___ 07:50AM ___ PTT-39.8* ___
==================
PERTINENT RESULTS:
==================
CT Head w/o Contrast ___:
1. Study is limited secondary to beam hardening artifact and
mild motion
degradation.
2. 4mm left frontal subdural hemorrhage, without definite
evidence of
fracture.
3. Small foci of subcutaneous air overlying left zygoma and
right frontal bone
without definite adjacent soft tissue stranding. While finding
may represent
small subcutaneous emphysema, findings may alternatively
represent
intravascular air.
4. Left occipital scalp skin staples.
XR Shoulder/Humerus ___:
No evidence of acute fracture or dislocation.
CXR ___:
Somewhat low lung volumes and increased vascular congestion with
mild edema.
Persistent small right pleural effusion and adjacent pulmonary
opacity which
may reflect compressive atelectasis or infection.
XR Pelvis/Femur ___:
No evidence of acute fracture or dislocation involving the left
hip or left
femur.
===============
DISCHARGE LABS:
===============
___ 05:15AM BLOOD WBC-6.0 RBC-2.62* Hgb-7.8* Hct-25.6*
MCV-98 MCH-29.8 MCHC-30.5* RDW-19.6* RDWSD-68.7* Plt ___
___ 05:15AM BLOOD ___
___ 12:18PM BLOOD Glucose-147* UreaN-59* Creat-2.7* Na-135
K-4.6 Cl-96 HCO3-25 AnGap-19
___ 05:15AM BLOOD ALT-9 AST-24 AlkPhos-141* TotBili-1.1
___ 07:50AM BLOOD proBNP-___*
___ 05:15AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
Brief Hospital Course:
Patient is a ___ with complex cardiac history including sCHF (EF
15%), CKD, Atrial Fibrillation, and CAD presenting with weakness
and found to have ___ on CKD and hyperkalemia.
#Hyperkalemia: Multifactorial, including receiving increased
potassium supplementation superimposed on likely cardiorenal
syndrome in the scenario of volume overload due to acute on
chronic systolic heart failure exacerbation. The patient was
currently considering renal replacement therapy, but has been
hesitant to accept further invasive therapies having seen the
effect that similar therapies have had on her family members in
the past. Further triggers for hyperkalemia include an increase
in PO potassium chloride prior to admission. She was
administered insulin/D50 with calcium gluconate for EKG with
evidence of wide-complex QRS, and serum potassium elevated to
7.5 on admission, with downtrended to 3.6 while on the MICU
service. She was diuresed with Lasix and chlorthalidone both for
volume overload, but also in an effort to decrease serum
potassium levels.
___ on CKD: Cr 3.4 from ___, with significant hyperkalemia
with EKG changes. Most likely due to decompensated heart
failure, as she has had increasing weight lately, resulting in
cardiorenal syndrome. The patient was unsure about commencing
dialysis as discussed above, and her hyperkalemia was managed
medically with diuresis. Cr was trended, as were electrolytes.
Medications were dosed with consideration of her GFR. Creatinine
continued to trend down with diuresis, 2.5 at time of discharge
#Acute on chronic sCHF: End-stage CHF on home palliative
dobutamine. Patient presented with acute on chronic systolic CHF
exacerbation, with BNP greater than baseline, increased weight
(57.9kg on discharge on ___, now 62kg), with decreased Na
consistent with hypervolemic hyponatremia. Dobutamine was
increased from 2.5 to 5 in the emergency department, with
improvement in lactate. She was diuresed with Lasix and
chlorthalidone to improve her volume status as described above.
Patient was stable on room air at the time of transfer.
Medications at home did not include an ACEi (in setting of CKD);
isosorbide mononitrate was transitioned to isosorbide dinitrate
while in-house for tight blood pressure control. Transitioned
back to PO toresmide 100mg BID at discharge.
___ fall: with injuries including hematoma to left hip and
shoulder. Xrays were negative for acute fracture or dislocation.
She was maintained on PRN tramadol and Tylenol, and her
gabapentin dose was decreased to 100mg QHS in the setting ___
on CKD. Neurosurgery was consulted because of small frontal
subdural hematoma seen on head CT but they felt no surgical
intervention was required.
# UTI: Patient had urinary frequency and urine culture positive
for ecoli sensitive to third generation cefalosporins. She was
discharged on cefpodoxime.
#Atrial fibrillation: therapeutic on Coumadin, INR 2.6. Coumadin
was continued, as was amiodarone for rate control. Digoxin
levels were closely monitored in the setting ___ on CKD and
digoxin was held. Consider restarting as an outpatient.
#Anemia: stable, chronic, likely due to anemia of chronic
disease. The patient was transfused 1u pRBCs on ___, likely a
result of hematoma from her fall.
#CAD: Continued home-dose aspirin.
#Hypothyroidism: Continued home-dose levothyroxine.
#DM: Not on home agents. Fingerstick glucose monitoring with
insulin sliding scale was conducted while in-house
#Gout: Allopurinol was held in the setting ___ on CKD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Digoxin 0.0625 mg PO EVERY OTHER DAY
8. Gabapentin 300 mg PO QHS
9. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Torsemide 100 mg PO BID
12. Warfarin 2 mg PO DAILY16
13. Potassium Chloride (Powder) 40 mEq PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION
Please use 64.2kg for weight, do not change weight/dosing.
RX *dobutamine 250 mg/20 mL (12.5 mg/mL) 2.5 mcg/kg/min IV
continuous Disp #*30 Vial Refills:*0
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 300 mg PO QHS
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Torsemide 100 mg PO BID
10. Warfarin 1 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Cefpodoxime Proxetil 200 mg PO Q24H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
12. Allopurinol ___ mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
14. Potassium Chloride (Powder) 40 mEq PO DAILY
15. Outpatient Physical Therapy
Rollator
Diagnosis: end stage heart failure
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Hyperkalemia
Acute on chronic heart failure with reduced EF
Secondary Diagnoses:
Acute kidney injury
UTI
Afib
Anemia
Fall on anticoagulation
Discharge Condition:
Stable
AOx3
Able to ambulate with walker
Cardiovascular exam notable for severe TR, systolic murmur, no
___ edema
Respiratory exam unremarkable
Discharge Instructions:
Ms. ___,
You were admitted and found to have very high potassium levels
and decrease functioning of the kidneys. We monitored you and
gave you medications to protect your heart. You were then
transferred to the cardiac service to help get fluid off your
body and get your kidneys back to their baseline.
We gave you medications, including Lasix, to bring the fluid off
and then transitioned you to your home dose of torsemide to
continue. You will also need to take potassium supplements at
home but we will have the nurse check your levels in a few days.
For your warfarin/Coumadin, you have only been needing 1mg daily
to remain in the right range so you should take that dose at
home.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
New medications:
cefpodoxime daily for 5 days
Change in medications:
warfarin 1mg daily (instead of 2mg daily)
Stop these medications:
digoxin
Be well,
Your ___ team
Followup Instructions:
___
|
10539102-DS-11 | 10,539,102 | 22,932,014 | DS | 11 | 2135-02-10 00:00:00 | 2135-02-11 21:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dysarthria, vertical diplopia, and dysmetria
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
The patient is an otherwise healthy ___ year old right-handed man
who presents as a transfer after receiving tPA for acute onset
dysarthria, vertical diplopia, and dysmetria.
Patient was at his church this AM, when at approximately 9:50
AM,
developed sudden onset dizziness described as "vertigo." He was
unable to remain upright and fell to the ground.
Upon arrival to the OSH, he was pale and diaphoretic with
slurred
speech. He had a HR in the ___ and his symptoms were felt to be
concerning for symptomatic bradycardia.
Then, at 12:25, he developed sudden onset vertical diplopia
described as "stacked vision." He was noted to have right sided
dysmetria and right leg weakness, prompting tele-stroke
activation. He was subsequently given tPA at 12:47. Initial
NIHSS
was 6.
The patient was transferred to ___ for further evaluation and
post-tPA monitoring.
Past Medical History:
Asymptomatic bradycardia, told by his PCP that he has a
"runner's
heart"
Hypertension, well controlled on amlodipine
Social History:
___
Family History:
No family history of stroke. Father died of skin cancer, mother
from "old age."
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 97.5, HR 58, BP 133/86, RR 15, Sa 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic Exam:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. 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 or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 ___ 5 ___ 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: Very mild right sided dysmetria with FNF that
improved on repeat evaluation 25 mins later. No intention
tremor.
Normal finger-tap bilaterally.
-Gait/Station: Deferred as post-tPA.
===
DISCHARGE PHYSICAL EXAM
Vitals: Tmax 98.9 HR ___ RR ___ BP 125/79-154/98 SpO2 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic Exam:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to read without difficulty. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii 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 FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 ___ 5 ___ 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Romberg absent.
-DTRs: deferred
-___: no dysmetria on FTN bilaterally, no intention
tremor. Normal finger-tap bilaterally.
-Gait/Station: Deferred
Pertinent Results:
___ 06:56AM BLOOD WBC-7.0 RBC-4.57* Hgb-14.7 Hct-44.3
MCV-97 MCH-32.2* MCHC-33.2 RDW-12.6 RDWSD-44.6 Plt ___
___ 06:56AM BLOOD ___ PTT-25.6 ___
___ 06:56AM BLOOD Glucose-92 UreaN-12 Creat-1.1 Na-141
K-4.0 Cl-103 HCO3-24 AnGap-14
___ 06:56AM BLOOD ALT-18 AST-23 CK(CPK)-167 AlkPhos-65
TotBili-1.1
___ 06:56AM BLOOD %HbA1c-5.4 eAG-108
___ 06:56AM BLOOD Triglyc-55 HDL-73 CHOL/HD-2.5 LDLcalc-101
___ 06:56AM BLOOD TSH-2.0
___ 03:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:45PM URINE Blood-NEG Nitrite-NEG Protein-10*
Glucose-NEG Ketone-20* Bilirub-NEG Urobiln-NORMAL pH-6.5
Leuks-NEG
___ 05:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG fentnyl-NEG
MRI BRAIN W/O CONTRAST (___):
IMPRESSION:
1. Acute right superior cerebellar infarct without hemorrhage,
significant
mass effect or hydrocephalus.
2. Right middle cranial fossa arachnoid cyst.
CT HEAD W/O CONTRAST (___):
IMPRESSION:
1. Evolution of the right superior cerebellar artery infarction
with minimal
amount of mass effect without sign of hydrocephalus or
hemorrhagic conversion.
2. Fluid density within the right middle cranial fossa
consistent with
arachnoid cyst, as described on prior MR.
3. Global parenchymal atrophy within expected range for age, as
well as white
matter changes consistent with chronic microangiopathic disease.
TTE (___):
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic
dysfunction most consistent with single vessel coronary artery
disease (PDA distribution). Mild
mitral regurgitation with mildly thickened leaflets. High normal
estimated pulmonary artery
systolic pressure. Mild-moderate tricuspid regurgitation. No
structural cardiac cause of syncope
identified.
Brief Hospital Course:
___ w/ hx of ___ transferred from OSH with sudden onset
dysarthria, dysmetria, and vertical diplopia, prompting tPA
administration on ___ @ 1247.
ACUTE ISCHEMIC STROKE: 24-hour post-tPA NIHSS was 0. MRI brain
showed evidence of ischemic stroke in R cerebellar peduncle,
with follow-up examination notable only for mild dysmetria in
right upper and lower extremities. Repeat CTH on hospital day 2
showed evolution of prior R cerebellar infarct without new acute
intracranial process. TTE did not reveal any cardiac thrombus
but was notable for focal hypokinesis; ASD notably could not be
excluded due to suboptimal image quality. Zio patch was placed
prior to discharge to detect paroxysmal atrial fibrillation. In
the interim, antiplatelet therapy with aspirin 81 mg and Plavix
75 mg was also started, along with statin therapy for secondary
stroke prevention.
===
TRANSITIONAL ISSUES:
1. Repeat TTE as outpatient to evaluate for underlying ASD or
PFO.
2. Outpatient evaluation of regional left ventricular systolic
dysfunction with basal inferior and inferolateral hypokinesis
noted on TTE.
3. Dual antiplatelet therapy with clopidogrel and aspirin for
three weeks, followed by indefinite aspirin monotherapy.
===
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (X) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (X) Yes (LDL = 101) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (X) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute right cerebellar infarct
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 speech difficulty,
double vision, and unsteadiness resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
--HIGH CHOLESTEROL
--HIGH BLOOD PRESSURE
We are changing your medications as follows:
ADD ASPIRIN 81 mg DAILY
ADD PLAVIX 75 mg DAILY for 3 WEEKS (___)
ADD ATORVASTATIN 40 mg DAILY
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
You will be contacted regarding your follow up with Dr. ___
___ within the next ___ business days. If you do not hear from
us, please call ___ to schedule a follow-up for ___
months.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10539155-DS-10 | 10,539,155 | 20,625,637 | DS | 10 | 2176-03-13 00:00:00 | 2176-03-17 20:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / omeprazole / Trileptal
Attending: ___
Chief Complaint:
Decline
Major Surgical or Invasive Procedure:
Lumbar Puncture (___)
History of Present Illness:
Mrs. ___ is a ___ year old woman with a past medical
history of prior hypertension, who is presenting in the setting
of a several month neurologic decline.
History is gathered from her son and daughter.
Essentially, Starting roughly in ___ of this year, Ms.
___
had a change in appetite and intermittent nausea. IN this
setting she has had a significant weight loss ofver the past
several months (>40 lbs). She reportedly has had evaluation for
this, but details unclear.
Starting more recently, for the past 3 months, she has developed
a progressive and fluctuating decline. It appears to have began
with subtle cognitive changes and confusion- errors with
previously simple tasks, poor memory for recent events,
intermittent confusion. She had trouble around the house with
previously ___ tasks.
Around this same time, there was a change in gait. She became
unsteady, and required first a walker, and then for the past 2
weeks, has been unable to use that. Prior to 3 months ago, her
family reports she was ambulating independently without any
difficulty. Her family described her holding the walker, but
closing her eyes and attempting to walk. She is felt to be very
unsafe.
In addition to gait, she has had trouble with motor tasks- using
spoons, feeding herself. She has a longstanding b/l hand and
jaw
tremor, which has significantly worsened. At times, she is
unable
to feed herself. With all of the above symptoms her family
reports a significant waxing and waning component.
Starting in ___ (in the backdrop of the above symptoms) She was
admitted to OSH following an episode of syncope on ___. She
had taken a shower and gotten dressed. she was waiting for her
husband in the bathroom when she passed out Immediate return to
conscousness. Work-up including echo, EKG, stress test was
benign. She did have transient brady cardia that admission.
She
was found to have orthostatic hypotension and started on
midodrine. Outpatient 30 day holter monitor was reportedly
benign.
Along the course, Mrs. ___ was given a somewhat unclear
possible diagnosis of MSA, though the family reports that other
physicians have disagreed.
Most recently, for the past week, the family reports onset of
new
events of "babbling". Her daughter, who was on the phone with
her during one of these events describes the events where Ms.
___ states completed unrelated or tangential things. The
language is fluent, clearly ___ and understandable. With
these events, Ms. ___ is sometimes frustrated. Duration is
very unclear and can last perhaps between minutes to an hour.
WHen previously asked, Ms. ___ reported remembering the
events. There have been three of these events in the past week.
For the first one of these she was seen and ___ and
"evaluated for stroke".
This morning, there was no acute event or change. She was seen
by a privately hired assistant (who had seen her the week prior)
who was concerned regarding her decline and recommened ED
presentation.
Notably, yesterday Mrs. ___ asked for a priest to be called
to
read her her last rights.
On neuro ROS, the pt/family denies 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.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits.
Past Medical History:
- "severe orthostatic hypotension, possible MSA)
- Sycope
- Prior Hypertension
- Weight loss- 40lb over n9 months
- GERD
- Osteopenia
- Essential Tremor
- Anxiety
- Monoclonal gammopathy of IgG type, elevated light chains of
unknown significance
Social History:
___
Family History:
- mother with epilepsy. otherwise no family neurologic
history.
Physical Exam:
Admission Physical Exam:
Vitals: 99.99 88 112/71 16 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: WWP.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person and place. It is
___ (but at first she is very unsure of this and I am
told previously got it wrong). Majority of her history is
provided by her family, though able to help clarify points.
Attentive to examiner, but trouble with ___ backwards. 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 from NIHSS. 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 or neglect. Phonemic naming 6 in 1 minute. Semantic 8
in 1 minute.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: B/l ptosis, otherwise no facial droop, facial musculature
symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk. Increased tone in RUE that significantly
increases with distraction. Cogwheeling present at right wrist.
Mild increase in tone in b/l ___ be cooperation. Right hand
pronates, no drift. Tremor in jaw noted.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4 ___ ___ 5 4 5 5 5
R 4 ___ ___ 5- 4 5 5 5
-Sensory: Patchy decreased sensation to pinprick on anterior
right leg. Otherwise no deficits to light touch, pinprick,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was equiv to flexor bilaterally.
-Coordination: Significant b/l postural and action tremor. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
RAM intact. No cerebellar overshoot with eye movements. Jaw
tremor.
-Gait: Able to stand. Somewhat unsteady. Can unsteadily ___
in place, but further assessment stopped due to onset of light
headedness.
================================================================
Discharge Exam:
Unchanged
Pertinent Results:
___ 07:15AM BLOOD WBC-8.4 RBC-3.21* Hgb-10.1* Hct-29.1*
MCV-91 MCH-31.5 MCHC-34.7 RDW-14.4 RDWSD-47.8* Plt ___
___ 09:15PM BLOOD WBC-8.4 RBC-3.38* Hgb-10.5* Hct-31.2*
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.6 RDWSD-48.8* Plt ___
___ 09:15PM BLOOD Neuts-57.2 ___ Monos-7.0 Eos-0.0*
Baso-0.1 Im ___ AbsNeut-4.81 AbsLymp-2.99 AbsMono-0.59
AbsEos-0.00* AbsBaso-0.01
___ 07:15AM BLOOD H/O Smr-AVAILABLE
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-24.1* ___
___ 09:15PM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-133
K-3.4 Cl-99 HCO3-23 AnGap-14
___ 09:15PM BLOOD Glucose-117* UreaN-15 Creat-0.7 Na-134
K-3.6 Cl-98 HCO3-25 AnGap-15
___ 07:15AM BLOOD ALT-27 AST-23 LD(LDH)-159 AlkPhos-54
Amylase-21 TotBili-1.2
___ 07:15AM BLOOD Lipase-14
___ 07:15AM BLOOD TotProt-5.7* Albumin-3.4* Globuln-2.3
Iron-90
___ 07:15AM BLOOD calTIBC-278 VitB12-469 Folate-GREATER TH
Ferritn-233* TRF-214
___ 07:15AM BLOOD Ammonia-35
___ 07:15AM BLOOD TSH-2.2
___ 07:15AM BLOOD CRP-3.5
___ 07:15AM BLOOD PEP-PND
___ 07:15AM BLOOD SED RATE-Test
___ 07:54PM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:54PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 07:54PM URINE RBC-2 WBC-9* Bacteri-NONE Yeast-NONE
Epi-6
___ 07:54PM URINE CastHy-13*
___ 07:59PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* Polys-2
___ ___ 07:59PM CEREBROSPINAL FLUID (CSF) TotProt-63*
Glucose-64
___ 07:59PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-PND
___ 07:59PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
___ 07:59PM CEREBROSPINAL FLUID (CSF) ADMARK TAU/A BETA
42-PND
___ 07:59PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS
(MS) PROFILE-PND
___ 07:59PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-PND
___ 07:59PM OTHER BODY FLUID IPT-PND
___ 01:50PM STOOL Blood-NEGATIVE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
RPR negative
===========================================================
MRI of the brain without and with IV contrast:
No acute infarct or mass effect or abnormal enhancement.
Extensive T2 FLAIR hyperintense foci in the cerebral white
matter as detailed
above, likely nonspecific in appearance and may relate to small
vessel
ischemic changes, etc.
Moderate dilation of the lateral and the third ventricles along
with mildly
prominent cerebral sulci, can relate to parenchymal volume loss.
Correlate
clinically for other etiologies.
Other details as above.
CT Chest:
Several pulmonary nodules, non of which requires CT follow-up
based on the
___ society recommendations.
No suspicious or malignant lesions. No lymphadenopathy. No
pleural
effusions.
13 mm left thyroid nodule.
CT Abd/Pelvis:
1. 2 hyperdense is splenic lesions, near the hilum, measuring
1.3 and 0.5 cm
respectively. These are incompletely characterized on the
current study,
however measure up to 150 ___ units and are suspicious
for intra
splenic aneurysms. Solid lesions such as splenic hemangioma is
also a
consideration.
2. Nonspecific 1.5 x 1.9 cm solid right adrenal lesion.
3. Likely thickened endometrium measuring up to 1.1 cm.
Echocardiogram
Mild symmetric left ventricular hypertrophy with normal
glogal/regaional systolic function. Mild mitral regurgitation.
No cardiac source of embolism identified. Increased PCWP.
Brief Hospital Course:
___ yo female, pmh HTN, admitted for months of neurological
decline to general neurology service. The decline is most likely
a combination of vascular dementia and orthostatic hypotension.
MRI revealed no acute infarct but prior small vessel ischemic
white changes and moderately large ventricles. A large volume
tap was performed. LP was noninflammatory or infectious (WBC 0,
Prot 63, Glucose 64, RBC 1). MOCA score before and after large
volume tap was 14 to 16. Gait was defered due to orthostatics.
During her stay, she had positive orthostatic vitals that were
fluid responsive. She was started on salt tabs. She was also
seen by nutrition who recommended ensure TID and MV. ___
recommended rehab. She improved to discharge to rehab.
.
# Cognitive Decline: We were initially concerned about a rapidly
progressive dementia, but on further history, it appeared to be
decline over months along with episodes of confusion upon
standing. On MRI, she was found to have prior strokes, so she
may have an underlying vascular dementia. An EEG was done for
concern of seizure episodes and was notable for slowing, but
without epileptiform discharges. An large volume LP was done to
rule out malignancy or infections. LP was
noninflammatory/infectious. Cytology was performed and was
negative for suspicious or malignant cells. A MOCA was done
before and after LP with minimal change (14 -16), and gait was
deferred due to orthostatics, but it is less likely Normal
presure hydrocephalus. Otherwise negative workup for toxic
metabolic (B12, Folate, TSH, ammonia WNL), infectious (RPR
negative, Lyme negative) and malignancy (CT Torso completed and
cytology negative). She likely has an vascular dementia, which
the family is planning to follow up with an outpatient
neurologist. The episodes of confusion are likely due to
orthostatic hypotension and global cerebral hypoperfusion.
.
# Orthostasis
Regarding her orthostasis, after fluid resuscitation, she was
started on salt tabs and her fluorinef was increased by 0.1mg to
0.2mg daily. Please monitor her potassium once a week. She was
already on midodrine 10mg TID which was continued during this
hospitalization.
.
With the additions above, her blood pressure on the day of
discharge increased appropriately with midodrine. Her sitting
blood pressure was 180s/70s and would drop to 100s systolics
with standing with minimal dizziness/unsteadiness. Essentially
we achieved the goal of limited symptoms with standing but the
sitting blood pressure slightly higher than desired. Her blood
pressure was repeated and her 4pm dose of midodrine was held
until sitting BPs were 172/86, standing 148/70. Her noon dose of
midodrine was changed from 10 TID to Midodrine 10 mg at 8 am and
7.5 mg at noon and 4 pm.
.
Her midodrine and fluorinef dosing will likely require titration
after she arrives are rehab. If she has sitting hypertension by
manual BP over SBP 170, prior to midodrine dose, please hold the
next dose of midodrine and let the blood pressure drift down.
The next day, change the corresponding prior dose of midodrine
by 2.5mg in order to minimize sitting hypertension. If she is
symptomatically orthostatic, her fluorinef could be titrated up
to symptomatic control (going up by 0.1mg each week to a max of
0.3mg daily dose), as blood pressure allows.
.
People with autonomic dysfunction will have elevated blood
pressures in supine position, so if elevated, recheck in sitting
or standing position. It is important that she does not lie down
after taking her midodrine. She must remain in an upright
sitting or standing position during the daytime. Midodrine also
cannot be taken 6 hours before sleeping. It is important that
she follow up with the a autonomic neurologist.
.
# Thyroid Nodule: 13 mm nodule noted on CT Torso to follow up as
outpatient. TSH was within normal limits (2.2).
.
Transitional Issues
- Nurtitional Issues: Nutrition recommend Ensure and MV
- Potassium and Sodium levels weekly.
- Follow up re: thyroid nodule
- Follow up re: hypogammaglobulinemia (known mgus)
- Nutritional status
- **PRIOR TO EACH MIDODRINE DOSE ** Take blood pressure in the
sitting position prior to midodrine administration. If sitting
or standing blood pressure >150 systolic, hold that dose of
midodrine and wait for BP to drift down. Midodrine increases
blood pressure so if it's already high we would not want to push
it into an unsafe range. Then decrease the next day's
corresponding dose of midodrine by 2.5mg.
- ** AFTER EACH MIDODRINE DOSE ** Please take a sitting blood
pressure 1 hour after midodrine administration. This will allow
us to determine how well the antecedent midodrine dose has
worked. If sitting systolic blood pressure is >170, consider
holding the next dose of midodrine - the next day, the dose due
to be given at that same time should be reduced by 2.5mg.
- ** PRIOR TO BED ** her blood presure should be taken. If blood
pressure is >180, patient should be sat up or she should sleep
with the head of the bed elevated.
- Please provide instructions to husband on discharge from
rehab.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Megestrol Acetate 40 mg PO BID
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE Q6H
5. Ondansetron 4 mg PO Q6H:PRN nausea
6. Midodrine 10 mg PO TID
7. Metoclopramide 10 mg PO TID
8. Lorazepam 0.5 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Citalopram 10 mg PO DAILY
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Fludrocortisone Acetate 0.1 mg PO DAILY
4. Megestrol Acetate 40 mg PO BID
5. Metoclopramide 10 mg PO TID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Aspirin 81 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Sodium Chloride 1 gm PO BID
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE Q6H
11. Multivitamins 1 TAB PO DAILY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q6H:PRN sob
13. Lorazepam 0.5 mg PO DAILY:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
14. Midodrine 10 mg PO QAM
15. Midodrine 7.5 mg PO NOON AND 4 ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Vascular Dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for worsening cognitive function. On imaging,
you were found to have old strokes. To look for other cause of
this worsening congitive function, we performed a lumbar
puncture, which was normal.
To look for causes of your weight loss, we performed imaging of
your chest, abdomen, and pelvis, which did not show anything
concerning for cancer. You also met with a nutritionist, who
recommended adding Carnation Instant Breakfast once a day and
Ensure plus three times a day.
During this hopsitalization, we also noticed that your blood
pressure dropped when you stood up (orthostatic hypotension).
This may also be contributing to your decreased cognitive
function and unsteady gate. We gave you some fluids and salt
tablets, which help with your low blood pressure when standing.
You should follow up with an autonomic neurologist. You should
take blood pressure at home prior to midodrine dose and 1 hour
after each midodrine dose. Please keep a log of the blood
pressures.
- **PRIOR TO EACH MIDODRINE DOSE ** Take blood pressure in the
sitting position prior to midodrine administration. If sitting
or standing blood pressure >150 systolic, hold that dose of
midodrine and wait for BP to drift down. Midodrine increases
blood pressure so if it's already high we would not want to push
it into an unsafe range. Then decrease the next day's
corresponding dose of midodrine by 2.5mg.
- ** AFTER EACH MIDODRINE DOSE ** Please take a sitting blood
pressure 1 hour after midodrine administration. This will allow
us to determine how well the antecedent midodrine dose has
worked. If sitting systolic blood pressure is >170, consider
holding the next dose of midodrine - the next day, the dose due
to be given at that same time should be reduced by 2.5mg.
- ** PRIOR TO BED ** her blood presure should be taken. If blood
pressure is >180, patient should be sat up or she should sleep
with the head of the bed elevated.
Please continue to drink fluids and maintain a good diet. We
recommend outpatient follow up a neurologist who specializes in
dementia to further evaluate your cognitive declines.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
10539412-DS-20 | 10,539,412 | 22,634,918 | DS | 20 | 2150-06-19 00:00:00 | 2150-06-20 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ABDOMINAL PAIN and WEAKNESS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of recurrent C. difficile
infection, cecal adenocarcinoma status post cecectomy, and
aphasia who presents with weakness, abdominal pain, and
diarrhea.
Because the patient is aphasic, much of the history was obtained
from her daughter, who is also her HCP. The daughter reports
that her mother has continuous loose stools ___ times per day
occurring on and off for the past year since ___
and worsening since her cecectomy surgery on ___. The
stools fluctuate between "explosive" and black to "thin brown
logs" but no bright red blood. The stools have been
foul-smelling until ___, after which the odor subsided.
There is some vague lower abdominal pain or suprapubic pain
associated with these symptoms. There is no pain with passage of
stool. Finally, her bowel movement frequency increases with
eating. As a result, patient's daughter reports decreased PO
intake and 58 pound weight loss since ___. Otherwise patient
denies other symptoms of fever, cough, vomiting, nausea. Today
she reports having only one bowel movement in the morning and
none since.
The daughter reports the diarrhea began in ___, when
she was in an ___ rehabilitation ___ following surgery
for a hip fracture. The rehabilitation ___ suffered an
outbreak of C. difficile. Since ___, the patient had
cecectomy for an adenocarcinoma discovered in her cecum.
Following this surgery, the patient also suffered from diarrhea
and was hospitalized multiple times. Previous C. difficile tests
were positive. Her C. difficile has been treated in the past
with vancomycin and most recently fidaxomicin (Dificid), last
dose ___. Most recently, the diarrhea has not been
associated with any odor. No fevers or chills.
ROS: 10-point ROS negative except as noted above in HPI
Past Medical History:
Cecal adenocarcinoma s/p cecectomy (___)
Primary progressive aphasia
Hip fracture s/p surgery in ___
Cataract surgery
Oculear lens implant in L and R eye
Pneumonia
HLD
Recurrent C. difficile
Social History:
___
Family History:
No family history of diabetes or heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS - Tc 98.4, 143/58, HR 85, RR 18, SaO2 96%
GENERAL: Elderly female in NAD
HEENT: AT/NC, EOMI, R pupil larger than L, pupillary reflex
intact, anicteric sclera, pink conjunctiva, MMM, poor dentition
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, II/VI systolic murmur RLSB/apex
LUNG: bibasilar crackles
ABDOMEN: nondistended, +BS, mild suprapubic tenderness, no
rebound/guarding, no hepatosplenomegaly, no CVA tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, nonverbal at baseline
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISHCARGE PHYSICAL EXAM
=======================
VS - Tc 98.6, 100/73, HR 84, RR 16, SaO2 100%
GENERAL: Elderly female in NAD
HEENT: AT/NC, EOMI, R pupil larger than L, pupillary reflex
intact, anicteric sclera, pink conjunctiva, MMM, poor dentition
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, II/VI systolic murmur RLSB/apex
LUNG: CTAB; poor effort
ABDOMEN: nondistended, +BS, mild LUQ pain on palpation
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, nonverbal at baseline
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 01:30PM BLOOD WBC-7.2 RBC-4.20 Hgb-9.8* Hct-33.3*
MCV-79* MCH-23.3* MCHC-29.4* RDW-21.1* RDWSD-60.0* Plt ___
___ 01:30PM BLOOD Neuts-39.8 ___ Monos-9.7 Eos-4.0
Baso-0.6 Im ___ AbsNeut-2.87 AbsLymp-3.30 AbsMono-0.70
AbsEos-0.29 AbsBaso-0.04
___ 01:30PM BLOOD ___ PTT-30.4 ___
___ 01:30PM BLOOD Glucose-93 UreaN-23* Creat-0.8 ___
K-3.9 Cl-103 HCO3-27 AnGap-13
___ 01:30PM BLOOD ALT-28 AST-45* AlkPhos-117* TotBili-0.2
___ 01:30PM BLOOD Lipase-103*
___ 01:30PM BLOOD Albumin-4.4 Calcium-10.1 Phos-3.4 Mg-1.7
Iron-29*
___ 01:30PM BLOOD calTIBC-469 VitB12-681 Ferritn-12*
TRF-361*
___ 08:15AM BLOOD IgG-1387 IgA-201 IgM-79
___ 08:15AM BLOOD tTG-IgA-3
___ 04:50PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:50PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 04:50PM URINE RBC-11* WBC-62* Bacteri-MOD Yeast-NONE
Epi-4
___ 04:50PM URINE Mucous-RARE
___ 11:31PM URINE Color-Straw Appear-Clear Sp ___
___ 11:31PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 11:31PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1
___ 11:31PM URINE Mucous-RARE
DISCHARGE LABS
==============
___ 08:15AM BLOOD WBC-6.4 RBC-4.59 Hgb-10.6* Hct-36.9
MCV-80* MCH-23.1* MCHC-28.7* RDW-21.4* RDWSD-61.2* Plt ___
___ 08:15AM BLOOD Glucose-84 UreaN-16 Creat-0.8 ___
K-4.1 Cl-107 HCO3-27 AnGap-12
___ 08:15AM BLOOD ALT-26 AST-43* AlkPhos-127* TotBili-0.2
___ 08:15AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0
IMAGING
=======
___ EKG
Normal sinus rhythm. Normal ECG. No previous tracing available
for
comparison.
___ CXR
IMPRESSION: No acute cardiopulmonary process.
___ RUQ U/S
IMPRESSION:
1. Normal abdominal ultrasound.
2. Nonvisualization of the gallbladder, either surgically absent
or completely decompressed.
MICROBIOLOGY:
___ Stool
___ 9:19 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.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
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.
___ Blood cultures x 2 sets: No growth (FINAL)
___ Urine culture # 1
**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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
___ Urine culture # 2: < 10K CFU organisms
Brief Hospital Course:
___ year old female with history of recurrent C. difficile
infection, cecal adenocarcinoma status post cecectomy, and
aphasia who presents with weakness, abdominal pain, and
diarrhea.
# DIARRHEA
Differential includes recurrent C diff (C diff negative this
hospitalization), infectious gastroenteritis, malabsorption due
bowel resection, Celiac, lactose intolerance among others. On
presentation did not have fevers and appeared well, making true
infectious diarrhea less likely. Elevated lipase concerning for
chronic pancreatitis although not specific. Communication with
her gastroenterologist Dr. ___ from ___-
reports the patient was hospitalized ___ for c. diff diarrhea,
a sigmoidoscopy showed no evidence of pseudomembranous colitis
and revealed normal rectum with some hemorrhoids. She was
discharged with several-week course of oral vancomycin. She was
seen again in outpatient setting on ___ for diarrhea at which
point C. diff test was negative but given history, she was
prescribed fidaxomicin for 10 day course, which she finished on
___. The gastroenterologist believes patient is
candidate for fecal transplant if found to be C. diff positive
in the future. Patient has not had bowel movement volume
consistent with diarrhea. Had well formed stool on ___ and
loose stool on ___. TTG-IGA negative. RUQ US finds no
abnormalities. Fecal culture for campylobacter, vibrio,
Yersinia, E coli o157:H7, and stool ova + parasites pending on
discharge.
# Transaminitis
Labs on ___ and ___ show stable and mild Transaminitis. RUQ US
shows no abnormalities and patient is stable on morning of ___
and does not have any concerning signs or symptoms. LFTs on
___: ALT 26, AST 43*, ALP 127*, TotBili 0.2. Recommend
outpatient follow-up w/ PCP or gastroenterologist. Could
consider MRCP to evaluate for chronic pancreatitis given report
of chronic diarrhea.
# Moderate malnutrition
Patient and daughter report decreased PO intake since surgery
and subsequent diarrhea in ___. Reports losing 58
pounds since then. Albumin normal on admission, though.
Attributes weight loss to diarrhea and fear of eating.
# Microcytic anemia
Given ongoing diarrhea, concern for both GI losses and
malabsorption. Iron studies ___ ferritin and low iron
consistent with iron deficiency anemia. Repleted with 1 dose IV
iron, further doses as outpatient
# POSSIBLE UTI
Patient with positive UA, decreased urinary frequency, s/p 1g
CTX in ED. On admission, complained of mild suprapubic
tenderness on exam, but on ___ reported resolution of
suprapubic discomfort. No fever, leukocytosis or flank
tenderness to suggest pyelonephritis. Could be contaminant from
diarrhea. Repeat UA on ___ shows only 4 WBCs. Because of risk
of C. diff, did not treat with antibiotics as she was
asymptomatic.
# Cecal adenocarcinoma s/p cecal resection: Patient with
successful cecal resection and anastomosis. However diarrhea has
only worsened. Per daughter patient had positive lymph node and
may need adjuvant chemotherapy. Defer management to outpatient
oncologist
# Hyperlipidemia: continued on home statin and held fenofibrate
given transaminitis
# Insomnia: chronic. Continued on home mirtazapine (was not
taking) and started trazadone.
# Aphasia: chronic, per daughter this is primary progressive
aphasia and not secondary to a stroke. Monitored without
significant change while admitted.
TRANSITIONAL ISSUES:
====================
- C.diff was pending on discharge: negative
- Fecal cultures pending
- patient may have IBS; would recommend following FODMAPS diet
and consider initiating probiotics as an outpatient
- patient found not to be compliant with some of her outpatient
medications (ie statin); to be discussed with primary care
- noted to have mildly elevated AST and alk phos; to be followed
up as an outpatient
- consider MRCP as outpatient to evaluate for chronic
pancreatitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Mirtazapine 30 mg PO QHS
3. Cyanocobalamin 250 mcg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QSUN
2. Calcium Carbonate 500 mg PO BID
3. Cyanocobalamin 250 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Mirtazapine 30 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
# Diarrhea
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 with diarrhea. We
tested for c.difficile, the test was pending at the time of
discharge. We think some of the diarrhea may be related to
irritable bowel syndrome. For this we recommend FODMAPS diet and
probiotics.
Followup Instructions:
___
|
10539617-DS-5 | 10,539,617 | 21,938,170 | DS | 5 | 2159-05-19 00:00:00 | 2159-05-19 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small Bowel Obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ old woman with a longstanding
history of Crohn's disease of the terminal ileum originally
diagnosed in the early ___. She has been well controlled on
___
alone, with no need for biologics or surgery. She reports that
beginning yesterday afternoon, she began noting increasing
abdominal distension and firmness along with RLQ pain. She last
ate yesterday afternoon, then stopped eating when the distension
began, but has not been having any nausea or vomiting. She has
been trying to stay hydrated by drinking clear liquids, which
also do not make her nauseated. No flatus or BMs since yesterday
AM. No fevers or chills at home.
Other than the clears, she has recently eaten yogurt and
strawberries as well as a sesame seed bagel and hummus.
Past Medical History:
GERD
Crohn's disease: diagnosed in ___, mainly in the terminal ileum
Iron deficiency anemia
Depression
Knee surgery (bilaterally, ___
Kidney Stone
Osteoarthritis
Osteopenia
Seasonal Allergies
Shingles
Procedures: colonoscopy in ___ showed Polyp in the cecum, which
was adenoma/low grade glandular dysplasia
Social History:
___
Family History:
Her father died of lung cancer. Her mother died of COPD. No
family history of inflammatory bowel disease. Her children are
healthy. History of gallstones, history of back pain, history of
lactose intolerance, history of measles and mumps.
Physical Exam:
General: appears well, tolerating a regular diet, minimal pain
VSS
Neuro: A&OX3
Cardio/pulm: no shortness of breath or chest pain
Abd: obese, nondistended, soft, nontender
Pertinent Results:
___ 06:15AM BLOOD WBC-6.0 RBC-4.12 Hgb-13.3 Hct-40.3 MCV-98
MCH-32.3* MCHC-33.0 RDW-13.2 RDWSD-47.7* Plt ___
___ 07:30AM BLOOD WBC-6.7 RBC-3.74* Hgb-12.2 Hct-36.9
MCV-99* MCH-32.6* MCHC-33.1 RDW-13.4 RDWSD-48.6* Plt ___
___ 10:24AM BLOOD WBC-11.4*# RBC-4.43 Hgb-14.3 Hct-42.8
MCV-97 MCH-32.3* MCHC-33.4 RDW-13.3 RDWSD-47.5* Plt ___
___ 10:24AM BLOOD Neuts-94.0* Lymphs-2.3* Monos-2.7*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-10.73*# AbsLymp-0.26*
AbsMono-0.31 AbsEos-0.01* AbsBaso-0.04
___ 06:15AM BLOOD Glucose-132* UreaN-8 Creat-0.7 Na-139
K-4.2 Cl-100 HCO3-26 AnGap-17
___ 07:30AM BLOOD Glucose-115* UreaN-8 Creat-0.6 Na-137
K-3.5 Cl-103 HCO3-27 AnGap-11
___ 10:24AM BLOOD Glucose-161* UreaN-12 Creat-0.7 Na-134
K-5.1 Cl-98 HCO3-22 AnGap-19
___ 06:15AM BLOOD Calcium-9.7 Phos-2.9 Mg-2.2
___ 07:30AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1
___ 10:24AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.1
___ 06:15AM BLOOD CRP-23.2*
___ 10:33AM BLOOD Lactate-2.6*
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 11:52 AM
Chronic-appearing focal stricture and wall thickening of the
distal ileum, 10 cm proximal to the ileocecal valve, with at
least a partial small-bowel
obstruction. There is tethering of this segment with an
adjacent proximal
loop of ileum, with a sinus tract without no patent fistula.
The findings
reflect known chronic Crohn's disease. No fluid collection.
Brief Hospital Course:
Mrs. ___ was admitted to the colorectal surgery service
with a small bowel obstruction related to stricture. She was
given steroids, cipro, and flagyl. She was feeling improved and
had sips which she tolerated well. Overnight into ___ she
passed flatus and her abdominal pain was improved. On ___
she tolerated a regular diet. She was seen by the GI team who
recommened to stop steroids....
Medications on Admission:
___, omeprazole
Discharge Medications:
1. BuPROPion 75 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*14 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
5. mercaptopurine 100 mg oral DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction related to Crohns Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids, steroids and
antibiotics. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10539617-DS-6 | 10,539,617 | 22,560,290 | DS | 6 | 2159-08-19 00:00:00 | 2159-08-19 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:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ with PMH Crohn's disease with known stricture
proximal to TI, depression presenting with 1 day b/l lower
abdominal pain with associated nausea without vomiting. Patient
reports her symptoms began ___ night as a cramping lower
abdominal pain after eating ___ food (steamed vegetables and
ric) that a friend brought over. Abdominal pain progressed into
___ and became so severe that she was unable to go in to
work. Early ___ morning, pain had reached ___ and patient
subsequently went into the emergency department. She denies
taking any medications to help alleviate the pain. She finds the
symptoms consistent with a prior hospitalization when she had a
SBO. She denies any fevers but has noted chills. Review of
systems is negative for a ny chest pain or shortness of breath.
She has not had any diarrhea, melena, or hematochezia. Last BM
was ___ and was noted to be quite hard stool. She denies
passing gas since ___. She has been able to tolerate tea.
Of note, patient was admitted to ___ on ___ until
___ with a small bowel obstruction. A CT scan showed a
chronic-appearing focal stricture and wall thickening of the
distal ileum 10 cm proximal to the ileocecal valve with at least
a partial small-bowel obstruction. There was tethering of the
segment with an adjacent proximal loop of ileum with a sinus
tract without a patent fistula. Her obstruction resolved and
since then she has had no further obstructions.
In the ED, initial vitals:
___ 83 127/80 26 100% RA
- Labs notable for: u/a with 80 ket, HCO3 21, normal LFTs, CRP
3.6, and wbc 10.1 with 90.8%N.
- Imaging notable for: CT a/p w/o evidence of active Crohn's
disease but with partial SBO.
- Patient was seen by Colorectal surgery team: In discussion
with patient, she refused NGT placement and does not wish to
have surgery. Admission to Medicine with conservative treatment
was recommended. - Pt given: 4mg IV morphine X 5, 4mg IV Zofran
X 3, 2L IVF, 75mg buproprion, 60mg fluoxetine, 10mg IV reglan.
- Vitals prior to transfer:
Today 12:57 98.9 99 141/90 15 95% RA
On arrival to the floor, pt reports minimal abdominal pain as
she just received morphine in ED prior to arrival.
ROS:
10 point review of systems as noted above.
Past Medical History:
Crohn's disease: diagnosed in ___, mainly in the terminal ileum
GERD
Iron deficiency anemia
Depression
Knee surgery (bilaterally, ___
Kidney Stone
Osteoarthritis
Osteopenia
Seasonal Allergies
Shingles
Social History:
___
Family History:
Her father died of lung cancer. Her mother died of COPD. No
family history of inflammatory bowel disease. Her children are
healthy. History of gallstones, history of back pain, history of
lactose intolerance, history of measles and mumps.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T99 131/80 HR99 93%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
Abdomen: obese, soft, ND, tenderness to deep palpation in b/l
lower abd and periumbilical region, hypoactive bowel sounds, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
DISCHARGE PHYSICAL EXAM
Vitals: T98.8 111/62 HR80 RR18 97%RA 1 BM
Exam:
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
Abdomen: obese, soft, ND, tenderness to deep palpation in b/l
lower periumbilical region, hypoactive bowel sounds, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
Pertinent Results:
ADMISSION LABS
___ 01:50AM BLOOD WBC-10.1*# RBC-4.47 Hgb-14.6 Hct-43.1
MCV-96 MCH-32.7* MCHC-33.9 RDW-13.7 RDWSD-48.6* Plt ___
___ 01:50AM BLOOD Neuts-90.8* Lymphs-2.6* Monos-5.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.13*# AbsLymp-0.26*
AbsMono-0.57 AbsEos-0.02* AbsBaso-0.02
___ 01:50AM BLOOD Plt ___
___ 01:50AM BLOOD ___ PTT-31.5 ___
___ 01:50AM BLOOD Glucose-159* UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-97 HCO3-21* AnGap-22*
___ 01:50AM BLOOD ALT-27 AST-25 AlkPhos-73 TotBili-0.8
___ 01:50AM BLOOD Albumin-4.5
___ 06:27AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.1
___ 01:50AM BLOOD CRP-3.6
___ 06:05PM BLOOD Lactate-1.9
DISCHARGE LABS
___ 06:11AM BLOOD WBC-4.6 RBC-3.47* Hgb-11.3 Hct-35.3
MCV-102* MCH-32.6* MCHC-32.0 RDW-14.2 RDWSD-52.4* Plt ___
___ 06:11AM BLOOD Plt ___
___ 06:11AM BLOOD Glucose-115* UreaN-6 Creat-0.5 Na-139
K-3.2* Cl-103 HCO3-25 AnGap-14
PERTINENT IMAGING
___ KUB
Nonspecific bowel gas pattern.
___ CT ABD/PELVIS WITH CONTRAST
1. Findings consistent with known chronic Crohn's disease. No
evidence to suggest active disease.
2. Chronic focal stricture and short segment wall thickening of
the distal ileum, approximately 10 cm proximal to the ileocecal
valve with at least a partial small bowel obstruction, overall
probably similar to the prior exam.
3. Tethering and adhesions of this short segment of small bowel
to an adjacent loop of proximal ileum without a patent fistula,
similar the prior exam.
4. Small but trace ascites. No drainable fluid collection.
URINE
___ 04:10AM URINE Color-Straw Appear-Clear Sp ___
___ 04:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ URINE CULTURE CONTAMINATED
Brief Hospital Course:
This is a ___ with PMH Crohn's disease with known stricture
proximal to terminal ileum presenting with 1 day b/l lower
abdominal pain with associated nausea without vomiting.
ACTIVE ISSUE
# Partial SBO: Imaging was consistent with partial SBO in the
setting of Crohn's disease c/b hx ileitis and known TI
stricture. Patient refused NGT or surgical management of
recurrent partial SBO. Patient was managed conservatively with
bowel rest, IVF, morphine for pain management, and zofran for
nausea. SHe quickly improved and diet was advanced, tolerated
well. She was seen by nutrition who educated her on low residue
diet. Patient was able to tolerate solid foods and had passed a
bowel movement by time of discharge.
CHRONIC ISSUES
# Crohn's disease c/b hx ileitis and known TI stricture: no
evidence of flare on imaging. Patient was continued on
mercaptopurine and educated on low residue diet.
# GERD: continued omeprezole
# Depression: continued wellbutrin and fluoxetine
# Allergies: continued cetirizine.
# TRANSITIONAL ISSUES
- F/U with gastroenterology Dr ___, who was notified re
this admission
# CODE STATUS: FULL CODE
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 75 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. mercaptopurine 100 mg oral DAILY
4. Omeprazole 20 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
congestion
6. Acetaminophen 1000 mg PO BID:PRN pain
7. Bismuth Subsalicylate 30 mL PO QID:PRN diarrhea
8. Cetirizine 10 mg PO DAILY
9. Melatin (melatonin) 5 mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. BuPROPion 75 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Fluoxetine 60 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
congestion
6. mercaptopurine 100 mg oral DAILY
7. Omeprazole 20 mg PO DAILY
8. Bismuth Subsalicylate 30 mL PO QID:PRN diarrhea
9. Melatin (melatonin) 5 mg oral DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Partial small bowel obstruction with known
stricture in termlnal ileum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to ___ with worsening belly pain and were found
to have a small bowel obstruction. You declined surgical
intervention or an NGT and you were treated with IVF and
pain/nausea medications. Your symptoms improved with time and
you were able to tolerate a low residue diet by the time you
left the hospital.
We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10539866-DS-6 | 10,539,866 | 27,919,499 | DS | 6 | 2198-12-29 00:00:00 | 2198-12-29 18:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / sulfa / codeine
Attending: ___.
Chief Complaint:
Left elbow pain, redness, swelling
Major Surgical or Invasive Procedure:
___ placement ___
History of Present Illness:
In brief, this patient is a ___ woman with a history of
HTN and GERD who presents with 5 days of pain, tenderness,
swelling, and erythema of her left elbow. The pain came on
suddenly the night of ___, waking the patient. She does not
recall major trauma, but thinks she may have bumped the joint
inadvertently while sleeping. She reports that the pain was
initially ___ that night, constant and throbbing, and came to
be associated the following day with nausea and general malaise.
She presented to her PCP ___, who prescribed cephalexin; the
patient took three doses that day and 2 doses the following day,
with worsening redness over the left elbow and stable symptoms
otherwise.
She presented to the ED ___, where she was diagnosed with
septic bursitis and cellulitus, given vancomycin/ceftriaxone IV
x2 over the course of about 12 hours. She was discharged the
following morning with clindamycin, which she took as
prescribed. By the evening of ___, her symptoms still had not
improved and came to be associated with mild chills. Patient
recorded temperatures between 99 and 100 by oral thermometer at
home. The following day, ___, she felt that the redness over
her elbow was spreading further and so she returned to the ED
that evening.
Of note, pt reports an episode of cellulitis of her right foot
in ___ after a cut got infected, treated with po Abx but
not sure which one.
In the ED, initial vitals were T 100.2, HR 90, BP 138/79, RR 18,
O2 96% RA. Labs were significant for WBC 7.3 (62% N), lactate
0.9, CRP 34, ESR 42. Patient was seen by orthopedic consult,
which did not recommend drainage of septic bursitis, given
concern for sinus tract formation and seeding of bursa in the
setting of infection. Patient was given vancomycin 1 gm IV and
admitted to the medicine floor for further evaluation and
treatment.
(+) per HPI
(-) trauma that broke the skin, though bumped elbow on canoe
gunwale ___ fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Atypical chest pain
-HTN
-Anxiety
-Mild exercise induced asthma
-GERD
-Constipation
-R foot cellulitis - secondary to deep massage-related cut in
___, ___ s/p successful tx with unknown oral abx
-Mild gastroparesis - secondary to listeria infection, ___
-L eye orbital - fracture secondary to lacrosse incident, s/p
repair with metallic inferior orbital prosthesis, ___
-Osteoarthritis in both knees
-L knee ACL and meniscal tear - managed non-surgically
-R frozen shoulder
Social History:
___
Family History:
-Father with diabetes and premature CAD (reported first MI at
age ___, CHF, HTN, died ___ MI at age ___
-Mother with pulmonary fibrosis.
-Brother with diabetes and possible congenital cardiac disease
status post corrective surgery in childhood.
Physical Exam:
Admission Physical Exam:
===========================
Vitals- 98.2(max 98.6) - 73(73-77) - 117(117-131)/74 - 18 -
96(96-99)%RA
General- Appears stated age. Sitting upright in bed. Smiling,
alert, oriented, no acute distress.
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- erythema and warmth over L elbow, extending inferiorly to
mid forearm and superiorly to mid-upper arm, most markedly over
olecranon; tender to palpation over medial aspect, particularly
medial condyle; swollen over olecranon; mild pain with full
flexion and full extension; PROM and AROM full; small healing
scab over crest of L olecranon; all distal extremities warm,
well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro- CNs2-12 intact; ___ strength in all extremities b/l,
initially difficult to assess biceps and triceps ___ pain;
sensation intact to light touch in all extremities b/l
Discharge Physical Exam:
===========================
Vitals: Tmax 98.___/___ - 18 - 98% RA
Ext- erythema markedly improved, now covering very localized
area over L olecranon and less intense in color; tender to
palpation over medial condyle; mild pain with full flexion and
full extension; PROM and AROM full; small healing scab over
crest of L olecranon; all distal extremities warm, well
perfused, 2+ pulses
Pertinent Results:
Admission Labs:
====================
___ 05:40PM LACTATE-0.9
___ 05:30PM GLUCOSE-101* UREA N-16 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-30 ANION GAP-14
___ 05:30PM CRP-34.0*
___ 05:30PM WBC-7.3 RBC-4.75 HGB-15.4 HCT-46.9 MCV-99*
MCH-32.5* MCHC-32.9 RDW-12.4
___ 05:30PM NEUTS-62.1 ___ MONOS-6.6 EOS-1.5
BASOS-0.7
___ 05:30PM PLT COUNT-240
___ 05:30PM SED RATE-42*
Discharge Labs:
====================
___ 06:20AM BLOOD WBC-5.6 RBC-4.28 Hgb-13.8 Hct-42.5
MCV-99* MCH-32.2* MCHC-32.5 RDW-13.0 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-97 UreaN-14 Creat-0.6 Na-140
K-4.1 Cl-103 HCO3-25 AnGap-16
___ 06:20AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.0
Imaging:
====================
___ elbow AP and lateral radiographs: No fracture, dislocation,
or degenerative change. No elbow joint effusion is identified.
No focal lytic or sclerotic lesion. Normal left elbow
radiographs.
___ chest port line placement radiograph: In comparison with
the study ___, there again is no evidence of acute
cardiopulmonary disease. Right subclavian PICC line extends to
the mid portion of the SVC.
Brief Hospital Course:
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with no significant PMH who
presented with persistent L elbow pain, erythema, and swelling,
concerning for septic bursitis and cellulitis. Pt. placed on IV
vancomycin for empiric therapy with good improvement in
symptoms.
Active Issues:
# Septic superficial olecranon bursitis/cellulitis: Significant
edema, erythema, and warmth over elbow with extending erythema
down forearm. Accompanied by systemic symptoms including chills
and malaise. Preserved range of motion on presentation argued
against infection of deep bursa or joint capsule. Upon
presentation, patient was already s/p cephalexin PO x2d,
vanc/cef IV ___, clindamycin PO x2d, and vanc 1gm IV ___ with minimal improvement. Ortho evaluated pt. in ED and did
not feel aspiration indicated. Pt. initiated on IV vancomycin
with good improvement in her systemic symptoms. L elbow
redness, pain, and swelling improved over the course of her
admission. ___ placed ___ with plan for ___ week total IV vanc
course, continuing at home with infusion service in place. Pt.
to follow up with PCP ___ to monitor for improvement and
determine length of course. Pt will have CBC and lytes drawn by
infusion service before this f/u appt. to guide management.
Of note, she initially refused PICC. We gave her the option of
PO linezolid as an alternative regimen. However, she felt that
the side effect profile was not desireable. Thus she ultimately
was agreeable with ___.
Chronic Issues:
# HTN: continued amlodipine
# GERD/gastritis: Continued sucralfate. Restarted omeprazole
___.
# Constipation: Continued polyethylene glycol.
# Atypical chest pain. Continued aspirin.
Transitional issues:
# ABX COURSE: Vancomycin 1gm q12hrs; DAY 1 ___ anticipate 2
or 3 week course total to be determined by clinical exam by PCP
___ ___.
# Pt. will have labs (CBC, chem10) by ___ on ___ and faxed
to PCP for drug monitoring. No indication for following vanc
trough given normal, unchanging renal function and lack of
serious infection.
# Pt. will follow-up with personal orthopedist in early
___ for evaluation and consideration of bursectomy.
# Pt. initiated on omeprazole 20mg due to anxiety and ?GI upset
from vancomycin. Please consider discontinuing once course
complete.
# Dr. ___, Dr. ___, Dr. ___, and
Dr. ___ all notified of admission at request of pt.
# Code: Full
# Emergency Contact: Husband, ___ ___ son, ___
___ son, ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Sucralfate 2 gm PO BID
4. Aspirin 81 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Polyethylene Glycol 17 g PO TID
7. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Vancomycin 1000 mg IV Q 12H Duration: 19 Days
RX *vancomycin 1 gram 1 gm IV every 12 hours Disp #*38 Gram
Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Amlodipine 5 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Polyethylene Glycol 17 g PO TID
7. Vitamin D ___ UNIT PO DAILY
8. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*21
Capsule Refills:*0
9. Sucralfate 2 gm PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Cellulitis
Superficial olecranon septic bursitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for evaluation and treatment of cellulitis and
septic bursitis over your left elbow. You were seen in the
emergency department by the orthopedics team who did not think
drainage was indicated and recommended antibiotics alone. You
were started on IV vancomycin, and your symptoms improved
significantly over the course of your admission. On ___, a
peripherally inserted central catheter (PICC) was placed, such
that you could be discharged and safely continue your antibiotic
regimen at home, for a total of ___ weeks. On ___, you were
also started on a low dose of omeprazole, to help with reflux
and nausea that is exacerbated by anxiety and more difficult to
manage in the setting of your illness.
You will follow up with Dr. ___ on ___. Labs will be
drawn by the ___ service the day prior and faxed to Dr. ___.
If your symptoms have resolved by this time, your doctor may
instruct you to stop antibiotic treatment after a total of 2
weeks (last dose ___. If symptoms persist, you may be
instructed to continue treatment for a total of 3 weeks (last
___. Your doctor ___ also review your blood counts
and electrolytes to monitor for any side effects of the
antibiotic medication. Please also follow-up with your
orthopedist on ___.
It was a pleasure to take part in your care.
Sincerely,
Your Medicine Team at the ___
Followup Instructions:
___
|
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