note_id
stringlengths 13
15
| subject_id
int64 10M
20M
| hadm_id
int64 20M
30M
| note_type
stringclasses 1
value | note_seq
int64 2
133
| charttime
stringlengths 19
19
| storetime
stringlengths 19
19
| text
stringlengths 1.56k
52.7k
|
|---|---|---|---|---|---|---|---|
10539937-DS-7 | 10,539,937 | 27,370,170 | DS | 7 | 2160-02-09 00:00:00 | 2160-02-22 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfasalazine / Methotrexate / celecoxib / Nortriptyline
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
punch biopsy
History of Present Illness:
Pt is a ___ w/ PMH UC, fibromyalgia, connective tissue disorder
p/w sore throat and rash. States 5 days prior developed both
sore throat and rash. Both have been progressively worse,
especially the rash which is pruritic and progressing over most
of her body, including the palms of hands, but not soles of her
feet. Her lips are also progressively chapped and dry. She
has only been able to take in pudding over the past few days.
No nausea, but did have one episode of emesis today. Denies any
fevers or chills the past five days. Also denies cough, SOB,
chest pain. No sick contacts, recent travel, or exposure to
woods. No IV drugs nor is she sexually active. Stopped
prednisone 1mo ago and started celebrex and nortyptiline 3 weeks
prior for worsening joint pains associated with her undefined
connective tissue disease. She has received MMR, and also had
the measles and chicken pox as a child.
In the ED intial vitals were 96.9 90 153/83 20 100%. Labs were
significant for WBC 17, Cr 1.8, Lactate 2.2. Patient was given
viscous lidocaine, 1 percocet, and 50 mg benadryl.
On the floor patient remained alert and awake, conversant. No
acute distress. Stated she would like something for the sore
throat.
Past Medical History:
ULCERATIVE COLITIS
FIBROMYALGIA
HYPERTENSION
MIGRAINE HEADACHES
MENIERE'S DISEASE
OBESITY
KIDNEY STONES
SUPERFICIAL THROMBOPHLEBITIS
OSTEOARTHRITIS
UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE
Social History:
___
Family History:
Father and brother both with colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - T:98.3 158/82 95 97% Ra
GENERAL: NAD
HEENT: AT/NC, Lips dried, dark, and tender to palpation with
layer or dark crusting. no LAD, no JVD. OP with blotches of
erythema and ?vesciles vs. white exudates on buccal mucosa
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Diffuse, moribilliform appearing rash from neck down
including back, torso, legs, and sole of hands. A few lesions
crusted over, but mostly macular-popular
DISCHARGE PHYSICAL EXAM
GENERAL: NAD
HEENT: AT/NC, Lips dried, no longer dark, and tender to
palpation with layer or dark or yellow crusting. OP with
blotches of erythema and vesciles on buccal and sublingual
mucosa
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese, soft, nondistended, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: motor exam grossly normal
SKIN: Diffuse, moribilliform appearing rash, erythematous
macules and papules from neck down including back, torso, legs.
Petechiase on palms of hands, soles of feet. A few lesions
crusted over and raised. Some open lesions on anterior thighs.
One bullae on ant thigh.
Pertinent Results:
ADMISSION LABS
___ 02:54PM BLOOD WBC-17.0* RBC-4.99 Hgb-14.0 Hct-43.5
MCV-87 MCH-28.0 MCHC-32.2 RDW-12.7 Plt ___
___ 02:54PM BLOOD Neuts-83.6* Lymphs-7.9* Monos-6.9 Eos-1.3
Baso-0.4
___ 02:54PM BLOOD Glucose-94 UreaN-27* Creat-1.8* Na-140
K-4.5 Cl-99 HCO3-24 AnGap-22*
___ 02:54PM BLOOD ALT-20 AST-35 AlkPhos-98 TotBili-0.3
___ 02:54PM BLOOD Lipase-17
___ 02:54PM BLOOD Albumin-5.3*
___ 06:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.5
___ 03:12PM BLOOD Lactate-2.2*
DISCHARGE LABS
___ 07:40AM BLOOD WBC-9.0 RBC-4.33 Hgb-12.4 Hct-38.1 MCV-88
MCH-28.7 MCHC-32.6 RDW-13.2 Plt Ct-84*
___ 07:40AM BLOOD Glucose-90 UreaN-9 Creat-1.1 Na-141
K-3.1* Cl-102 HCO3-25 AnGap-17
OTHER LABS
___ 10:35AM BLOOD ESR-38*
___ 10:35AM BLOOD ESR-38*
___ 10:35AM BLOOD Ret Aut-1.7
___ 04:40PM BLOOD ___ dsDNA-NEGATIVE
___ 10:35AM BLOOD CRP-36.9*
___ 10:35AM BLOOD C3-202* C4-42*
___ 06:20AM BLOOD HIV Ab-NEGATIVE
___ 10:35AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-Test
___ 10:35AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test Name
___ 10:35AM BLOOD RUBEOLA ANTIBODY, IGM-Test Name
Brief Hospital Course:
Pt is a ___ w/ ___ UC, fibromyalgia, connective tissue disorder
p/w sore throat and rash.
# ___: The patient presented with a
progressively worsening erythematous rash that involved her lips
and oral mucosa. Dermatology was consulted and believed her
presenation was most consistent with ___ Syndrome
caused by medication, most likely celecoxib which the patient
recently started. They also considered infectious causes or
erythema multiforme but believed this was less likely.
Celecoxib, NSAIDs, and nortriptyline were discontinued. Her rash
stabilized with symptomatic and supportive treatment. GYN was
consulted to ensure to vaginal lesions, and the patient did not
have ophthalmologic symptoms confirmed on exam by Ophtho. She
was able to tolerate a shower on ___ and was discharged later
that day.
She will need to follow-up with dermatology within 7 days. She
will also have to follow-up with allergy after her rash resolves
to determine if she had a reaction to medications. Unncessary
medications should be avoided in this patient.
#Pharyngitis: likely due to SJS as above. Viral etiologies were
entertained but monospot and viral serologies were negative. She
was managed symptomatically with viscous lidocaine and
chloraspetic spray.
#Thrombocytopenia: Patient had low platelets on admission
(110's) that continued to downtrend with a nadir of 77. Etiology
is unclear - her 4T score for HIT was low (1). Other possible
etiologies include medication effect and her omeprazole was
discontinued. Her platelets remained stable in the 80's for the
last three days of her admission.
#Acute Kidney Injury: The patient had elevated Cr on 1.9 on
admission (baseline 1.1). This was likely prerenal azotemia from
poor po intake due to oral lesions. She was given IV fluids
until she was able to tolerate more intake. Her Cr was back to
baseline at the time of discharge.
Chronic Issues
#CTD/Fibromyalgia - patient was continued on hydroxychloroquin,
bentyl, gabapentin
#UC - she showed no signs of flares during this admission
#HTN - was continued on her nifedipine, triamterene/HCTZ
Transitional Issues
- Avoid unnecessary medications
- f/u with derm over the next week
- when improved, Allergy/Immunology evaluation to determine if
TCA's or Acetaminophen can be re-introduced or used in the
future
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. CeleBREX (celecoxib) 200 mg oral BID
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID lichen
sclerosis
4. Codeine Sulfate 30 mg PO Q 8 HRS PRN pharyngitis
5. Dexamethasone Intensol (dexamethasone) 0.5/5ml oral ___ x
daily sore throat
6. DiCYCLOmine 10 mg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
8. Gabapentin 100 mg PO TID
9. Hydroxychloroquine Sulfate 400 mg PO QHS
10. Lorazepam 0.5 mg PO HS:PRN insomnia
11. NIFEdipine 30 mg PO QHS
12. Omeprazole 40 mg PO BID
13. Simvastatin 40 mg PO DAILY
14. TraZODone 50 mg PO HS:PRN insomnia
15. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
16. Duloxetine 60 mg PO DAILY
17. Aspirin-Caffeine-Butalbital ___ CAP PO Frequency is Unknown
migraine
Discharge Medications:
1. Codeine Sulfate 30 mg PO Q 8 HRS PRN pharyngitis
2. DiCYCLOmine 10 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. Hydroxychloroquine Sulfate 400 mg PO QHS
6. Lorazepam 0.5 mg PO HS:PRN insomnia
7. NIFEdipine 30 mg PO QHS
8. Simvastatin 40 mg PO DAILY
9. TraZODone 50 mg PO HS:PRN insomnia
10. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
11. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
12. Sarna Lotion 1 Appl TP PRN itching
13. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
14. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID lichen
sclerosis
15. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
RX *potassium chloride 20 mEq 2 tablets PO daily Disp #*40
Packet Refills:*0
16. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
17. Maalox/Diphenhydramine/Lidocaine ___ mL PO PRN mouth pain
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ mL
by mouth daily Disp #*1 Bottle Refills:*0
18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN throat pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to participate in your care at ___
___. As you know, you were admitted for a
rash over your entire body. The Dermatologists were consulted
and believed that you had a reaction to a medicine that you were
taking. Most likely this was a medication that you started
recently, in particular Celecoxib. They also considered the
possibility that you had an infection, however we have not
identified an infectious source that would explain your
symptoms. When the eye doctors saw ___, they did not believe
you have involvement of your eyes with your rash.
After you leave the hospital, please do not take any unnecessary
medications. Do NOT restart taking Celecoxib or any NSAIDs
including tylenol or ibuprofen. You will need to follow-up with
Dermatology within the next 7 days, and with Allergy after your
rash has resolved. Please call the allergist office at
___ to schedule an appointment.
We also noted that your platelets were low; we think that this
could be due to your omeprazole. We stopped your omeprazole, and
started you on another acid medication.
Followup Instructions:
___
|
10540275-DS-8 | 10,540,275 | 26,753,931 | DS | 8 | 2151-11-11 00:00:00 | 2151-11-12 16:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Demerol / Penicillin V / amoxicillin
Attending: ___.
Chief Complaint:
chest abscess, fevers, arthralgias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old female to male transgender
individual with hx of DM who presents with fevers and chills in
the setting of a chest wall wound.
He presented to ___ Urgent care on ___ for evaluation
of a draining wound in the right upper chest. He has had a
chronic epidermoid cyst which became more red over the last
several weeks. On the day prior to presentation, he noticed this
cyst doubled in size and became more inflamed, so he presented
to ___ urgent care. He was diagnosed with an
abscess that was approx. 4cm. and loculated. It was incised,
drained, loculations bluntly dissected, wick placed, and he was
discharged on PO clindamycin for a 7 day course for possible
overlying cellulitis.
He developed worsening joint aches bilaterally in his shoulders,
hips, and knees as well as shaking chills, so he presented to
___ ED. Notably, he has had ___ episodes of these joint aches
in the past month that self resolved after hours, without any
edema or erythema, or associated skin rash.
He presented to ___ ED for further evaluation.
In the ED:
- Initial vitals were 99.7 128 136/91 22 100%ra
- Labs notable for: WBC 7.6, 12.3, 3.7; Plt 198, 117; Lactate
2.5, 1.8; UA 6 wbc, small leuk, neg nitr, no bac; Blood cultures
drawn
- CXR was negative for pneumonia
- Patient received 2L NS, 1L LR, Clindamycin 600mg IV x 4 doses,
glipizide 10mg x1, metformin 1000mg x3 doses,
- Decision was made to admit given persistent tachycardia to
100-110, and recurrence of fever to 100.6 despite antibiotics.
On the floor, he reports persistent RUQ abdominal pain radiating
to the back which developed in the ED. He has mild anorexia but
improved since yesterday. He denies current fevers, chest pain,
dyspnea, dysuria, vision problems, rash, joint swelling, joint
erythema.
Past Medical History:
Diabetes Mellitus Type II
Hx of Acute Pancreatitis (___), unknown etiology.
Pilonidal cyst s/p surgical excision
Appendicitis s/p appendectomy, c/b bowel perforation requiring
partial bowel resection
Gender reassignment surgery (TAH-BSO, b/l mastectomy)
Social History:
___
Family History:
Mother is alive, ___ years old, has HTN and ___.
Father is alive, ___ years old, with ___
syndrome and open heart surgery but not sure the reason.
Sister is alive, ___ years old, with ___
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VS: 98.9 127/71 96 18 96%ra
Gen: Alert and oriented x3, no acute distress, somewhat anxious
but very pleasant
HEENT: Pupils appear somewhat dilated around 6mm, equally round
and reactive to light, EOMI, no conjunctival injection,
Cardiac: mildly tachycardic, normal S1, S2, no MRG, regular
rhythm
Pulm: LCAB
Abd: b/l mastectomy scars, open appendectomy scar RLQ,
laparoscopic scars LLQ, soft, tenderness to palpation in RUQ,
negative ___ sign, no guarding or rebound
GU: no CVA tenderness
Ext: warm and well perfused, no peripheral edema, DP and ___ are
not palpable bilaterally
Skin: 1cm incised cyst in R upper chest, with 1cm surrounding
area of mild erythema and induration, wick in place
Neuro: no focal neurological deficits
Psych: appropriate mood and affect, somewhat anxious appearing
========================
DISCHARGE PHYSICAL EXAM
========================
VS: 99.1 138/86 ___ 114 (96-114) 18 97%ra
Gen: Alert and oriented x3, no acute distress, somewhat anxious
but very pleasant
HEENT: Pupils appear somewhat dilated around 6mm, equally round
and reactive to light, EOMI, no conjunctival injection,
Cardiac: mildly tachycardic, normal S1, S2, no MRG, regular
rhythm
Pulm: LCAB
Abd: b/l mastectomy scars, open appendectomy scar RLQ,
laparoscopic scars LLQ, soft, tenderness to palpation in RUQ,
negative ___ sign, no guarding or rebound
GU: no CVA tenderness
Ext: warm and well perfused, no peripheral edema, DP and ___ are
not palpable bilaterally
Skin: 1cm incised cyst in R upper chest, with 1cm surrounding
area of mild erythema and induration, wick in place
Neuro: no focal neurological deficits
Psych: appropriate mood and affect, somewhat anxious appearing
Pertinent Results:
===================
ADMISSION LABS
===================
___ 08:50PM BLOOD WBC-7.6 RBC-5.63* Hgb-15.0 Hct-43.4
MCV-77* MCH-26.6 MCHC-34.6 RDW-13.1 RDWSD-35.8 Plt ___
___ 08:50PM BLOOD Neuts-65.0 ___ Monos-10.8 Eos-1.6
Baso-0.3 Im ___ AbsNeut-4.94 AbsLymp-1.67 AbsMono-0.82*
AbsEos-0.12 AbsBaso-0.02
___ 08:50PM BLOOD Glucose-375* UreaN-12 Creat-0.9 Na-133
K-3.9 Cl-94* HCO3-30 AnGap-13
___ 04:10AM BLOOD ALT-33 AST-16 AlkPhos-100 TotBili-0.4
___ 04:10AM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.0 Mg-1.6
___ 04:30AM BLOOD ___ Comment-GREEN
___ 04:30AM BLOOD Lactate-2.5*
___ 12:27PM BLOOD Lactate-1.8
===================
DISCHARGE LABS
===================
___ 06:31AM BLOOD WBC-5.0 RBC-4.36 Hgb-11.3 Hct-34.0
MCV-78* MCH-25.9* MCHC-33.2 RDW-13.3 RDWSD-37.8 Plt ___
___ 06:31AM BLOOD Neuts-71.0 Lymphs-15.7* Monos-11.5
Eos-1.2 Baso-0.2 Im ___ AbsNeut-3.53 AbsLymp-0.78*
AbsMono-0.57 AbsEos-0.06 AbsBaso-0.01
___ 06:31AM BLOOD Plt ___
___ 06:31AM BLOOD Glucose-201* UreaN-12 Creat-0.7 Na-136
K-3.7 Cl-100 HCO3-26 AnGap-14
___ 12:00PM BLOOD ALT-36 AST-30 AlkPhos-84 TotBili-0.7
___ 06:31AM BLOOD Calcium-9.1 Phos-2.3* Mg-1.7
===================
MICROBIOLOGY
===================
+Blood Culture ___
No growth to date as of ___
+Blood Culture ___
No growth to date as of ___
===================
IMAGING
===================
+CXR PA/Lateral ___
Normal heart size, mediastinal and hilar contours. No focal
consolidation, pleural effusion or pneumothorax.
+KUB ___
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
IMPRESSION:
Nonobstructive bowel gas pattern.
Brief Hospital Course:
___ year old transgender female to male with hx of diabetes
mellitus type II, hx of acute pancreatitis of unknown etiology,
presented with R chest abscess at the site of an epidermoid
cyst.
# R chest abscess: He has had an epidermoid cyst in the right
chest for years, which became more erythematous over the past
several weeks. On ___ it became acutely enlarged, tender, and
with some drainage. He presented to ___ urgent
care on ___ for drainage, and this was I&D'd and started on PO
clindamycin. He developed worsening fevers, chills, and joint
aches in hips, knees, shoulders, so went to ED and noted to be
persistently tachycardic to 110 with Tmax of 100.6 despite IV
clindamycin, and also developed new abdominal pain/nausea. He
was admitted for monitoring. His chest wound had a 1cm linear
incision with a surrounding area of mild erythema and
induration. The packing was changed and his wound was dressed
with gauze. He was continued on PO clindamycin, but this was
switched to doxycycline due to concern of clindamycin induced
thrombocytopenia. He will finish a 7 day total course of
antibiotics with doxycycline (end ___ and follow-up with PCP
for wound check on ___.
# Abdominal pain: He reported significant RUQ and epigastric
abdominal pain radiating to the back, which developed in the ED
and associated with nausea/anorexia. Notably, the pain was
different in quality than his acute pancreatitis pain. LFTs and
lipase were within normal limits. KUB was obtained due to
concern of SBO due to numerous abdominal surgeries, but this was
negative for obstruction. Abdominal pain was moderate on day of
discharge and patient was tolerating POs, so was discharged with
counseling that pain should improve over time.
# Diabetes Mellitus type II: patient had blood sugars in the
300s in ED in the setting of chest wall infection. Labs were
negative for DKA. He was treated with insulin sliding scale, and
discharged on his home metformin and glipizide.
# Tachycardia: patient reports a chronic history of sinus
tachycardia to 110 even when resting at home, which was
previously attributed to anxiety. EKG did not show any
concerning findings. HR during admission ranged from 95-115. He
denied respiratory symptoms. This should be monitored in the
outpatient setting.
# Bilateral arthralgias: patient reported recent history of
episodic bilateral shoulder, hip, and knee pain which would
spontaneously resolve, not associated with joint swelling,
erythema, rash, or dysuria. He continued to have symptoms during
admission but there were no concerning physical exam findings.
This should be monitored and if persistent, may consider work-up
for spondyloarthropathy.
# Thrombocytopenia: Developed thrombocytopenia to 106k from 198k
on admission. This was attributed to clindamycin. Notably,
patient did receive heparin this admission but HIT workup not
pursued given low clinical suspicion. He was switched to
doxycycline on day of discharge.
TRANSITIONAL ISSUES:
# Continue doxycycline 100mg q12h thru ___
# Has chronic resting tachycardia to 110. Recommend further
evaluation in outpatient setting
# If joint pains and abscesses continue, would consider work-up
for spondyloarthropathy
# Chest abscess wound check with PCP ___ ___
# Repeat CBC to evaluate for thrombocytopenia.
CODE: FULL CODE
CONTACT: Mother, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlipiZIDE 10 mg PO BID
3. Testopel (testosterone) Dose is Unknown implant q3 months
Discharge Medications:
1. GlipiZIDE 10 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Testopel (testosterone) IMPLANT Q3 MONTHS
4. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Doses
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*7 Capsule Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8hrs Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Chest wall abscess
SECONDARY DIAGNOSIS:
1. Diabetes Mellitus Type II
2. Tachycardia - NOS
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 ___. You came to the
hospital because of fevers, joint aches, and a chest wall
abscess. We treated you with antibiotics. You also reported
abdominal pain, so we took an x-ray of your abdomen which was
normal. We also obtained blood tests including liver and
pancreas tests, which were also normal. We believe it is safe
for you to discharge home with oral antibiotics. Once your chest
wall infection improves, your other symptoms should improve as
well.
IMPORTANT INSTRUCTIONS:
- Continue doxycycline 100mg every 12 hours thru ___
- Please keep your abscess wound clean with guaze and change it
every day. This will heal on its own.
- Follow-up with PCP next week to monitor your wound and
symptoms
- Resume your glipizide and metformin
Again, it was our pleasure caring for you. We wish you the best!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10540624-DS-14 | 10,540,624 | 21,450,079 | DS | 14 | 2124-03-27 00:00:00 | 2124-03-28 12:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right ankle pain
Major Surgical or Invasive Procedure:
open reduction and internal fixation of right, closed ankle
fracture, ___, ___.
History of Present Illness:
___ no significant past medical history tfx from OSH with right
trimal s/p reduction at OSH under conscious sedation I/s/o
mechanical fall. Patient was hanging Christmas decorations at
approximately 2300, when she fell off the couch landing on her
right ankle with immediate pain and deformity. Denies HS or LOC.
At OSH, displaced R trimalleolar fracture reduced under
procedural sedation for reduction, splinting and transferred
here
for further orthopedic evaluation I/s/o no orthopedic in house
surgeon per report.
Patient denies other injuries. Denies distal numbness, tingling,
weakness. Denies recent fevers/chills/illnesses.
PMH/PSH:
Diverticulitis s/p surgery
Remote hx of DVT ___ years prior in setting of pregnancy and
other risk factors which patient cannot recall. Was never on
systemic anticoagulation
Past Medical History:
Diverticulitis s/p surgery
Remote hx of DVT ___ years prior in setting of pregnancy and
other risk factors which patient cannot recall. Was never on
systemic anticoagulation
Social History:
___
Family History:
non-contributory
Physical Exam:
the extremity is neurovascularly intact.
patient is afebrile and hemodynamically stable.
no acute distress. pain well-controlled
Pertinent Results:
reviewed and unremarkable.
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left closed ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for surgical fixation, 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 left lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO 5X DAILY
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*60 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY dvt prophylaxis
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. crutch 2 crutches miscellaneous with ambulation
please administer two axillary crutches for ambulation. dx -
closed right ankle fracture. prognosis good. ___: 13 months.
RX *crutch please administer two axillary crutches for
ambulation. use with ambulation. Disp #*2 Each Refills:*0
4. Docusate Sodium 100 mg PO BID
use while taking narcotic pain medicaiton
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*14 Capsule Refills:*0
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
OK to request partial fill. Wean as tolerated.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*28 Tablet Refills:*0
6. Senna 8.6 mg PO BID
use while taking narcotic pain medication.
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 2 tablets by
mouth twice daily Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right, closed ankle ankle fracture involving fibula and
posterior malleolus.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non weight bearing on the right lower extremity.
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 enoxaparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Followup Instructions:
___
|
10540652-DS-18 | 10,540,652 | 26,814,669 | DS | 18 | 2194-09-13 00:00:00 | 2194-09-15 08:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
SSRI
Attending: ___.
Chief Complaint:
Confusion, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is ___ speaking F with recently diagnosed
___ disease, anorexia, recent UTI, mastectomy of left
breast who presented to the emergency room with increasing
confusion, insomnia, and hallucinations, found to be
hyponatremic.
Translation provided by pt's son.
With regards to her confusion, her son states that the patient
has had a subacute decline in functional status and cognition
over the last few months. She has additionally had decreased PO
intake, and has lost about 20 pounds over the past year. For the
three days prior to admission, the patient had an acute
worsening
of symptoms - wandering around her home, insomnia,
auditory/visual hallucinations including seeing her late mother,
speaking to herself, and a worsening of her baseline tremor in
bilateral hands.
Of note, the patient was seen on ___ at the movement disorders
clinic for an initial visit, for evaluation of her hand tremor,
L
>R. The tremor has existed for years. Her other symptoms have
included global bradykinesia, weakness, constipation, urinary
frequency without incontinence, and anxiety, especially after
her
husband's recent chronic hospitalization. She was started on
Lexapro 5 mg for anxiety, and given instructions to wean off her
home At___. The plan was to start carbidopa levodopa after
Ativan had been completely weaned off. She has no yet started on
carbidopa levodopa because she is still weaning off the Ativan.
In addition, she was seen at her primary care clinic on ___ with
urinary frequency and +Blood on UA, was started on Bactrim x 5
days for a presumed UTI.
Neurology evaluated the patient in the ED and determined that
the
acute change in her symptoms are most likely associated with her
UTI, insomnia, anorexia, and hyponatremia (see below). They
recommended that she continue her Ativan taper and begin the
carbidopa/levodopa treatment for ___ as previously
planned at her ___ visit.
-ED vitals: initially 97.2 92 191/99 20 96% RA
-Her hypertension resolved with pain control, was provided
morphine 2mg IV x 2 + tylenol ___.
-The patient developed hypoNa was found to be hyponatremic to
121. s/p 1 L LR -> Na responded to 130. CXR no e/o pathology.
Urine culture from ___ grew mixed flora. UA trace leuk, small
amount of blood. Was found to be retaining urine, Foley placed.
HCT unable to be performed due to pt being unable to continue
the
study.
-Exam: bilateral coarse tremors, CN II-XII intact, extremity
strength intact, numbness in lower extremities. NC/AT HEENT
exam,
nl cardiac and pulmonary exam.
On arrival to the floor, the patient described that she felt
much
better than prior. She continues to feel weak and needs help
with
ambulation. She denied HA, dizziness, n/v, SOB, CP, abdominal
pain, dysuria, diarrhea.
Past Medical History:
Recently diagnosed ___ disease
Anorexia
Elevated A1c
Hepatitis
Left breast mastectomy
Vitamin D deficiency
Bilateral hand tremors
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ Temp: 97.6 PO BP: 121/72 HR: 66 RR: 18 O2
sat: 96% O2 delivery: RA
GENERAL: Malnourished, pleasant,bilateral hand tremor, L > R. In
no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs appreciated.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Non distended, non-tender to palpation in all four
quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: alert and oriented to person, place, and time.
CN2-12
intact. Normal strength throughout (baseline decreased in L arm
s/p L mastectomy). Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
VS:24 HR Data (last updated ___ @ 1135)
Temp: 97.5 (Tm 97.8), BP: 105/72 (96-134/56-76), HR: 88
(70-89), RR: 18 (___), O2 sat: 93% (93-95), O2 delivery: Ra,
Wt: 96.56 lb/43.8 kg
GENERAL: Anxious-appearing, cachectic woman sitting up in bed,
pleasant, bilateral hand (resting) tremor, L > R. In no acute
distress.
HEENT: PERRL, dilated pupils, but reactive, EOMI. Sclera appear
slightly icteric and without injection. Moist mucous membranes.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs appreciated.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Non distended, non-tender to palpation in all four
quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Alert and orientedx3. CN2-12 intact. Normal strength
throughout (baseline decreased in L arm s/p L mastectomy).
Moving
all 4 limbs spontaneously. Slight hyperflexia. Cogwheel rigidity
in upper extremities L>R. Subjectively states that her left
shoulder, arm, and leg feel weaker than Right side.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:28PM BLOOD WBC-8.6 RBC-3.66* Hgb-11.3 Hct-33.4*
MCV-91 MCH-30.9 MCHC-33.8 RDW-11.8 RDWSD-39.4 Plt ___
___ 09:28PM BLOOD Neuts-80.5* Lymphs-12.2* Monos-6.5
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.96* AbsLymp-1.05*
AbsMono-0.56 AbsEos-0.01* AbsBaso-0.02
___ 09:28PM BLOOD Glucose-151* UreaN-15 Creat-0.7 Na-121*
K-4.5 Cl-85* HCO3-26 AnGap-10
___ 01:03PM BLOOD ALT-29 AST-70* AlkPhos-63 TotBili-1.6*
___ 07:10AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
___ 09:28PM BLOOD Osmolal-256*
IMAGING RESULTS:
================
___ Imaging CHEST (PA & LAT)
IMPRESSION:
No evidence of pneumonia.
___ Imaging CT LIMITED ___ SCANS
IMPRESSION:
Nondiagnostic study due to the patient's inability to continue
the imaging.
DISCHARGE LABS:
===============
___ 06:37AM BLOOD WBC-4.3 RBC-3.92 Hgb-12.4 Hct-37.9 MCV-97
MCH-31.6 MCHC-32.7 RDW-12.4 RDWSD-43.8 Plt ___
___ 06:37AM BLOOD Glucose-107* UreaN-26* Creat-0.6 Na-139
K-4.9 Cl-99 HCO3-28 AnGap-12
___ 06:37AM BLOOD ALT-33 AST-49* TotBili-0.7
___ 06:37AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0
Brief Hospital Course:
Ms ___ is a ___ speaking F with recently
diagnosed ___ disease, anorexia, recent UTI, mastectomy
of left breast (in the ___) who presented to the emergency room
with increasing confusion, insomnia, and hallucinations, found
to
be hyponatremic which improved with fluid restriction now
normalized, started on Carbidopa-Levodopa for ___ also
with deconditioning. She was clinically stablilized and
discharged to rehab.
ACUTE/ACTIVE ISSUES:
====================
___ Disease
Recently diagnosed on ___. Originally on Ativan taper which was
completed ___ then began carbidopa/levodopa on ___.
- Started carbidopa-levodopa ___ mg tablet (Sinemet brand)
Titration schedule below
# Confusion
Initially, Ms. ___ confusion was assumed to be directly
related to her hyponatremia. However, she continues to endorse
feeling more confused than baseline and having hallucinations
that her grandson is in the room, despite knowing that he is not
there. Therefore, consider additional workup to rule out other
causes of confusion. Asked neurology about possibility of DLB
diagnosis rather than ___, they will continue to follow
her as an outpatient. Also considered serotonin syndrome given
recent start of escitalopram, findings of high temperature,
agitation, and hyperreflexia on
exam; however, she was on a low dose of SSRI and had no
improvement with stopping escitalopram so this is unlikely.
Would
caution against restarting any SSRI in the future.
#Failure to thrive
# Weakness
# Deconditioning
# 20 lb weight loss in last year
Patient reports decreased PO intake with weight loss of 20
pounds
in the last year. Malignancy is unlikely as she denies GI
bleeding/dark stools, abd pain/discomfort. She is up to date for
preventative screening (yearly mammograms, pap smear UTD), but
unsure if she has had a colonoscopy. The patient describes
feeling subjectively too weak to walk since ___, despite asking
to walk with nurses on previous days. Her strength is ___ in the
lower extremities on exam. This may be a component of her
failure
to thrive, hyponatremia, and PD not yet treated. Recommend
continuing with Ensure supplementation with meals for weight.
#Anxiety
Pt expressing anxiety. Has been on SSRI in past but will not
restart given hx of hyponatremia. Will start gabapentin 300 BID
today and uptitrated to 300TID as tolerated after ___ days.
Started gabapendin 300 BID per neurology recs with
recommendation to uptitrate up to TID
# Hyponatremia, resolved
Presenting Na 121. Likely multifactorial AMS d/t starting
escitalopram on ___ and hyponatremia, perhaps compounded by UTI.
Her hallucinations and confusion resolved. Urine
lytes (high urine osmols + Na) were consistent with SIADH
picture,
thought to be due to SSRI with contribution of hypovolemia iso
of failure to thrive/ poor PO intake/
recent nausea and vomiting. considered paraneoplastic SIADH was
considered but not thought to be likely. Her sodium resolved
with fluid restriction and increased PO intake.
# UTI, resolved
UTI resolved after 3-day course ceftriaxone ___ - ___.
Patient describes urinary frequency and urgency prior to PCP
___ ___, for which she was started on Bactrim. In the
ED,
she was unable to void and a Foley was placed. Considered
neurogenic bladder from PD though bladder scanned, not
retaining.
CHRONIC/STABLE ISSUES:
======================
#Bilateral UE tremor: bilateral, resting, not currently on
medications. Started Sinamet ___.
CORE MEASURES:
==============
# CODE:full (presumed)
# CONTACT:
___ (daughter) ___
___ (son) ___
TRANSITIONAL ISSUES
===================
[]Outpatient PCP ___
[]Outpatient neurology ___
[]Continue to uptitrate Sinemet according to the schedule
outlined below per her outpatient neurologist
NEW MEDICATIONS
Gabapentin
Carbidopa-Levodopa (___) (Also known as Sinemet)
Please Increase the dose of the Carbidopa-Levodopa as follows:
Week 1 (___) Take half tablet in the morning
Week 2 (___) Take half tablet in the morning, half tablet
at noon
Week 3 (___) Take half tablet in the morning, half tablet
at noon, half
tablet in the early evening
Week 4 (___) Take one tablet in the morning, half tablet at
noon, half
tablet in the early evening
Week 5 (___) Take one tablet in the morning, one tablet at
noon, half
tablet in the early evening
Week 6 (___) Take one tablet in the morning, one tablet at
noon, one
tablet in the early evening and continue on this regimen
CHANGED MEDICATIONS
NONE
STOPPED MEDICATIONS
Escitalopram
Lorazepam
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. LORazepam 0.25 mg PO QAM
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY Duration: 1
Week
Please uptitrate (increase the dose) according to the schedule
in your discharge paperwork.
3. Gabapentin 300 mg PO TID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___!
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were feeling confused
with hallucinations, and insomnia and weakness.
- You also were noted to have decreased food intake, weight
loss, and worsening of your tremors.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital we monitored you and your
blood for your sodium levels which were low when you came in. To
treat this we encouraged you to eat and also not to drink too
much water. Your sodium levels continued to improve.
- We consulted our nutrition team who encouraged you to
continue to eat healthy fats and healthy meals to gain weight so
you can get stronger. We gave you two Ensure drinks per meal to
help you gain some of the weight you have lost.
- We started you on a new medication for your ___
Disease called Sinemet (carbidopa-levodopa) which will help with
your tremors. We discontinued your Ativan.
- We discontinued your Escitalopram as we think this may have
contributed to your low sodium. We started you on a new
medication, Gabapentin to try to help with your anxiety.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications.
- Please continue to eat healthy fats and to try to increase
your caloric intake.
- Please continue to drink Ensures to help gain weight to get
stronger. Do not drink too much water so that you are too full
to eat.
NEW MEDICATIONS
Gabapentin
Carbidopa-Levodopa (___) (Also known as Sinemet)
Please Increase the dose of the Carbidopa-Levodopa as follows:
Week 1 (___) Take half tablet in the morning
Week 2 (___) Take half tablet in the morning, half tablet
at noon
Week 3 (___) Take half tablet in the morning, half tablet
at noon, half
tablet in the early evening
Week 4 (___) Take one tablet in the morning, half tablet
at noon, half
tablet in the early evening
Week 5 (___) Take one tablet in the morning, one tablet at
noon, half
tablet in the early evening
Week 6 (___) Take one tablet in the morning, one tablet at
noon, one
tablet in the early evening and continue on this regimen
CHANGED MEDICATIONS
NONE
STOPPED MEDICATIONS
Escitalopram
Lorazepam
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10540723-DS-7 | 10,540,723 | 23,358,880 | DS | 7 | 2122-12-06 00:00:00 | 2122-12-09 10:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Persistent HA s/p admission for IPH.
Major Surgical or Invasive Procedure:
No major surgical or invasive procedure.
History of Present Illness:
Mr. ___ is a ___ M PMHx AFib/AFlutter, CAD s/p LAD PCI
___ and CABG ___, CHF, renal artery stenosis s/p stents
(___), bilateral carotid artery stenosis s/p L ICA stent
(___), with recent admission from ___ with IPH, and
recent ED visit on ___ for HA who re-presents today with
persistent HA.
Mr. ___ initially presented to ___ ED on ___ with
transient
word-finding difficulties. NCHCT revealing a L temporal IPH. CTA
showed a likely chronically occluded R ICA and high grade
stenosis (~75%) of the L ICA stent. MRI did not reveal an
underlying lesion or micro-hemorrhages. It was felt that Mr.
___ likely had an ischemic infarct with hemorrhagic conversion
due to his use of ASA, Plavix and warfarin. This infarct was
likely cardioembolic. Athero-embolism was also felt to be a
possibility.
Mr. ___ was discharged home from the ICU on ASA alone, with
instructions to restart Coumadin on ___. BP goals were stated
to
be 120-160. Of note, he did complain of a headache on the day of
discharge and continued to have significant speech and memory
issues.
Mr. ___ also re-presented to the ___ ED on ___ with
headache. A NCHCT showed interval improvement in his IPH, and
neurological examination was stable. He was discharged home with
oxycodone for pain control.
Mr. ___ returns to the ED today with persistent HA. If
anything, his speech appears more fluent, and he is able to
describe "a terrible headache, the oxycodone didn't help." He
reports that he tried taking oxycodone 5mg q5hrs but did not get
any significant relief. He denies nausea/vomiting, blurry or
double vision, or any positional quality to his headache. He
denies any new focal weakness or numbness.
Of note, Mr. ___ blood pressure was elevated to sBP 200 on
presentation. It did improve modestly on re-check, but remained
above 160.
Past Medical History:
Coronary artery disease (s/p LAD stent in ___, ___, s/p 3-vessel CABG ___
Meningioma s/p resection
Adjustment disorder
Left posterior meningioma s/p resection
Sleep apnea
Obesity
Carotid stenosis s/p left ICA stent (___)
CHF (congestive heart failure), ___ class III
Chronic renal insufficiency
Bilateral renal artery stenosis s/p stents (___)
Hyperlipidemia
Hypertension
Left lumbar radiculopathy
Atrial flutter
Atrial fibrillation
Social History:
___
Family History:
Mother with TIAs in her ___, breast cancer, skin cancers
Father with MI at age ___
Physical Exam:
Admission Exam
VS T98.3 HR98 BP201/104->163/93 RR18 Sat100%RA
GEN - Awake, cooperative, NAD
HEENT - NC/AT, no scleral icterus noted, MMM
NECK - Supple, R>L carotid bruits appreciated
RESP - normal WOB
CV - RRR
ABD - Soft, NT/ND
EXTR - No C/C/E bilaterally
NEUROLOGICAL EXAMINATION
MS - Alert, oriented to person and time only. Knows hospital,
but
unable to state name. Able to name high frequency objects but
not
low frequency objects. Semantic paraphasic errors. Repetition
intact to simple phrases but impaired for complex phrases. Able
to follow 3-step commands. Poor short term memory. Able to
register ___ words and recall ___ at 1 minute. Has vague
recollection that he met this examiner 2 days ago.
CN - PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal
saccades. VFF to finger wiggling. Facial sensation intact to
light touch. Face symmetric. ___ strength in trapezii
bilaterally. Tongue midline.
MOTOR - Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
SENSORY - No deficits to light touch throughout.
REFLEXES -
Bi Tri ___ Pat Ach
L ___ 3 2
R ___ 3 2
Plantar response was flexor bilaterally.
COORD - No intention tremor, no dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
GAIT - Deferred.
Discharge Exam
His physical exam is as follows:
Tmax/T current: 98/97.9, BP: 124-153/72-84, HR: 80-95, RR ___,
02% 97-100% RA
Mental status: awake and oriented x 3, attention is normal and
he is capable of saying DOWB and MOYB, has poor STM
(registration ___ and recall ___ even with categorical and MC
prompts). His long term memory is normal and he is able to
remember his birthday and where he lives. Naming is normal for
high frequency and abnormal for low frequency objects (he said
thermometer instead of stethoscope). Calculation is normal and
comprehension intact for cross body commands.
CN: PERRL 3-2mm, EOMI, symmetric face and smile, ___ strength in
trapezii bilaterally. Able to push tongue against cheek
bilaterally with normal strength.
Motor: normal bulk and tone bilaterally. No pronator drift
bilaterally.
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 throughout.
GAIT - deferred
Pertinent Results:
___ 02:25PM BLOOD WBC-10.4* RBC-4.84 Hgb-13.8 Hct-41.9
MCV-87 MCH-28.5 MCHC-32.9 RDW-15.0 RDWSD-47.0* Plt ___
___ 10:10AM BLOOD WBC-10.7* RBC-4.72 Hgb-13.5* Hct-41.4
MCV-88 MCH-28.6 MCHC-32.6 RDW-15.3 RDWSD-49.0* Plt ___
___ 02:25PM BLOOD Neuts-82.9* Lymphs-9.0* Monos-6.8
Eos-0.3* Baso-0.4 Im ___ AbsNeut-8.60* AbsLymp-0.93*
AbsMono-0.71 AbsEos-0.03* AbsBaso-0.04
___ 02:25PM BLOOD Plt Smr-NORMAL Plt ___
___ 07:10PM BLOOD ___ PTT-29.8 ___
___ 10:10AM BLOOD Plt ___
___ 10:10AM BLOOD ___ PTT-30.0 ___
___ 02:25PM BLOOD Glucose-115* UreaN-21* Creat-1.2 Na-138
K-4.2 Cl-98 HCO3-29 AnGap-15
___ 10:10AM BLOOD Glucose-158* UreaN-24* Creat-1.2 Na-138
K-3.9 Cl-100 HCO3-30 AnGap-12
___ 08:06AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3
___ 02:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:34PM BLOOD Lactate-2.0
___ 10:10AM BLOOD AT-107 ProtSFn-119
___ 10:24AM BLOOD PROTHROMBIN MUTATION ANALYSIS-CANCELLED
___ 10:10AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-PND
___ 10:10AM BLOOD FACTOR V ___-CANCELLED
___ 10:10AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-Test
___ 10:10AM BLOOD PROTEIN C ANTIGEN-Test
___ CT head
1. No significant interval change in the temporal lobe
intraparenchymal
hemorrhage other than apparent resolution of the
intraventricular component.
2. No new focal hemorrhage or large infarct.
___ CTA head
1. Stable appearance of the left temporal intraparenchymal
hemorrhage.
2. No signs of dural venous sinus thrombosis.
NOTE ON ATTENDING REVIEW:
Study suboptimal, due to poor opacification of the venous
sinuses. Part of
the left transverse sinus and the sigmoid sinuses and the
proximal left
internal jugular vein are not well seen.
There is slightly expanded appearance of the left internal
jugular vein
proximally, with slightly ill-defined and multifocal enhancement
within.
These are better assessed on the subsequent MR and MR venogram
studies.
Findings can relate to slow flow or subacute-chronic thrombosis
with some
recanalization or poor opacification. (Surgical clips related
to craniotomy
noted in the left occipital region- details not known.)
Intracranial arteries better assessed and described on prior CT
angiogram
study.
MRI
1. Unchanged 2.9 x 5.4 x 2.7 cm left temporal lobe parenchymal
hemorrhage with
associated edema and mild mass effect. No evidence of
associated abnormal
postcontrast enhancement beyond the degree of intrinsic T1
hyperintensity.
Small amount of blood layering within the left occipital horn
lateral
ventricle.
2. Absent signal on PC MRV seqeunces within the left transverse
and sigmoid
sinus with partial loss of the normal flow void on spin echo
sequences, which
however, demonstrate normal enhancement on postcontrast
sequences. This is
relatively unchanged in comparison to CTA from ___ and
MR from ___
___. Findings may represent slow flow versus subacute
thrombosis with
recanalization, the chronicity of which is uncertain as no
remote studies are
available for comparison and there is evidence of left-sided
craniotomy in the
occipital region, details of which are not known.
Correlate clinically and with details of prior procedure.
3. Pl. See recent CTV study.
4. Occluded right internal carotid artery. Please see recent CT
angiogram
study
Followup studies can be considered as needed for better
assessment of any
interval change.
Brief Hospital Course:
Mr. ___ is a ___ M with Afib/Aflutter, CAD s/p LAD PCI
___ and CABG ___, CHF, renal artery stenosis s/p stents
(___), bilateral carotid artery stenosis s/p L ICA stent
(___) who was recently admitted for L temporal IPH, likely
secondary to hemorrhagic conversion of an embolic stroke. He was
discharged home on ___ and then returned to the ED on ___
with persistent HA, and given a stable exam and stable imaging,
he was discharged home. He represented on ___ with persistent
HA and hypertensive urgency (BP 201/104-->163/93). His exam was
stable from the prior admission; notably, he could not name low
frequency objects, made semantic paraphasic errors, could not
repeat complex phrases, was able to follow complex commands,
registration was ___, but recall was ___ at 3 minutes.
Additionally, his gait was unsteady.
CTV demonstrated partial filling defect within inferior left
sigmoid sinus and IJ, which could represent slow flow versus
subacute thrombus. MRV demonstrated absent flow in left
transverse and sigmoid sinus with partial loss of flow void.
This appeared stable compared to prior imaging. Given the
chronicity of this and the recent hemorrhage, aggressive
anticoagulation was not started. His IPH was stable on CT. He
was restarted on his home Coumadin 7.5mg daily on ___ as
previously planned to treat his Afib and a possible VST, and he
was continued on his home ASA 81mg daily for his stents in
consultation with his cardiologist Dr. ___ his neurologist
Dr. ___. Hypercoagulable (except factor V Leiden and
prothrombin mutation which will need to be ordered as
outpatient) workup pending.
He fell in the hospital on ___, but he had no injuries,
head strike, LOC, or new neurological deficits. He was evaluated
by ___.
His headache markedly improved after the hypertension was
regulated. He sometimes reported that his headache was
completely relieved, but at other times, he would report that
his headache had been ___ persistently and had never abated. It
did not wake him from sleep, was not present on awakening, and
did not change with coughing or positional changes. He was
treated with Tylenol #3 as needed with good effect.
He became mildly hypotensive when he was given captopril as
needed for SBP>160. When he was exclusively treated with his
home antihypertensives, his blood pressure normalized and
remained within an SBP goal of 120-160. As a result, it is
likely that his hypertension was due to medication
non-compliance in the setting of cognitive deficits; the patient
has poor memory and likely does not recall taking or not taking
his medications. He will need close supervision of his
medication in the home environment through ___.
He was discharged home with a home visiting nurse ___
medication supervision), home physical therapy, and speech
therapy after evaluation by ___ and OT. SW offered patient
referral to Elder Services which could provide services to
patient at home including help with medication monitoring, but
the patient declined.
Transitional issues/Key information for providers:
-___ labs listed below are pending
Labs
___ 10:10 AT III
___ 10:10 PROT S
___ 10:24 PROBLEM
Send Outs
___ 10:10 Beta-2-Glycoprotein 1 Antibodies IgG
___ 10:10 CARDIOLIPIN ANTIBODIES (IGG, IGM)
___ 10:10 PROTEIN C ANTIGEN
Microbiology
___ 13:43 BLOOD CULTURE Blood Culture, Routine
-Factor 5 Leiden and Prothombin Gene Mutation can be sent in
outpatient setting; could not be done as inpatient
-CTV demonstrated partial filling defect within inferior left
sigmoid sinus and IJ, which could represent slow flow versus
subacute thrombus
-MRV demonstrated absent flow in left transverse and sigmoid
sinus with partial loss of flow void
-Started on Coumadin 7.5mg daily and continued on ASA 81mg daily
per discussion with outpatient cardiologist Dr. ___ and
neurologist Dr. ___ up with home ___, home ___, and speech therapy; hypertension
likely due to medication non-compliance so importance of
continuing ___ services should be emphasized. The patient has
poor insight into some of his cognitive (severe memory deficits)
deficits and thinks he can take medications without assistance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY preventive
2. Atorvastatin 80 mg PO QPM hyperlipidemia
3. BuPROPion 150 mg PO DAILY depression
4. Furosemide 20 mg PO BID CHF
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Cromolyn Sodium (Nasal Inhalation) 2 SPRY NS DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY preventive
2. Atorvastatin 80 mg PO QPM hyperlipidemia
3. BuPROPion 150 mg PO DAILY depression
4. Furosemide 20 mg PO BID CHF
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Warfarin 7.5 mg PO DAILY16
8. Cromolyn Sodium (Nasal Inhalation) 2 SPRY NS DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
venous sinus thrombosis
hypertensive urgency
headache
prior IPH
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Dear Mr. ___,
You were admitted with headache and hypertension. You were
found to have a possible clot in the vessels in your brain. We
have restarted your Coumadin at 7.5mg every evening, and you
will also continue your home aspirin. This plan was made with
your outpatient cardiologist and neurologist.
We have set you up with a home visiting nurse, home physical
therapy, and speech therapy. We think that is very important
that you allow the visiting nurse to visit you and help you with
your medications to prevent dangerously high blood pressure and
bleeds in the brain in the future.
It was a pleasure meeting you!
Your ___ Neurology Team
Followup Instructions:
___
|
10540723-DS-9 | 10,540,723 | 21,168,255 | DS | 9 | 2124-01-10 00:00:00 | 2124-01-15 21:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LLE weakness, shaking, and altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with HTN, HLD, afib on
eliquis, CHF, CAD s/p CABG, L posterior meningioma s/p
resection,
and CKD who presents after being unable to raise his left lower
extremity while urinating thus causing a fall. He is followed by
Dr. ___ shaking thought to be ___ hypoperfusion in
setting
of severe cervical atherosclerodic disease.
Yesterday around noon, he was talking to his sister on the
phone,
who said he sounded weird and a bit off. Later that afternoon,
he
felt like his left leg went out and was unable to control it. He
then started to slip and fell to the ground. Tenants heard him
and dragged him over to the couch. He was shaking as well for 20
seconds every 15min for 3 hours. This was a different kind of
shaking than previously noted. He was sitting down/lying down
with shaking. Arms would go into fists, get straight/tucked in.
Legs as well. Not confused afterwards, and he was trying to talk
during event. No tongue biting, ?incontinence. He did not want
to
go the hospital, so he got into bed. This morning, he was having
trouble walking and was unable to get himself to the bathroom.
Also seemed mentally slower, which was how his daughter
convinced
him to come to the hospital.
At baseline, he walks without a walker and is independent. No
seizures. No recent infections. Takes all his medications.
He follows with Dr. ___ as an outpatient. Starting ___, he kept having episodes of falling. Associated with large
amplitude shaking of arms and legs but not in rhythmic pattern.
He would maintain consciousness and did not feel like he was
presyncopal. EEG in ___ showed frequent left posterior temporal
blunt and sharp waves and focal theta slowing and drowsiness.
Ambulatory EEG showed occasional mild left mid and posterior
temporal theta slowing but no epileptiform discharges. One
episode of shaking was associated with BP 70/52. He has gotten
into a car accident because of the shaking. He was found to have
significant stenosis of his R carotid artery, and this was
thought to be the cause of his shaking likely related to
cerebral
hypoperfusion given extensive cervical atherosclerosis. He was
admitted ___ for an elective right external carotid stent
placement and started on aspirin 81, Plavix 75, and eliquid 5
BID. Plan to continue Plavix only for 1mo given bleeding risk.
He
developed sudden onset LUE weakness and drift while in hospital,
and CTA showed R external carotid stent was patent. Symptoms
improved with fluid bolus for SBP 100. He was discharged with
___.
Neuro exam nonfocal on discharge.
Past Medical History:
Coronary artery disease (s/p LAD stent in ___, ___, s/p 3-vessel CABG ___
Meningioma s/p resection
Adjustment disorder
Left posterior meningioma s/p resection
Sleep apnea
Obesity
Carotid stenosis s/p left ICA stent (___)
CHF (congestive heart failure), ___ class III
Chronic renal insufficiency
Bilateral renal artery stenosis s/p stents (___)
Hyperlipidemia
Hypertension
Left lumbar radiculopathy
Atrial fib
Social History:
___
Family History:
Mother with TIAs in her ___, breast cancer, skin cancers
Father with MI at age ___
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: T: 98.8F HR: 59 BP: 136/65 RR: 18 SaO2: 97% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___, ___.
Able to relate history with mild difficulty. Speech is fluent
with full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. No dysarthria.
Normal prosody. Mild apraxia. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: Anisocoria R>L by 0.5mm, both briskly
reactive.
VF full to number counting. EOMI, no nystagmus. V1-V3 without
deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor: Normal bulk and tone. No drift. +asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5-* 5 5 5
* pain limited
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 3+ 3+ 3+ 3+ 2
Plantar response extensor bilaterally
- Sensory: No deficits to light touch bilaterally
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
==============
DISCHARGE EXAM
==============
Essentially unchanged.
Pertinent Results:
====
LABS
====
___ 08:45PM BLOOD WBC-11.3* RBC-4.67 Hgb-13.7 Hct-42.0
MCV-90 MCH-29.3 MCHC-32.6 RDW-14.9 RDWSD-48.4* Plt ___
___ 05:25AM BLOOD ___-8.4 RBC-4.48* Hgb-12.9* Hct-41.2
MCV-92 MCH-28.8 MCHC-31.3* RDW-14.9 RDWSD-49.4* Plt ___
___ 08:45PM BLOOD Neuts-72.5* Lymphs-12.9* Monos-11.1
Eos-2.0 Baso-0.4 Im ___ AbsNeut-8.17* AbsLymp-1.45
AbsMono-1.25* AbsEos-0.22 AbsBaso-0.04
___ 08:45PM BLOOD ___ PTT-40.7* ___
___ 08:45PM BLOOD Glucose-93 UreaN-25* Creat-1.1 Na-138
K-4.2 Cl-98 HCO3-23 AnGap-21*
___ 05:25AM BLOOD Glucose-90 UreaN-16 Creat-1.1 Na-137
K-4.1 Cl-99 HCO3-27 AnGap-15
___ 08:45PM BLOOD ALT-23 AST-23 AlkPhos-85 TotBili-0.7
___ 05:25AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.3
___ 07:11AM BLOOD %HbA1c-5.8 eAG-120
___ 08:45PM BLOOD Triglyc-114 HDL-40 CHOL/HD-3.7 LDLcalc-86
___ 08:45PM BLOOD TSH-2.6
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:15AM URINE Color-Straw Appear-Clear Sp ___
___ 12:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
=======
IMAGING
=======
- ___ CT head
1. 6 mm focal hypodensity within the left frontal lobe
periventricular white matter appears new or increased from the
previous CT from ___, likely a punctate interval
subacute infarct.
2. No intracranial hemorrhage or mass effect.
3. Re- demonstration of encephalomalacia in the left occipital
and temporal lobes.
- ___ CTA head & neck
1. There are stable areas of encephalomalacia. Small focus of
left frontal lobe low-attenuation likely represents subacute
infarct, stable since ___
2. Left ICA stent with unchanged occlusion of the left internal
carotid artery immediately distal to the stent.
1. Complete occlusion of the right internal carotid artery to
the carotid terminus.
2. Unchanged narrow of the left M1 segment of the middle
cerebral artery, high-grade stenosis of the right P1 segment of
the posterior cerebral artery, high-grade narrowing right V4
segment of the vertebral artery.
3. Multiple outpouching arising from the ascending aorta, which
are stable and likely postsurgical.
4. Left upper lobe 4 mm pulmonary nodule, stable from ___.
Brief Hospital Course:
Mr. ___ is ___ year-old gentleman with multiple stroke risk
factors and severe atherosclerotic disease of his extra- and
intracranial vessels presenting with bilateral leg weakness,
shaking, and altered mental status. These have been occuring for
the last several months. His exam is presently non-focal.
Imaging is significant for complete occlusion of the right ICA,
stenosis of right PCA, right vertebral, and occlusion of the
left ICA. His intracranial circulation is essentially entirely
dependent on an already stenotic posterior circulation with no
visible contribution from the ophthalmic arteries. The transient
bilateral leg weakness may be a result of left MCA territory
filling via the a-comm, stealing flow from bilateral ACAs in the
process. Shaking episodes and altered consciousness possibly due
to basilar hypoperfusion. He is already on maximal medical
treatment with apixaban and Plavix, many of his extracranial
carotid stents have thrombosed, and he does not want to pursue
ECA-ICA bypass. He is fully aware and accepting of the
tenuousness of his situation.
- BP goal 110-140/70-90. Allow some higher pressures to maintain
cerebral perfusion.
- His metoprolol 50mg XL was stopped because his SBPs ranged
from the ___ while on half of his home dose. His
cardiologist was emailed and may elect to restart this, perhaps
at a reduced dose.
- Consider Aggrenox after Plavix course complete in 1 month.
- He will go home with a ___ home safety evaluation and home
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO QPM
10. Furosemide 40 mg PO QAM
11. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Aspirin 81 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO QPM
10. Furosemide 40 mg PO QAM
11. HELD- Metoprolol Succinate XL 50 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until told to resume by your cardiologist or neurologist.
12.Thigh-high compression stockings
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Transient ischemic attack
- Multiple cranial vessel occlusions and stenoses
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 transient left sided
weakness, likely resulting from an ACUTE ISCHEMIC STROKE or a
TRANSIENT ISCHEMIC ATTACK (aka mini 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
- Hypertension
We are making the following changes to your medication regimen:
- STOP taking metoprolol 50mg XL for now. Your blood pressure
has a tendency to be low at times, and this may correspond to
your episodes of shaking. We will inform your cardiologist and
they may choose to resume some amount of this drug.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
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:
___
|
10541097-DS-19 | 10,541,097 | 26,429,348 | DS | 19 | 2159-06-08 00:00:00 | 2159-06-08 10:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
___: ORTHOPAEDICS
Allergies:
Skelaxin
Attending: ___.
Chief Complaint:
worsening pain and multiple falls
Major Surgical or Invasive Procedure:
LATERAL LUMBAR INTERBODY FUSION (XLIF) RIGHT L2-L3
History of Present Illness:
___ female with lumbar disc rupture and L2-L3
spondylolisthesis who presents with worsening pain and multiple
falls. The patient is neurovascularly intact. This injury will
require surgical fixation.
Past Medical History:
Manic Depression, Anxiety, Mumps, Mononucleosis, Chickenpox,
Arthritis, Hernia.
Social History:
Social history: She used to work as a ___
___ but now she has a ___ business as well as
___ business at home. Currently she is living
with her boyfriend and she has been married once and divorced.
She denies any smoking, but she admitted to using marijuana,
last use being three months ago. She also tried cocaine ___ years
ago. She used to drink heavily to control her pain.
Physical Exam:
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: in no acute distress, well developed,
well nourished.
SKIN: The posterior lumbar incision is clean, dry, and
intact without any signs of infection.
Range of Motion The patient has decreased range of motion
of the lumbar ___ secondary to post-operative pain. She has
limited range of motion of L knee secondary to pain.
Musculoskeletal Upper extremity joints: normal. Lower
extremity joints: L knee with minimal bruising, otherwise
normal.
Trapezius muscle: non tender
bilaterally. paraspinal muscles: non tender.
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
Reflexes
Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)
R 2 2 2 2 2
L 2 2 2 2 2
___: Negative
Babinski: Downgoing
Clonus: No beats
Perianal sensation: Normal
Rectal tone: Intact
Pertinent Results:
___ 05:56AM BLOOD WBC-10.3* RBC-3.75* Hgb-10.2* Hct-32.1*
MCV-86 MCH-27.2 MCHC-31.8* RDW-14.7 RDWSD-45.7 Plt ___
___ 05:41PM BLOOD WBC-11.0* RBC-3.89* Hgb-10.6* Hct-33.0*
MCV-85 MCH-27.2 MCHC-32.1 RDW-14.6 RDWSD-44.8 Plt ___
___ 03:00PM BLOOD WBC-9.7 RBC-4.07 Hgb-11.3 Hct-35.5 MCV-87
MCH-27.8 MCHC-31.8* RDW-14.6 RDWSD-46.1 Plt ___
___ 03:00PM BLOOD Neuts-61.6 ___ Monos-7.8 Eos-5.1
Baso-0.4 Im ___ AbsNeut-5.97 AbsLymp-2.37 AbsMono-0.76
AbsEos-0.49 AbsBaso-0.04
___ 05:56AM BLOOD Plt ___
___ 05:41PM BLOOD Plt ___
___ 03:00PM BLOOD ___ PTT-25.5 ___
___ 05:56AM BLOOD Glucose-102* UreaN-11 Creat-1.2* Na-140
K-4.4 Cl-102 HCO3-24 AnGap-14
___ 01:18PM BLOOD Glucose-98 UreaN-16 Creat-1.4* Na-135
K-5.6* Cl-100 HCO3-20* AnGap-15
___ 03:00PM BLOOD Glucose-93 UreaN-19 Creat-1.4* Na-139
K-4.9 Cl-105 HCO3-26 AnGap-8*
___ 05:56AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8
___ 01:18PM BLOOD Calcium-8.8 Phos-4.2 Mg-1.7
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
Patient was admitted to the ___ Dr. ___ Surgery
___ 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:
MEDS: Prozac 40 MG Capsule 1 capsule Orally Once a day, Taking
Fentanyl 100 MCG/HR Patch 72 Hour 1 patch to skin Transdermal ,
Taking Tizanidine HCl 4 MG Capsule 1 capsule as needed Orally
Three times a day, Taking Lyrica 150 MG Capsule 1 capsule Orally
Once a day
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
may take over the counter
2. Morphine SR (MS ___ 30 mg PO Q12H Post surgical Pain
1 week then decrease to 15mg Q12H for 1 week then stop
RX *morphine 30 mg 1 capsule(s) by mouth every twelve (12) hours
Disp #*14 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth Q3H Disp #*56 Tablet
Refills:*0
4. FLUoxetine 60 mg PO DAILY
5. Pregabalin 75 mg PO TID
6. Tizanidine 4 mg PO TID:PRN pain/spasm
hold for somnolence or hypotension
Discharge Disposition:
Home
Discharge Diagnosis:
L2-L3 disk degeneration and spondylosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without 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.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care:If it is dry then you can leave the
incision open to the air.Once the incision is completely dry
(usually ___ days after the operation) you may take a shower.Do
not soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery, do not get the incision
wet.Cover it with a sterile dressing.Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Corset for comfort
Treatments Frequency:
If the incision is draining cover it with a new sterile
dressing.If it is dry then you can leave the incision open to
the air.Once the incision is completely dry (usually ___ days
after the operation) you may take a shower.Do not soak the
incision in a bath or pool.If the incision starts draining at
anytime after surgery,do not get the incision wet.Call the
office at that time.
Followup Instructions:
___
|
10541305-DS-15 | 10,541,305 | 21,839,447 | DS | 15 | 2131-09-14 00:00:00 | 2131-09-16 10:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with no prior cardiac history
presenting with acute onset of constant mid-sternal CP, ___
in intensity, for the last 36 hours which woke her up from
sleep. The patient states the pain is worse with leaning
forward, laying back, deep inspiration, and any movement. Pt
tried antacids at home to no relief of her chest pain; she notes
improvement since she received colchicine in the ED. Of note,
the patient states she had a recent URI and endorses a cough.
Denies SOB, lightheadedness/dizziness, palpitations, orthopnea,
diaphoresis, recent travel, smoking history, and lower extremity
edema. She does not take OCP's.
In the ED initial vitals were:
Pain 5, T 97.5, P 92, BP 124/80, 96% RA
EKG: Diffuse ST segment elevations in all leads except V1 and
V2. Q waves in leads II, III, aVF.
Labs/studies notable for: Trop 0.31, WBC 21.1, CXR showing
clear lungs without focal consolidation and no acute
cardiopulmonary process.
Patient was given: 1L NS, Colchicine PO 0.6 mg x1, and
Ibuprofen 800 mg PO x 1
Vitals on transfer: T 97.7 BP 114/61 HR 82 RR 17 O2 99% on RA
On the floor, Pt reports the above history.
Past Medical History:
1. CARDIAC RISK FACTORS: Obesity.
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY: Migraine headaches
Social History:
___
Family History:
Unknown, as Pt is adopted. Does not speak with her family much.
Physical Exam:
==============
ADMISSION EXAM
==============
VS: T 97.7 BP 114/61 HR 82 RR 17 O2 99% on RA
GENERAL: Obese Caucasian woman sitting at a 30 degree angle in
bed, in no acute distress. Alert and cooperative with exam.
NECK: JVP visible 1-2cm above the clavicle at 30 degree
incline.
CHEST: Winces with light palpation of the anterior chest wall
during cardiac auscultation.
CARDIAC: Distant heart sounds. RRR, no murmurs/gallops/rubs.
No pulsus paradoxus with inspiration.
LUNGS: Distant breath sounds. Clear to auscultation
bilaterally.
ABDOMEN: Normoactive bowel sounds. Soft, nontender to
palpation.
EXTREMITIES: Warm and well perfused. No pitting edema. +1
dorsalis pedis pulses bilaterally.
==============
DISCHARGE EXAM
==============
VS: T 98.1-99.9 BP 99-113/58-73 HR 78-110 RR 18 O2 98-100% on RA
I/O: Not recorded // 1100/Not recorded
Weight: 105.3kg <- 106.7kg
GENERAL: Obese Caucasian woman sitting at a 30 degree angle in
bed, in no acute distress. Appears fairly comfortable. Alert
and cooperative with exam.
NECK: JVP flat at the clavicle at 30 degree incline.
CHEST: Pain to moderate palpation of the anterior chest wall.
No pain with auscultation.
CARDIAC: Distant heart sounds. RRR, no murmurs/gallops/rubs.
LUNGS: Distant breath sounds. Clear to auscultation
bilaterally.
ABDOMEN: Normoactive bowel sounds. Soft, nontender to
palpation.
EXTREMITIES: Warm and well perfused. No pitting edema. +1
dorsalis pedis pulses bilaterally.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:01AM BLOOD WBC-21.1* RBC-4.42 Hgb-12.0 Hct-37.2
MCV-84 MCH-27.1 MCHC-32.3 RDW-14.1 RDWSD-43.5 Plt ___
___ 11:01AM BLOOD Neuts-75.3* Lymphs-16.3* Monos-6.5
Eos-0.9* Baso-0.4 Im ___ AbsNeut-15.86* AbsLymp-3.43
AbsMono-1.36* AbsEos-0.19 AbsBaso-0.08
___ 11:01AM BLOOD Glucose-94 UreaN-5* Creat-0.6 Na-138
K-3.9 Cl-99 HCO3-25 AnGap-18
___ 11:01AM BLOOD cTropnT-0.31*
___ 09:00AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
___ 11:01AM BLOOD HCG-<5
=================
PERTINENT IMAGING
=================
--------------------
CXR (___): No acute cardiopulmonary process.
--------------------
ECHOCARDIOGRAM (___):
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
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
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Compared
with the prior study (images reviewed) of ___, the findings
are similar.
Brief Hospital Course:
___ with no PMHx presenting with acute-onset pleuritic chest
pain in the setting of a recent URI. Pain notably worse laying
supine and relieved with resting at 45 degrees. Presentation
consistent with myocarditis/pericarditis. Troponin peaked at 0.3
and declining at time of discharge. ECG with diffuse STE and PR
depression. She underwent echocardiogram which revealed
preserved EF and no evidence of effusion. She was started on
0.6mg BID colchicine which she tolerated well and 800mg
ibuprofen TID, which greatly improved her pain. She was HD
stable at time of discharge and plans to arrange PCP follow up
within the next ___ weeks.
=============
ACTIVE ISSUES
=============
# MYO/PERICARDITIS:
Troponin peaked to 0.3 on admission. Chest pain improved with
two days of anti-inflammatory Tx (ibuprofen + colchicine). EKG
with persistent diffuse ST elevations and TWI consistent with
pericarditis. Discharged with a slow taper of 0.6mg colchicine
BID and 800mg ibuprofen TID. Cardiac MRI not performed given
improvement with anti-inflammatories, as well as Pt's wishes to
go home.
# LEUKOCYTOSIS: Peaked at 21 on admission. No localizing
signs/Sx of infection. Downtrended at discharge to 15.6. No
localizing signs/Sx of infection, afebrile.
Likely related to pericarditis.
=====================
CHRONIC/STABLE ISSUES
=====================
# MIGRAINES:
- Tylenol PRN headaches.
===================
TRANSITIONAL ISSUES
===================
-New Medications:
-colchicine 0.6mg BID for at LEAST 3 months (consider longer
duration as clinically indicated).
-Ibuprofen 800mg TID for at least 2wk (longer duration as
clinically indicated).
-Consider indomethacin if CP persistent with ibuprofen.
-Consider role for cardiac MRI.
-Please offer smoking cessation counseling.
# CODE: Full, but "I don't want to be a vegetable"
# CONTACT: Friend ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral QID:PRN migraines
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*2
RX *colchicine 0.6 mg 1 tablet(s) by mouth every twelve hours
Disp #*5 Tablet Refills:*0
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*42 Tablet Refills:*0
RX *ibuprofen 400 mg 2 tablet(s) by mouth three times a day Disp
#*20 Tablet Refills:*0
3. HELD- Excedrin Migraine (aspirin-acetaminophen-caffeine)
250-250-65 mg oral QID:PRN migraines This medication was held.
Do not restart Excedrin Migraine until discussed with PCP
___:
Home
Discharge Diagnosis:
-myocarditis
-pericarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with chest pain and found to
have a condition called pericarditis and myocarditis which
likely occurred following your recent upper respiratory illness.
You had an ultrasound of your heart which did NOT demonstrate
any dangerous fluid around the heart nor did it show a reduced
ability to pump properly. You were started on two new
medications:
1. Ibuprofen 800mg three times a day for at least the two weeks
2. Colchicine 0.6mg twice a day for at least the next three
months.
After you are discharged, it is very important that you
establish care with a primary care doctor within the next two
weeks who can monitor your recovery and guide the duration of
the above medications. If you develop any of the danger signs
listed below, please return to the ED immediately.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10541442-DS-6 | 10,541,442 | 25,517,134 | DS | 6 | 2154-04-12 00:00:00 | 2154-04-12 20:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
word finding difficulty, headache, gait unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old man with a history of aflutter
(s/p ablation and in sinus since) and psoriasis (on Humira).
Went to urgent care with headache, word finding difficulty, and
gait instability x 1 week.
He has had a severe HA x 1 week. Never had a HA lasting longer
than 1 day before. Pain is in his forehead and bilateral
temples. It tingles intermittently. The HA was ___, better in
the mornings and gets worse over the course of the day. His
baseline headaches are described as bilat temporal throbbing
"stress headache," ___ in intensity that always lasts <1 day
and improves with Tylenol. The headache began to improve today
but he still has sensitivity to the touch at his temples. At
baseline he has severe astigmatism with keratoconus causing
vision problems but feels there may be some slight worsening in
his vision in both eyes over the week.
He is also having trouble with "word retrieval" this week,
described as difficulty naming common words. Comprehension is
intact.
He also complains of episodes of stumbling for the past week.
This stumble happens when standing up from sitting or laying
down. It is not consistently in one direction every time. He
describes it as an unsteady sensation making him take an extra
step. He feels more clumsy, hitting his feet on things
bilaterally. He has not fallen.
He saw his dermatologist ___ who thought he may have a
viral illness. Recently (2 wks ago), tapered off cyclosporine
after being on this x 6 months. He also endorses a lot of work
stress.
Review of Systems: Endorses difficulty focusing. Denies fevers.
___ ST, RN. Denies double vision. Denies loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, difficulties comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
complaints. He 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 dysuria. Denies new arthralgias or
myalgias. Has chronic psoriatic rash but no new rash.
Past Medical History:
- ATRIAL FLUTTER s/p ablation
- HYPERLIPIDEMIA
- HERNIA s/p repair x 2
- PSORIASIS
- CORNEAL TRANSPLANTS
- H/O SYNCOPE X 1
- DEPRESSION
nephrolithiasis
GERD
oral surgery
Social History:
___
Family History:
- mother: schizophrenia
- father: ___ disease and ?TIAs
- brother: crohn's disease
Physical Exam:
***Admission Exam:***
Vitals:
98.5 80 129/81 16 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT. Tender temples bilaterally with symmetric temporal
artery pulsations.
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: psoriasis.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. Pt. was able to name both
high and low frequency objects except for difficulty naming
hammock ("kammock"). Able to read without difficulty. Speech
was not dysarthric. Able to follow both midline and
appendicular commands. Attentive, able to name ___ backward
without difficulty. There was no neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consensually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch
VII: No facial droop, facial musculature symmetric
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk. No pronator drift bilaterally. Mild action
tremor noticed in hands bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3 2+ 3 2+ 2
R 3 2+ 3 2+ 2
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS (visual and tactile).
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg with subjective unsteadiness.
***Discharge Exam:***
Vitals:
99.7 80 ___ 18, >95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT. Temples not tender
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: psoriasis.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. 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. Attentive, able to name ___ backward
without difficulty. There was no neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consensually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch
VII: No facial droop, facial musculature symmetric
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk. No pronator drift bilaterally. No tremor
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-___ brisk throughout without spread or crossing
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch. No extinction to DSS
(visual and tactile). Negative Romberg.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Tandem stable.
(Overall normal neuro exam)
Pertinent Results:
___ 10:05PM BLOOD WBC-8.9 RBC-4.74 Hgb-15.2 Hct-42.5 MCV-90
MCH-32.1* MCHC-35.7* RDW-12.8 Plt ___
___ 10:05PM BLOOD Neuts-60.1 ___ Monos-7.0 Eos-3.9
Baso-0.7
___ 10:05PM BLOOD Plt ___
___ 10:05PM BLOOD Glucose-89 UreaN-23* Creat-1.1 Na-138
K-4.2 Cl-101 HCO3-31 AnGap-10
___ 09:17AM BLOOD Cholest-PND
___ 09:17AM BLOOD %HbA1c-PND
___ 09:17AM BLOOD Triglyc-PND HDL-PND
___ 10:05PM BLOOD CRP-0.5
___ 10:05PM BLOOD HoldBLu-HOLD
___ 09:17AM BLOOD SED RATE-PND
MRI Brain : FLAIR hyperintensities in the left periatrial white
matter likely represent early changes of small vessel disease.
Otherwise, No significant abnormalities are seen on MRI of the
brain without and with gadolinium. No significant abnormalities
are seen on MRA of the head and neck.
MRi ___: Changes of cervical spondylosis with foraminal
changes most pronounced at C3-4 level as described above. Disk
bulging at C5-6 level contacts the spinal cord without
deformity. No evidence of high-grade spinal stenosis or cord
compression seen. No abnormal signal within the spinal cord.
NCHCT in ED (and in ___ - both with hypodensity in the L
parietal lobe white matter (consistent with location of MRI
lesion) without change in size or appearance. Stability of this
hypodensity was discussed and confirmed with neuroradiology (as
it is not formally noted in the read)
Brief Hospital Course:
Mr. ___ is a ___ with a history significant for psoriasis on
adalimumab for the past couple of weeks, aflutter s/p ablation
who was admitted yesterday after presenting with one week of
intermittent bitemporal/bifrontal throbbing headache with
temporal tenderness, mild "word retrieval" difficulties and
stumbling, and after head CT showed a hypodensity in the left
posterior periventricular region.
Since 1 day PTA, his headache resolved, although his headache
tends to come and go anyway, more prominent in the evenings than
in the mornings. The headache involves essentially the entire
frontal/temporal regions, and the temporal tenderness is diffuse
and includes the forehead and crown rather than around the
temporal artery. He denies jaw claudication or polymyalgia
symptoms. He takes acetaminophen up to ___ times per day, and he
has been taking it at least once or twice a day for the past
week. He has had some chills at night the past week, but no
rigors or fevers.
He reports that the word retrieval difficulties are chronic, but
somewhat more noticeable/prominent over the past week when he
has had the headache.
On exam on discharge, he did not have prominent or tender
temporal arteries, and temporal pulses were normal. His
neurologic exam was normal except for mild hyperreflexia at the
patella bilaterally. Of note, he has a normal gait, and is able
to tandem walk.
Labs are notable for BUN/Cr ___. CRP 0.5. ESR from this
admission was pending on discharge.
MRI done overnight shows a region of T2/FLAIR hyperintensity in
the left periatrial white matter, read as likely representing
early changes of small vessel disease, although focal
demyelination may be another possibility. MRA unremarkable. MR
___ unremarkable. We reviewed his prior ___ from ___, and
a hypodensity is visible in the left periatrial white matter at
that time (also visible on the ___ done this admission),
indicating that this is chronic for at least ___ years.
At this point, the most likely etiology for his headache is
likely analgesic overuse, as well as dehydration or post-viral
phenomenon. Humira side effect is also a possibility although
his headaches historically have predated initiation of Humira.
He will avoid analgesic overuse and will call us with concern
for focal neurologic deficit or headaches requiring frequent
analgesics. He will also follow up in Neurology Resident Clinic.
His wife also noted intermittent leg movements during sleep
where he kicks her during deep sleep - this could be periodic
limb movements of sleep or a REM behavior disorder. We
recommended an outpatient sleep study for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 200 mg PO QAM
2. BuPROPion 100 mg PO NOON
3. Restasis 1 drop Other BID
4. Fluoxetine 30 mg PO DAILY
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
6. Aspirin 81 mg PO DAILY
7. Humira (adalimumab) 40 mg/0.8 mL subcutaneous weekly
8. sodium chloride 5 % ophthalmic DAILY
9. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion 200 mg PO QAM
3. BuPROPion 100 mg PO NOON
4. Cetirizine 10 mg PO DAILY
5. Fluoxetine 30 mg PO DAILY
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
7. sodium chloride 5 % ophthalmic DAILY
8. Humira (adalimumab) 40 mg/0.8 mL subcutaneous weekly
9. Restasis 1 drop Other BID
Discharge Disposition:
Home
Discharge Diagnosis:
headache - possibly post viral + medication rebound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a headache that resolved with tylenol.
MRI showed a white matter lesion in the back right side of your
brain that has been stable for several years and is likely not
the source of your headache. Most likely your headache and
symptoms were post-viral with associated headache rebound from
frequent tylenol use. Please do not use pain killers for your
headaches more than ___ weekly - if this is needed, please
discuss this with neurology or with your primary care doctor ___
this can actually make headaches worse).
In addition, given your frequent leg movements during sleep, we
recommend you also get an outpatient sleep study.
Followup Instructions:
___
|
10541475-DS-21 | 10,541,475 | 26,247,422 | DS | 21 | 2135-06-13 00:00:00 | 2135-06-13 13:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
lisinopril / vancomycin
Attending: ___.
Chief Complaint:
Left lower extremity pain
Inability to ambulate
Major Surgical or Invasive Procedure:
ORIF Left distal femur fracture
History of Present Illness:
Ms. ___ is a ___ female with PMH of THR at ___
___ that was complicated by infection that was treated with
2-stage revision. Cultures ultimately grew polymicrobial
infection including bacteroides, coagulase-negative Staph, and
group B strep and she is now followed by Dr. ___ in
orthopedics. Patient was sent to the ED from Dr. ___ clinic
today. The history was gathered from the patient and her
daughter. They state that she has been wheel chair bound for at
least the past several months (since at least ___. There
was no inciting event that caused her to become WC bound. She
had no falls. The patient did have pneumonia one month ago that
has now been treated. She states that the pain has been getting
worse since ___.
Past Medical History:
-HTN
-Asthma
-anxiety
-GERD
-HLD
-Osteoporosis
-Uterine CA
-Cholecystectomy
-Vertebroplasty
-Hysterectomy
-Recent L Meniscus
-left hip replacement s/p staged explant now with spacer
Social History:
___
Family History:
Noncontributory
Physical Exam:
No apparent distress
Afebrile, vital signs stable
Heart rate regular
Breathing non-labored
LLE surgical site clean, dry, intact
Fires ___, FHL, TA, G
Sensation intact to light touch throughout
Extremity warm and well-perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was
admitted to the orthopedic surgery service where workup revealed
and left distal femur fracture. The patient was taken to the
operating room on ___ for left femoral ___ plate, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
high risk for DVT and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. rOPINIRole 0.25 mg PO QPM
3. DULoxetine 60 mg PO DAILY
4. Mirtazapine 45 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
RX *acetaminophen 650 mg 1 tablet(s) by mouth Five times each
day Disp #*70 Tablet Refills:*0
2. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*28 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 Units SC Every evening Disp #*28
Syringe Refills:*0
5. OxycoDONE (Immediate Release) 2.5-7.5 mg PO Q3H:PRN Moderate
Pain
RX *oxycodone 5 mg 0.5-1.5 capsule(s) by mouth every three (3)
hours Disp #*90 Capsule Refills:*0
6. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. DULoxetine 60 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Mirtazapine 45 mg PO QHS
11. Omeprazole 20 mg PO DAILY
12. rOPINIRole 0.25 mg PO QPM
13. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left distal femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight-bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
Physical Therapy:
Weight-bearing as tolerated
Treatments Frequency:
Wound monitoring
Dry sterile dressing as needed
Followup Instructions:
___
|
10541652-DS-28 | 10,541,652 | 23,630,660 | DS | 28 | 2168-04-23 00:00:00 | 2168-04-23 20:02:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
PICC placement ___
History of Present Illness:
Mr. ___ is a ___ year old man with h/o hep C c/b HCC s/p
chemoembolization, afib on coumadin, urinary retention with
chronic foley who presented with hematuria and weakness and
found to have UTI resistent to fluoroquinolones.
Mr. ___ was see by his PCP ___ ___ for hematuria and urinalysis
and urine cultures werer drawn. He denies any pain either with
the foley or in the back. He denies any fevers or chills. Family
noted some weakness. Due to antibiotic resistence profile and
limited insurance, patient was sent to ED for IV antibiotics.
His last foley exchanged was ___.
In the ED initial vitals were: 97.8 66 121/65 16 99%
- Labs were significant for glc 200, normal CBC and
electrolytes, INR 2.6
- urinalysis with 103 RBC and 136 WBC
- Patient was given zosyn and his foley was changed.
Vitals prior to transfer were: 97.8 57 163/70 18 96% RA
On the floor, initial VS were 97.6 187/76 -> 174/78 on repeat 57
18 98% RA. Patient comfortable in bed, denied any discomfort.
Did have some pain with foley removal but now has no issues.
Daughter available to translate for initial meeting. Patient
speaks very little / no ___.
Past Medical History:
*Hepatitis C, Chronic c/b HCC of liver s/p chemoembolization
(___) c/b pleural effusions and urinary retention
*EFFUSION, PLEURAL - R>L
*T2DM
*h/o CEREBROVASCULAR ACCIDENT ___ right MCA, prior h/o left
cerebellum CVA, no residual weakness, some personality change
*ATRIAL FIBRILLATIONON COUMADIN
*HYPERTENSION
*HYPERLIPIDEMIA
Social History:
___
Family History:
brother diagnosed with colon cancer
mother d ___ brain tumor
father d ___ stomach problems
9 siblings - 2 died from old age in their ___ although one of
them had DM
3 children - 1 son had htn
2 grandchildren a/w
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - 97.6 187/76 -> 174/78 on repeat 57 18 98% RA
GENERAL: elderly man lying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: foley in place, draining clear urine
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
Vitals: Tmax 97.6 BP 154/70 P 75 R 20 SaO2 100% RA
GENERAL: elderly man lying in bed in NAD
CARDIAC: irregularly irregular, no murmurs, gallops, or rubs
LUNG: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no CVA tenderness
GU: foley in place, draining clear yellow urine with no clots or
blood
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 09:50PM BLOOD Glucose-200* UreaN-16 Creat-1.0 Na-134
K-4.6 Cl-100 HCO3-24 AnGap-15
___ 10:10PM BLOOD ___ PTT-65.0* ___
___ 09:50PM BLOOD WBC-7.6 RBC-5.07 Hgb-14.3 Hct-45.2 MCV-89
MCH-28.3 MCHC-31.7 RDW-15.2 Plt ___
___ 09:50PM BLOOD Neuts-68 Bands-0 ___ Monos-6 Eos-1
Baso-0 ___ Myelos-0
PERTINENT LABS
==============
___ 09:00AM BLOOD ___ PTT-66.4* ___
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-5.7 RBC-5.31 Hgb-15.1 Hct-47.5 MCV-89
MCH-28.4 MCHC-31.8 RDW-15.3 Plt ___
___ 07:10AM BLOOD Glucose-132* UreaN-17 Creat-1.1 Na-138
K-4.8 Cl-104 HCO3-27 AnGap-12
___ 07:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
___ 07:10AM BLOOD ___ PTT-56.6* ___
RELEVANT MICRO
==============
Urine culture results from PCP (in patient's chart):
+ for Psuedomonas
cefepime - S
ceftazidime - S
ciprofloxacin - I
gentamicin - S
imipenem - S
levofloxacin - I
piperacillin/tazo - S
tobramycin - S
___ 09:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:55PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 09:55PM URINE RBC-103* WBC-136* Bacteri-FEW Yeast-NONE
Epi-0
RELEVANT IMAGING
================
CXR ___:
In comparison with the study of ___, there has been
placement of right subclavian PICC line extends well into the
jugular system in the neck. No evidence of acute pneumonia or
vascular congestion. The right costophrenic angle is now clear.
This information has been telephoned to the venous access access
nurse.
___ PICC line placement ___:
FINDINGS:
1. Existing right arm approach PICC with tip in the right
jugular system of the neck, repositioned with approximately 10
cc of saline. Single lumen PICC line with tip now terminating in
the mid SVC.
IMPRESSION:
Successful repositioning of existing right arm PICC line. The
line is ready to use.
Brief Hospital Course:
BRIEF SUMMARY
=============
Mr. ___ is a ___ year old man with h/o hep C c/b HCC s/p
chemoembolization, afib on coumadin, urinary retention with
chronic foley who presents with hematuria and weakness and found
to have a pseudomonas UTI, resistent to fluoroquinolones.
ACTIVE ISSUES
=============
# Urinary tract infection - The patient presented with hematuria
to his primary care doctor, who performed urinalysis and urine
culture that was positive for pseudomonas urinary tract
infection that had intermediate resistance to fluoroquinolones.
At baseline, he has a chronic foley for urinary retention placed
by urology, which was last exchanged on ___. His primary care
physician subsequently sent him to ___ in order to receive
intravenous antibiotics. In the emergency department, the
patient's foley was exchanged and he was started on Zosyn. He
received one dose of Zosyn on the floor and was subsequently
changed to cefepime 1g q24h per infectious disease. The patient
did not have any evidence of fevers or costoverterbral
tenderness suggestive of pyelonephritis. Additionally, his
hematuria resolved with antibiotic therapy. The patient received
a PICC line on ___ and was approved by his insurance to receive
antibiotics at home. The PICC line placement was initially
complicated by placement in the jugular vein but was
re-positioned by ___ with confirmation of placement. He was
discharged with 5 additional days of 1g cefepime daily to
complete a total 7-day course of antibiotics.
# Hypertension - The patient presented with elevated systolic
blood pressure of 187. He was without any headaches or visual
changes to suggest hypertensive emergency. He received 10mg IV
hydralazine with decrease of BP to 151/59. Patient does not
appear to have an outpatient blood pressure regimen. The
hypertension was thought to be likely secondary to foley
exchange and stress from the hospitalization. The patient's
blood pressure was 154/70 on day of discharge.
CHRONIC ISSUES
==============
# Atrial fibrillation - The patient had an INR of 2.6 on
admission. After receiving antibiotics on the morning following
admission on ___, the patient was noted to have a
supratherapeutic INR of 3.4. His home warfarin was held. On
repeat check on ___, his INR was 2.3. He was restarted on his
home warfarin dosing. He has a follow-up appointment with
___ Coumadin Clinic on ___ at 11:45 am to
receive a repeat check of his INR and titration of warfarin (as
needed) while he is on antibiotics.
# Type 2 diabetes - Stable. The patient was resumed on his home
regimen of 10 units glargine in the morning with Humalog sliding
scale.
TRANSITIONAL ISSUES
===================
# The patient will need a repeat INR check on ___ at 11:45 am
at the ___ Couma___ clinic.
# Last foley exchange was performed on ___ in the ED.
# Code: Full code
# Emergency Contact: daughter Mrs. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Simvastatin 20 mg PO QHS
4. Warfarin 4 mg PO 5X/WEEK (___)
5. Warfarin 6 mg PO DAYS (WE)
6. Glargine 10 Units Breakfast
7. alpha lipoic acid ___ mg oral daily
8. Vitamin D 800 UNIT PO 1X/WEEK (MO)
9. Fexofenadine 180 mg PO DAILY
10. Sarna Lotion 1 Appl TP QID:PRN pruritis
11. Senna 17.2 mg PO EVERY OTHER DAY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. Sarna Lotion 1 Appl TP QID:PRN pruritis
3. Senna 17.2 mg PO EVERY OTHER DAY
4. Simvastatin 20 mg PO QHS
5. Warfarin 6 mg PO DAYS (WE)
6. alpha lipoic acid ___ mg oral daily
7. Vitamin D 800 UNIT PO 1X/WEEK (MO)
8. Multivitamins 1 TAB PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Fexofenadine 180 mg PO DAILY
11. CefePIME 1 g IV Q24H
RX *cefepime [Maxipime] 1 gram 1 g IV daily Disp #*5 Vial
Refills:*0
12. Warfarin 4 mg PO 6X/WEEK (___)
13. Glargine 10 Units Breakfast
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
# Urinary tract infection
# Hypertension
SECONDARY DIAGNOSIS
===================
# Atrial fibrillation
# Type 2 diabetes
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 went to see your primary care doctor for
blood in your urine and were found to have an infection in your
urine. Your primary care doctor sent you to the hospital to
receive intravenous antibiotics. We have started you on these
antibiotics while in the hospital. You received a ___ line to
continue these antibiotics while you are at home.
You will need your INR checked at the ___ Coumadin
Clinic on ___. You have been scheduled for an appointment at
11:45 am. Please continue on all of your usual home medications,
including your regular dose of Coumadin, which you should take
today when you get home.
We wish you a speedy recovery!
Best,
Your ___ Care Team
Followup Instructions:
___
|
10541652-DS-29 | 10,541,652 | 27,356,810 | DS | 29 | 2168-05-15 00:00:00 | 2168-05-15 17:14:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Cipro
Attending: ___
Chief Complaint:
Unsteadiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old man with a history of HCC,
HTN, HLD, DM, A fib on warfarin, prior R MCA stroke, recurrent
UTIs, presenting with worsening gait instability, lethargy, and
facial droop, and found to have a new brain lesion on NCHCT.
The patient was recently admitted from ___ for a
floroquinolone
resistant UTI, and he was sent out with a PICC line and 7 days
of
IV cefepime. He returned to the ED ___ for worsening gait
instability, this was felt to be due to recrudesence of his
prior
stroke symptoms in the setting of his UTI (which has happened on
prior occasions). He was discharged home and sucessfully
completed
his antibiotic course. His PICC line was removed ___ and he was
noted by his daughter (caregiver) to be very steady on his feet
throughout all of last week, and back to his normal self.
However, about 5 days ago the patient began to decline again,
with rapid worsening in the past ___ days. His gait became
increasingly unsteady, and he started to walk with his head down
and leaning forwards, propelling himself forwards and almost
falling. In the past 24 hours he has not been able to stand on
his own without assistance. His daughter also noted slurred
speech and increased facial droop from baseline. She also noted
he seemed overall tired with whole body weakness and drowsiness.
Both his thinking and his movements have seemed very slow. He
also has been slightly more confused recently, interjecting
abnormal topics into conversations, as if he does not understand
fully the conversation his family is having. However he can
follow simple requests and has no paraphasic errors. He has
complained about headache to her which he desribes as a ringling
ot trembline sensation since yesterday. The patient has been
seen by neurology on recent occasions and it is noted that he
tends to get a worsening facial droop and more difficulty with
gait when he gets a UTI (which he did have earlier this month).
The patient was evaluated in the ED, where Na was found to be
130, and UA was positive. NCHCT obtained however which showed a
new mass lesion in his R frontal lobe pushing into his lateral
ventricle.
On neurologic review of systems, there are no visual changes, no
increased focal weakness, numbness or tingling. No aphasia. ROS
positive as above.
No recent fevers at home, no nausea, vomiting, diarrhea, no
chest
pain.
Past Medical History:
- TIA's and R MCA stroke in ___
- afib on coumadin with INR goal of 2.5-3.0
- DM2, complicated by nephropathy, retinopathy, and vasculopathy
(foot ulcer)
- BPH
- MVA with hemothorax and embolic strokes
- s/p fall with head strike on ___
- L leg hematoma in setting of superatherapeutic INR
- Hepatitis infection (HAV, HepB?) -- vs Hep C?
- s/p chemoembolization of a hepatocellular carcinoma
- polymyalgia rheumatica dx ___ high Sed Rate.
- degenerative changes and severe tendinitis
involving his left and right shoulders.
- HTN
- Hyperlipidemia
- MVA, complicated by hemothorax due to injury to the right
internal mammary artery which needed to be embolized and he
required right chest tube placement.
- thigh hematoma???
- Urinary retention (BPH)- foley ___ in place
Social History:
___
Family History:
brother diagnosed with colon cancer
mother d ___ brain tumor
father d ___ stomach problems
9 siblings - 2 died from old age in their ___ although one of
them had DM
3 children - 1 son had htn
2 grandchildren a/w
Physical Exam:
===========================
ADMISSION PHYSICAL EXAM
===========================
VS 99.2 68 159/64 16 98% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Abdomen: Soft, NT
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Naming of stroke cards is impaired
although this may be partially due to a language barreier; calls
a feather a leaf, a glove a hand, and cannot name cactus or
hammock. Describes stroke picture as two separate pictures one
with a woman shopping and another children stealing cookines.
Normal prosody. No dysarthria per daughter. ___ registration
and recall ___. No evidence of hemineglect. No left-right
agnosia. + Grasp reflex.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils 2->1. On fundoscopic exam, optic
disc margins were sharp. Visual fields were full to finger
counting.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. L lower facial droop at rest, improved with activation
VIII. hearing was grossly intact.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
There is paratonia. No pronation, no drift. No tremor or
asterixis.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Decreased pinprick sensation on the L arm compared to the R.
Decreased pinprick in a stocking distribution in his legs
bilaterally.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 1 1 0 0
R 2 1 1 0 0
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Decreased
speed and amplitude with RAM worse on the L.
- Gait -
Very difficult to get the patient to stand up, needs assistance
to get to the edge of the bed. With standing he continually
propells backwards and cannot stand without assistance even for
a
second. If he attempts to take a few steps he makes very small
steps with a frontal type gait.
==============================
DISCHARGE PHYSICAL EXAM
==============================
Pertinent Results:
=========
LABS
=========
___ 08:25PM BLOOD ___ PTT-51.1* ___
___ 05:40AM BLOOD ___ PTT-42.8* ___
___ 08:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
==========
IMAGING
==========
NCHCT (___):
New hyperdense 1.5 x 1.2 cm lesion/structure arising along the
frontal horn of the right lateral ventricle either protruding
from the adjacent
periventricular white matter or arising from the ependyma. This
lesion was not present on ___. Differential diasnogis
possibilities include rapidly growing neoplasm or vascular
lesion with possible some inernal hemorrhage. Infection is not
excluded given short term interval development. This can be
further evaluated with MRI, assuming no clinical
contraindication.
MRI head (___):
1. A small 1.3cm focus of blood products adjacent to the right
side of
lateral ventricle anterolaterally, in the parenchyma or from the
ventricular wall- ? Cavernoma/amyloid angiopathy; limited
assessment for any associated mass lesion given the blood
products. Small amount of layering blood products in the
occipital horns bilaterally. New since MR of ___ and CT
head of ___. Close f/u NECT to assess for interval change
and close followup MR in ___ few weeks to assess for interval
change and any underlying lesion as new since prior studies.
2. Chronic cerebral and cerebellar infarcts as before.
NCHCT (___):
1. There is no significant interval change since ___.
The lesion
lateral to the right frontal horn with internal hemorrhage is
stable. Multiple areas of old infarcts are unchanged.
2. Prominent ventricles could be due to communicating
hydrocephalus in
addition to atrophy, which been stable since ___.
Brief Hospital Course:
Mr. ___ is an ___ year old right handed man with a past medical
history including right MCA stroke (___), diabetes mellitus,
hypertension, hyperlipidemia, atrial fibrillation on coumadin
and urination issues requiring chronic foley complicated by
recurrent UTIs who presented to the ___ ED ___ with worsening
gait instability, mild confusion, and increased facial droop.
___ in the ED showed "new hyperdense 1.5 x 1.2 cm
lesion/structure arising along the frontal horn of the right
lateral ventricle either protruding from the adjacent
periventricular white matter or arising from the ependyma." Pt
was admitted to the neurology service for further management.
Mr. ___ underwent an MRI of the head with and without contrast
on ___ that showed "a small 1.3 cm focus of blood products
adjacent to the right side of
lateral ventricle anterolaterally." Due to this finding,
coumadin was held during hospitalization. Repeat ___ on ___
showed no significant interval change. Coumadin was held at
discharge and Mr. ___ follow-up with Dr. ___ as an
outpatient. Repeat outpatient MRI was recommended in ___ weeks
and, pending results, Dr. ___ re-address ___
warfarin at that time.
Mr. ___ was also found to have a dirty UA with urine culture
growing entercoccus. Mr. ___ underwent a voiding trial during
hospital stay as chronic foley catheter precipitated the
infection. Mr. ___ failed this trial; he initially urinated
multiple times overnight. When an anti-cholinergic medication
was started (tolterodine), he retained urine requiring straight
cath. Foley catheter was re-inserted at discharge and Mr. ___
___ follow-up with his urologist and primary care doctor as an
outpatient. He was discharged on a 14 day course of PO
amoxicillin.
Otherwise, Mr. ___ was started on amlodipine for hypertension at
discharge. He was continued on his home statin for history of
hyperlipidemia. He was continued on glargine for his history of
diabetes mellitus. He was placed on heparin SQ.
==============================
TRANSITIONS OF CARE
==============================
-Coumadin was discontinued due to small right frontal lobe
intraparenchymal hemorrhage.
-Recommend repeat MRI in ___ weeks and pending result,
considering restarting coumadin.
-Urine culture grew enterococcus; placed on amoxicillin at time
of discharge to complete a 14 day course.
-Underwent voiding trial and trial of anti-spasmodic
(tolterodine). Without the anti-spasmodic, Mr. ___ voided ___
times overnight. With the anti-spasmodic, Mr. ___ developed
urinary retention requiring straighT catheterization twice.
Foley catheter was re-inserted at time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. Sarna Lotion 1 Appl TP QID:PRN pruritis
3. Senna 17.2 mg PO EVERY OTHER DAY
4. Simvastatin 20 mg PO QHS
5. Warfarin 6 mg PO DAYS (WE)
6. alpha lipoic acid ___ mg oral daily
7. Vitamin D 800 UNIT PO 1X/WEEK (MO)
8. Multivitamins 1 TAB PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Fexofenadine 180 mg PO DAILY
11. Warfarin 4 mg PO 6X/WEEK (___)
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Fexofenadine 180 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Sarna Lotion 1 Appl TP QID:PRN pruritis
6. Senna 17.2 mg PO EVERY OTHER DAY
7. Simvastatin 20 mg PO QHS
8. Vitamin D 400 UNIT PO BID
9. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 875 mg 1 tablet(s) by mouth two times a day Disp
#*18 Tablet Refills:*0
11. Glargine 10 Units Breakfast
12. alpha lipoic acid ___ mg oral daily
13. Outpatient Physical Therapy
431.0 intracerebral hemorrhage
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Right frontal lobe bleed abutting the lateral ventricle
Secondary diagnosis:
Urinary tract infection
Hypertension
Hyperlipidemia
Atrial fibrillation
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after having a small brain
bleed. Because of this, we stopped your coumadin. We recommend
you follow-up with Dr. ___ when to restart this
medication.
You were also found to have a urinary tract infection. We
discharged you with oral antibiotics for this. This infection is
related to your foley catheter use. We tried to remove the foley
catheter and start you on a medication to decrease the amount of
times you urinated; however, this medication made it difficult
for you to urinate. We re-inserted your foley catheter at time
of discharge. We have updated your urologist regarding these
concerns and you should be contacted to make an appointment for
further management.
We wish you all the best!
Followup Instructions:
___
|
10541652-DS-31 | 10,541,652 | 25,097,507 | DS | 31 | 2168-08-24 00:00:00 | 2168-08-24 15:08:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old male with MMY including atrial
fibrillation off of coumadin, HTN, CVA, DM, ___ s/p TACE in
___, urinary retention with chronic indwelling foley x ___ year
with catheter exchanges every 6 weeks followed by urology who
presents with altered mental status, worsening gait instability
and tea colored urine x 1 day. He had an episode of yelling out
overnight in his sleep the night prior to presentation. Urine
culture in the past grew pseudomonas and enterococcus. Per his
daughter he has increased gait instability. He also reports
increased weakness. He does not report n/v/d/abdominal
pain/chills/fevers/chest pain/sob. For the treatment of his last
UTI in ___, he went home with a PICCL for a planned 7 day
course of abx but there were concerns with bleeding and the
PICCL
moving and thus the PICCL was d/c'ed earlier after a 5 day
course
of abx. His dtr would prefer him to be treated with pills and
avoid a PICCL if possible.
.
In ER: (Triage Vitals:0 99 69 158/53 16 98% ra )
Meds Given: vancomycin/cefepime
Fluids given: none
Radiology Studies:CXR
consults called: none
.
PAIN SCALE: ___
All other ROS negative.
Past Medical History:
ONCOLOGIC PAST MEDICAL HISTORY
First diagnosed with ___ in ___ when and MRI
demonstrated
two large liver lesions, one in segment VII measuring 5.5 x 4.6
cm, and a second in segment VI measuring 3.5 x 3.2 cm. S/p TACE
in ___
OTHER PMH
- TIA's and R multifocal MCA stroke in ___
- bilateral cerebellar strokes
- R frontal intracranial hemorrhage
- afib on coumadin with INR goal of 2.5-3.0
- DM2, complicated by nephropathy, retinopathy, and vasculopathy
(foot ulcer)
- BPH
- MVA with hemothorax and embolic strokes
- s/p fall with head strike on ___
- L leg hematoma in setting of superatherapeutic INR
- Hep C
- Cirrhosis
- s/p chemoembolization of a hepatocellular carcinoma
- polymyalgia rheumatica dx ___ high Sed Rate.
- degenerative changes and severe tendinitis
involving his left and right shoulders.
- HTN
- Hyperlipidemia
- MVA, complicated by hemothorax due to injury to the right
internal mammary artery which needed to be embolized and he
required right chest tube placement.
- thigh hematoma???
- Urinary retention (BPH)- foley ___ in place. Had UDS which
demonstrated a hypersensitive bladder and phasic detrusor
overactivity. He has had many voiding trials along with a trial
of oxybutynin, catheter d/c resulting in urinary retention,
constipation and permanent replacement of the foley catheter
(___). No cystoscopy report noted.
Social History:
___
Family History:
brother diagnosed with colon cancer
mother d ___ brain tumor
father d ___ stomach problems
9 siblings - 2 died from old age in their ___ although one of
them had DM
3 children - 1 son had htn
2 grandchildren a/w
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS:
1. VS: T 97.9 P 57 BP 136/65 RR 18 O2Sat on ___95% on RA
GENERAL: Non-icteric sclera
Nourishment: good
Grooming: good
Mentation: alert but often falls asleep.
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [X] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[X] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X]WNL
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[X] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
[X] Soft [-] Rebound [] No hepatomegaly [X] Non-tender []
Tender
[] No splenomegaly
[X] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [] WNL
[+ ] Increased tone and stiffness throughout [ X]Upper extremity
strength ___ and symmetrical [ ]Other:
[+ ] Bulk -diminshed [X] Lower extremity strength ___ and
symmetrica [ ] Other:
8. Neurological [] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ -] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[+ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
[X] Warm [X] Dry
10. Psychiatric [] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
12. Genitourinary [] WNL
[+ ] Catheter present- draing clear yellow urine [] Normal
genitalia [ ] Other:
Discharge Exam: No significant changes
Pertinent Results:
Admission Labs:
___ 09:30PM BLOOD WBC-6.5 RBC-4.73 Hgb-13.7* Hct-40.4
MCV-85 MCH-29.0 MCHC-34.0 RDW-14.6 Plt ___
___ 09:30PM BLOOD Glucose-331* UreaN-20 Creat-1.0 Na-131*
K-4.2 Cl-99 HCO3-22 AnGap-14
___ 09:30PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
___ 09:40PM BLOOD Lactate-1.7
Discharge Labs:
___ 06:26AM BLOOD WBC-6.4 RBC-4.93 Hgb-14.1 Hct-42.5 MCV-86
MCH-28.7 MCHC-33.2 RDW-13.9 Plt ___
___ 07:03AM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-134
K-4.6 Cl-101 HCO3-26 AnGap-12
___ 12:45PM BLOOD WBC-8.4 RBC-5.04 Hgb-14.2 Hct-42.8 MCV-85
MCH-28.1 MCHC-33.1 RDW-13.7 Plt ___
___ 12:45PM BLOOD Glucose-176* UreaN-17 Creat-0.9 Na-133
K-4.4 Cl-101 HCO3-25 AnGap-11
Urine Culture: ___
Tests: (1) URINALYSIS, COMPLETE (5463SB=)
Color ___ YELLOW YELLOW
*1
Appearance ___ [A] TURBID CLEAR
___ Strip 1.013
1.001-1.035
pH ___ Strip 6.5 5.0-8.0
Glucose ___ Ql Strip NEGATIVE NEGATIVE
___ Ql Strip NEGATIVE NEGATIVE
Ketones ___ Ql Strip NEGATIVE NEGATIVE
Hgb ___ Ql Strip [A] 2+ NEGATIVE
Prot ___ Ql Strip [A] 2+ NEGATIVE
Nitrite ___ Ql Strip NEGATIVE NEGATIVE
Leukocyte esterase ___ 3+ NEGATIVE
WBC #/area UrnS HPF [A] > OR = 60 /HPF < OR = 5
RBC #/area UrnS HPF [A] ___ /HPF < OR = 3
Squamous #/area UrnS HPF
___ /HPF < OR = 5
Bacteria #/area UrnS [A] MANY /HPF NONE
SEEN
Hyaline Casts #/area NONE SEEN /LPF NONE
SEEN
Tests: (2) CULTURE, URINE, ROUTINE (395X=)
Bacteria ___ Cult
[A] SEE NOTE
*2
CULTURE, URINE, ROUTINE
MICRO NUMBER: ___
TEST STATUS: FINAL
SPECIMEN SOURCE: URINE, CLEAN CATCH
SPECIMEN QUALITY: ADEQUATE
RESULT: Greater than 100,000 CFU/mL of Pseudomonas
aeruginosa
___
----------------
___ MIC
CEFEPIME S 4
CEFTAZIDIME S 4
CIPROFLOXACIN S <=0.25
GENTAMICIN S <=1
IMIPENEM S <=0.25
LEVOFLOXACIN S 0.5
PIP/TAZOBACTAM S <=4
TOBRAMYCIN S <=1
S=Susceptible I=Intermediate R=Resistant * = Not Tested
NR = Not Reported **NN = See Therapy Comments
Brief Hospital Course:
___ with PMH of hepatitis C cirrhosis, HCC, CVA's, atrial
fibrillation, ICH while on coumadin, DMII, BPH with indwelling
foley catheter, and multiple prior UTI's now presenting with
altered mental status.
1. ?Metabolic encephalopathy: DDx includes UTI vs. hyponatremia
vs. hepatic encephalopathy. Prior UTI's have presented with AMS
as well. No evidence of liver decompensation on exam, so hepatic
encephalopathy less likely. Rapid improvement on initial
presentation likely attributable either to antibiotic therapy or
correction of his sodium. Mild confusion later in his hospital
course likely related to hospital setting, mild delirium.
2. ?Bacterial UTI: Difficult to distinguish true infection from
colonization. Patient received five days of Cefepime prior to
discharge. Patient seen in consultation by infectious disease
and will continue to be followed by ___ as an
outpatient. If TACE is to be considered, ___
___ a repeat urine culture three days prior. In further
discussion w/the patient's daughter, ___ does not appear to be
a true allergy; removed from hospital alert system.
3. Hep C Cirrhosis; HCC: Followed by ___ as an outpatient,
who is aware of his admission. Next TACE planned for ___
but may be delayed in light of this hospitalization.
4. Atrial fibrillation: Not on a nodal agent as an outpatient;
off of coumadin given h/o ICH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fexofenadine 180 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Sarna Lotion 1 Appl TP QID:PRN pruritis
7. Senna 17.2 mg PO 3X/WEEK (___)
8. Simvastatin 20 mg PO QHS
9. Vitamin D 400 UNIT PO BID
10. alpha lipoic acid ___ mg oral daily
11. Lantus (insulin glargine) 100U/ml 12 subcutaneous daily
12. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Fexofenadine 180 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Sarna Lotion 1 Appl TP QID:PRN pruritis
6. Senna 17.2 mg PO 3X/WEEK (___)
7. Simvastatin 20 mg PO QHS
8. Vitamin D 400 UNIT PO BID
9. Lantus (insulin glargine) 100U/ml 12 subcutaneous daily
10. alpha lipoic acid ___ mg oral daily
11. Amlodipine 5 mg PO DAILY
12. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Confusion
Possible UTI
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 confusion which may have
been related to a urinary tract infection. You were given
several days of antibiotics. Please follow-up with your primary
care physician to ensure your confusion resolves.
Followup Instructions:
___
|
10541652-DS-32 | 10,541,652 | 26,489,597 | DS | 32 | 2168-09-07 00:00:00 | 2168-09-08 11:44:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ complex medical hx notable for Afib (several CVAs,
now off A/C secondary to right frontal ICH ___, prior
cerebellar and R. MCA strokes, HTN, DM, HCC (s/p TACE ___, and
urinary retention (chronic indwelling foley x ___ year; c/b
multiple UTIs v. colonization) who presents with AMS starting
day prior to admmission, following recent discharge 4 days prior
to admission for pseudomonal UTI.
Per patient's daughter, patient discharged on ___ 4 days
prior to admission, and was mentally intact, though continued
with red/bloody urine ___ the foley and some persistent weakness.
___, the daughter started with URI symptoms of sore throat
though no fevers, and then ___ evening patient with
difficulty sleeping, feeling very cold, and developed a sore
throat and lost his voice. ___ morning, prior to presentation
to our ___, he was noted to be stiff and difficult to get out of
bed, dragging his body, and much more altered, unable to
recognize daughter, and with difficulty focusing on anything.
Fingerstick glucose was 125, and was given 12 units of lantus.
Noted to have developed a wet hacking cough, and with very shaky
movements of all his extremities, but per daughter no obvious
rhythmic movements. Given his prior strokes, she was worried he
might be having a stroke. Gave him tylenol, then tried some
water and a protein shake, but he threw this up. Around 1pm, he
had a very large loose/diarrheal BM, nonbloody, nonmelenic, and
his MS improved greatly, close to baseline. He did not remember
the morning's events. Patient called PCP, and was advised to
bring her father to the ___.
On remainder of ROS, patient denied any
dizziness/lightheadedness, CP, SOB, palpitations, rhinorrhea,
headaches, abdominal pain, further vomiting or nausea, pain with
Foley. Per daughter, noted that while his urine was no longer
red 1 day after last discharge, was now darker.
Of note, patient was admitted ___ for AMS ___ the context
of UTI for which he was treated w/ a 5-day course of cefepime
(hx pseduomonas; finished course ___ house). ___ Foley
last changed on ___, prior to last discharge.
___ COURSE:
VS - Tmax 99.2; HR 74-87; BP 114-127/57-63; RR ___ 93-97% on
RA; Gluc 175
Initial exam: ___ hip flexor on R (remainder of motor exam nl);
L. facial droop (old per family member at ___. Required 2
person assist (baseline per daughter is able to ambulate w/
walker)
Neuro stroke consulted; impression was that initial symptoms
might be representative of recrudescence of stroke symptoms;
however, exam ultimately unchanged from prior
Initial labs - WBC 18.2 (up from 8.4 2 days earlier)
Interventions - 1L NS, ceftriaxone 1g; vanc 1g (6pm); Pip-tazo
4.5g (8pm)
ROS:
Neuro - no headache or neck pain
GI - no abd pain
ID - sick contacts include his daughter, who has a URI w/
rhinorrhea
Past Medical History:
- ICH
- CVA (___)
- Recurrent UTI
- TIAs and R multifocal MCA stroke ___ ___
- bilateral cerebellar strokes
- R frontal intracranial hemorrhage ___, stopped
anticoagulation at that time)
- DM2, complicated by nephropathy, retinopathy, and vasculopathy
(foot ulcer)
- BPH
- MVA ___ ___ with hemothorax and embolic strokes
- s/p fall with head strike on ___
- L leg hematoma ___ setting of superatherapeutic INR
- Hepatitis C
- Cirrhosis
- s/p chemoembolization of a hepatocellular carcinoma ___ ___
- polymyalgia rheumatica dx ___ high Sed Rate.
- degenerative changes and severe tendinitis involving his left
and right shoulders.
- HTN
- Hyperlipidemia
- Possible thigh hematoma from ___ during ___ war
- Urinary retention (BPH)- foley ___ ___ place. Had UDS which
demonstrated a hypersensitive bladder and phasic detrusor
overactivity. He has had many voiding trials along with a trial
of oxybutynin, catheter d/c resulting ___ urinary retention,
constipation and permanent replacement of the foley catheter
(___). No cystoscopy report noted.
Social History:
___
Family History:
brother diagnosed with colon cancer
mother d ___ brain tumor
father d ___ stomach problems
9 siblings - 2 died from old age ___ their ___ although one of
them had DM
3 children - 1 son and 2 daughters with htn
2 grandchildren ___ good health
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
VS - 97.6; BP 181/83; P ___ RR 18; 97% on RA
Access: R ___
General - elderly M lying ___ bed ___ no distress; intermittently
with wet cough; primarily ___, speaks some ___,
daughter at bedside
___ - L lower facial droop (chronic); MMM; posterior
oropharynx poorly visualized
Cor - irregularly irregular; no MRG
Pulm - Comfortable on room air, RR 20, no accessory muscle use.
Coarse sounds at left base which clear with coughing; otherwise
clear.
Abd - soft, flat, non-tender, normal bowel sounds
GU - foley ___ place draining dark urine; no clots
Extrem - thin, no edema, DP pulses 2+
Neuro -
Mental status - oriented to ___ ___. Knows he is
___ the hospital due to an infection.
CN - left sided facial droop (chronic); CN ___ otherwise intact
Motor - weakness ___ left triceps; ___ hip flexion on left;
otherwise ___. DTRs 2+ on left, 1+ on right. No ankle clonus.
Sensation - intact to light touch throughout
Cerebellar - FNF intact bilaterally
DISCHARGE PHYSICAL EXAM:
===================
VS - not taken given that patient is CMO
No longer checking ___
General - elderly ill-appearing M lying ___ bed comfortable and
conversive through daughter interpreting. Wrapped ___ blankets
and towels; intermittently with wet cough; primarily
___, speaks some ___ daughter and wife at
bedside, daughter translating/interpreting throughout interview
___ - L lower facial droop (reportedly chronic); dry MM; clear
OP on exam, no erythema, PERRL, EOMI.
CV - irregularly irregular, with inconsistent ___ systolic
murmur heard throughout; no rubs/gallops
Lungs - clear ___ anterior fields, clear ___ posterior upper
fields, with minor crackles ___ the bases, no wheezing
Abd - soft, flat, non-tender, bowel sounds present
GU - foley ___ place, draining clear urine
Ext - thin, no edema, DP pulses 2+
Neuro - A+O to person, place, month, year (did not know date).
EOMI, PERRL, hearing intact bilaterally, CN5 intact, tongue
midline. Facial asymmetry with L ptosis/facial droop (stable
from prior). Moving all extremities on command
Skin - diffusely warm/diaphoretic
Pertinent Results:
==== ADMISSION LABS ====
___ 03:45PM BLOOD WBC-18.2*# RBC-5.25 Hgb-14.7 Hct-44.5
MCV-85 MCH-27.9 MCHC-33.0 RDW-14.5 Plt ___
___ 03:45PM BLOOD Neuts-90.6* Lymphs-4.2* Monos-4.9 Eos-0.1
Baso-0.3
___ 03:45PM BLOOD ___ PTT-38.8* ___
___ 03:45PM BLOOD Glucose-200* UreaN-23* Creat-1.2 Na-130*
K-4.4 Cl-95* HCO3-23 AnGap-16
___ 03:45PM BLOOD ALT-24 AST-31 AlkPhos-82 TotBili-1.0
___ 03:45PM BLOOD cTropnT-<0.01
___ 03:45PM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.3 Mg-1.9
___ 03:57PM BLOOD Lactate-1.8
___ 04:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:10PM URINE Blood-NEG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD
___ 04:10PM URINE RBC-15* WBC-47* Bacteri-FEW Yeast-NONE
Epi-0
___ 04:10PM URINE CastHy-4*
___ 01:20AM URINE Hours-RANDOM Creat-137 Na-28 K-72 Cl-11
==== INTERIM LABS ====
___ 04:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
==== DISCHARGE LABS ====
___ 07:50AM BLOOD WBC-8.3 RBC-4.59* Hgb-13.2* Hct-39.4*
MCV-86 MCH-28.9 MCHC-33.6 RDW-14.3 Plt ___
___ 07:50AM BLOOD Glucose-298* UreaN-14 Creat-0.8 Na-132*
K-4.5 Cl-100 HCO3-23 AnGap-14
___ 07:50AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0
==== MICROBIOLOGY ====
___ 4:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ BLOOD CULTURES: No growth
___ BLOOD CULTURES: No growth
___ BLOOD CULTURES: No growth
___ BLOOD CULTURES: No growth
___ STOOL CDIFF: Negative for toxigenic C. difficile by the
Illumigene DNA amplification assay.
___ URINE LEGIONELLA: NEGATIVE FOR LEGIONELLA SEROGROUP 1
ANTIGEN.
___ URINE CULTURES: No growth
___ 7:00 pm SPUTUM Source: Expectorated.
**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 CLUSTERS AND ___
SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
==== IMAGING ====
___ CT Head Non Con:
No evidence of acute intracranial process. Sequelae of multiple
prior infarcts are again seen ___ the right frontal and parietal
lobes as well as the bilateral cerebellum.
___ CT CSpine Non Con:
No evidence of acute fracture or traumatic malalignment.
Multilevel degenerative changes as described above.
___ CXR (AP):
Mild left basal atelectasis. No pneumonia or CHF.
___ CXR (AP):
Small bilateral pleural effusions are new since ___.
Slight increase ___ heart size and caliber of the hilar vessels
all suggests mild cardiac decompensation.
There is also new heterogeneous consolidation at the base of the
right Lung which could be atelectasis or early pneumonia.
___ CXR (PORTABLE):
Large right pleural effusion, small left pleural effusion and
bibasilar consolidation, particularly left lower lobe, have all
increased since ___. Moderate cardiomegaly is chronic.
Pulmonary hyperinflation most likely due to emphysema or small
airway obstruction.
___ EKG:
Atrial fibrillation with a controlled ventricular response.
Consider anteroseptal myocardial infarction, age indeterminate.
Non-specific T wave abnormalities. Low QRS voltage ___ the limb
leads. Compared to the previous tracing of ___ the QRS
voltage is lower.
Brief Hospital Course:
___ yo M w/ complex medical hx notable for Afib (several CVAs
attributed to this; now off A/C secondary to right frontal ICH
___, prior cerebellar and R. MCA strokes, HTN, DM, HCC (s/p
TACE ___, and urinary retention (chronic indwelling foley x ___
year; c/b multiple UTIs v. colonization) who presents with AMS 4
days after discharge from a recent hospitalization for sensitive
pseudomonal UTI, found to have a new leukocytosis and fevers.
ACUTE ISSUES:
=================
#End of life/GOC/CMO: Per family meeting on ___ with ___
attending and outpatient PCP regarding goals of care and
hospice, patient and family moving opted to transition to
hospice. Daughter has arranged for funeral transportation back
to ___ through ___ ___ ___. After discussions with family
on ___, family elected to transition to ___ care. Patient
continues with waxing and waning mental status, though at times
is clear, recognizing family. Started on morphine solution,
given a trial of 2mg which patient tolerated well, not required
more. Has been using scopolamine patch, liquid tylenol, but
otherwise not requiring anti-emetics, or anti-secretion
medications. Will need continued assessment of pain, SOB and
other symptoms for management while under hospice care.
#Pneumonia: Patient presented with AMS and URI symptoms, as well
as new productive cough, with new leukocytosis to 18, from 8.4
on discharge 3 days prior to this admission, CXR findings
consistent with pneumonia, treated with IV cefepime, and
broadened adding IV vancomycin ___ the setting of patient with
continued high fevers on monotherapy with IV cefepime. Patient
was treated symptomatically with supplemental oxygen as needed,
as well as nebulizer therapy and standing tylenol for fevers
with diaphoresis. Blood cultures remained negative. Urine
cultures without signs of acute infection (recently treated for
UTI at most recent hospitalization 4 days prior to this
admission, sensitive pseudomonas ___ UCx), and cdiff, urine
legionella, and influenza testing were negative. Patient
completed an 8 day course of vanc/cefepime for presumed
pulmonary infection despite negative cultures. Did receive flu
shot this year.
#Delirium Acute, due to Toxic Metabolic Encephalopathy:
Patient also noted by family to be more confused prior to
admission, exacerbated when spiking high fevers, ___ the setting
of above URI symptoms. Evaluated by neuro ___ the ___, felt
consistent with possible recrudescence of old stroke ___ the
setting of metabolic derangements and likely infection. With
treatment of the pneumonia and symptomatic treatment of fever
with standing tylenol, the patient's confusion improved, though
he continues to wax and wane with some mild confusion at times.
Noted to be slightly more hyponatremic on admission, which
remained stable ___ the low 130s despite fluids, less likely
contributing to acute delirium. His acute delirium with toxic
metabolic encephalopathy is likely related to his underlying
progressive HCC, and will continue to decline over time. ___ case
of any medication contribution, any sedative medications were
discontinued once the patient was transitioned to CMO following
disucssions with the family.
#HypoNa: Mild, at 130 on admission, unlikely to be the source of
his transient AMS. Most likely hypovolemic. Repeat ___ AM
improved to 134 following IVF ___ the ___. Urine Na 28 (ambivalent
range between 20 and 40). Continued to have sodium levels ___ the
low 130s, encouraged PO intake if ___ line with patient's goals
of care.
CHRONIC ISSUES:
=================
#DM: Home regimen is lantus 12 units daily, continued initially
on admission, along with low dose insulin sliding scale.
Fingerstick glucose checks and insulin administration were
stopped once patient was transitioned to CMO.
#Afib: Patient noted to be ___ afib throughout admission, not on
any nodal agent or anticoagulation as an outpatient (given prior
ICH on anticoagulation). Continued rate controlled off any
medication.
#HCC: Followed by Dr. ___ as an outpatient. Per recent notes
and discussions with inpatient heme-onc, patient is no longer a
candidate for TACE therapy. Following discussions with the
family, hospice was involved and the patient was transitioned to
CMO, with plan for discharge to hospice.
TRANSITIONAL ISSUES:
=================
#Continue morphine solutions as needed for pain/SOB as disease
progresses
#Consider anti-emetics and oral care as needed ___ the future as
disease progresses
#Continue liquid tylenol for symptom management of
sweats/fevers/pain
#Stopped non comfort focused meds given patient's change ___
goals of care and transition to CMO
# Code: DNR/DNI confirmed with daughter ___ on ___
# Emergency Contact: ___ (daughter/HCP): ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO BID
2. Fexofenadine 180 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Sarna Lotion 1 Appl TP QID:PRN pruritis
6. Senna 17.2 mg PO 3X/WEEK (___)
7. Simvastatin 20 mg PO QPM
8. Vitamin D 400 UNIT PO BID
9. Glargine 12 Units Breakfast
10. alpha lipoic acid ___ mg oral DAILY
11. Amlodipine 5 mg PO DAILY
12. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
Discharge Medications:
1. Sarna Lotion 1 Appl TP QID:PRN pruritis
2. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth sores
This is a new medication to treat your sore throat and mouth
sores.
3. Scopolamine Patch 1 PTCH TD Q72H
This is a new medication to treat any nausea.
4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN
pain/fever/diaphoresis
This is a new medication to treat any bothersome oral
secretions/salivation.
5. Lorazepam 0.25-0.5 mg PO Q4H:PRN anxiety/nausea
This is a new medication to treat any anxiety and any nausea.
6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
Pain or respiratory
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
-Hepatocellular carcinoma
-Pneumonia
-Failure to thrive
Secondary Diagnoses:
-Hyponatremia
-Hematuria
-Diabetes Mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your recent hospital
stay at the ___. You came ___
with congestion, sore throat, and a cough with fevers, and were
found to have a lung infection and were treated with a course of
intravenous antibiotics. Your breathing at times was very
difficult, and you were treated with nebulizer therapy ___
addition to antibiotics. You had hiccups, however these improved
with time.
Because of your many health issues, your doctors discussed with
___ and your family the possibility of focusing on making you
feel comfortable and with less pain and less shortness of
breath. The hospice team, who help make sure we treat your
symptoms and make you comfortable, came and talked with you and
your family while you were ___ the hospital. Given your medical
complications, you are no longer a candidate for treatment with
chemotherapy and TACE therapy for your liver cancer.
Your medication list, including any new medications started
while you were ___ the hospital, is listed below. Your future
medical appointments are also listed below for you.
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10541960-DS-6 | 10,541,960 | 25,726,231 | DS | 6 | 2134-07-16 00:00:00 | 2134-07-21 18:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Right arm pain c/f compartment syndrome
Major Surgical or Invasive Procedure:
___- completion fasciotomy; vac placement
___- Right forearm compartment release w/ CT release
___- Debridement, VAC change
___- Dorsal closure, STSG to volar
History of Present Illness:
___ female with past medical history of malignant
melanoma and upper extremity DVT who presents with right hand
swelling. the patient had a PICC line removed approximately 2
weeks ago from that extremity. She reports that a day and a half
ago, she fell onto her arm. Only today, she noticed that he was
swelling with significant pain. She denies chest pain, shortness
of breath, fevers, chills.she reports scratching the volar
aspect
of her right forearm today. She went to an outside hospital who
transferred for further evaluation by hand team.
Past Medical History:
PAST MEDICAL HISTORY:
Hx of melanoma s/p multiple excision
hx of endometrial cancer s/p TAH and unilateral
salpingo-oopherectomy
RUE DVT (___)
Depression/Anxiety
GERD
HOME MEDICATIONS:
Xanax 1mg PO TID
Citalopram
Iron
Multivitamin
Ambien 10mg PO qhs
Sertraline 100mg po daily
Atorvastatin 40mg Po daily
Pandoprazole 40mg PO BID
Lasix 20mg PO daily
ALLERGIES: Codeine (nausea)
Social History:
___
Family History:
FAMILY HISTORY: 5 paternal uncles with "endocarditis". Father
deceased from endocarditis at age ___. Mother is healthy.
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
RUE skin graft well taken.
Thigh skin donor site is clean
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have symptoms concerning for RUE compartment syndrome and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for Right forearm
compartment release w/ Carpal tunnel release. Postoperatively,
she continued to have evidence of rhabdomyolysis with ___ on
labwork. She was noted to have worsening swelling on ___
and underwent completion fasciotomy with vac placement.
Occupational therapy was consulted for range of motion and
splint application. Medicine was consulted for assistance for
management of rhabdomyosis and the ___. She was also found to
have an anemia, which was also worked up. On ___ she
underwent debridement and VAC change. Her exam continued to
improve after this debridement, with some return of sensation
but her contracture continued. On ___ she underwent Dorsal
hand wound closure, STSG to volar hand with thigh skin graft
donor sites, which the patient tolerated well. For full details
of the procedures please see the separately dictated operative
reports. The patient's home medications were continued
throughout this hospitalization. The patient worked with OT who
determined that discharge to home with services was appropriate.
The ___ hospital course was otherwise unremarkable.
We attempted to contact the patient's home case manager numerous
times. Our case management was able to reach them. She has home
health aids already established. She will be set up with ___
nursing for dressing changes and OT.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact with well
taken RUE skin graft, and the patient was voiding/moving bowels
spontaneously. The patient is NWB with ROM as tolerated in the
RUE. The patient will follow up with Dr. ___ week in
clinic. 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:
Xanax 1mg PO TID
Citalopram
Iron
Multivitamin
Ambien 10mg PO qhs
Sertraline 100mg po daily
Atorvastatin 40mg Po daily
Pandoprazole 40mg PO BID
Lasix 20mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*40
Tablet Refills:*0
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. ALPRAZolam 1 mg PO TID
5. Atorvastatin 40 mg PO QPM
6. Sertraline 100 mg PO DAILY
7. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right upper extremity compartment syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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 RUE.
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:
- For the right arm, please place daily xeroform over the skin
graft wound only, gauze fluffs and ACE wrap loosely. The dorsal
hand incisions with the sutures can have gauze changed daily.
The Orthoplast splint should be placed.
- For the thigh wounds, they can left open to air.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___ in 1
week. Please call ___ to confirm your appointment.
Physical Therapy:
OT: Active and Passive range of motion of all joints in RUE.
Activity as tolerated. Non weight bearing for now. Orthoplast
splint at rest.
Treatments Frequency:
OT: Active and Passive range of motion of all joints in RUE.
Activity as tolerated. Non weight bearing for now. Orthoplast
splint at rest.
WOUND CARE:
- For the right arm, please place daily xeroform over the skin
graft wound only, gauze fluffs and ACE wrap loosely. The dorsal
hand incisions with the sutures can have gauze changed daily.
The wrist incision can be left without dressing. The Orthoplast
splint should be placed.
- For the thigh wounds, they can left open to air.
Followup Instructions:
___
|
10542149-DS-3 | 10,542,149 | 22,819,680 | DS | 3 | 2169-06-28 00:00:00 | 2169-06-28 23:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
metoprolol
Attending: ___
Chief Complaint:
dysarthria, clumsy hand
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old woman with history of papillary thyroid
cancer s/p thyroidectomy ___ presumed remission), HTN, DM2,
who presents as ED to ED transfer for evaluation of dysarthria
and right-sided ataxia that started ~ 18 hrs prior to
presentation at OSH ED, 21 hrs to ___ ED.
History obtained by patient and her son at bedside as well as
per
chart review. The patient is very circumferential on history
taking with tangential thought and as such history details are
based on information extraction throughout the conversation. The
patient reports that she was in her usual state of health up
until last night at about ___, when she began to experienced
dysarthria and right-sided ataxia since ___.
She was in her usual state of health and was doing her laundry
at
home. She walked downstairs to the basement to pick up her
laundry at around ___. When she was walking back up the stairs,
she noticed a funny feeling, as if both her legs were weak and
she was swaying, although not to clear direction. She was not
dizzy at the time and did not have visual changes. She noted
bilateral tip of fingers and toes numbness that resolved. When
she put down the laundry basket she noticed that her right hand
was not working well. She thought it was strong but clumsy. She
could not even write her name and was worried about how she
would
write checks. She tried to pour herself a glass of water, but
kept missing the glass, pouring water everywhere, and then
having
trouble raising the glass to her mouth.
She presented to ___ initially where telestroke was called.
NIHSS4 for ___ as month of year, dysarthria, RUE dysmetria, RLE
drift. ___ was without hemorrhage but notable for meningioma.
No tPA as outside window. She was transferred to ___ for
neurology consultation.
On further review of events leading up to presentation, the
patient endorses that she has had recent falls, however the son
is only aware of one fall several weeks ago, which occurred
without headstrike and was described as mechanical. She also has
a history of spinal stenosis and osteoarthritis. In a routine
visit to her PCP, her BP was notably high, but this was
attributed to white coat hypertension. On presentation to ___,
DBP was 117, down to 95 without intervention.
Regarding her oncologic history, she notes she has had three
different types of cancers in different locations: papillary
thyroid cancer ___ years ago s/p resection, squamous cell
cancer
found in her lung (one solitary nodule), and an unspecified
neuroendocrine cancer found in an axillary lymph node. Leading
up
to today's presentation, she has been in her usual state of
health though, without significant B symptoms, unexpected weight
loss, change in thought process. Her son notes that at baseline,
she enjoys conversations.
AT BI M:
=========
INR 1, PTT 30
WBC 6.5, HgB 16.5, PLT 201
NCHCT: chronic right parasafital meningioma with localized mass
effect, unchanged as per MRI ___
2. mild involutional small vessel disease
no hemorrhage
ROS:
Notable for diabetic peripheral neuropathy, numbness along right
V3 distribution ___ mass excision, lower back pain from lumbar
Past Medical History:
DM2
HLD
HTN
Hypothyroidism s/p surgical removal
? squamous cell lung nodule
? neuroendocrine tumor in LN
lumbar stenosis
Surgical Hx:
===========
THyroidectomy, tonsillectomy, colonic polypectomy
Social History:
Allergies:
==========
metoprolol (reaction unclear)
SOCIAL HISTORY:
She used to work as a "___" per her son.
___ status: ___
Children: Yes
Tobacco use: Former smoker
Year Quit: ___
Years Since ___
Quit:
# Packs/Day: 3
# Years Smoked: 50
Pack Years: 150
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
- Modified Rankin Scale:
[] 0: No symptoms
[x] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Physical Exam:
PHYSICAL EXAMINATION:
Vitals:
afebrile, BP 180/80, RR16, 95-100RA
General: Awake, cooperative
HEENT: no lesions noted in oropharynx.
Neck: Supple. Scarring from thyroidectomy, more pronounced along
right side of neck
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: Bilateral pedal edema, 1+
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert and oriented to date and year and city.
Attentive to examiner although with tangential and
circumferential thought. She has a plethora of spontaneous
speech
output with digressions through conversation (at baseline per
her
son). Follows simple midline, appendicular, cross-body and
two-step commands. Naming is intact to high and low frequency
objects. No neglect. No apraxia.
-Cranial Nerves: Right pupil 3>2. Left 4>3. EOMI with ___ beats
nystagmus on right lateral gaze. She has hypermetric saccades
when looking at target on right but not on left. No skew
deviation. VFF to finger counting. She has right facial numbness
along scar tissue from thyroidectomy in distribution of V3.
Tongue midline. She has dysarthria with guttural sounds but not
labial sounds.
-Motor: Normal bulk, decreased tone throughout. Right pronator
drift. No adventitious movements, such as tremor or asterixis
noted.
[___]
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: She has diminished sensation to pinprick and
temperature in stocking-glove distribution. She has diminished
JPS in both her toes bilaterally. Romberg deferred secondary to
gait instability.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: She has dysmetria with right FNF. She has
difficulty with rapid alternating movements with her right hand.
HKS testing is limited by body habitus. She has no ataxia when
asked to touch her right heel to my finger.
-Gait: deferred out of concern for gait instability, fall risk
DISCHARGE EXAM:
97.5 PO 151 / 81 72 18 96 RA
Neurologic:
-Mental Status: Alert and oriented to date and year and city.
Attentive to examiner although with tangential and
circumferential thought. She has a plethora of spontaneous
speech
output with digressions through conversation (at baseline per
her
son). Follows simple midline, appendicular, cross-body and
two-step commands. Naming is intact to high and low frequency
objects. No neglect. No apraxia.
-Cranial Nerves: pupils 3->2. She has hypermetric saccades
when looking at target on right but not on left. No skew
deviation. VFF to finger counting. Right facial droop.
Tongue midline. She has dysarthria.
-Motor: Right pronator
drift. No adventitious movements, such as tremor or asterixis
noted.
[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: She has diminished sensation to pinprick and
temperature in stocking-glove distribution. She has diminished
JPS in both her toes bilaterally. Romberg deferred secondary to
gait instability.
-Reflexes:
Plantar response was flexor bilaterally.
-Coordination: She has dysmetria with right FNF.
-Gait: wide based gait
Pertinent Results:
LABORATORY DATA:
___ 04:35PM ___ COMMENTS-GREEN TOP
___ 04:35PM CREAT-0.7
___ 04:35PM estGFR-Using this
___ 04:29PM GLUCOSE-105* UREA N-14 CREAT-0.8 SODIUM-143
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18
___ 04:29PM estGFR-Using this
___ 04:29PM ALT(SGPT)-16 AST(SGOT)-17 ALK PHOS-83 TOT
BILI-0.6
___ 04:29PM ALBUMIN-4.6 CALCIUM-8.7 PHOSPHATE-3.8
MAGNESIUM-1.9
___ 04:29PM WBC-8.0 RBC-5.23* HGB-15.2 HCT-46.7* MCV-89
MCH-29.1 MCHC-32.5 RDW-14.5 RDWSD-46.9*
___ 04:29PM PLT COUNT-192
___ 06:44AM BLOOD TSH-0.83
___ 06:44AM BLOOD %HbA1c-5.7 eAG-117
___ 06:44AM BLOOD ALT-15 AST-24 LD(LDH)-358* CK(CPK)-249*
AlkPhos-77 TotBili-0.7
EKG: left atrial enlargement, prior anterior ischemic infarct
(chronic) NSR
IMAGING:
___ NCHCT - 1.5x1.6 cm calcified mass with broad dural base
along
posterior right falx; no hemorrhage or large territory infarct
___ CTA head and neck - ? narrowing of left vertebral artery
just
prior to merge into basilar artery. multifocal atherosclerotic
calcifications in bilateral common carotid arteries and within
siphon
1. Examination is moderately degraded by motion.
2. Acute to subacute infarction in the lateral left thalamus.
3. Right posterior parafalcine probable meningioma measuring up
to 2.2 cm.
4. No additional areas of abnormal enhancement to suggest
metastatic disease.
5. No evidence of acute intracranial hemorrhage.
6. Findings of probable moderate to extensive chronic small
vessel ischemic
disease.
7. Question Dolichoectasia of the cavernous internal carotid
arteries
measuring up to 8 mm on the left and 6 mm on the right.
8. Otherwise, grossly patent circle of ___ with no evidence
of occlusion.
9. Paranasal sinus disease , as described.
Brief Hospital Course:
Mrs. ___ is a ___ year old woman with DM2, HTN who was
admitted to the Neurology stroke service with 2 days of
dyasrthria and clumsy hand secondary to an acute ischemic stroke
in the left thalamus.
#Left thalamic ischemic infarct
Given the location and risk factors, the etiology is thought to
be small vessel disease. Her A1c 5.7 and was LDL 152. She also
has a 150 pack year history of smoking although she stopped ___
years. We started her on aspirin 81 mg daily and atorvastatin 40
mg daily. Initially her atenolol was halved given acute stroke
(goal is perfusion), but was resumed at 50 mg daily on HD2. She
should have ongoing BP monitoring and increased atenolol as
needed for BP goal in long run of <140/50. ___ evaluated and
recommended rehab.
Of note, she is often non-compliant with medications because she
says she doesn't medications. We have made a call to her primary
care to continue medication compliance counseling.
#social work: social work was involved during her stay given
some conflict with her children. They felt like she was not
taking her condition seriously given her refusal of rehab and
wanting to go home. Social work stepped in to help patient and
family dynamics.
Transitional Issues:
====================
[] Please continue to monitor and treat blood pressure, with
long term goal BP<140/90
[] Please follow-up LDH as it was elevated in 300s range in the
hospital
[] Patient at time reluctant to take medications, continue to
encourage secondary prevention for stroke with aspirin and
atorvastatin
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 = 152 ) - () 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 - () 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. Atenolol 50 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Furosemide 40 mg PO 1X:ASDIR PRN leg swelling
5. Fluticasone Propionate NASAL 1 SPRY NU BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Atenolol 50 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Furosemide 40 mg PO 1X:ASDIR PRN leg swelling
6. Levothyroxine Sodium 150 mcg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic stroke
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 ___,
___ were hospitalized due to symptoms of difficulty walking and
slurred speech 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 ___ 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 fats in your blood
We are changing your medications as follows:
- START taking aspirin 81 mg daily
- START taking atorvastatin 40 mg daily
Please take your other medications as prescribed.
Monitor your blood pressure as ___ may need a higher dose of
blood pressure medication.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ 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
___
- 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:
___
|
10542559-DS-3 | 10,542,559 | 26,286,660 | DS | 3 | 2148-07-11 00:00:00 | 2148-07-11 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies
Attending: ___
Chief Complaint:
Sternal dehiscence
Major Surgical or Invasive Procedure:
___ wound reexploration, tightening of sternal
wires
PRIOR ADMIT
___
1. Coronary artery bypass graft x 4
2. Skeletonized left internal mammary artery sequential
grafting to the diagonal and the left anterior descending
artery
3. Skeletonized in situ right internal mammary artery graft
to the obtuse marginal artery.
4. Long saphenous vein graft to posterior descending artery.
5. Endoscopy harvesting of the long saphenous vein.
History of Present Illness:
___ ___, with ___ CAD, DM2 (A1c 8.8% ___, HTN,
obesity, HLD, OA, and a question of mild dementia presented to
___ on ___ following an episode of intractable
chest pain and shortness of breath, found to have an NSTEMI. The
patient was brought to the Operating Room on ___ where the
patient underwent coronary artery bypass graft x 4, skeletonized
left internal mammary artery sequential grafting to the diagonal
and the left anterior descending artery, skeletonized in situ
right internal mammary artery graft to the obtuse marginal
artery, long saphenous vein graft to posterior descending
artery. Overall the patient tolerated the procedure well and had
an uneventful post op course. She was discharged to rehab on
___ in stable condition. She was recently discharged home from
rehab. She presented to OSH after developing sharp chest pain at
incision site after coughing. Her family noted yellow drainage
from the wound and brought patient to OSH ED. She was
transferred
for ___ eval. She denies fevers and chills at home. She has
significant pain at incision site.
Past Medical History:
Past Medical History:
-Coronary artery disease
-Hypertension
-T2DM
-Hyperlipidemia
-Osteoporosis
-Dementia
PSH:
___ at ___
1. Coronary artery bypass graft x 4
2. Skeletonized left internal mammary artery sequential
grafting to the diagonal and the left anterior descending
artery.
3. Skeletonized in situ right internal mammary artery graft
to the obtuse marginal artery.
4. Long saphenous vein graft to posterior descending artery.
-tonsillectomy, aged ___
Social History:
___
Family History:
-No family history of cardiac disease.
Physical Exam:
Admit PE:
Temp 98.0 SR 97 134/79 99% RA
Weight: 64.86 kg
___: NAD, sleeping in bed but arousable
Skin: Dry [] intact [] Dehiscence of mid-lower pole with yellow
purlence, mild erythema, + TTP to light touch, sternum stable
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
___: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: + Left: +
___ Right: + Left: +
Radial Right: + Left: +
Left saph site clean/dry/intact
Carotid Bruit: Right:none Left:none
Discharge PE:
Vital Signs I/O
24 HR Data (last updated ___ @ 1248)
Temp: 97.5 (Tm 98.4), BP: 145/80 (145-156/76-82), HR: 89
(77-89), RR: 16 (___), O2 sat: 94% (94-99), O2 delivery: Ra
Fluid Balance (last updated ___ @ 1249)
Last 8 hours Total cumulative 100ml
IN: Total 100ml, IV Amt Infused 100ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 50ml
IN: Total 100ml, IV Amt Infused 100ml
OUT: Total 50ml, Urine Amt 0ml, wound vac 50ml
___: NAD [x]
Neurological: A/O x2 [x] non-focal [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: diminished at bases No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema none
Left Lower extremity Warm [x] Edema none
Pulses:
DP Right:+ Left:+
___ Right:+ Left:+
Radial Right:+ Left:+
Skin/Wounds: Dry [x] intact [x]
Sternal Incision - red, well healing granulation tissue with
minimal erythema at wound edges (approx. 6cm long x 2cm wide x
1cm deep)
RUE ___ site -c/d/i
Pertinent Results:
LABS:
Admit
___ 05:59AM BLOOD WBC-10.3* RBC-3.85* Hgb-10.7* Hct-34.8
MCV-90 MCH-27.8 MCHC-30.7* RDW-14.6 RDWSD-48.3* Plt ___
___ 05:59AM BLOOD Neuts-50.9 ___ Monos-9.4 Eos-4.8
Baso-0.6 Im ___ AbsNeut-5.26 AbsLymp-3.46 AbsMono-0.97*
AbsEos-0.50 AbsBaso-0.06
___ 05:59AM BLOOD ___ PTT-25.7 ___
___ 05:59AM BLOOD Glucose-115* UreaN-12 Creat-0.9 Na-137
K-4.6 Cl-104 HCO3-22 AnGap-11
___ 06:53PM BLOOD ALT-6 AST-16 LD(LDH)-152 AlkPhos-115*
Amylase-175* TotBili-0.4
___ 06:53PM BLOOD Lipase-65*
Discharge
___ 09:34AM BLOOD WBC-8.9 RBC-3.57* Hgb-9.6* Hct-31.3*
MCV-88 MCH-26.9 MCHC-30.7* RDW-15.0 RDWSD-48.3* Plt ___
___ 04:12AM BLOOD ___
___ 09:34AM BLOOD Glucose-119* UreaN-6 Creat-0.6 Na-139
K-4.5 Cl-101 HCO3-27 AnGap-11
___ 05:42AM BLOOD ALT-<5 AST-13 AlkPhos-85 Amylase-96
TotBili-0.2
___ 05:42AM BLOOD Lipase-22
___ 09:34AM BLOOD Phos-3.5 Mg-1.7
coags:
___ 04:12AM BLOOD ___
___ 05:23AM BLOOD ___ PTT-64.7* ___
___ 05:42AM BLOOD ___ PTT-133.4* ___
MICRO
___ 8:30 am SWAB STERNAL WOUND.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Ertapenem Susceptibility testing requested by ___
___
___.
Susceptible to Ertapenem test result performed by ___
___.
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 (except
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 8 I
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
=
=
=
=
=
================================================================
STUDIES:
CXR PICC (right arm 36cm DL PICC) placement ___:
New right-sided PICC line terminates at the cavoatrial junction.
There has been no other short-term change
IMPRESSION: PICC line terminating at the cavoatrial junction.
.
ABD XRay ___
Nonspecific bowel gas pattern characterized by mild gastric
distension and
small quantities of fluid in the colon, without dilatation.
Elevated left
hemidiaphragm with left basilar atelectasis, unchanged
.
CXR ___:
Mild improvement in left basilar atelectasis. Probable small
persistent
left-sided pleural effusion, difficult to directly assessed with
with this
technique.
.
TEE ___ (*PRELIM*)
Echocardiographic Measurements
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aortic Valve - LVOT diam: 1.9 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: No spontaneous echo contrast is seen in the ___.
Good (>20 cm/s) ___ ejection velocity. No thrombus in the ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
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 aortic arch. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Trivial MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: Trivial/physiologic pericardial effusion.
___ COMMENTS: Written informed consent was obtained from the
patient. The patient was under ___ anesthesia throughout the
procedure. No glycopyrrolate was administered. The TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
Conclusions
A limited exam was performed in setting of sternal debridement
with recent PE.
No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. 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 aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are moderately thickened. Trivial mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
.
CHEST CT w/Contrast ___
IMPRESSION:
Limited exam due to motion artifact. However, within these
limitations:
1. Status post median sternotomy and CABG without CT evidence of
postsurgical
complications. Mild midline anterior chest wall soft tissue
stranding likely
postsurgical. No evidence of drainable fluid collections.
2. Probable right lower lobe and left upper lobe subsegmental
pulmonary
emboli. No evidence of right ___ strain or pulmonary
infarction.
3. Partial left lower lobe collapse. Trace left pleural
effusion.
4. 8 mm right thyroid lobe nodule.
5. 8 mm distal descending aortic atherosclerotic ulcer.
6. Moderate emphysema.
RECOMMENDATION(S):
8 mm right thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule
.
PA/LAT CXR ___
Increasing moderate left pleural effusion is probably due to
chronic
postoperative left lower lobe collapse. Elevation left
hemidiaphragm is mild, probably a reflection of the atelectasis
rather than an indication of phrenic nerve palsy.
Brief Hospital Course:
___ year old Female with PMHx of CAD, DM2, HTN, obesity, HLD, OA
who presented with
NSTEMI on ___, and who went to CABG x 4(LIMA-LAD seq to ___,
___ ___, who represented ___ with
sternal wound dehiscence and drainage. She went to OR on ___
for sternal debridement with vac placement. In the OR, the
inferior sternal wound was open and there was loosening of the
wires. There was some tunneling that probed to bone, so the
presumptive diagnosis of osteomyelitis was made, but it was
unclear if the infection truly went deep and was just more
superficial. OR swab was positive for Klebsiella and mixed
organisms, which
were corynebacterium and CoNS per micro lab. She was treated
with meropenem given resistance profile and later switched to
ertapenem (confirmed ertapenem sensitive).
Of note, on her admit Chest CT, she was noted to have probable
right lower lobe and left upper lobe subsegmental pulmonary
emboli, and she has been started on Coumadin (goal INR ___ for
this. She developed nausea and vomiting but KUB showed no
obstruction/ileus, and this resolved with Reglan/Zofran. LFTs
were normal on ___. She remained NSR on tele. She continues
with Imdur x 5 more months for skeletonized arterial grafts. She
has baseline dementia and has been occasionaly been pleasantly
confused but cooperative. Today she was alert and oriented.
She was evaluated by the Physical Therapy service for
assistance with strength and mobility. By the time of discharge
on POD ___ s/p CABG and ___ s/p sternal debridement, she was
ambulating freely, the wound was healing with VAC last changed
___ and pain was controlled with oral analgesics (APAP &
Ultram). The patient was discharged ___ House Rehab in
good condition with appropriate follow up instructions.
Medications on Admission:
Medications at rehab:
1. Acetaminophen 1000 mg PO Q6H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation
6. Furosemide 40 mg PO DAILY
7. Insulin SC Sliding Scale - Insulin SC Sliding Scale using
Humalog Insulin
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Duration: 6 Months
9. Losartan Potassium 50 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Tartrate 50 mg PO TID
12. Potassium Chloride 20 mEq PO DAILY
13. Protonix
14. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Ertapenem Sodium 1 g IV 1X Klebsiella osteomyelitis
Duration: 1 Dose
1gm IV q24h
Next dose due ___ at 12noon please
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
4. Metoclopramide 5 mg PO QIDACHS Duration: 3 Days
5. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line
please follow EKG for QTc if given
6. Pantoprazole 40 mg PO Q24H
7. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
8. ___ MD to order daily dose PO DAILY16 pulmonary emboli
goal INR ___
MD to order dose daily
Pt to receive 3mg prior to rehab transfer on ___
9. Albuterol Inhaler ___ PUFF IH Q6H
10. Furosemide 20 mg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
hold if SBP<100
12. Metoprolol Tartrate 75 mg PO TID
hold if SBP<100 or HR<60
13. Potassium Chloride 10 mEq PO DAILY
Hold for K >4.5
14. Senna 17.2 mg PO QHS
15. TraMADol ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*14 Tablet Refills:*0
16. Acetaminophen 1000 mg PO Q6H
17. Aspirin EC 81 mg PO DAILY
18. Atorvastatin 40 mg PO QPM
19. Bisacodyl ___AILY:PRN constipation
20. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
21. Glucose Gel 15 g PO PRN hypoglycemia protocol
22. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
skeletonized arterial grafts Duration: 5 Months
23. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Sternal dehiscense s/p debridement
Klebsiella sternal osteomyelitis
Micro pulmonary embolism
Coronary artery disease s/p CABGx4 ___
Secondary diagnosis
-Hypertension
-T2DM
-Hyperlipidemia
-Osteoporosis
-Dementia
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating with assistance
Sternal pain managed with oral analgesics
Sternal Incision - red, well healing granulation tissue with
minimal erythema at wound edges (approx. 6cm long x 2cm wide x
1cm deep)
RUE ___ site -c/d/i
No Edema
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10542587-DS-9 | 10,542,587 | 25,540,495 | DS | 9 | 2183-10-30 00:00:00 | 2183-11-03 16:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLQ abdominal pain, fever, nausea, decreased appetite, elevated
WBC count
Major Surgical or Invasive Procedure:
___: drainage of paracolic gutter abscess
History of Present Illness:
Mr. ___ is a ___ yo male who presented with RLQ abdominal
pain that began ten days prior. His pain began while he was
eating
and he noted feeling sore on his right abdomen and progressed to
feeling like "someone was stabbing me with a knife." The pain
has
not moved from his R abdomen and does not radiate. He has been
taking 4 ibuprofen and ___ Aleve daily until two days ago with
only moderate pain relief. Sitting up exacerbates his pain,
pressure on his right abdomen increases his pain to ___. Since
his presentation he has experienced nausea, fever, chills upon
waking up, night sweats, fatigue, lethargy and a burning
sensation in his RLQ. He has had a decreased appetite,
unitentional 5lb weight loss. He had a 2 day history of
constipation, took a laxative this morning and has had several
bowel movements today. He has had increased urinary frequency
over the past 10 days, and notes his urine has changed color
from
light yellow to brown to yellow, but denies dysuria. He also
noted some sortness of breath over the prior two days, but
denied
chest pain or gasping for breaths.
Past Medical History:
-Bladder cancer ___, treated with local chemotherapy)
-weight lifting injury to spinal cord in ___
Past Surgical History:
-C-spine fusion (___)
Social History:
___
Family History:
Sister has diabetes, mother had ___, another sister had
skin cancer. No family history of diabetes or cancer that runs
in the family
Physical Exam:
Physical Exam: ___
Vitals:102.7 F /BP 118/78 / 121 bpm /RR 26
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: normoactive bowel sounds, soft, nondistended, tender in RLQ
to palpation, no rebound or guarding, no palpable masses, no
CVAT
Ext: No ___ edema, ___ warm and well perfused
Physical Exam:upon discharge: ___
Vitals:Stable
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: normoactive bowel sounds, soft, nondistended, slightly
tender right lower quadrant, drain intact, no erythema or
drainage of drain site.
Ext: No ___ edema, ___ warm and well perfused, positive pedal
pulses bilaterally
Pertinent Results:
___ 03:30PM URINE HOURS-RANDOM
___ 03:30PM URINE UHOLD-HOLD
___ 03:30PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 03:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
___ 03:30PM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:30PM URINE MUCOUS-RARE
___ 11:40AM LACTATE-2.1*
___ 11:30AM GLUCOSE-120* UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
___ 11:30AM estGFR-Using this
___ 11:30AM ALT(SGPT)-34 AST(SGOT)-26 ALK PHOS-98 TOT
BILI-0.9
___ 11:30AM LIPASE-23
___ 11:30AM ALBUMIN-3.6
___ 11:30AM WBC-19.6* RBC-4.56* HGB-14.0 HCT-43.9 MCV-96
MCH-30.7 MCHC-31.9 RDW-14.3
___ 11:30AM NEUTS-83.4* LYMPHS-8.7* MONOS-6.7 EOS-0.9
BASOS-0.3
___ 11:30AM PLT COUNT-261
___ 11:30AM ___ PTT-25.9 ___
Radiology Report CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS
Study Date of ___
IMPRESSION:
1. Findings consistent with perforated appendicitis with large
abscess
formation. Collection would be amenable to percutaneous
drainage.
2. Bilateral adrenal adenomas.
3. Fusiform infrarenal abdominal aortic aneurysm measuring up to
3.9 cm.
IMAGE CATH FLUID ___ Study Date of ___
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter
into the fright paracolic collection. Samples was sent for
microbiology evaluation.
Brief Hospital Course:
The patient presented to Emergency Department on ___
complaining of a 10 day history of RLQ abdominal pain, fever,
nausea, decreased appetite, elevated WBC count, and CT findings
of paracolic gutter fluid. He was admitted to the floor for to
follow up with blood cultures, urine cultures, continue Cipro
and Metronidazole, Acetominophen for fever, a plan for abdominal
fluid drainage, maintain NPO, IV fluids and to follow up with
hypoenhancing adrenal lesions with urology. The patient was
diagnosed with a paracolic gutter abscess.
The patient had a drain placed into the abscess that will go
home with him. he is instructed to record his output daily and
when the output is less than 10ccs for 3 days he is to call
radiology to have the drain removed. he understands this and has
the contact information.
Throughout the patient's hospitalization he was closely
monitored.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO and the diet was
advanced on ___ after the drain was placed, to a Regular
diet, which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely. The patient did not
have a fever the day of discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan
Medications on Admission:
Ibuprofen
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
last dose will be ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*26 Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose will be ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*39 Tablet Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
do not drive while taking this medicationl do not use machinery
while taking this medication
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID constipation
stop use if having loose stool
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
1. Ciprofloxacin HCl 500 mg PO Q12H
last dose will be ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*26 Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose will be ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*39 Tablet Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
do not drive while taking this medicationl do not use machinery
while taking this medication
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID constipation
stop use if having loose stool
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
paracolic gutter abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital on ___ with a 10 day history of
right lower quadrant abdominal pain, fever, nausea, decreased
appetite, elevated WBC count, and CT findings of paracolic
gutter fluid. You were admitted to ___ for NPO and IV fluids.
You were seen by infectious disease for f/u blood cultures, f/u
urine cultures, continued Cipro and Metronidazole and
Acetominophen for fever. You were seen by gastrointextinal
department for abdominal fluid drainage and Urology for f/u on
your hypoenhancing adrenal lesions.
You had a drain placed and will be leaving with the drain.
Please record your output daily and when the output is less than
10ccsfor 3 days please call ___ to plan removal of
drain with Interventional Radiology.
Please adhere to the following instructions for your discharge.
ACTIVITY:
-Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
-You may climb stairs.
-You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
-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.
-Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
YOUR BOWELS:
-Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
-If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
-After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
Followup Instructions:
___
|
10542901-DS-3 | 10,542,901 | 22,228,441 | DS | 3 | 2132-01-24 00:00:00 | 2132-01-24 12:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, foot pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of IV drug use, hepatitis C and
Raynaud's referred from ___ for MRI of spine to
evaluate for epidural abscess. Patient was ambulatory into the
___ for evaluation of lower back pain, bilateral
paresthesias, and 2 days of bilateral foot swelling, patchy
lower
extremity erythema and blisters. She received vancomycin there
as well as toradol.
She had 2 days of back pain which started suddenly when she
leaned deep to the side off of a barstool-sized chair. Since
that
time she's had severe back pain in the thoracic and lumbar
region. Today she complained of an episode of fecal
incontinence. In a similar timeframe, she has noticed blisters
on her feet that make it difficult to walk. She did not have
any
specific trauma that she can remember; she does wear flip flops
and feet are exposed. She also noticed feeling hot/subjective
fever, chills, and nausea, and is having diarrhea and reports
fecal incontinence today; no urinary incontinence. She does
report some numbness but also pain in both feet.
The patient uses IV heroin with last IV drug use today. She is
homeless.
In the ED, initial VS pain 7 98.1 88 118/57 16 98% RA. Per
notes, pt initially refused to answer questions; belongings
searched and crack pipe and insulin syringe with cloudy liquid
in
it discarded. Labs sig for WBC normal at 4.8; CPK in mid ___,
H/H 10.4/31.7 (last Hct 43 in ___, K 3.0, UA neg, tox positive
for barbituates, opiates, cocaine. She was unable to tolerate
MRI initially and so she was intubated for the MRI. MRI C/T/L
spine was limited but showed no epidural abscess or fluid
collection. There was herniation at C5-6 level moderately
narrowing the spinal canal and affecting left C6 root. There
were T2/Flair Hyperintensities in psoas/paraspinal muscles.
could
be infectious v. edema from trauma. The patient self-extubated.
She was given a dose of ceftriaxone in the ED, although it is
unclear what source of infection was being targeted (potentially
endocarditis); she had no fevers in the ED since 11pm last
night.
UA was negative, CXR negative; blood cx drawn.
Past Medical History:
IVDA crack/cocaine abuse
Raynaud's
Bipolar disorder
PTSD
Anxiety
ADHD
History of ?scalp abscess ___ yrs ago treated at ___ after
shooting
up in neck
Social History:
___
Family History:
Mother had stroke at age ___, grandmother had MI at age ___,
grandfather stroke at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.0 115/65 84 20 100% RA
GEN: tearful disheveled woman, easily irritated
HEENT: scattered excoriations across face. OP clear.
NECK: supple, no JVD
CV: normal rate, reg rhythm, unable to appreciate murmur
PULM: CTAB, no w/r/r
BACK: point tenderness between T10-L3, no point tenderness along
C-spine
ABD: soft, NTND, NABS
SKIN: large ~2cm diameter blistering lesions with pus in various
stages of opening/healing on plantar aspect of foot. small area
of erythema surrounding each. No e/o cellulitis spreading up
feet/legs.
NEU: CN II-XII intact b/l.
-Strength ___ b/l UE grip strength, wrist flexion/extension,
elbow flexion/extension. Strength 4+/5 shoulder
abduction/adduction symmetric b/l (pt reports difficulty d/t
pain). Strength only anti-gravity at hip flexors and extensors
b/l. 3+/5 at bilateral knee flexion, 4+/___/l. No
effort at plantarflexion or dorsiflexion b/l.
-Sensation: intact to light touch throughout all extremities in
all dermatomes. Intact to proprioception in bilateral first toes
-Reflexes: 2+ at knees b/l, unable to elicit ankles b/l. 2+ at
biceps b/l.
-No perineal loss of sensation. Rectal tone normal.
PSYCH: AAOx3. Easily irritable.
DISCHARGE PHYSICAL EXAM
VS: 97.8 109/57 68 18 94% RA
GEN: appears comfortable
HEENT: scattered excoriations across face. OP clear.
NECK: soft cervical collar in place
CV: normal rate, reg rhythm, unable to appreciate murmur
PULM: CTAB, no w/r/r
BACK: point tenderness between T10-L3, no point tenderness along
C-spine
ABD: soft, NTND, NABS
SKIN: large ~2cm diameter blisters on plantar aspect and side of
foot in relatively symmetric distribution; No e/o cellulitis
spreading up
feet/legs.
NEU: CN II-XII intact b/l.
-Strength ___ b/l UE grip strength, wrist flexion/extension,
elbow flexion/extension. Strength ___ shoulder
abduction/adduction symmetric b/l (pt reports difficulty d/t
pain). Strength ___ at hip flexors and extensors
b/l. ___ at bilateral knee flexion, 4+/___/l. ___
plantarflexion and dorsiflexion right; ___ left. Give-way
weakness seems ___ pain. Walks to and from bathroom; antalgic
gait
-Sensation: intact to light touch throughout all extremities in
all dermatomes.
PSYCH: AAOx3.
Pertinent Results:
ADMISSION LABS
___ 02:13AM WBC-4.8# RBC-3.39*# HGB-10.4*# HCT-31.7*#
MCV-94 MCH-30.7 MCHC-32.8 RDW-13.5 RDWSD-46.5*
___ 02:13AM NEUTS-48.9 ___ MONOS-14.7* EOS-6.0
BASOS-0.4 IM ___ AbsNeut-2.36 AbsLymp-1.43 AbsMono-0.71
AbsEos-0.29 AbsBaso-0.02
___ 02:13AM PLT COUNT-228
___ 02:13AM ___ PTT-28.2 ___
___ 02:13AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:13AM calTIBC-228* VIT B12-368 FOLATE-16.4
FERRITIN-98 TRF-175*
___ 02:13AM CALCIUM-8.4 PHOSPHATE-2.6* MAGNESIUM-2.2
IRON-51
___ 02:13AM CK(CPK)-4547*
___ 02:13AM GLUCOSE-87 UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-3.0* CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
___ 02:27AM LACTATE-0.9
___ 04:00AM URINE bnzodzpn-NEG barbitrt-POS opiates-POS
cocaine-POS amphetmn-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS
___ 07:30AM BLOOD WBC-3.5* RBC-3.66* Hgb-11.3 Hct-34.5
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.6 RDWSD-46.7* Plt ___
___ 07:09AM BLOOD Glucose-85 UreaN-10 Creat-0.7 Na-139
K-4.5 Cl-102 HCO3-32 AnGap-10
___ 07:09AM BLOOD ALT-100* AST-85* CK(CPK)-241* AlkPhos-58
TotBili-0.1
IMAGING
MRI C/T/L SPINE ___
IMPRESSION:
1. No evidence of epidural abscess or paravertebral fluid
collection.
2. Extensive symmetric enhancing hyperintensities of the
paraspinal muscles
which could represent infection, edema secondary to trauma, or
muscle necrosis
caused by lying unconscious for extended time.
3. Disc protrusion at C5-C6 that moderately narrows the spinal
canal and
compresses the cord. Severe left neural foraminal narrowing at
this level.
4. Bilateral pleural effusions.
ECHOCARDIOGRAM ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF = 60%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious vegetations
seen
Brief Hospital Course:
___ with h/o IVDA presenting with subjective fevers (not
confirmed in hospital) and back pain with weakness and reported
numbness, found to have disc protrusion at C5-6 without any
acute surgical need, question of hyperintensities of paraspinal
muscles, as well as blisters from trauma on feet.
1) Back pain/C5-6 disc protrusion: Ortho Spine consulted and
recommended no need for surgical intervention. Her reported
symptoms and exam did not correlate with a cervical spine
lesion. Cervical soft collar recommended and provided; plan
will be to f/u outpt with Ortho Spine. Her pain was actually
located in the lower thoracic and lumbar spine; no e/o spinal
infection nor disc or injury at these levels; strongly suspected
lumbago given edema in paraspinal muscles likely from strain
after her bending episode. Added muscle relaxant to help with
this and standing Tylenol; rec'd 2 doses of toradol. Pt
mobilized over several days and pain regimen decreased. In
regards to hyperintensities of paraspinal muscles, initially it
was difficult to tell what the etiology of this was, however,
there was no drainable collection and infection/myositis was
unlikely given no fever or leukocytosis during the entire
hospital stay. Discussed with ___ who recommended against muscle
biopsy; there is no further imaging that would better delineate.
This is most likely edema from muscle strain and/or muscle
breakdown from possibly lying down/being down. Her CK had been
mildly elevated in the 4000s on admission; trended down to 200s
by discharge.
2) Foot lesions: large blisters related to mechanical trauma
from poor shoes. Had initially received vancomycin but this was
stopped given no signs of systemic infection. Seen by wound
care and dermatology. Per derm, no need for debridement or abx.
Derm recs were to apply mupirocin and Xeroform per wound care,
with dry gauze overlay. I performed an unroofing of one blister
on day 1 and the fluid from the blister did come back with MSSA,
so started Bactrim to complete a total ___) Subjective Fevers: Never documented here. WBC was normal
with normal diff, no left shift. Infectious workup negative
except the superficial skin issues above. TTE was negative; TEE
was not pursued as there were no fevers and no positive blood
cultures.
4) Diarrhea: Resolved by admission
5) Anemia: normal MCV. Stable H/H. No obvious bleeding. Normal
iron, normal ferritin. H/H increased to normal by discharge
6) Bipolar: continued home olanzapine, Effexor.
7) Heroin abuse: seen by SW; Pt interested in suboxone
initiation and was provided with information for local suboxone
clinics. ___ house contacted but no beds available.
8) Transaminitis: suspect ___ hep C; never treated. Stable in
house.
TRANSITIONAL ISSUES
#Pt will pursue ___ clinic; provided with info
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OLANZapine 5 mg PO QHS
2. Gabapentin 800 mg PO TID
3. Venlafaxine XR 37.5 mg PO DAILY
Discharge Medications:
1. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
2. OLANZapine 5 mg PO QHS
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
3. Venlafaxine XR 37.5 mg PO DAILY
RX *venlafaxine 37.5 mg 1 capsule(s) by mouth daily Disp #*14
Capsule Refills:*0
4. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
5. Cyclobenzaprine 5 mg PO BID:PRN back muscle spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
7. HYDROmorphone (Dilaudid) 4 mg PO Q8H: PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
8. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % apply to blisters daily Refills:*0
9. Senna 17.2 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 2 tabs by mouth twice a day Disp #*30
Tablet Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar strain
Pedal blisters d/t friction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted with a strain of your back and
blisters on your feet. You were seen by our orthopedic spine
surgeons who felt that you did not need any surgery but you
should wear the cervical soft collar and you will follow up with
them as an outpatient. You were given medications to help with
your pain, but you should limit these as you transition to home.
You were also seen by our dermatologists. You did not have any
fevers and you were not found to have a systemic infection. We
are giving you a short course of an oral antibiotic to make sure
your blisters on your feet heal.
We have provided you with a special dressing called Duoderm that
you should apply to your blisters and change daily until they
are healed.
Our social worker discussed with you referrals to a ___
clinic and we hope that you will follow through with this.
We have set you up with a new primary care doctor here at ___
since you did not have one.
Followup Instructions:
___
|
10542901-DS-4 | 10,542,901 | 21,994,716 | DS | 4 | 2135-08-09 00:00:00 | 2135-08-09 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / erythromycin base
Attending: ___.
Chief Complaint:
Facial swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
depression, IV drug use, hepatitis C, Raynaud's who presents
with
cheek pain.
She presents from ___ on a ___ with left cheek
pain.
She developed a toothache on ___ and was started on oral
penicillin, but her cheek began swelling and her pained
worsened.
She continued to tolerate food and was afebrile. She has not had
recent skin infections. She denies a prior history of dental
issues. She has not had neck pain or stiffness. She denies
fevers, chills, nausea, vomiting, dyspnea, chest pain, headache,
vision changes. She denies recent IVDU.
EMERGENCY DEPARTMENT COURSE
Initial vital signs were notable for:
- T98.3, HR 65, BP 106/60, RR 18, ___ 98% RA
Exam notable for:
- No trismus, tolerating secretion
- Poor dentition, no active purulence
- No tenderness to palpation of gum or teeth
- Tenderness to palpation of left cheek
Labs were notable for:
- Normal CBC, lactate, Chem7
- Negative UCG
Patient was given:
- Cloazepam 1mg PO
- IV dlinamycin 600mg
- Gabapentin 800mg
- Ibuprofen 600mg
- Bupropion 150mg
- Lorazepam 2mg IM
- Haloperidol 5mg IM
- Diphenhydramine 25mg IV
- Gabapentin 800mg
- Buprenorphine-Naloxone 2mg-0.5mg 2 tab
- IV Clindamycin 600mg
Consults: OMFS
Upon arrival to the floor:
- She reports improvement, but not resolution of her pain
Past Medical History:
IVDA crack/cocaine abuse
Raynaud's
Bipolar disorder
PTSD
Anxiety
ADHD
Social History:
___
Family History:
Mother had stroke at age ___, grandmother had MI at age ___,
grandfather stroke at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 97.4, HR 50, BP 98/52, RR 16, RR 99% RA
GENERAL: Tired appearing, lying in bed, answering questions
appropriately
HEENT: Pupils equal and reactive, no scleral icterus. Moist
mucous membranes. Poor dentition. Pain to palpation of L upper
cheek. Poor dentition with no evidence of drainage, purulence or
erythema on L upper molars. No submandibular, cervical or
supraclavicular lymphadenopathy noted.
CARDIAC: S1/S2 regular, borderline bradycardia, no murmurs
LUNGS: Clear bilaterally
ABDOMEN: Soft, non-tender
EXTREMITIES: Warm, no lower extremity edema
NEUROLOGIC: A+Ox3, moving all four extremities appropriately
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 144)
Temp: 97.4 (Tm 97.4), BP: 106/67, HR: 73, RR: 18, O2 sat:
96%, O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM, poor dentitation. Pain to
palpation over left maxillary sinus area. Swelling of left
cheek.
PERRL
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended,
NEURO: Alert and conversant. Thought process clear and goal
directed.
DERM: Warm and well perfused,
Pertinent Results:
ADMISSION LABS
==============
___ 12:04PM BLOOD WBC-8.4 RBC-4.04 Hgb-12.5 Hct-40.1
MCV-99* MCH-30.9 MCHC-31.2* RDW-13.0 RDWSD-47.3* Plt ___
___ 12:04PM BLOOD Neuts-65.7 ___ Monos-8.4 Eos-3.0
Baso-0.6 Im ___ AbsNeut-5.54 AbsLymp-1.84 AbsMono-0.71
AbsEos-0.25 AbsBaso-0.05
___ 12:04PM BLOOD Glucose-76 UreaN-14 Creat-0.7 Na-137
K-6.6* Cl-100 HCO3-22 AnGap-15
___ 06:29AM BLOOD HCV VL-PND
___ 12:04PM BLOOD Lactate-1.1 K-4.5
IMAGING
=======
CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST
1. Periapical abscess involving the second maxillary bicuspid,
___ #13, with erosion through the buccal surface of the
maxillary alveolus and associated overlying soft tissue abscess
measuring 0.9 x 0.6 cm (series 3, image 6).
2. There is mild adjacent stranding within the subcutaneous
adjacent to the masseter, however no evidence of deep space
infection within the neck is appreciated.
3. Multiple additional maxillary tooth dental caries.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of
depression, IV drug use, hepatitis C, Raynaud's who presents
with cheek pain and was found to have dental abscesses with
buccal erosion.
============
ACUTE ISSUES
============
#Dental Abscess
Presents with several days of cheek pain and found to have
dental abscesses with erosion through the buccal surface without
evidence of deep space infection on CT imaging. There was no
evidence of systemic infection. She was started on empiric
unasyn. She was then evaluated by the ___ team who recommended
transition to augmentin for a total of 10 day course. They
recommend that she have tooth #13 removed within the next ___
days, for which she will need to be seen as an outpatient. If
she were to not have her tooth removed, there is high risk for
the infection to return. Blood cultures were pending without
growth to date at the time of discharge.
#Depression
On ___ from ___ being treated for depression and
SI. She has since been discharged from this facility and has a
bed offer from Women'___ at ___. We continued her on
bupropion Hcl SR 150mg BID and she will be discharged to ___
___.
#Opiate Use Disorder
Last opiate use about ___ years ago. Last crack cocaine use about
2 weeks ago. No other recent drug use. She was continued on
Buprenorphine-Naloxone 8mg-2mg 2tabs qAM and
Buprenorphine-Naloxone 2mg-0.5mg 2tabs at 5pm. She was
prescribed a two week supply on discharge.
#Hepatitis C
Unclear if this has been treated or not. LFTS without evidence
of hepatitis. HCV VL pending on discharge.
==============
CHRONIC ISSUES
==============
#Axniety
- Clonazepam 1mg BID PRN anxiety
- Hydorxyzine 50mg q8hrs PRN agitation
#Pain
- Gabapentin 800mg TID
- Ibuprofen 800mg TID PRN pain
#Insomnia
- Benadryl 50mg QHS PRN insomnia
#Dyspepsia
- Alum-Mag Hydroxide-Simethicone q4hs PRN
===================
TRANSITIONAL ISSUES
===================
[] Needs to have tooth #13 removed to prevent recurrence of his
infection within the next ___ days (prior to completion of her
antibiotic course). Please ensure she calls ___ for the
Oral & Maxillofacial Surgery at ___ for same
day appointments. The earlier in the morning that she calls
starting at 7am the more likely she is to get an appointment.
[] Needs routine dental care given evidence for multiple caries.
She can call ___ Dental at ___ for an appointment.
[] Continued treatment for depression and substance abuse.
[] History of hepatitis C infection, unknown whether previously
treated. A viral load was pending at the time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Tablet (8mg-2mg) 2 TAB SL DAILY
2. Buprenorphine-Naloxone Tablet (2mg-0.5mg) 2 TAB SL QPM
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. Gabapentin 800 mg PO TID
7. HydrOXYzine 50 mg PO Q8H:PRN agitation
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
dypsepsia
10. benzocaine 20 % topical Q2H:PRN tooth pain
11. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia
12. magnesium hydroxide 400 mg (170 mg) oral QHS:PRN
constipation
13. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tab-cap by mouth twice a day Disp #*18 Tablet Refills:*0
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
dypsepsia
RX *alum-mag hydroxide-simeth [Advanced Antacid-Antigas] 200
mg-200 mg-20 mg/5 mL 30 ml by mouth q4hr Disp #*1 Bottle
Refills:*0
3. benzocaine 20 % topical Q2H:PRN tooth pain
for topical oral pain.
RX *benzocaine [Oral Analgesic] 20 % Apply to tooth q2hr Disp
#*1 Tube Refills:*0
4. Buprenorphine-Naloxone Tablet (2mg-0.5mg) 2 TAB SL QPM
5. Buprenorphine-Naloxone Tablet (8mg-2mg) 2 TAB SL DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
RX *bupropion HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % 15mL mouth rinse twice a day
Refills:*0
8. ClonazePAM 1 mg PO BID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
9. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia
RX *diphenhydramine HCl 50 mg 1 capsule(s) by mouth at bedtime
Disp #*14 Capsule Refills:*0
10. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
11. HydrOXYzine 50 mg PO Q8H:PRN agitation
RX *hydroxyzine HCl 50 mg 1 tablet(s) by mouth q8hr Disp #*42
Tablet Refills:*0
12. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
13. magnesium hydroxide 400 mg (170 mg) oral QHS:PRN
constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 5 ml by
mouth at bedtime Refills:*0
14. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
RX *sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___
spray nasal q2hr Disp #*1 Spray Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Final Diagnosis:
Dental Abscess
Opioid Use Disorder
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 being involved in your care while you were
admitted at ___.
Why were you admitted to the hospital?
-You were having left sided mouth and cheek pain due to an
infection called an abscess.
What happened while you were at the hospital?
-We performed imaging tests to evaluate the infection.
-We had our oral surgeons evaluate you and provide
recommendations.
-We started you on antibiotics to treat your infection.
What should you do when you leave the hospital?
-You will need to continue taking antibiotics (augmentin) for
the next ___ days for your tooth infection.
-You need to have your tooth #13 removed. If the tooth does not
get removed, the infection will return. You can call
___ for the Oral & Maxillofacial Surgery at ___
___ for same day appointments. The earlier in the
morning that you call starting at 7am the more likely you are to
get an appointment.
-It is very important for you to have your tooth removed in the
next ___ days. If you do not have the tooth removed the
infection can worsen and become serious requiring major surgery
or potentially even be life threatening.
-You should make an appointment to see a dentist for oral care.
You can call ___ Dental at ___ for an appointment.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10543435-DS-21 | 10,543,435 | 20,406,355 | DS | 21 | 2113-06-14 00:00:00 | 2113-06-20 08:23:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left sided chest and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with afib on Coumadin fell 3 weeks prior to presentation.
She fell down the stairs while holding a laundry basket. She
sought care at an OSH today after her daughter visited and
noticed she was uncomfortable. She was found to have a
supratherapeutic INR in the 10'___ and received kaycentra and
vitamin K for reversal of INR. She was transferred to ___ for
further management.
Imaging showed L sided rib fractures ___ with associated small
hemothorax. She also had a large L psoas muscle hematoma with
layering of contrast.
Past Medical History:
afib on Coumadin, hypothyroidism
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Examination: upon admission: ___
VITAL SIGNS:
HR: 130 (a-fib ; not rate controlled) BP: 135/76 RR: 20 O2
sat:95%RA
General Appearance: NAD, resting comfortably
Chest: CTA Bilaterally, no wheezes or rales
Cardiovascular: reg rate, nl S1/S2,
Abdomen: soft, NT/ND, NABS, no HSM ; eccymotiss along lef tflank
extending to buttock region
Extremities: no lower extremity edema
Neurological: A&O x3
Pulses: Palpable bilateral femoral pulses. Palpable bilateral
brachial/radial pulses
Discharge Physical Exam:
VS: 98.4, 108/94, 95, 18, 94%ra
Gen: A&O x3, sitting up comfortably in chair, NAD
Pulm: LS ctab
CV: HRR
Abd: soft, NT/ND. L flank ecchymosis
Ext: no edema
Pertinent Results:
___ 08:00AM BLOOD WBC-6.8 RBC-2.90* Hgb-9.6* Hct-29.5*
MCV-102* MCH-33.1* MCHC-32.5 RDW-15.9* RDWSD-55.8* Plt ___
___ 02:16AM BLOOD WBC-7.9 RBC-2.99* Hgb-9.7* Hct-29.7*
MCV-99* MCH-32.4* MCHC-32.7 RDW-15.9* RDWSD-53.7* Plt ___
___ 10:59PM BLOOD Hct-28.7*
___ 09:45AM BLOOD ___
___ 08:00AM BLOOD Plt ___
___ 02:16AM BLOOD Plt ___
___ 02:16AM BLOOD ___
___ 03:43PM BLOOD ___ PTT-33.0 ___
___ 03:43PM BLOOD ___
___ 08:00AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-137
K-3.9 Cl-104 HCO3-21* AnGap-16
___ 02:16AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-135
K-3.8 Cl-104 HCO3-18* AnGap-17
___ 08:00AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.0
___ 03:54PM BLOOD Glucose-113* Lactate-1.9 Na-139 K-3.5
Cl-107 calHCO3-21
___ 03:54PM BLOOD freeCa-1.00*
___: CXR:
Previous mild edema has almost cleared from the right lung.
Severe
cardiomegaly persists. Moderate left pleural effusion is
larger. Left lower lobe is airless, presumably collapse.
Moderate to large left pleural effusion is roughly stable in
volume although distributed somewhat differently. Upper
mediastinum is stable. Right lung grossly clear. Extent of
chest cage trauma, for example fracture of the lateral left
second rib, is that better detailed on the recent torso CT.
CT (Abd/Pelvis) - ___
Large left retroperitoneal hemmorhage with fluid-fluid level and
evidence of punctate hyperdensities which may represent active
extravasation.
CT Head: No acute traumatic injury
Brief Hospital Course:
Ms. ___ was transferred from an OSH for further
management of her left sided rib fractures with hemothorax and L
sided psoas muscle hematoma after a fall she sustained 3 weeks
ago. She was given ___ and vitamin K to reverse her INR
in the setting of the hematoma. She was admitted to the ICU for
close hemodynamic and urine output monitoring. She had received
2UPRBC on transfer and initial CBC did not increase as expected.
Serial CBCs were drawn and her HCT was stable at 29 on multiple
rechecks. Interventional radiology evaluated her and considered
her for angio/embolization of the left psoas hematoma. She
continued to be stable and did not require additional
transfusion or intervention so the procedure was deferred.
On hospital day 2, she was given a regular diet, and restarted
on her home PO meds, other than warfarin. INR was 1.7 and again
HCT was stable at 29. She worked with ___ who recommended
discharge home after ___ additional ___ visits. She was
transferred to the floor in stable condition on the evening of
hospital day 2.
On hospital day 3, her hematocrit stabilized at 29.5. Her
hemodynamic status was stable. She did not resume her Coumadin
during this hospitalization and her INR drifted down to 1.2.
She was evaluated by physical therapy and cleared for discharge
home. A follow-up appointment was made with her cardiologist to
discuss resuming her Coumadin. Aspirin was started.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ and ___
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Levothyroxine Sodium 50 mcg PO/NG DAILY
Diltiazem Extended-Release 180 mg PO DAILY
Metoprolol Tartrate 50 mg PO/NG BID
Warfarin 5mg QD
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO HS
6. TraMADol 25 mg PO Q6H:PRN pain
7. Diltiazem Extended-Release 180 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Tartrate 100 mg PO BID
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left retro-peritoneal hematoma
left hemothorax
left ___ rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital after you sustained a fall in
which you sustained left sided rib fractures, a bleed in your
chest, and a collection of blood in your left flank. You had
been on a blood thinner, Coumadin, at the time of the accident
and your bleeding studies were elevated. You required blood
products to correct the abnormality. Your blood work has
stabililzed and there has been no further evidence of bleeding.
You are being discharged with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
10543435-DS-22 | 10,543,435 | 24,840,393 | DS | 22 | 2114-10-26 00:00:00 | 2114-10-27 18:28:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ hypertension and atrial fibrillation on Coumadin who
presented to ED w/ today for shoulder pain and epistaxis status
post mechanical fall onto her face with C2 pedicle and TP
fractures as well as multiple facial fractures. She reports she
fell while at the bank around 1 pm and over the next couple of
hours noted facial bruising and persistent nosebleed. She
reported to OSH where imaging showed multiple facial fractures
as well as C2 fracture. She was transferred to ___ for further
care.
Past Medical History:
-Afib
-HTN
-Iron deficiency anemia
-Type 2 DM
-Hypothyroidism
-Vitamin D deficiency
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission
T 97.8 °F (36.6 °C)
HR 60
RR 20
BP 106/76
SatO2 94% Non-Rebreather
GEN: supine with C collar, NAD
HEENT: Edematous face with multiple ecchymoses bilaterally,
EOMI, PERRL 3->2 bl, yellow discharge along left eyelid,
evidence of recent epistaxis, poor dentition
CV: irregular rhythm, no M/R/G
PULM: CTA anteriorly and at posterior apices bl, no W/R/R, no
respiratory distress on nasal cannula
ABD: soft, NT, ND, large and nontender ventral hernia
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
NEURO: A&O, CNII-X and XII intact, deferred CNXI due to C
collar, no sensorimotor asymmetry or deficit
DERM: ecchymoses on face per above
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
DRE: Melena, normal tone
Discharge:
97.5
PO 93 / 61
R Sitting 99 18 96 Ra
Pertinent Results:
___ 08:40PM BLOOD WBC-8.7 RBC-2.91* Hgb-9.4* Hct-30.1*
MCV-103* MCH-32.3* MCHC-31.2* RDW-12.2 RDWSD-46.3 Plt ___
___ 09:15AM BLOOD WBC-6.6 RBC-2.41* Hgb-8.0* Hct-24.6*
MCV-102* MCH-33.2* MCHC-32.5 RDW-12.4 RDWSD-46.3 Plt ___
___ 12:51AM BLOOD WBC-6.6 RBC-2.45* Hgb-8.2* Hct-25.3*
MCV-103* MCH-33.5* MCHC-32.4 RDW-12.6 RDWSD-47.2* Plt Ct-98*
___ 12:51AM BLOOD Glucose-96 UreaN-34* Creat-0.9 Na-142
K-4.2 Cl-109* HCO3-21* AnGap-12
___ 08:40PM BLOOD UreaN-47* Creat-1.1
INR 2.6 to 1.3
Brief Hospital Course:
Ms. ___ is an ___ year old female with a history of
atrial fibrillation on coumadin who was transferred to ___
___ on ___ for trauma surgery evaluation after
a mechanical fall. The patient arrived to the ED with the
following known injuries based on OSH imaging:
- Multiple facial bone fractures including the maxillary sinus,
bilaterally ; the hard palate; and the nasal bone.
- Fracture the body of C2 with no evidence of vascular injury.
CT Head and CT Torso were negative for traumatic injury. Given
epistaxis and melena on exam as well as reported on presentation
to the OSH, Kcentra was administered in the ED for reversal of
coagulopathy ___ warfarin with INR from 2.7 to 1.3.
She was admitted to ICU for monitoring. Hematocrit had an
initial drop from 30 to 25 but remained stable over the next ___
hours. The spine service recommended non-operative management, C
collar for 3 months and follow-up as an outpatient. Plastics
surgery recommended follow up as an outpatient for possible
delayed operative and sinus precautions, including a no chew
diet for ___ weeks.
In the ICU, the patient had an increasing oxygen requirement up
to 70% (Venturi mask). CXR showed pulmonary edema likely from
fluid resuscitation in the setting of trauma. She received
furosemide with good response. Her oxygen requirement was weaned
and she ready for transfer to the surgery floor for further
optimization.
The patient's home coumadin was resumed on ___. However, she
was noted to have melanic, guiaic positive stools the next day.
Gastroenterology was consulted for possible upper endoscopy to
evaluate for source of bleeding. They felt that her melanic
stools were most likely residual from blood swallowed in the
setting of her facial fractures rather than due to an upper GI
bleed. Given that her hematocrit had remained stable and that
she remained in a C collar whih would require extra precautions
in performing upper endoscopy, gastroenterology recommended
deferring an upper endoscopy procedure until patient's C collar
was removed (as an outpatient) as long as she had no further
episodes of bleeding. As such, the patient's coumadin was
resumed on ___. She was observed as an inpatient for signs of
further bleeding as her INR approached therapeutic range, of
which there were none.
On ___, the patient was tolerated a soft (no chew) diet,
voiding spontaneously without issue, ambulating independently,
and her pain was well controlled on oral pain medications alone.
She was deemed ready for discharge to home with services. The
patient was instructed to continue to follow with her PCP for
medication management including coumadin dosing and to monitor
for any additional signs of bleeding. Her PCP should also help
to arrange for the patient to have an upper endoscopy procedure
electively once her C collar is cleared by spine surgery to
evaluate for an upper GI bleed. The patient demonstrated
understanding of her discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 180 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*2
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C2 fracture
Fracture of maxillary sinus, bilaterally
Fracture of the para-sagittal hard palate
Fracture of the nasal bone
Secondary diagnosis:
Gastric intestinal bleed
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 after a fall. You were found
to have facial fractures and a C2 cervical spine fracture. You
were seen by the Neurosurgery team and they recommended
non-operative management of the cervical fracture. You should
remain in a hard collar for 3 months and outpatient follow-up in
the ___ Spine clinic. The Plastic Surgery team was consulted
for your facial fractures. They recommend:
-Conservative management
-Recommend sinus precautions x 1 week - elevate head on several
pillows, no smoking, no nose blowing, open mouth sneezing, no
drinking through straws.
-Can apply cold compresses intermittently
-Recommend no-chew diet for ___ weeks. Nutrition may be
consulted
during admission to discuss diet modification/nutritional
supplementation
-At discharge, please follow up in ___ chief
resident clinic (Dr. ___ to discuss possible fracture
repair. Phone number: ___
Broken neck (C2 fracture): You will need to use your C collar
for 3 months and follow-up with Spine Surgery to make sure you
are healing appropriately.
Multiple face fractures: You will need to see your Plastic
Surgeon in clinic to discuss whether you will need surgery at a
later time. Follow this recommendations: soft (non-chew) diet
for 6 weeks.
You were noted to have bloody stool therefore the
Gastroenterology service was consulted. They deferred doing an
endoscopy due to your facial and neck fractures. However they
suggested starting Protonix, a medication that protects your
stomach from ulcers which can bleed. Your Coumadin has been
restarted and your INR is 1.9 at the time of discharge. Please
continue to monitor your INR and dose Coumadin appropriately.
Return to the ED if you have any more GI bleeding.
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.
General guidelines
Wear the cervical collar at all times. Don't stop wearing the
collar until your doctor tells you to.
Keep two collars on hand in case one becomes damaged or you
need to remove one for cleaning.
Check the skin under your brace daily for redness, tenderness,
or drainage.
Use chairs with arms. The arms make it easier for you to stand
up or sit down; this puts less strain on your neck.
Remove things that may cause you to fall, such as throw rugs
and electrical cords.
Use nonslip bath mats, grab bars, and a shower chair in your
bathroom.
Arrange your household to keep the items you need handy. Keep
everything else out of the way.
Keep your hands free by using ___ pack, apron, or pockets
to carry things.
Activity
Don't bend, twist, or reach until your doctor says it's okay.
Don't lift anything heavier than 4 pounds until your doctor
says it's okay.
Don't move your head up or down or side to side.
Nap if you are tired, but don't stay in bed all day.
Don't drive until your doctor says it's okay or while you are
taking opioid pain medication.
Followup Instructions:
___
|
10543486-DS-18 | 10,543,486 | 23,227,808 | DS | 18 | 2181-06-03 00:00:00 | 2181-06-04 21:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
Placement of nasogastric tube ___
History of Present Illness:
___ with anorexia nervosa, borderline personality disorder,
attention deficit disorder, depression, who is presenting with
failure to thrive ___ lb weight loss) in the setting of a
recent emotional stressor, namely that her best friend's husband
died from a cocaine overdose ~ 2 weeks ago. She is only eating
yogurts, peanut butter and fruit. She denies suicidal ideation
at this time but was admitted under ___ for initiation of
nutrition in a monitored inpatient setting. She says the last
time she was hospitalized was in ___ at ___.
In the ED initially VS were T: 98.2 HR: BP: 88 96/63 16 98%
EKG was notable for SR 78 NA/NI, diffuse T wave flattening. Labs
were notable for potassium 2.4. She was given potassium 60 mEq
PO and admitted to medicine for further management.
She denies any chest pain, shortness breath, nausea, vomiting or
abdominal pain.
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Anorexia Nervosa, restricting, denies binging, purging or
laxative abuse
- Hx of a heart murmur
- Attention deficit disorder
- Borderline personality disorder
- Hx of multiple suicide attempts with drug overdose
- Hx of cutting her wrists
PAST PSYCH HISTORY:
Hospitalizations: Anorexia Nervosa, restricting type since age
___ and first hospitalized at age ___ @ ___, ___
___, ___, ___
___ Residential ___ with her last admission to
___ ___
Self-injury:
- age ___ first overdose on trazodone and "other pills"
- second OD age ___ overdosed on Tylenol ___ x1
- age ___ last SA by OD on Tylenol ___, denies that she was
medically admitted "they pumped my stomach and charcoaled me"
- Reports that she has overdosed "5 times"
- Reports that she has hx of cutting arms with razors and has
had to be sutured in the past and last cut as recently as 2
weeks ago, hx of burning herself with matches and lighters, the
last ___ years ago
Harm to others: denies
Access to weapons: denies
Social History:
Patient grew up up in ___, parents divorced when she was
___ and she lived with her mother who now lives in ___
and ___ father lives in ___. She is in regular contact with
both parents and reports hx of sexual abuse but preferred not to
disclose by whom. She graduated from high school and is a
part-time student @ ___ and is
studying nursing. She currently lives with 2 roommates in
___ and is on SSDI. Her grandparents live in ___ but
are in their ___ and not able to provide or be a source of
support for her.
SUBSTANCE ABUSE HISTORY:
Alcohol: since age ___, drinks a "a couple of times a week, wine
with my friends." ___ to intoxication, denies blackouts or
w/d sz
Illicits: "weed" and "coke," last used cocaine ___ years ago
Tob: 1ppd
Caffeine: Coffee,"4 ___ {20 oz coffee} a day and ___ energy
drinks
Family History:
- Parents alcoholic, unclear whether they are still drinking
- Paternal aunt with anorexia
- Family history depression, anxiety.
Physical Exam:
Admission Physical Exam:
================================
Vitals: T: 95/61 87 16 100% RA
Height: 62 in. ___
Weight: 33.7 kgs. (74.29 lbs) ___
BMI: 13.6
IBW:50 kg
%IBW:67 %
General: Cachectic, Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Linear scars on arms bilaterally and left abdomen at
previous cutting sites. Warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact, motor strength grossly intact.
MS: makes poor eyecont, but speaks in fluent sentences without
flight of ideas or tangential thoughts. Feels depressed and
anxious. Poor insight.
Discharge Physical Exam:
==================================
VS: 98.5 112/63 98 (supine), 100/70 127 (standing) 16 99% RA
Tmax 99.0 SBP 100-112 at rest, HR 91-120 at rest
Weight: 46.7kg IBW: 50 kg
GENERAL: NAD, resting in bed
HEENT: NC/AT, NG tube in place
LUNGS: Clear to auscultation b/l
CV: Tachy, reg rhythm, no m/g/r
ABDOMEN: +BS, soft/ND/NT, no guarding
EXTREMITIES: WWP, no edema. Calves nontender to palpation.
NEURO: Sits up in bed without difficulty
PSYCH: Mood: "anxious." Affect: euthymic. Rate/rhythm of
speech WNL. Content of thought: does not want to be discharged
to inpatient program today.
Pertinent Results:
Admission labs:
======================
___ 04:30PM BLOOD WBC-4.6 RBC-4.27 Hgb-13.4 Hct-37.6 MCV-88
MCH-31.4 MCHC-35.7* RDW-13.0 Plt ___
___ 04:30PM BLOOD Neuts-56.3 ___ Monos-6.9 Eos-1.0
Baso-1.9
___:45AM BLOOD ___ PTT-31.8 ___
___ 04:30PM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-139
K-2.4* Cl-85* HCO3-46* AnGap-10
___ 04:30PM BLOOD Albumin-5.0 Calcium-10.1 Phos-1.9* Mg-2.6
Discharge labs:
======================
___ 12:55PM BLOOD WBC-5.3 RBC-2.95* Hgb-9.2* Hct-28.4*
MCV-96 MCH-31.2 MCHC-32.4 RDW-13.4 Plt ___
___ 12:55PM BLOOD Plt ___
___ 12:55PM BLOOD Glucose-75 UreaN-25* Creat-0.5 Na-141
K-4.7 Cl-106 HCO3-27 AnGap-13
___ 12:55PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3
Heme Labs:
======================
___ 09:35AM BLOOD calTIBC-285 Ferritn-35 TRF-219
Endo Labs:
======================
___ 09:35AM BLOOD TSH-1.1
___ 06:00AM BLOOD Cortsol-16.7
GI Labs:
======================
___ 04:30PM BLOOD ALT-14 AST-28 AlkPhos-63 TotBili-0.2
___ 04:30PM BLOOD Lipase-51
___ 07:05AM BLOOD ALT-36 AST-26 AlkPhos-40 TotBili-0.1
Psych:
======================
___ 09:35AM BLOOD Carbamz-5.2
Urine:
======================
___ 08:00PM URINE Color-Straw Appear-Clear Sp ___
___ 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 08:00PM URINE Hours-RANDOM
___ 08:00PM URINE UCG-NEGATIVE
Micro:
======================
Urine Cx: Negative
EKG:
======================
___: Sinus rhythm. Non-specific inferolateral ST-T wave
flattening. No previous
tracing available for comparison.
___: Sinus rhythm. Within normal limits. Compared to the
previous tracing
of ___ sinus tachycardia has resolved. Other minor
abnormalities have
also resolved.
Rate PR QRS QT/QTc P QRS T
94 162 72 356/415 65 50 45
Imaging:
======================
CXR (___)
No previous images. The heart is normal in size, and lungs are
clear without vascular congestion, pleural effusion, or acute
focal pneumonia.
Right hand x-ray (AP/lateral/oblique) ___
There is no evidence of acute fracture or dislocation or other
bone
or joint space abnormality.
Abdominal x-ray ___
One supine images of the abdomen shows air-filled loops of large
bowel. There
are no dilated small-bowel loops to suggest obstruction. There
is fecal
loading of the sigmoid colon. There is no pneumatosis or
secondary evidence
of free air. The visualized osseous structures are
unremarkable.
IMPRESSION:
Stool within the sigmoid colon. No small or large bowel dilation
to suggest
obstruction or ileus.
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%). The estimated cardiac
index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler
imaging suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No structural heart disease or pathologic flow identified.
CXR ___
In comparison with study of ___, there is little change in
the
appearance of the heart and lungs. There has been placement of
an enteric
tube that extends well into the stomach.
CXR ___
As compared to the previous radiograph, the course of the
nasogastric tube is unchanged. The tip of the tube is not
visible as it is
not included in the film. Unchanged appearance of the lung and
of the heart.
CXR ___
As compared to the previous radiograph, the nasogastric tube was
pulled back. Tip of the tube now projects over the middle parts
of the
stomach. No evidence of complications, notably no pneumothorax.
Otherwise,
the image is unchanged.
Brief Hospital Course:
___ F h/o anorexia nervosa (restricting type), mood disorder,
borderline personality disorder, attention deficit disorder p/w
failure to thrive in setting of psychosocial stressor and
increased restricting behavior.
ACTIVE DIAGNOSES
#) Anorexia Nervosa/Failure to thrive: Patient had increased
restricting behavior in setting of recent social stresser with
loss of friend to cocaine overdose. She was admitted under
___. Weight on admission was 32.7kg. There was
suspicion for purging behavior though pt has had restricting
type AN in the past. She demonstrated good PO intake but
continued to have weight loss despite increase in calories,
possibly due to purging (as suggested by persistently uptrending
bicarbonate level). Due to increasing bicarb, dip in weight,
and concern for noncompliant behavior (she was found drinking
water from bathroom faucet), an NG tube was placed ___ and she
was started on tube feedings, with 4500 kcal/day in tube feeds,
plus additional calories via TID snacks. NG tube came out the
first night due to vomiting/coughing, and it was replaced. The
next day it came out a few centimeters due to patient picking at
the tape on her nose, but it remained in good position on x-ray.
There were no further issues with NG tube placement thereafter,
and a bridle was successfully avoided. Calorie count was
decreased ___ to 4400 kcal/day including tube feeds plus PO
snacks, but there was a plateau in weight gain so she was
returned to her initial tube feeding regimen on ___.
Weight immediately began to improve when tube feeds were
initiated, from 36.2kg just prior to NG tube placement to 46.7kg
by the time of discharge (93.4% of ideal body weight, which is
50kg). Also, bicarbonate level returned to normal on ___,
decreasing from 36 to 29 and remaining within normal limits
thereafter. Feeding regimen consisted of three cans Two-Cal HN
TID and TID snacks with ~300 kcal each. Pt was required to
finish snacks within allotted time, otherwise she was to receive
additional half can of tube feed. She was allowed to have one
juice instead of water between meals.
Ms. ___ received lorazepam around meal times, which was
approved by Psychiatry as a short-term option while hospitalized
but is not to continue after discharge. She often had nausea and
received ondansetron on a PRN basis. QTc was monitored weekly
and remained within normal limits. Electrolytes were monitored
to assess for signs of refeeding syndrome, which did not become
a problem. A daily multivitamin with minerals was added to her
medication regimen. She was medically stable throughout much of
hospitalization and at the time of discharge.
Interdisclipinary meeting with pt's outpatient providers and
inpatient care team occurred and pt was presented the
opportunity to be transferred to inpatient eating disorder
treatment at ___. Since pt declined, team concluded that it
was necessary to pursue legal guardianship to determine proper
placement. Guardianship was granted on ___, and plans were
made for patient to be discharged to ___ from hospital.
#) Orthostatic hypotension: Orthostatic hypotension is likely
secondary to decreased body weight, and it may improve as
patient gains weight. Transthoracic echo was checked ___ to
make sure that there was no structural cardiac cause for
orthostasis, and it was within normal limits. She was treated
with IV fluid boluses as necessary for symptomatic or severe
orthostasis; last bolus was ___. Orthostasis may improve
as she continues to gain weight, although many young, small
women have persistent orthostatic hypotension without underlying
pathology.
#) Mood disorder: Pt has h/o bipolar d/o, anxiety, depression,
and self cutting behavior. In conjunction with Psychiatry, her
psychotropic medication regimen was managed. Quetiapine 400mg
PO q HS was continued. Due to risk of agranulocytosis and lack
of clear benefit in Ms. ___ case, carbamazepine dose was
decreased and then stopped ___. In efforts to avoid
medications that could contribute to orthostasis, mirtazapine
was discontinued ___. She consistently denied SI/HI during
this hospitalization. She did not display aggressive behavior
toward others but was noted to have punched walls on a few
occasions; hand x-ray was checked ___ due to swelling and was
negative for fracture.
#) Attention deficit disorder: Pt was on methylphenidate at
home, which was stopped on ___. Methylphenidate can suppress
appetite and should be avoided.
#) Anemia: Hemoglobin was low but stable with a range of 9.1 to
9.4 from ___ through discharge. Iron was slightly above
the upper limit of normal at 170, and transferrin, ferritin and
TIBC were WNL.
CHRONIC DIAGNOSES
#) History of heart murmur: Transthoracic echo was checked to
assess for structural heart abnormality as cause of orthostatic
hypotension, and it revealed no valvular dysfunction.
TRANSITIONAL ISSUES
#) Please communicate with patient's outpatient psychiatry and
eating disorder team to ensure continuity of care after she is
discharged from inpatient program.
___ ___ (therapist)
___ ___ (NP, psychopharmacologist)
___ (nutritionist) - who can be contacted through PCP's
office
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 400 mg PO QHS
2. Mirtazapine 45 mg PO HS
3. Concerta (methylphenidate) 36 mg Oral QD
4. Carbamazepine 400 mg PO BID
Discharge Medications:
1. QUEtiapine Fumarate 400 mg PO QHS
2. Docusate Sodium 100 mg PO BID
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Senna 1 TAB PO BID:PRN constipation
5. Citalopram 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Anorexia nervosa
Secondary: Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care at ___
___. As you know, you came to the hospital
due to an exacerbation of disordered eating. You were started
on a regimented diet as well as tube feedings. Your weight
improved closer toward a healthy level. The outcome of your
guardianship hearing determined that you will go to an inpatient
treatment program after discharge for further recovery.
Your blood pressure and heart rate were monitored daily, and
continued to be abnormal with standing. This condition
("orthostatic hypotension") may improve as your weight improves,
although many young women have orthostatic hypotension
regularly.
We wish you the very best in the recovery process.
Best regards,
Your ___ team
Followup Instructions:
___
|
10543835-DS-14 | 10,543,835 | 22,948,575 | DS | 14 | 2195-08-07 00:00:00 | 2195-08-08 07:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking woman w/Afib, CVA, HTN presents after a
fall early this am. The patient denies feeling CP, palp or LH
prior to fall. States that the floor was slippery. Her daughter
believes she tripped on a blanket while getting out of bed. She
was unable to lift pt from the floor and called EMS. Complains
of right shoulder pain and left knee pain.
In ED pt had XR of shoulder, knee, and chest and CT of Cspine,
and head all without acute abnormality. She was found to have a
lactate of 4.9 which improved to 2.6 after 2L NS. She also had
mild leukocytosis. She was admitted due to concern for
infection.
On arrival to floor pt has no pain. Daughter reports that pt
does not like to drink fluids because she has to get up to
urinate and so daughter has to force her to drink. No n/v/d,
fever or sick symptoms.
ROS: +per HPI, 10 systems reviewed and otherwise negative
Past Medical History:
Afib, on Coumadin
CVA in ___ w/residual R sided weakness and visual deficit
Hypertension
hyperlipidemia
low back pain
hypothyroidism
peripheral vascular disease
thrombocytosis(530 to 660)
GERD
MGUS
glucose intolerance (a1c is 6.5%)
history of ___ cyst
Social History:
___
Family History:
Mother died in ___. Unsure about medical history of other
family members.
Physical Exam:
Admit Exam
VS: 97.6 195/67 71 18 100%ra
PAIN: 0
GEN: nad
HEENT: edentalous
CHEST: clear
CV: irreg irreg
ABD: nabs, soft, nt/nd
EXT: +1 pitting edema (stable)
NEURO: alert, follows commands
Discharge Exam
VS: AVSS, BP 170/70
Pain: ___
Gen: NAD, pleasant, ambulating well with walker
HEENT: MMM
CV: irreg, irreg
Lungs: CTAB/L
Abd: soft, NT, ND, NABS
Ext: trace edema
Neuro: AAOx3, fluent speech
Skin: left knee and right neck ecchymoses
Pertinent Results:
Admit Labs:
.
___ 10:20AM WBC-13.0*# RBC-3.38* HGB-10.2* HCT-29.7*
MCV-88 MCH-30.1 MCHC-34.2
RDW-14.4
___ 10:20AM NEUTS-89.8* LYMPHS-5.0* MONOS-4.5 EOS-0.4
BASOS-0.3
___ 10:20AM PLT COUNT-760*
___ 10:20AM ___ PTT-37.7* ___
___ 10:20AM GLUCOSE-149* UREA N-44* CREAT-2.1* SODIUM-142
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-20
___ 10:23AM LACTATE-4.9*
___ 02:50PM LACTATE-2.6*
___ 10:55AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 10:55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
.
Discharge Labs:
.
___ 06:00AM BLOOD WBC-8.1 RBC-3.10* Hgb-9.4* Hct-26.9*
MCV-87 MCH-30.5 MCHC-35.1* RDW-14.8 Plt ___
___ 06:00AM BLOOD Glucose-119* UreaN-33* Creat-1.7* Na-142
K-4.5 Cl-110* HCO3-22 AnGap-15
___ 06:00AM BLOOD ___ PTT-43.5* ___
___ 10:55AM URINE Color-Straw Appear-Hazy Sp ___
___ 10:55AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 10:55AM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-1
.
.
Microbiology:
Blood cultures x 2 sets (___) - pending, no growth to date
.
.
IMAGING
.
CT Head (___)
IMPRESSION: Expected evolution of left parietal and occipital
infarct. No acute intracranial findings.
.
CT C-spine (___)
IMPRESSION: No acute fracture or subluxation. Moderate
multilevel degenerative changes.
.
X-Ray Right shoulder (___)
IMPRESSION: No acute fracture or dislocation.
.
X-Ray Left Knee (___)
IMPRESSION:
No fracture.
.
CXR PA/LAT (___)
IMPRESSION: Mild pulmonary edema with no evidence of pneumonia.
.
Brief Hospital Course:
ASSESSEMENT & PLAN: ___ yo w/Afib, CVA, HTN presents after a fall
early this am.
.
# Mechanical Fall: pt not using walker, slipped on bedsheets
- Pt appeared to be at baseline per daughter, able to ambulate
well with walker in hospital.
- She did not have any evidence of trauma or acute injury and
was otherwise asymptomatic.
- Risk of head bleed while on Coumadin with fall risk was d/w
daughter. Given that this is pt's first major fall, will
continue Coumadin for now and continue further discussion in
outpt setting with PCP.
.
# HTN: poorly controlled, daughter reports that BP elevated at
recent renal visit
- home meds (lisinopril and Lopressor) were continued
- BP remained elevated, with systolics up to the 190's, despite
home meds. However, her diastolic was actually in good range,
in the ______ - ___. She was asymptomatic. Her HR was in the
50-60___, so did not increase her BB. She had mild ___ on this
admit, so did not increase her ACEi. Hydralazine was trialed
with good effect, BP 170/70. We recommend hydralazine in
addition to her home regimen until she is seen in f/u to
determine her volume status and whether her Cr is stable, if so
would consisder stopping hydralazine and increasing ACEi or
adding diuretic (HCTZ was suggested by Renal at most recent
visit).
# Elevated Lactate / leukocytosis / ___: likley due to
dehydration
- with IVF, her lactate downtrended, her Cr returned to baseline
and her leukocytosis resovled.
- she did not have any fever or localizing symptoms
- UA was unremarkable, CXR was w/o infiltrate and blood cultures
are pending
.
Chronic:
# Prior CVA: residual cognitive, motor and visual deficits.
Remains on Coumadin. INR therapeutic.
# Hypothyroidism: continued synthroid
# Pre-DM: not on medication. Continue to monitor as outpt.
.
Transitional Issues:
1. f/u with PCP for BP check, will need to consider changing
hydralazine to longer acting med, such as increasing ACEi or
adding diuretic like HCTZ to her BP regimen if BP still high.
Will need Cr check.
2. INR check as previous (twice weekly INR checks, followed by
PCP ___
3. PENDING STUDIES AT TIME OF DISCHARGE:
### blood culture x 2 sets (___): no growth, final pending
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Simvastatin 40 mg PO DAILY
4. Warfarin 2.5 mg PO 4X/WEEK (___)
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Warfarin 3.75 mg PO 3X/WEEK (___)
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Simvastatin 40 mg PO DAILY
5. Warfarin 2.5 mg PO 4X/WEEK (___)
6. Warfarin 3.75 mg PO 3X/WEEK (___)
7. HydrALAzine 25 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical Fall
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:
You came to the hospital after a mechanical fall at home.
Imaging in the ER with X-ray and CT scan did not show any acute
injury or damage. Your initial bloodwork was concerning for
possible infection, so you were admitted for close monitoring
and work-up. Your bloodwork improved with IVF. There was no
evidence of infection. Your blood pressure was noted to be
high, so a new medication has been added to your regimen.
.
The risks/benefits of blood thinning with Coumadin in the
setting of older age and fall was discussed. You should
continue to discuss this with your PCP to determine if you
should continue on Coumadin. For now, you should continue your
prior Coumadin regimen and continue to have your Coumadin
checked as previous (twice a week).
.
Please follow-up with your physicians as listed below.
.
Please take your medicatiosn as listed below.
.
Followup Instructions:
___
|
10543835-DS-17 | 10,543,835 | 24,240,543 | DS | 17 | 2198-08-27 00:00:00 | 2198-08-27 17:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / allopurinol
Attending: ___.
Chief Complaint:
Right foot/ankle pain
Major Surgical or Invasive Procedure:
2 units PRBCs
History of Present Illness:
History of Present Illness: Ms. ___ is a ___ with a-fib (off
anticoagulation) and presumed myelodysplastic syndrome (q2month
PRBC transfusions), presenting with right foot pain and redness
since ___. Patient lives with her daughter, who
reports that the patient developed right foot and ankle pain on
___ and was barely able to walk (baseline used walker for
ambulation). Saw PCP ___ ___, who obtained xray of ankle and
prescribed supportive therapy: ACE wrap, ice, elevation.
Subsequently, Ms. ___ remained in bed most of the weekend, and
on ___ fell off the couch without head strike. EMTs
were called to put patient back in chair. At that time the
patient reportedly put her feet on the floor and experienced
___ pain in her right foot. Over the weekend the patient
remained in bed unable to ambulate due to foot pain. Ms. ___
daughter called into her PCP's office today (___) and reported
these events, and the PCP advised daughter to go into ED for
evaluation.
Notably, the patient has a past medical history of gout in the
right MTP joints and was on allopurinol for some time. She has a
questionable history of cellulitis about ___ years ago; the
daughter reports that the patient had a red, painful patch of
skin on her right leg but does not recall if she was treated
with antibiotics. Denies any recent fever or chills at home.
Does report one episode of non-bloody vomitus on ___ night
and baseline diarrhea due to the Colace and senna she takes
daily to avoid constipation.
In the ED, initial vital signs were: 98.5 63 156/71 18 97% RA
- Exam notable for: Right foot erythema and tenderness, distal
pulses intact
- Labs were notable for baseline CKD Cr 1.6, anemia with hct
20.0
- Studies performed include FOOT AP,LAT & OBL RIGHT
- Patient was given Acetaminophen 650 mg, Vancomycin 1000 mg
- Vitals on transfer: 98 65 149/70 18 99% RA
Upon arrival to the floor, the patient accompanied by daughter,
who provided most of the history, although the patient could
answer simple questions when spoken loudly. Patient kept
repeating "I can't walk" and raised her right leg. Otherwise
denies any specific symptoms aside from her right foot pain.
Past Medical History:
-DM
-Hypertension,
-Hyperlipidemia,
-AFib
- chronic dCHF: TTE (___): EF 55-60%, E decel time 38-46. E
decel time 289, sev LAE, 2+ MR, ___ TR
-CVA ___ - right face/arm/leg weakness
. left carotid thrombus assoc with HIT
. s/p emergent Left carotid endarterectomy and atherectomy
(___)
HIT (Heparin-induced Thrombocytopenia)
PAD (___)
. s/p right common iliac and external iliac stenting (___)
. s/p right ___ toe amupation ___ infection
-hypothyroidism
-h/o back pain
-left rotator cuff tendinitis
-leg edema with venous insufficiency,
-anemia
-GERD
-MGUS
-h/o of ___ cyst
-gout
Social History:
___
Family History:
No family history of premature CAD, sudden
cardiac death or cardiomyopathy; most of family executed at
young ages in the ___ and medical history unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- 98.2PO 154/56 63 18 100 RA
GENERAL: AOx2 (knows she's at ___, does not know year but
knows season is ___), NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, dentures in place.
Oropharynx is clear. Patient has crusting of dried blood on left
lateral aspect of nose.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses Radial 2+ bilaterally. Patient has
3x9cm area of slight erythema and swelling on lateral aspect of
right foot that is tender to palpation. Lateral aspect of right
leg very slightly erythematous but not swollen or tender to
palpation. Right fourth toe amputated.
SKIN: Skin on back diffusely covered with seborrheic keratosis.
One 3x5cm area of skin breakdown on right upper back, no acute
bleeding or purulence.
NEUROLOGIC: CN2-12 grossly intact. ___ strength in upper
extremities bilaterally, ___ in lower extremities but limited by
patient cooperation. Gait deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tmax 100.0 BP 150-190s/50-90s HR 60-70s RR ___ on RA
GENERAL: AOx2 (knows she's at ___, does not know year), NAD
HEENT: Patient has crusting of dried blood on left lateral
aspect of nose.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: CTAB, no wheezes, rales, rhonchi.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. Patient has
unchanged 3x9cm area of slight erythema (marked) and swelling on
lateral aspect of right foot that is tender to palpation,
slightly less tender than previous days. Plantar surface tender
but slightly less so than on ___. Difficult to assess strength
due to pain with passive/active ROM in all directions at ankle
joint. Right fourth toe amputated. Pulses not palpable, DP
dopplerable but not TP; Foot warm and appears well-perfused. As
of ___, left thumb DIP slightly red, swollen, and TTP.
SKIN: Skin on back diffusely covered with seborrheic keratosis.
One 3x5cm area of skin breakdown on right upper back, no acute
bleeding or purulence.
NEUROLOGIC: CN2-12 grossly intact. Difficult to assess strength
due to patient cooperation but patient moving all extremies
evenly and well, but seemingly weak throughout. Gait deferred
due to foot pain.
Pertinent Results:
ADMISSION LABS
==============
___ 03:15PM BLOOD WBC-5.1# RBC-2.20* Hgb-6.5* Hct-20.0*
MCV-91 MCH-29.5 MCHC-32.5 RDW-16.5* RDWSD-54.2* Plt ___
___ 03:15PM BLOOD Neuts-69 Bands-4 ___ Monos-5 Eos-0
Baso-0 ___ Metas-2* Myelos-0 NRBC-2* AbsNeut-3.72
AbsLymp-1.02* AbsMono-0.26 AbsEos-0.00* AbsBaso-0.00*
___ 03:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 03:15PM BLOOD Plt Smr-LOW Plt ___
___ 03:15PM BLOOD Glucose-116* UreaN-43* Creat-1.6* Na-145
K-3.8 Cl-105 HCO3-26 AnGap-18
___ 08:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.8
___ 03:19PM BLOOD Lactate-0.9
MICROBIOLOGY
==============
___ SCREENMRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}INPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
IMAGING
==============
___ FOOT AP,LAT & OBL RIGHT
IMPRESSION:
No significant interval change since recent exam. Postoperative
changes at
the fourth toe. Well corticated erosive changes at the distal
aspect of the
proximal phalanx of the right great toe, potentially due to
gout.
___ ABIs
FINDINGS:
On the right side, monophasic Doppler waveforms were seen on the
femoral,
popliteal, and dorsalis pedis arteries. Absent waveform is seen
in the
posterior tibial artery. The right ABI was 0.17 at rest. Pulse
volume
recordings showed diminished amplitudes in the thigh and calf is
severely
diminished amplitudes in the ankle and metatarsals.
On the left side, monophasic Doppler waveforms were seen on the
femoral,
superficial femoral, popliteal, posterior tibial and dorsalis
pedis arteries.
The left ABI and was 0.39 at rest. Pulse volume recordings
showed diminished
amplitudes in the thigh, calf, ankle and metatarsals.
IMPRESSION:
Aorto bi-iliac arterial insufficiency with additional
significant bilateral
SFA and tibial arterial insufficiency.
___ R FOOT MRI W/ CONTRAST
IMPRESSION:
1. Enhancement, and bony erosions centered at the of fourth and
fifth tarsal
metatarsal joint with a paucity of adjacent marrow and soft
tissue edema
suggests gout, in particular given findings of gout elsewhere in
the foot,
with infection felt to be less likely although not excluded.
For further
evaluation, a dual energy CT to evaluate for uric acid crystals
can be
obtained.
2. A 0.9 cm rounded lesion within the base of the fifth
metatarsal with
peripheral rim enhancement which may represents an intraosseous
ganglion
rather than an abscess. Similarly there is a small loculated
soft tissue
fluid pocket adjacent to the fifth TMT joint, which is
nonspecific and could
reflect a ganglion, given the lack of surrounding soft tissue
edema.
3. Extensive tophus gouty changes at the first
metatarsophalangeal joint.
Gout likely also involves the great toe interphalangeal joint
with marked
abnormality at the proximal phalanx head, neck and distal shaft.
4. Tiny area of signal abnormality and enhancement along the
dorsal second
metatarsal base at the TMT joint could also reflect a small area
of
inflammatory erosion.
4. Tenosynovitis within the master knot of ___.
RECOMMENDATION: Dual energy CT of the foot without IV contrast
may be
obtained to further evaluate the presence of uric acid crystals
at the fifth
tarsal metatarsal joint.
DISCHARGE LABS
==============
___ 06:52AM BLOOD WBC-7.2 RBC-2.70* Hgb-8.0* Hct-24.7*
MCV-92 MCH-29.6 MCHC-32.4 RDW-15.7* RDWSD-52.3* Plt ___
___ 06:52AM BLOOD Glucose-116* UreaN-60* Creat-2.0* Na-142
K-4.2 Cl-101 HCO3-23 AnGap-22*
___ 06:52AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.3
___ 06:52AM BLOOD CRP-174.5*
Brief Hospital Course:
Ms. ___ is a ___ female with a-fib (off
anticoagulation) and presumed myelodysplastic syndrome (q2month
palliative PRBC transfusions) who presented with right foot pain
and redness x4 days, presumed cellulitis and possible ankle
sprain. Was afebrile and no elevated white count, started on
clindamycin 300 mg PO/NG Q6H on ___. Also received 2 units
PRBCs on ___ for chronic anemia. Patient still with very
painful foot preventing ambulating, so MRI foot obtained showing
what appeared to be severe gouty changes. Also ordered ABIs
showing severely reduced ABI on right and absent posterior
tibial waveform on right. Course of action was to start steroid
pulse and allopurinol. Patient seen by physical therapy who
recommended discharge to ___ rehab. Patient discharged in
stable condition.
ACTIVE ISSUES
=============
# Right foot and ankle pain; cellulitis: Patient presenting with
erythematous area on right lateral foot,tender to palpation,
preventing her from ambulating at her baseline. Diagnosis
initially presumed to be cellulitis with possible ankle sprain,
XR negative for fracture. Clindamycin 300 mg PO QD started ___,
provided supportive elevation, ice, Tylenol; no clinical
response to treatment initially (either erythema or pain),
considered alternative diagnoses, ordered foot MR. ___ showing
what appeared to be severe gouty changes, ABIs showing severely
reduced ABI on right and absent posterior tibial waveform on
right. Course of action was to start steroid pulse and
allopurinol. Clindamycin 300 mg PO QD continued for planned ___nding ___.
# Gout: Extensive gouty findings seen on ___ foot MR,
rheumatology consulted and found history, physical, and imaging
highly suspicious for gout, uric acid 9.4. Starting allopurinol
50mg QD on ___. Starting short steroid course, 20mg
prednisone on ___, 15mg QD next 3 days, 10mg QD next 3 days,
5mg QD next 3 days then stop. Patient will make appointment to
follow up with ___ clinic within the month. Patient
still pain but slightly improved on discharged, not bearing
weight on right foot.
# Chronic anemia: Per previous hematology notes likely has an
underlying myelodysplastic syndrome given immature cells and
nucleated RBCs on previous peripheral smears, receives
intermittent palliative PRBC transfusions for hct < 20, next
visit was scheduled for ___. Transfused 2u PRBCs ___ with
appropriate response. Discharged with hct 24.7, appointment with
heme/onc on ___.
# Paroxysmal atrial fibrillation: Patient was formerly
anti-coagulated but warfarin was discontinued due to
fall/bleeding risk and overall goals of care. Inpatient
continued to hold any anticoagulation. Continued home
carvedilol.
# Dementia: patient with moderate dementia, able to answer
questions and oriented to person and place but not time,
perseverates on certain phrases and topics; patient enrolled in
adult daycare program four days a week at ___. No
changes inpatient.
# Hypertension: Continued amlodipine 10 mg PO QD and hydralazine
5 mg PO/NG BID. Patient hypertensive up to 170s and once to 190s
systolic while inpatient, hydralazine increased to 10 mg PO/NG
BID on ___ and continued at that dose on discharge.
CHRONIC ISSUES
==============
# Chronic Diastolic Heart Failure: Continued furosemide 40 mg PO
QAM and carvedilol 6.25 mg PO BID.
# Hyperlipidemia: Continued atorvastatin 20 mg PO QD.
# Hypothyroidism: Continued levothyroxine 25 mcg.
TRANSITIONAL ISSUES
===================
[] Patient with slightly elevated Cr 2.0 on discharge from
baseline around 1.6, perhaps secondary to decreased PO intake;
please encourage PO intake and recheck electrolytes on ___,
if still elevated may require IV fluids or further renal workup
[] Follow-up appointment with oncology on ___
[] Patient will need appointment with rheumatology to follow up
gout and medication changes; should call ___ and
schedule an appointment within one month to follow up
[] Continue taking Clindamycin 300 mg PO/NG Q6H (end date
___ started in the hospital
[] Continue steroid pulse (15mg for ___, 10mg for
___, 5mg ___, then stop)
[] Continue Allopurinol 50 mg PO/NG DAILY started in the
hospital
[] Hydralazine dose increased due to elevated blood pressure,
increased from HydrALAZINE 5 mg PO/NG BID to HydrALAZINE 10 mg
PO/NG BID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 6.25 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO QHS
4. amLODIPine 10 mg PO DAILY
5. HydrALAZINE 5 mg PO BID
6. Atorvastatin 20 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H Foot Pain
2. Allopurinol 50 mg PO DAILY
3. Clindamycin 300 mg PO Q6H Duration: 3 Days
4. PredniSONE 15 mg PO DAILY Duration: 3 Doses
15mg for ___, 10mg for ___, 5mg ___, then stop
5. HydrALAZINE 10 mg PO BID
6. amLODIPine 10 mg PO DAILY
7. Atorvastatin 20 mg PO DAILY
8. Carvedilol 6.25 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Furosemide 40 mg PO DAILY
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Senna 8.6 mg PO QHS
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
-Cellulitis, right foot
Secondary diagnosis
-Acute gout flare
-Paroxysmal atrial fibrillation
-Dementia
-Chronic anemia
-Chronic diastolic congestive heart failure
-Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having pain
in your right foot and trouble walking.
We started you on antibiotics for your foot to treat a possible
skin infection, but felt there may be something else going on
causing the severe foot pain. We took a MRI of your foot to see
if there were any other problem, and found what looked like
inflammation from gout. We also performed a test of your
arteries and found you had poor blood supply to your right foot.
We continued the antibiotics for your foot and also started some
medications for your gout: allopurinol, and a "pulse" of
steroids that should reduce the pain and inflammation in her
foot.
You received two units of blood for your chronic anemia.
We increased one of your blood pressure medications,
hydralazine, because you were having some very high blood
pressure in the hospital.
We felt it was safe for you to be discharged to a rehabilitation
facility for a while to regain your strength and help with
walking.
You will need to make a rheumatology appointment in the next
month to follow up on medications for gout. Please call
___ to schedule an appointment. Please take all
medications as directed as follow up with all medical
appointments.
It was a privilege to help care for you.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
10543994-DS-21 | 10,543,994 | 22,498,151 | DS | 21 | 2188-01-23 00:00:00 | 2188-01-23 14:24:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pancreatic mass, jaundice
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stenting
History of Present Illness:
___ y.o male with h.o DM who was transferred from OSH for
evaluation of pancreatic head mass. Pt reports dark urine, light
stools, and jaundice over the last couple of weeks. He denies
any pain including with eating. He denies fever, chills, nausea,
vomiting, diarrhea, melena, brbpr, dysuria or decreased PO
intake. He states he otherwise feels well. Per report, pt had
recent angiography this week without CAD but did reveal aortic
stenosis. He denies headache, dizziness, ST, URI, cough, CP,
palpitations, SOB, paresthesias.
.
Currently, pt feels well and denies any pain. He does report
that his memory is not that good. He is unable to recall his
medications or his pharmacy.
.
10 pt ROS reviewed and otherwise negative.
Past Medical History:
DM2
aortic stenosis
?hypothyroidism, ?BPH ?dementia
Social History:
___
Family History:
sister with heart problems
Physical Exam:
Admission Exam:
GEN: well appearing, NAD
vitals: T 98.5, Bp 139/64, HR 55 RR 18 sat 97% on RA
HEENT: ncat EOMI +icteric, MMM
neck: supple
chest: b/l ae no w/c/r
heart: s1s2 rr ___ holosystolic murmur loudest in aortic area
abd: +bs, soft, ND, NT, no guarding or rebound
ext: no c/c/e 2+pulses
neuro: face symmetric, speech fluent, moves all extremities
psych: calm, cooperative
skin: +jaundice
.
Discharge Exam:
AVSS
NAD, no longer jaundice, less icteric
___ SEM
Abd soft NT
Pertinent Results:
___ 10:24PM LACTATE-1.0
___ 10:10PM GLUCOSE-201* UREA N-24* CREAT-1.3* SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
___ 10:10PM ALT(SGPT)-453* AST(SGOT)-379* LD(LDH)-313*
ALK PHOS-690* TOT BILI-6.8*
___ 10:10PM LIPASE-93*
___ 10:10PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-2.2
___ 10:10PM URINE HOURS-RANDOM
___ 10:10PM URINE HOURS-RANDOM
___ 10:10PM URINE UHOLD-HOLD
___ 10:10PM URINE GR HOLD-HOLD
___ 10:10PM WBC-6.2 RBC-4.51* HGB-14.1 HCT-45.6 MCV-101*
MCH-31.3 MCHC-30.9* RDW-14.6
___ 10:10PM NEUTS-73.9* LYMPHS-15.0* MONOS-6.9 EOS-3.3
BASOS-0.9
___ 10:10PM PLT COUNT-149*
___ 10:10PM ___ PTT-33.8 ___
___ 10:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.5
LEUK-NEG
.
OSH
"4CM pancreatic head mass with adenopathy" on u/s and CT
CXR:
There are subpleural reticular opacities as seen on prior CT
compatible with early interstitial lung disease. The heart size
appears mildly enlarged. The mediastinal contour is normal. No
pleural effusion or pneumothorax. Bony structures are intact.
IMPRESSION:
Subpleural reticular opacities better assessed on the recent CT
of the chest likely representing early interstitial lung
disease. Mild cardiomegaly
EXAMINATION: CTA PANCREAS W/ CTCP
INDICATION: ___ year old man with obstructive jaundice and new
pancreatic head
mass, s/p ERCP with stenting. Please eval new pancreatic head
mass for
resectability/staging parameters.
TECHNIQUE: Following low-dose, noncontrast MDCT images of the
abdomen, 200 cc
Omnipaque intravenous contrast was administered in scans were
obtained in the
late arterial, portal venous, and equilibrium phases. Coronal
and sagittal
reformations were performed.
DOSE: DLP: 1014 mGy-cm
COMPARISON: Outside hospital CT abdomen and pelvis as well as
outside
hospital ultrasound from ___.
FINDINGS:
CHEST: Limited views of the lung bases demonstrate bibasilar
parenchymal
scarring with no nodules or opacities. The heart is moderately
enlarged there
is no pleural or pericardial effusion. Aortic valve
calcifications are chunky.
ABDOMEN: The liver contains scattered hypodensities in the
right lobe, too
small to characterize. In segment 5, there is a 3 x 2.4 cm
hypodensity which
is only apparent on the portal venous phase, and may represent a
metastatic
lesion. There is central pneumobilia, appropriate due to recent
common bile
duct stenting. There is no intrahepatic biliary dilatation. The
gallbladder
contains contrast from recent ERCP, and a radiopaque stone in
the body of the
gallbladder.
The pancreatic duct is dilated in the body and neck, up to 8 mm,
and tapers as
it approaches the pancreatic head. Within the head, there is an
ill-defined
2.4 x 2.0 cm (8:48) (axial), 2.9 x 2.5 cm (10:36) (coronal)
periampullary
hypodensity, which is concerning for malignancy. The mass
appears to be
confined to the pancreatic head without extending to the
adjacent vessels,
small bowel, or mesentery. No other lesions are identified
within the
pancreatic body or tail.
The spleen is normal in size and attenuation. The adrenal glands
are normal in
size and morphology bilaterally. The kidneys are mildly
atrophic, but enhance
symmetrically display prompt contrast excretion. The left kidney
contains a
5.2 x 2.8 cm hypodensity at the lower pole, measuring fluid
density, likely a
simple cyst. Other smaller hypodensity is seen in the left
kidney, likely
simple cysts. There is no evidence of hydronephrosis or stones.
The distal
esophagus, stomach, and visualized small bowel are normal in
caliber. The
partially visualized large bowel is unremarkable. There are no
pathologically
enlarged mesenteric or retroperitoneal lymph nodes. No
intra-abdominal free
air or free fluid.
VESSELS: The abdominal aorta demonstrates mild atherosclerotic
calcification
without aneurysmal dilatation. There is a focus of calcification
at the origin
of the celiac axis, with mild poststenotic dilatation. Celiac
axis
demonstrates conventional anatomy.
BONES: No blastic or lytic lesions suspicious for metastatic
disease.
IMPRESSION:
1. Ill-defined hypodense periampullary mass with resultant
pancreatic duct
dilatation, appears to be confined to the pancreas with no
evidence of
vascular or local invasion.
2. 3 x 2.4 cm hypodensity in segment 5 of the liver may
represent a
metastatic lesion. Biopsy or MRI can be performed for further
workup.
PANCREATIC CANCER STAGING Morphologic Evaluation
Appearance (in the pancreatic parenchymal phase):
hypoattenuating
Size (maximal axial dimension in cm): 2.4 Cm
Location (head right of SMV, body left of SMV): head/uncinate
Pancreatic duct narrowing/abrupt cutoff with or without upstream
dilatation:
present
Biliary tree abrupt cutoff with or without upstream dilatation:
absent
Arterial evaluation
SMA involvement: absent
Solid soft-tissue contact: ?180°
Increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: absent
Extension to first SMA branch: Absent
Celiac Axis involvement: absent
Solid soft-tissue contact: ?180°
Increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: Absent
Common hepatic artery involvement: absent
Solid soft-tissue contact: ?180°
Increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: absent
Extension to celiac axis: absent
Extension to bifurcation of right/left hepatic artery: Absent
Variant anatomy: none
Variant vessel contact: absent
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: Absent
Venous evaluation
MPV involvement: absent
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity (tethering or
tear drop):
absent
SMV involvement: absent
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity (tethering or
tear drop):
absent
Extension to first draining vein: absent
Thrombus within vein: absent; type of thrombus: None
Venous collaterals: absent
Extrapancreatic evaluation
Liver lesions: suspicious
Peritoneal or omental nodules: absent
Ascites: absent
Suspicious lymph nodes: absent
Other extrapancreatic disease (invasion of adjacent structures):
absent
The study and the report were reviewed by the staff radiologist.
CA ___ PENDING
Brief Hospital Course:
___ with Aortic Stenosis, admitted from OSH with nausea
abdominal pain, found to have a pancreatic mass causing
obstruction, underwent stenting, with CT scan suggestive of
pancreatic mass as well as a liver mass.
.
# Bile obstruction with likely pancreatic cancer: No signs of
cholangitis. OSH reports noted ~4 cm mass in head of pancreas.
Images reviewed with radiology, but staging was not entirely
adequate with the OSH CT. He underwent ERCP on ___ with
sphincterotomy, stenting, and biopsy. CTA pancreas protocol
also ordered to help with staging. CA ___ sent and pending at
discharge. Oncology follow up arranged to discuss findings and
determine treatment plan
.
# Aortic stenosis: Stable. Has bibasilar crackles but possibly
more related to his chronic lung disease noted on previous
imaging. His cardiologist was updated as to his
hospitalization, and IVF were given with caution post ERCP.
.
# DM2 controlled: HISS utilized in house with controlled FSBG
.
# HTN, benign: Stable
# BPH: stable continued home medications
# Dementia: Very mild, continued Aricept
# Hypothyroidism: Levoxyl continued
.
# Code-full, confirmed, but would not want anything prolonged
___ wife ___ ___
.
TRANSITIONAL ISSUES:
- The pt will need ERCP follow-up regarding his stent
- Pt to see Oncology in early ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Donepezil 5 mg PO HS
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral bid
3. Tamsulosin 0.4 mg PO HS
4. 70/30 44 Units Breakfast
70/30 44 Units Dinner
5. Artificial Tears ___ DROP BOTH EYES PRN dry
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin ___ mcg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
10. FoLIC Acid 1 mg PO DAILY
11. glimepiride 4 mg oral bid
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Temazepam 15 mg PO HS:PRN insomnia
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry
2. Donepezil 5 mg PO HS
3. Finasteride 5 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. 70/30 44 Units Breakfast
70/30 44 Units Dinner
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral bid
9. Cyanocobalamin ___ mcg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. glimepiride 4 mg oral bid
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Temazepam 15 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Bile obstruction
Pancreatic mass
Aortic stenosis
Hypertension
Type 2 diabetes mellitus
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of bile obstruction and
jaundice. As we discussed this is likely related to a mass in
your pancreas, likely cancerous. You underwent an ERCP with
biopsy and stenting. Please do not take Aspirin or other blood
thinners for the next 5 days. Please follow up closely with
your PCP and with the oncology doctors as ___.
Followup Instructions:
___
|
10544221-DS-18 | 10,544,221 | 23,809,568 | DS | 18 | 2125-06-16 00:00:00 | 2125-06-17 00:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w recently diagnosed unresectable cholangiocarcinoma on
ertapenem for ecoli bacteremia p/w fever of 104.
Mr. ___ was recently discharged on Ertapenem for E.coli
bacteremia sensitive to only imipenem. He notes that he has been
feeling well for the last few days since his discharge. He notes
improved appetite, normal bowel movements and no abdominal pain.
Today earlier the IV nurse noticed that he had a fever of 104
therefore he was instructed to go the ER for evaluation. In ER
he
had RUQ ultrasound which showed no acute change. He had no fever
in the ER and his WBC was within normal range.
Past Medical History:
DMII, Hepatitis B, Cholangitis,
Obstructing liver Mass: Poorly-differentiated carcinoma
Past Surgical History:
___ Diagnostic laparoscopy with liver biopsy, and placement
of fiducials for radiation.
Social History:
___
Family History:
No hx of liver disease, cancer or heart disease per pt.
Physical Exam:
Vitals:98.3 96 109/70 18 97%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, nontender, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:24PM LACTATE-2.0
___ 08:15PM GLUCOSE-192* UREA N-7 CREAT-0.9 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-15
___ 08:15PM ALT(SGPT)-42* AST(SGOT)-65* ALK PHOS-304* TOT
BILI-1.4
___ 08:15PM ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-2.3*
MAGNESIUM-1.7
___ 08:15PM LIPASE-73*
___ 08:15PM URINE HOURS-RANDOM
___ 08:15PM URINE GR HOLD-HOLD
___ 08:15PM URINE UHOLD-HOLD
Brief Hospital Course:
___ w recently diagnosed unresectable cholangiocarcinoma on
ertapenam for multidrug resistant ecoli bacteremia p/w fever of
104 while at home. He was admitted to the Transplant Surgery
service ___. He was afebrile during the admission. Fever
work up including blood and urine cultures and CXR were
non-revealing. We opted to defer repeat CT scan given he had a
scan recently, He tolerated regular diet and bowel movements
without abdominal symptoms. Infectious disease was consulted. He
was discharged ___ home with ___ continuing ertapenem.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Acetaminophen 500 mg PO Q6H:PRN pain/headache
6. Dronabinol 5 mg PO BID
7. Ertapenem Sodium 1 g IV DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Simethicone 40-80 mg PO QID:PRN gas pain
11. Enoxaparin Sodium 70 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain/headache
Maximum 4 of the 500 mg tablets daily ___ mg)
2. Docusate Sodium 100 mg PO BID
3. Dronabinol 5 mg PO BID
4. Enoxaparin Sodium 70 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
Expel 0.1 ml from 80 mg syringe for total dose of 70 mg for
injection twice a day
5. Ertapenem Sodium 1 g IV DAILY
4 weeks of IV ertapenem
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
No driving if taking this medication
7. Lorazepam 0.5 mg PO Q6H:PRN anxiety
8. MetFORMIN (Glucophage) 1000 mg PO BID
Check blood sugars at home
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. Simethicone 40-80 mg PO QID:PRN gas pain
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fever of unknown origin, resolved
Unresectable cholangiocarcinoma
MDR E coli plan 4 total weeks of ertapenem
Known portal vein thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ office at ___ for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, pain not controlled by your pain medication,
swelling of the abdomen or ankles, yellowing of the skin or
eyes, inability to tolerate food, fluids or medications, you
note having nosebleed, rectal bleeding, dark tarry stool or easy
bruising or any other concerning symptoms.
Continue the IV ertapenem using the PICC per pre hospitaliztion
dosing and duration.
PICC line care per outpatient care protocol for flushes and
dressing changes.
Continue bowel regimen, eat small frequent meals, take dietary
supplements like Ensure or carnation instant breakfast and stay
hydrated
Weigh daily and call Dr ___ if you lose more than 3
pounds in a day or 5 pounds in a week. If you continue to lose
weight the Lovenox (Enoxaparin) dosing will require adjustment
Followup Instructions:
___
|
10544620-DS-10 | 10,544,620 | 27,336,318 | DS | 10 | 2174-09-08 00:00:00 | 2174-09-08 19:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
lethargy, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female hx. HIV on ART (last CD4 unknown), CVA c/b
seizure disorder, left hemiparesis s/p G tube for nutrition,
CKD, left ureteral obstruction s/p left nephrostomy tube ___
and ESWL with stent removal ___, recent admission for HCAP
presenting from ___ with lethargy.
Per nursing ___ records, today patient was noted lethargic and
difficult to arouse without respiratory distress. Records note
decreased PO intake recently. Of note, several new medications
appear on patient's med list from nursing ___, including
diazepam:PRN anxiety as well as furosemide 20mg daily, which was
restarted on discharge.
Of note, patient was recently hospitalized from ___ for
fever 2d post ESWL and ureteral stent removal. She was treated
for HCAP with vanc/cefepime x8d course (last day ___.
Hospitalization also notable for patient's nephrostomy tube
falling out with replacement by ___. Nephrostomy tube was capped
on discharge with plans for urology f/u.
In the ED initial vitals were: 97.9 74 105/64 18 98%.
- Labs were significant for H/H of ___ (b/l), LFTs with alkP
158, chem panel with Bun/Cr ___ (b/l 1.5), trop 0.02, lactate
1.0.
u/a showed large leuks/WBCs with many bacteria and epis.
- Patient was given vanc/ceftriaxone.
On the floor, patient currently has no complaints, is oriented
x2, occasionally speaking ___-creole intermixed with ___.
Past Medical History:
- HIV dx ___ s/p blood transfusion, most recently under good
control
- Tropical spastic paraperesis (HTLV-1) with mild
non-progressive ___ weakness/spacticity
- ___ pulmonary TB
- CVA (thought to be secondary to past MI with thrombus and
embolus) with left-sided hemiparesis (___)
- Seizure dx in ___
- multiple hospitalizations for malnutrition (G-tube, ARF,
depression requiring ECT)
- bilateral acute on chronic subdural hematomas with bilateral
uncal herniation (___)
- Chronic pain
- Hyperlipidemia
- EColi Bacteremia
Social History:
___
Family History:
Mother deceased CAD. Father with prostate cancer. Brother died
of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: T: 97.5 BP: 117/53 P: 85 R: 20 O2: 99% RA
General: awake, alert, repeating phrases
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, G tube in
place with no surrounding erythema/fluctuance, left sided
nephrostomy tube draining bloody fluid
GU: no skin breakdown around groin, foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; some venous stasis changes on anterior shin bilaterally
Neuro: left hemiparesis, possible right hemineglect
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T: 98.7 (98.5-98.9) BP: 125/78 (113-125/60-78) P:87
(75-87) R: 20 (___) O2: 100%RA ___
General: Awake, interactive, speaking in full sentences
HEENT: Sclera anicteric, mucus membranes moist, both eyes open
Neck: Supple, LAD, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur at
lower left sternal border
Lungs: Clear to auscultation anteriorly, no wheezes or crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present.
G-tube in place with gauze in place that is clean, dry and
intact.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: Oriented to location, month, year. Cannot say days of
week forwards. Increased tone in left arm and leg, no movement.
Moves right upper and lower limbs spontaneously.
Pertinent Results:
ADMISSION LABS:
================
___ 06:05PM BLOOD WBC-10.2 RBC-3.13* Hgb-8.4* Hct-28.5*
MCV-91 MCH-26.7* MCHC-29.3* RDW-17.2* Plt ___
___ 06:05PM BLOOD Neuts-63.5 ___ Monos-4.5 Eos-2.3
Baso-0.6
___ 06:05PM BLOOD Glucose-108* UreaN-25* Creat-2.6*# Na-138
K-4.2 Cl-104 HCO3-22 AnGap-16
___ 06:05PM BLOOD ALT-14 AST-22 AlkPhos-159* TotBili-0.2
___ 06:05PM BLOOD Lipase-77*
___ 06:05PM BLOOD CK-MB-2
___ 06:05PM BLOOD cTropnT-0.02*
___ 06:05PM BLOOD Albumin-3.0*
___ 06:12PM BLOOD Lactate-1.0
___ 06:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
OTHER LABS:
==========
___ 07:40AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.6
___ 07:40AM BLOOD CK-MB-2 cTropnT-0.01
___ 06:05AM BLOOD Glucose-108* UreaN-16 Creat-2.2* Na-148*
K-4.5 Cl-114* HCO3-23 AnGap-16
Test Result Reference
Range/Units
% CD3 (MATURE T CELLS) 70 ___ %
ABSOLUTE CD3+ CELLS ___
cells/uL
% CD4 (HELPER CELLS) 26 L ___ %
ABSOLUTE CD4+ CELLS ___
cells/uL
% CD8 (SUPPRESSOR T CELLS) 43 H ___ %
ABSOLUTE CD8+ CELLS ___
cells/uL
HELPER/SUPPRESSOR RATIO 0.61 L 0.86-5.00
ABSOLUTE LYMPHOCYTES ___
cells/uL
THIS TEST WAS PERFORMED AT:
___
___
Test Result Reference
Range/Units
COMMENT(S) ___
Comment: Source: Line-___
Test Name Flag Results Units
Reference Value
--------- ---- ------- -----
---------------
Lacosamide, S H 14.6 mcg/mL
1.0 - 10.0
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
DISCHARGE LABS:
===============
___ 05:10AM BLOOD WBC-7.3 RBC-2.75* Hgb-7.3* Hct-25.1*
MCV-91 MCH-26.7* MCHC-29.3* RDW-17.9* Plt ___
___ 05:10AM BLOOD Glucose-115* UreaN-19 Creat-2.0* Na-140
K-4.6 Cl-108 HCO3-23 AnGap-14
___ 05:10AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
MICROBIOLOGY:
=============
___ 6:35 pm URINE CATHETER. URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 5:00 pm URINE Source: Catheter. URINE CULTURE (Final
___: YEAST. 10,000-100,000 ORGANISMS/ML..
___ 10:29 am STOOL CONSISTENCY: NOT APPLICABLE Source:
Stool. C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/OTHER STUDIES:
=======================
1. ECG ___: Sinus rhythm. Leftward axis. Left ventricular
hypertrophy. Early precordial R wave transition. Consider prior
lateral myocardial infarction. Compared to the previous tracing
of ___ the rate has slowed. There is variation in
precordial lead placement. There appears to have been further
evolution of the ischemic ST-T wave changes recorded on ___
and the tracing is similar to that of ___ in leads V4-V6.
Otherwise, no diagnostic interim change. Clinical correlation is
suggested.
2. CHEST (PORTABLE AP) ___ : Reduced pleural effusion on
the left without persistent opacification at the left lung base,
compatible with pneumonia in the appropriate setting. However,
even if pneumonia were successfully treated, it might take
several more weeks for the opacity to clear more definitely.
Atelectasis is also a differential diagnosis. Follow-up
radiographs are recommended to show clearance within ___ weeks.
3. CT HEAD W/O CONTRAST ___ : No evidence of acute
intracranial abnormality.
4. PORTABLE ABDOMEN ___ : Expected and unchanged location
of the left percutaneous nephrostomy catheter.
5. RENAL U.S. ___ : No hydronephrosis.
6. NEPHROSTOGRAM ___ : Patent left ureter with rapid
emptying of contrast from the collecting system.
7. EEG ___: This is a mildly abnormal EEG due to the
presence of a slower than normal background with bursts of
generalized or bifrontally predominant slowing; this pattern is
consistent with a mild encephalopathy of toxic, metabolic, or
anoxic etiology. No focal or epileptiform features were seen.
Brief Hospital Course:
___ is a ___ y/o woman with history of HIV on ARVs, CVA
with left hemiparesis, seizure disorder and chronic kidney
disease who was sent to ED from ___ because of nursing
concerns of lethargy and altered mental status s/p ureteral
stent removal on ___ and hospitalization for health care
acquired pneumonia from ___.
====================
Acute Issues
====================
# Lethargy/encephalopathy: The differential diagnosis initially
included infectious, metabolic, pharmacologic, and neurologic
causes. Infectious etiologies were ruled out due to lack of
temperature and white count as well as negative urine and blood
cultures. She had no evidence of acute intracranial process on
head CT. Her renal function was worse than her baseline but had
a small improvement during her hospitalization (see below). She
had been on diazepam recently at her rehab, which was held in
the setting of acute encephalopathy. ___ doxepin was also held
as well as furosemide. Neurology was consulted on ___, who
recommended checking CD4 count (returned 557), HIV viral load
(returned undetectable), Keppra level (pending), and lacosamide
level (elevated at 14.6). The patient received EEG, which showed
diffuse slowing consistent with a mild encephalopathy of toxic,
metabolic, or anoxic etiology but no focal or epileptiform
features were seen. The patient's mental status improved over
the course of her hospitalization and she was able to interact
in full sentences at discharge. Her lacosamide was decreased to
50 mg BID in the setting of worsened renal function. Keppra
level is pending at discharge and the primary team will contact
___ regarding the results for further dosing of this
medication. She will have follow-up with neurology as an
outpatient for further titration of her antiepileptics.
# Acute on chronic kidney injury: Patient had creatinine of 2.6
on admission, worsened from her baseline of 1.3-1.5 measured
during her last admission. She had no evidence of obstruction on
renal US and had normal UOP. FeNa was <1% though 3L of IV fluids
did not improve her creatinine significantly (only to 2.2)
making prerenal cause less likely. Her urine was spun during her
hospitalization and was most consistent with some degree of
acute tubular necrosis as granular casts were seen on urine
microscopy. Her creatinine improved to 2.0 on discharge, which
is thought to be possibly a new baseline for her.
# Left ureteral obstruction s/p left nephrostomy tube ___ and
ESWL with stent removal ___: Patient was seen by urology
in-house, as she had missed her outpatient urology appointment
originally scheduled for ___. Per urology recommendations,
antegrade nephrostogram was performed, showing patent left
ureter. The nephrostomy tube was capped prior to discharge with
a plan to follow-up with outpatient urologist Dr. ___ on
___. Her ___ furosemide was held on discharge. The patient
received a voiding trial per urology on ___, which was
successful and she was discharged without a foley.
# Hypernatremia: The patient developed hypernatremia to 148 on
___. She was given 1L D5W and restarted on free water flushes
in her G-tube, which corrected her sodium back to normal.
# Nutrition: Patient has a G-tube that had been previously
placed for nutrition but was cleared during last hospitalization
(discharged ___ for a regular diet for thin liquids.
Nutrition recommended restarting tube feeds on ___ due to poor
intake and she was initiated on Jevity 1.2, 5 cans daily along
with free water flushes 200 mg q6h. She should continue to be
evaluated by nutrition. Additionally, she was changed to a
pureed solids and thin liquid diet per speech and swallow
evaluation.
====================
Chronic issues
====================
# HIV: Receives care at ___ for her HIV. She has no records on
file at ___ about her disease management. The patient's
Epzicom (abacavir-lamivudine) 600-300 mg oral daily was broken
up into the individual components. She was discharged on
abacavir 600 mg daily and lamivudine 150 mg daily (decreased due
to renal function). She was continued on etravirine, darunavir,
raltegravir, ritonavir.
# Cerebrovascular accident: Patient has history of R MCA stroke
in ___ with resultant development of seizure disorder. She also
has history of bilateral subdural hematoma. Per discharge
summary signed ___, the patient had been started on
Levetiracetam and lacosamide that were supposed to be tapered
over ___ weeks and then switched to daily dosing. However,
patient still has not been weaned due to multiple subsequent
hospitalizations and acute illnesses, so neurology was consulted
here. Drug levels of Keppra (pending) and lacosamide (elevated,
see above) were checked during her hospitalization. She was
discharged on ___ drug regimen of levetiracitam for seizure
prophylaxis and lacosamide was decreased due to decreased renal
function.
# Coronary artery disease: Stable, ___ medications were
continued: aspirin, pravastatin and metoprolol.
# Social: Health care proxy was confirmed to be daughter,
___ ___ on ___. MOSLT form was reviewed
with daughter by phone on ___ with no changes.
TRANSITIONAL ISSUES
===================
# Patient has Keppra level pending. Once the results arrive, the
primary team will call ___ rehab regarding any changes to
her Keppra dose.
# On discharge, patient was discontinued off doxepin, diazepam,
and furosemide. Her lacosamide was decreased to 50 mg BID in the
setting of worsened renal function.
# The patient's Epzicom (abacavir-lamivudine) 600-300 mg oral
daily was broken up into the individual components. She was
discharged on abacavir 600 mg daily and lamivudine 150 mg daily
(decreased due to renal function).
# Patient had speech&swallow eval. She was recommended to have
pureed solids and thin liquids as oral diet with crushed pills
in applesause. Consider further evaluation for possible
advancement of diet.
# Due to poor PO intake, patient was reinitiated on tube feeds
with Jevity 1.2 (5 cans per day) with free water flushes 200 ml
q6h. Please consider continued nutrition evaluation.
# Please repeat CBC and electrolytes (checking renal function)
in 1 week. On discharge, H/H was 7.3/25.1 and creatinine was
2.0.
# CODE: DNR, okay to intubate per MOLST form
# CONTACT: daughter, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN wheeze
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
stomach upset
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Diazepam 2 mg PO Q6H:PRN anxiety
6. Fleet Enema ___AILY:PRN constipation
7. Milk of Magnesia 30 mL PO DAILY:PRN constipation
8. Ipratropium-Albuterol Neb 1 NEB NEB BID:PRN congestion
9. Aspirin 81 mg PO DAILY
10. Baclofen 10 mg PO QHS
11. Citalopram 20 mg PO DAILY
12. Doxepin HCl 10 mg PO DAILY
13. Epzicom (abacavir-lamivudine) 600-300 mg oral daily
14. Furosemide 20 mg PO DAILY
15. Gabapentin 400 mg PO TID
16. Etravirine 200 mg PO BID
17. Raltegravir 400 mg PO BID
18. LeVETiracetam 250 mg PO QAM
19. LeVETiracetam 500 mg PO QHS
20. Metoprolol Succinate XL 25 mg PO DAILY
21. Multivitamins 1 TAB PO DAILY
22. RiTONAvir 100 mg PO BID
23. Pravastatin 10 mg PO DAILY
24. Darunavir 600 mg PO BID
25. LACOSamide 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Baclofen 10 mg PO QHS
3. Citalopram 20 mg PO DAILY
4. Darunavir 600 mg PO BID
5. Etravirine 200 mg PO BID
6. LeVETiracetam 250 mg PO QAM
7. LeVETiracetam 500 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. Pravastatin 10 mg PO DAILY
10. Raltegravir 400 mg PO BID
11. RiTONAvir 100 mg PO BID
12. Acetaminophen 650 mg PO Q6H:PRN pain fever
13. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN wheeze
14. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
stomach upset
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Fleet Enema ___AILY:PRN constipation
17. Ipratropium-Albuterol Neb 1 NEB NEB BID:PRN congestion
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Milk of Magnesia 30 mL PO DAILY:PRN constipation
20. LACOSamide 50 mg PO BID
21. Abacavir Sulfate 600 mg PO DAILY
Previously taken in combo pill, but given renal function
lamivudine was decreased, so now 2 pills.
22. LaMIVudine 150 mg PO DAILY
Previously taken in combo pill, but given renal function
lamivudine was decreased, so now 2 pills.
23. Gabapentin 300 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
# Lethargy/encephalopathy
SECONDARY DIAGNOSIS
===================
# Ureteral obstruction s/p PCN placement
# HIV
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___ from ___ -
___ because you were more tired than normal and had confusion.
We were able to determine that these changes were not due to
infection, seizure, or bleeding in your brain. We stopped some
of your medications while you were in the hospital because they
were not needed (doxepin, diazepam, furosemide). We also had
made adjustments to your HIV medication (lamivudine decreased to
150 mg daily) and your anti-seizure medication (lacosamide
decreased to 50 mg twice a day).
You were seen by urology while you were in the hospital. They
recommended imaging, which showed that your ureters were
draining well. We have capped the tube draining from your
kidney, and you will need to follow-up with your outpatient
urologist for ultimate removal of the tube.
You were also seen by the neurology specialists while in the
hospital and have recommended an outpatient follow-up
appointment on ___.
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
10544620-DS-7 | 10,544,620 | 23,051,365 | DS | 7 | 2174-05-03 00:00:00 | 2174-05-03 11:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
___ yo F with h/o HIV (unknown recent CD4 or AIDS dx), right CVA
with residual L hemiparesis, left ureteral stent for unknown
reasons who is admitted after being found unresponsive and
relatively hypotensive to ___ at her long term care facility.
The patient is currently intubated and able to give history, so
HPI is gathered from chart, rehab paperwork and family.
Family last spoke to her one day prior to admission (she lives
at a long term care facility) and she was at baseline mental
status at that time, however on the night of transfer at 9pm she
was found by nursing staff to be altered "non verbal but able to
open/move eyes on command, BP 98/62, HR 74, temp 98.8, 92% RA,
___ 193". She was ___ transferred to ___ where she was
given 0.4mg Narcan and reportedly awoke. They confirmed with the
family that she doesn't have access to any narcotics. the
patient became somnolent again after the Narcan wore off so she
was placed on a Narcan drip. A Foley was placed however minimal
urine output returned. Unable to send off a urinalysis or urine
tox. A CT head was performed showing no acute abnormality but
old right MCA infarct. Labs at ___ showed: Na 142, K 5.1, Cl
107, Glu 178, BUN 24, Cr 2.7, trop < 0.03, AG 10, lactate 1.8,
Hb 10.8, Hct 33.5, Plt 270, INR 1.18. She was transferred to
___ ED given that she continued to be unresponsive on a narcan
drip.
In the ___ ED, additional labs notable for UA with large
___ but 135 epis. CT A/P with mild left renal stranding
concerning for pyeloneprhitis and she was given ceftriaxone. ABG
7.25/53/72.
On arrival to the FICU, she was still somnolent and there was
concern that she was unable to protect her airway, so she was
intubated.
Review of systems:
Unable to obtain (intubated).
Past Medical History:
- HIV, unkonwn recent CD4/VL
- HIV dx ___ s/p blood transfusion, most recently under good
control
- Tropical spastic paraperesis (HTLV-1) with mild
non-progressive ___ weakness/spacticity
- ___ pulmonary TB
- CVA (thought to be secondary to past MI with thrombus and
embolus) with left-sided hemiparesis (___)
- multiple hospitalizations for malnutrition (G-tube, ARF,
depression requiring ECT)
- bilateral acute on chronic subdural hematomas with bilateral
uncal herniation (___)
- Chronic pain
- Hyperlipidemia
Social History:
___
Family History:
Mother deceased CAD. Father with prostate cancer. Brother died
of lung cancer.
Physical Exam:
On Admission:
General: middle aged woman, intubated and sedated
HEENT: Sclera anicteric, ETT in place
Neck: supple, JVP not elevated
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
General: middle aged woman, alert, answering questions
appropriately, speech difficult to understand given combination
of accent and prior stroke
Afeb 112/68 Hr ___
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, harsh early
systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
G tube site clean, dry, intact
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: rt hemiparesis
Pertinent Results:
On Admission:
___ 03:24AM BLOOD WBC-7.8 RBC-3.74* Hgb-10.5* Hct-36.0
MCV-96 MCH-28.1 MCHC-29.2* RDW-14.4 Plt ___
___ 03:24AM BLOOD Glucose-150* UreaN-27* Creat-3.0* Na-140
K-4.9 Cl-109* HCO3-25 AnGap-11
___ 03:24AM BLOOD ALT-10 AST-15 LD(LDH)-162 AlkPhos-101
TotBili-0.2
___ 03:24AM BLOOD Lipase-25
___ 03:24AM BLOOD Albumin-3.7 Calcium-9.4 Phos-5.2* Mg-2.7*
___ 03:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:18AM BLOOD Lactate-1.5
On discharge:
___ 06:44AM BLOOD WBC-6.7 RBC-3.10* Hgb-8.8* Hct-30.2*
MCV-97 MCH-28.3 MCHC-29.1* RDW-15.3 Plt ___
___ 06:44AM BLOOD UreaN-17 Creat-1.3* Na-139 K-3.9 Cl-108
HCO3-22 AnGap-13
Micro:
___ 5:40 am URINE Site: NOT SPECIFIED
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORKUP REQUESTED PER ___ ___ (___) AT ___
___.
MORGANELLA ___. >100,000 ORGANISMS/ML..
PROVIDENCIA ___. 10,000-100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
VIRIDANS STREPTOCOCCI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
| ___
| |
AMIKACIN-------------- 4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- 2 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R 256 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 8 R
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Imaging/Studies:
___ CT Abdomen/Pelvis without contrast
1. Although the left NU stent appears to be in appropriate
position, there is mild left sided hydronephrosis with
surrounding fat stranding, and ureteral thickening and fat
stranding around the left ureter, concerning for pyelonephritis
secondary to stent obstruction.
2. The distal end of the nephroureteral stent is surrounded by
a large
calcification, measuring up to 3.4 cm, suggestive of the fact
that the stent has not been exchanged for at least ___ year.
3. Fibroid uterus.
___ CXR
In comparison with the earlier study of this date, the tip of
the endotracheal tube lies approximately 5 cm above the carina.
Nasogastric tube extends well into the stomach. Again there is
some enlargement of the cardiac silhouette with indistinctness
of pulmonary vessels suggesting some elevated pulmonary venous
pressure. Part of the haziness of the lower lungs could be a
manifestation of scatter radiation related to the size of the
patient.
___ MRI Head
No acute infarcts mass effect hydrocephalus. Chronic right
middle cerebral
artery infarct. Small bilateral chronic subdural collections.
___ Echocardiogram
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild regional left ventricular systolic
dysfunction with apical anterolateral, anterior, and inferior
hypokinesis. The image quality is however poor and uncertainty
remains about the diagnosis of regional wall motion dysfunction
in the distribution described above. Overall left ventricular
systolic function is mildly depressed (LVEF= 47 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality due to poor echo windows
limiting interpretability of left ventricular wall motion. Given
this limitation there maybe a left ventricular regional wall
motion abnormality c/w CAD in the distribution of a distal LAD
lesion. If clinically indicated consider repeat
echocardiographic examination only with iv echo contrast to
further delineate regional wall motion. Mild symmetric left
ventricular hypertrophy.
Brief Hospital Course:
___ with PMH HIV, history of subdural hematoma, L hemiparesis,
and chronic pain on baclofen presening from her long term living
facility with altered mental status and somnolence, intubated
for airway protection. She was found to have sepsis from a
urinary source due to UTI and stent.
Hospital course:
# Altered mental status
The initial concern was for toxic ingestion as urine opiates
were positive. However, it was eventually felt that this was
multifactorial. EEG showed seizure activity, and her seizures
were felt to be secondary to toxic metabolic insult (opiodis,
urosepsis) on top of a poor substrate (prior MCA CVA, small
bilateral chronic subdural hemorrhages). She was intubated for
airway protection. She was loaded with keppra and lacosamide.
Repeat EEG was unremarkable and patient's level of consciousness
improved. She began responding to commands and moving her
extremities on her right side and gradually improved over
several days and ultimately was completely awake, alert and
interactive. After several unsuccessful attempts, an LP was
performed. CSF labs were unremarkable and gram stain was
negative.
On the regular floor, pt's mental status has been improving, but
she has not yet passed swallow eval, therefore continues on TF
via NG and then PEG.
For seizures, neurology recommends tapering new anti-epileptics.
# Sepsis with urinary source
Has baseline creatinine of around 1.8, and presented with
worsening hydronephrosis and ___ with creatinine 3.0 on
admission. She had a left percutaneous neprhostomy tube placed.
She was treated with vancomycin and zosyn. Urine cultures grew
multiple species which speciated to Morganella, Providencia,
Enterococcus and Strep viridans. Urology recommended outpatient
follow up for definitive management of her pre-existing ureteral
stent. ID was consulted as well.
Plan is for stent removal on ___ and then antibiotics to stop
in ___ clinic the following week.
# Acute renal failure
Creatinine 3.0 on admission. Secondary to
obstruction/hydronephrosis with possible element of prerenal
state. She had a percutaneous neprhostomy tube placed (as above)
and was fluid resuscitated.
Her renal function has steadily improved.
Chronic Issues
# HIV - continued HAART, dose reduce lamivudine given renal
failure but then returned to normal.
# Hyperlipidemia - continued pavastatin
# Depression - continued citalopram
# Spasticity - cotninued Baclofen, decreased dose and has done
well.
FOLLOW-UP:
1. A Cbc c diff, bun/cr, lft should be obtained on ___ and faxed
to ___ - ATTENTION ID FELLOW
2. Leveirectam and lacosamide should be tapered over coming ___
weeks. Reducing dosing and then switching to qD and then
stopped. they were started for seizures but the neurologists
felt after her sepsis resolves they will likely not be needed.
3. Her PEG was placed because of aspiration. Speech and swallow
felt that as her strenth improves and with intervention, she
could return to normal PO intake and PEG could be removed.
4. ___ for strength so she can return to her wheelchair
5. On tube feeds her glucoses have been elevated and glargine
was started. It will need to be adjusted.
6. ___ is going home on vanco/cefipime for her urosepsis.
7. ___ - Dr. ___ will be removing encrustation on JJ stent
and I believe remove both nephrostomy tube and JJ stent
8. ___ - Seeing ID. Likely stopping antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Citalopram 40 mg PO DAILY
3. Gabapentin 400 mg PO TID
4. Baclofen 20 mg PO TID
5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
6. Multivitamins 1 TAB PO DAILY
7. Milk of Magnesia 30 mL PO PRN constipation
8. Bisacodyl ___AILY:PRN constipation
9. Fleet Enema ___AILY:PRN constipation
10. Docusate Sodium (Liquid) 100 mg PO BID
11. Baclofen 10 mg PO HS
12. Epzicom (abacavir-lamivudine) 600-300 mg oral daily
13. Etravirine 200 mg PO BID
14. Raltegravir 400 mg PO BID
15. RiTONAvir 100 mg PO BID
16. Pravastatin 10 mg PO HS
17. Darunavir 600 mg PO BID
18. Lidocaine Jelly 2% 1 Appl TP ASDIR to mouth PRN
19. Doxepin HCl 10 mg PO HS
20. zinc oxide 20 % topical daily
21. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Baclofen 10 mg PO QHS
3. Citalopram 20 mg PO DAILY
4. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
5. Fleet Enema ___AILY:PRN constipation
6. Lidocaine Jelly 2% 1 Appl TP ASDIR to mouth PRN
7. zinc oxide 20 % topical daily
8. Vancomycin 1000 mg IV Q 24H
9. LeVETiracetam 500 mg PO BID
10. Epzicom (abacavir-lamivudine) 600-300 mg oral daily
11. LACOSamide 100 mg PO BID
12. Insulin SC 8 unit of Glargine ONCE on ___ @ ___
13. Hydrocerin 1 Appl TP QID:PRN dry skin
14. Heparin 5000 UNIT SC BID
15. CefePIME 1 g IV Q12H
16. RiTONAvir 100 mg PO BID
17. Raltegravir 400 mg PO BID
18. Darunavir 600 mg PO BID
19. Docusate Sodium (Liquid) 100 mg PO BID
20. Etravirine 200 mg PO BID
21. Gabapentin 400 mg PO TID
22. Multivitamins 1 TAB PO DAILY
23. Pravastatin 10 mg PO HS
24. Bisacodyl ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Urosepsis, Seizures
Discharge Condition:
Mental Status: Clear and coherent though details are sometimes
confusing.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___ you were treated for seizures and infection from your
kidney. Because you had trouble swallowing, we placed a tube in
your stomach for nutrition. Please make sure you come back for
your follow-up appointments.
Followup Instructions:
___
|
10544620-DS-9 | 10,544,620 | 26,584,473 | DS | 9 | 2174-08-27 00:00:00 | 2174-08-28 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
hypoxemia
hypotension
tachycardia
pneumonia
Major Surgical or Invasive Procedure:
PICC line (___)
PICC repositioning, nephrostomy tube replacement ___
History of Present Illness:
History obtained per OMR and rehab facility as patient is poor
historian. Ms. ___ is a ___ with PMH significant for HIV on
HAART, CVA c/b seizure d/o and l. hemiparesis s/p G-tube for
nutrition, and admission for urosepsis in ___ attributed to
retained l. ureteral stent now admitted with ___ hour h/o
fever and hypoxia in the setting of recent urological procedure.
She underwent extrocorporeal shock wave lithotripsy on ___
with removal of left ureteral stent and l ureteroscopy. The
procedure was uncomplicated, however per her rehab she developed
fever and hypoxia to ___ this AM, and was sent to the ED for
this reason.
Of note, patient previously received enteral nutrition through
G-tube per S/S recommendations during ___ admission. Per her
rehab, she has been taking everything PO for several months, but
it is unclear whether she was ever re-evaluated by rehab.
In the ED, initial vital signs were: 99.5 108 ___ 95% ra.
TMax was 102.9. SBP transiently dropped to ___ in early AM of
___, but improved with IVF. Labs were notable for WBC 13.6, Cr
2, Grossly positive UA, normal lactate. CXR concerning for l.
sided effusion, b/l interstitial edema, and l. basilar
atelectasis vs. consolidation. She was given 2L IVF, vancomycin,
levofloxacin, and zosyn, and her percutaneous nephrostomy was
uncapped after discussing with urology.
On Transfer Vitals were: 99.5 95 125/70 18 99% Nasal Cannula
On the medical floor patient states no complaints aside from
wanting to drink water. Denies fever, chills, N/V, DOE, PND,
cough, abdominal pain, chest pain, diarrhea, constipation.
Past Medical History:
- HIV dx ___ s/p blood transfusion, most recently under good
control
- Tropical spastic paraperesis (HTLV-1) with mild
non-progressive ___ weakness/spacticity
- ___ pulmonary TB
- CVA (thought to be secondary to past MI with thrombus and
embolus) with left-sided hemiparesis (___)
- Seizure dx in ___
- multiple hospitalizations for malnutrition (G-tube, ARF,
depression requiring ECT)
- bilateral acute on chronic subdural hematomas with bilateral
uncal herniation (___)
- Chronic pain
- Hyperlipidemia
- EColi Bacteremia
Social History:
___
Family History:
Mother deceased CAD. Father with prostate cancer. Brother died
of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 100.5 BP: 127/83 HR: 112 RR: 18 O2: 85% RA-> 95% 2L
General: Appears older than stated age. Chronically ill
appearing. Oriented to hospital and name, but doesn't know date
HEENT: Dry MM. NCAT. Unable to ascertain JVP
CV: RRR. Ns1&S2. NMRG
Lungs: Decreased breath sounds diffusely with inspiratory wheeze
throughout. Mild bibasilar inspiratory crackles
Abdomen: BS+4. S/NT/ND. G-tube site appears free from infection
GU: Foley draining bright red fluid. L. nephrostomy tube
draining dark serosanguinous fluid. L PCN site with mild
erythema, expressable purulence, and foul odor
Ext: 2+ edema of BLE
Neuro: ___ strength in LUE and LLE. ___nd RLE.
Skin: Unstageable sacral decubitus ulcer
DISCHARGE PHYSICAL EXAM
98.1 144/92 93 18 100/3.5L
(unclear why O2 started overnight, not passed on in MD/RN
signout, later was RR18 Sa97% on RA)
Gen: Chronically ill woman lying in bed, awakens to voice,
responds to questions appropriately
HEENT: perrl, No icterus. MMM. OP clear.
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses visible
anteriorly.
NEURO: A&Ox3
Tubes/drains: foley catheter with gross hematuria, L perc neph
tube with small volume of frank blood in tube
Pertinent Results:
ADMISSION LABS
___ 11:30PM BLOOD WBC-13.6* RBC-3.79* Hgb-10.3* Hct-33.3*
MCV-88# MCH-27.1 MCHC-30.9* RDW-15.0 Plt ___
___ 11:30PM BLOOD Neuts-73.9* Lymphs-17.1* Monos-7.8
Eos-1.0 Baso-0.2
___ 11:30PM BLOOD Glucose-260* UreaN-22* Creat-2.0* Na-139
K-4.3 Cl-102 HCO3-24 AnGap-17
___ 11:44PM BLOOD Lactate-1.7
___ 10:00AM BLOOD ALT-19 AST-53* AlkPhos-103 TotBili-0.6
___ 10:00AM BLOOD proBNP-___*
___ 10:00AM BLOOD Albumin-2.9*
___ 10:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:49AM BLOOD ___ O2 Flow-2 pO2-96 pCO2-47*
pH-7.37 calTCO2-28 Base XS-0 Comment-NASAL ___
DISCHARGE LABS
___ 06:00AM BLOOD WBC-10.8 RBC-3.37* Hgb-8.9* Hct-30.5*
MCV-91 MCH-26.5* MCHC-29.3* RDW-17.4* Plt ___
___ 06:00AM BLOOD Glucose-128* UreaN-22* Creat-1.4* Na-139
K-4.5 Cl-106 HCO3-24 AnGap-14
OTHER STUDIES
___ LINE PLACMENT SCH
___ PORT. LINE PLACEM
IMPRESSION:
1. Right-sided PICC extending into the right jugular vein with
nonvisualization of the distal tip.
2. Worsening moderate right-sided pulmonary edema, persistent
left-sided moderate effusion.
___ OROPHARYNGEAL SWA
Normal oropharyngeal swallowing video fluoroscopy.
___ CHEST W/O CONTRAST
IMPRESSION:
1. Moderate left and small right dependent pleural effusions
are new compared to abdominal CT of ___. Parenchymal
opacification in left lower lobe surrounded by fluid is very
likely due to passive atelectasis, but coexisting infection is
also possible in this immunosuppressed patient.
2. 3 mm left apical noncalcified lung nodule is
statistically most likely benign. If the patient has known risk
factors for lung cancer, followup CT could be performed in ___
year.
3. Partially calcified left ventricular aneurysm is similar
in appearance to ___onsider cardiac
echo if not recently performed.
4. Small pericardial effusion. Enlarged main pulmonary
artery suggestive of pulmonary arterial hypertension.
___ HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large
vascular territory
infarction.
2. Stable, bifrontal, small chronic subdural collections and
right
frontoparietal encephalomalacia.
3. Status post bilateral craniotomies with stable postsurgical
changes.
___ (PORTABLE AP)
IMPRESSION:
1. Increased cardiomegaly and/or pericardial effusion and
moderate
interstitial pulmonary edema.
2. Interval development of a moderate-large left pleural
effusion with
adjacent atelectasis. Left lower lobe consolidation could be
atelectasis, but
is more likely pneumonia.
___
Baseline artifact. Sinus tachycardia. Left anterior fascicular
block.
Borderline intraventricular conduction delay. Compared to the
previous tracing
of ___ rate is now somewhat faster. ST segment elevation and
T wave
inversion in the precordial leads are now less prominent.
Brief Hospital Course:
___ with history of HIV on HAART, CVA with residual L-sided
weakness and G-tube for nutrition, and CKD (unclear etiology)
who presents with hypotension and tachycardia from her rehab
facility. Potential sources included PNA and urinary tract; PNA
was more likely given presentation with hypoxemia, CXR with LLL
opacity and effusion. She was treated with vanc/cefepime for
HCAP for 7d course; she was discharged with PICC, though d/c
complicated by malposition of PICC requiring ___ manipulation.
Urine cultures grew yeast only, so she was not treated for
urinary pathogens. Additionally, percutaneous nephrostomy tube
was replaced ___ during PICC repositioning in ___ due to
falling out (unclear cause) on ___.
ACUTE
#Sepsis:
On admission, ___ SIRS criteria (fever, leukocytosis,
tachycardia) in the setting of recent urological
instrumentation. Potential sources included PNA vs urinary
tract; HCAP felt to be most likely given CXR with LLL
consolidation and effusion, UCX with yeast. Other possible
sources included skin wound as below, though less likely. HCAP
treated with ABX; her volume status was carefully monitored
(given sepsis and heart failure), and IVFs were judiciously
given. BCX were negative, UCX grew yeast, Cdiff neg, sputum
contaminated.
#HCAP
Pt with hypoxemia on admission, consolidation LLL with pleural
effusioin, SIRS/sepsis physiology in setting of rehab/recent
___ hospitalizations. Could not obtain clean sputum cultures
due to mental status. She was treated with vanc/cefepime and
should have total of 8d course ___ day ___ should finish
___, doses/freq per med list). PICC can be pulled after abx
completed.
#Hypoxia (resolved):
Most likely multifactorial due to HCAP above with pleural
effusion, volume overload with elevated BNP on admission,
mechanical factors (positioning, body habitus). HCAP was treated
with abx as above; pt's volume status was managed based on vital
signs. Duonebs were given for wheezing. Diuresis was never
required.
#Urinary tract
Urologic procedure on ___ - s/p urologic procedures to remove
stone encrusted stent. Now with perc nephrostomy tube with
grossly bloody drainage; this is not unexpected
post-procedurally per urology. She is discharged with the tube
capped. Of note, tube fell out on ___ and was replaced by ___
___. UCX finalized with yeast only, so no abx were given
directed at urinary pathogens. She should follow up with urology
in 1 week; if oliguric, anuric, or febrile, uncap the tube and
drain to gravity.
# Swallow eval:
Video swallow with no aspiration or penetration, okay to take
regular diet with thin liquids. Patient can take all meds and
food PO; G-tube maintained for nutritional requirements if
intake by mouth insufficient.
CHRONIC
# H/o CVA:
S/p R MCA infarct with residual L sided weakness. Followed by
neurology at ___ despite valiant efforts, could not obtain
records.
#H/o seizure:
Recently dx in ___. Likely related to CVA. Neuro records could
not be obtained as above. Keppra, lacosamide, and neurontin were
continued.
#Chronic Kidney Disease:
Baseline Cr unclear, appears to be 1.2-1.5 based on numbers this
hospitalization with urosepsis c/b ___. Meds renally dosed.
#HIV on HAART:
On HAART therapy, followed by ___. Home antiretrovirals
(abacavir, etravirine, darunavir, ritonavir) were continued.
#Skin impairments
Irritant incontinence dermatitis of gluteal area, intertrigo.
Would care was consulted; please see full recommendations
(marked with *** below).
TRANSITIONAL
1. Patient with gross hematuria and grossly bloody small volume
perc nephrostomy tube drainage. Patient will follow up with
urology in ___ days.
2. Perc nephrostomy tube: will be capped when pt leaves
hospital. If oliguric, anuric, or febrile, uncap the tube and
drain to gravity.
3. Lung nodule on CT should be followed up as an outpatient
4. HCAP: pt should get 8 days vanc/cefepime via PICC (dose/freq
per d/c medications). ___ is day #7; ___ is day 8. At
completion of abx, PICC can be pulled
***WOUND CARE RECOMMENDATIONS
(per ___ wound care nurse)
Recommendations: Pressure relief per pressure ulcer guidelines
Support surface:Atmos Air
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times
Waffle Boots ( X ) Multipodis Splints ( )
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-
Standard Air ( X ) ROHO ( )
Elevate ___ while sitting.
Moisturize B/L ___ and feet BID
Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
( )Apply moisture barrier ointment to the periwound tissue
with each dressing change.
( )Apply protective barrier wipe to periwound tissue and air
dry.
Apply Xeroform gauze to gluteal cleft
Using Foam cleanser and disposable soft wash cloths to cleanse
skin on gluts
Pat the tissue dry
Every third cleansing apply a thin layer of Critic Aid AF
Use large Sofsorb pads under patient to wick stool away from
skin
To skin folds (breasts and pannus) use a thin layer of Critic
Aid
AF daily and folded Sofsorb pads to keep skin folds separated
Support nutrition and hydration.
___ MD or wound care nurse if wound or skin deteriorates.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Darunavir 600 mg PO BID
3. Baclofen 10 mg PO QHS
4. Bisacodyl ___AILY:PRN constipation
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Doxepin HCl 10 mg PO HS
8. Etravirine 200 mg PO BID
9. Gabapentin 400 mg PO TID
10. LACOSamide 100 mg PO BID
11. LeVETiracetam Oral Solution 250 mg PO DAILY
12. LeVETiracetam Oral Solution 500 mg PO HS
13. Lidocaine Jelly 2% 1 Appl TP ASDIR to mouth PRN
14. Raltegravir 400 mg PO BID
15. RiTONAvir 100 mg PO BID
16. Epzicom (abacavir-lamivudine) 600-300 mg oral daily
17. clotrimazole-betamethasone ___ % topical TID
18. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
19. Pravastatin 10 mg PO HS
20. Multivitamins 1 TAB PO DAILY
21. Milk of Magnesia 30 mL PO HS:PRN constipation
22. Furosemide 20 mg PO DAILY
23. Metoprolol Succinate XL 25 mg PO DAILY
24. Fleet Enema ___AILY:PRN constipation
25. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
26. Aspirin 81 mg PO DAILY
27. Cefpodoxime Proxetil 400 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Citalopram 20 mg PO DAILY
6. Darunavir 600 mg PO BID
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Etravirine 200 mg PO BID
9. Fleet Enema ___AILY:PRN constipation
10. Gabapentin 400 mg PO TID
11. LACOSamide 100 mg PO BID
12. LeVETiracetam Oral Solution 250 mg PO DAILY
13. LeVETiracetam Oral Solution 500 mg PO HS
14. Lidocaine Jelly 2% 1 Appl TP ASDIR to mouth PRN
15. Milk of Magnesia 30 mL PO HS:PRN constipation
16. Multivitamins 1 TAB PO DAILY
17. Pravastatin 10 mg PO HS
18. Raltegravir 400 mg PO BID
19. RiTONAvir 100 mg PO BID
20. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
21. Baclofen 10 mg PO QHS
22. clotrimazole-betamethasone ___ % topical TID
23. Doxepin HCl 10 mg PO HS
24. Epzicom (abacavir-lamivudine) 600-300 mg oral daily
25. Furosemide 20 mg PO DAILY
26. Metoprolol Succinate XL 25 mg PO DAILY
27. CefePIME 2 g IV Q24H
28. Vancomycin 750 mg IV Q 24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: HCAP
Secondary: s/p CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
___ Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted with fever and low blood pressure. You were found to
have a pneumonia and were treated with antibiotics for this with
improvement. While you were here, we had you on tube feeds for
a few days but we allowed you to eat regular food after you
passed a swallow evaluation.
Please see below for your medications and appointments.
Followup Instructions:
___
|
10544756-DS-5 | 10,544,756 | 29,420,002 | DS | 5 | 2176-08-29 00:00:00 | 2176-08-29 20:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Fall from toilet (fell asleep vs syncope)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a history of atrial
fibrillation on Eliquis previous colectomy with ileostomy (for
colonic pseudoobstruction) who is now transferred to ___ from
___ for evaluation of a C1 fracture after a fall from
her toilet. The fall occured around 1AM this morning when she
woke up to use the bathroom. She is unsure as to whether or not
she fell asleep while on the toilet or if she had a syncopal
episode. Of note, he has no history of syncope. She was able to
stand and walk back to bed but over the course of the day was
having worsening pain in her head and neck and so was brought to
___ Emergency Department for evaluation. She underwent
a CT head, which was negative, and a CT C spine which showed a
non-displaced C1 fracture. She was transferred to ___ for
spine and trauma evaluation.
Currently, she is afebrile and hypertensive in the setting of
pain. She continues to have neck pain but denies pain elsewhere.
She also denies dizziness, chest pain, shortness of breath,
paresthesias or weakness. On exam, she is neurologically intact
and does not have evidence of any other injuries. Labs are
notable for a Hct of 34.5. Her last dose of eliquis was
yesterday evening. Spine was consulted and recommended an MRI C
spine to further evaluate her injury.
Past Medical History:
PMH:
Hypertension
Paroxysmal atrial fibrillation
PSH:
Cholecystectomy
Near-total colectomy with ileostomy for colonic
pseudoobstruction (___)
Ileostomy reversal (___)
Re-do ileostomy (___) for anastomotic leak
Social History:
___
Family History:
Reviewed, noncontributory to this admission for C1 fracture
Physical Exam:
Physical Exam On Admission
==========================
Vitals: Temp 98.0, HR 78, BP 175/72, RR 18, SpO2 97% RA
General: awake, alert, no acute distress
HEENT: no facial lacerations or bruises
Neck: ___ J collar in place
CV: regular rate and rhythm
Pulm: normal respiratory effort
GI: abdomen soft, non-distended, non-tender
Extremities: warm and well perfused
Neuro: cranial nerves ___ in tact, gross sensory motor function
in tact
MSK: no bony tenderness, pelvis stable
Discharge Exam
==============
98.6 145/69 70 20 96 Ra
General: Alert, oriented, no acute distress, pleasant in
conversation.
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear.
Neck: C-collar in place, unable to assess JVP or for
thyromegaly.
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. Ileostomy
is
well vascularized and healthy appearing, brown stool in bag.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: CNs2-12 intact, strength/sensation full and intact
throughout, no dysmetria. Gait not assessed.
Pertinent Results:
ADMISSION LABS
==============
___ 04:30PM BLOOD WBC-16.0* RBC-3.78* Hgb-11.1* Hct-34.5
MCV-91 MCH-29.4 MCHC-32.2 RDW-15.3 RDWSD-51.1* Plt ___
___ 04:30PM BLOOD Neuts-76.0* Lymphs-14.2* Monos-8.8
Eos-0.1* Baso-0.4 Im ___ AbsNeut-12.14* AbsLymp-2.26
AbsMono-1.40* AbsEos-0.02* AbsBaso-0.06
___ 04:30PM BLOOD ___ PTT-25.3 ___
___ 04:30PM BLOOD Plt ___
___ 04:30PM BLOOD Glucose-112* UreaN-13 Creat-0.6 Na-140
K-4.4 Cl-105 HCO3-21* AnGap-14
___ 04:30PM BLOOD cTropnT-<0.01
DISCHARGE LABS
==============
___ 06:17AM BLOOD WBC-11.1* RBC-3.55* Hgb-10.3* Hct-33.5*
MCV-94 MCH-29.0 MCHC-30.7* RDW-15.4 RDWSD-54.2* Plt ___
___ 06:17AM BLOOD Glucose-82 UreaN-11 Creat-0.4 Na-142
K-4.5 Cl-105 HCO3-23 AnGap-14
___ 06:17AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
NOTABLE LABS
============
___ 06:52AM BLOOD ALT-16 AST-20 LD(LDH)-179 AlkPhos-55
TotBili-0.2
___ 04:30PM BLOOD cTropnT-<0.01
___ 06:52AM BLOOD Albumin-3.8 Calcium-9.3 Phos-3.7 Mg-1.6
Iron-78
___ 06:52AM BLOOD calTIBC-506* VitB12-489 Hapto-186
Ferritn-21 TRF-389*
___ 06:52AM BLOOD TSH-1.9
___ 07:18AM BLOOD CRP-3.0
MICRO
=====
___ 4:09 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 10:26 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING
=======
CXR
IMPRESSION:
No acute cardiopulmonary process.
MRI C-SPINE
IMPRESSION:
1. Study is moderately degraded by motion.
2. Redemonstration of patient's known right C1 anterior and
posterior arch
fractures, better visualized on prior outside noncontrast
cervical spine CT.
3. Apical odontoid ligament and bilateral alar ligaments edema,
and
atlantooccipital membrane edema with question disruption,
concerning for
ligamentous injury.
4. Minimal nonspecific probable epidural enhancement anterior to
right
midbrain at C1-2 level anterior to the tectorial membrane, with
no definite evidence of epidural hematoma elsewhere in cervical
spine. While findings may be related to trauma, epidural
extravasation or mass such as schwannoma is not excluded on the
basis of this motion degraded examination. Recommend
follow-up imaging to resolution.
5. Nonspecific prevertebral fluid anterior to C4 through C6
vertebral bodies without definite evidence of vertebral body
fracture or anterior longitudinal ligament disruption.
6. Within limits of study, no definite focal cervical spinal
cord lesion
identified.
7. Limited imaging of thoracic spine suggests T3 vertebral body
probable bone island. If available, consider correlation with
any available prior CT imaging which includes the T3 vertebral
body. If concern for sclerotic
metastatic lesion, consider bone scan for further evaluation.
8. Multilevel cervical spondylosis as described.
RECOMMENDATION(S): Minimal nonspecific probable epidural
enhancement anterior to right midbrain at C1-2 level anterior to
the tectorial membrane, with no definite evidence of epidural
hematoma elsewhere in cervical spine. While findings may be
related to trauma, epidural extravasation or mass such as
schwannoma is not excluded on the basis of this motion degraded
examination. Recommend follow-up imaging to resolution.
MRI BRAIN
IMPRESSION:
1. Right C1 anterior arch and left lateral mass fractures are
again noted.
Previously seen epidural enhancement at the level of C1-C2 is
less conspicuous compared to the prior cervical spine MRI and
may be secondary the adjacent posttraumatic edema. No evidence
for pathologic epidural enhancement ventral to the brainstem.
2. Extensive T2/FLAIR signal abnormalities in the supratentorial
white matter, nonspecific but likely sequela of chronic small
vessel ischemic disease in this age group er.
3. Leptomeningeal FLAIR hyperintensity, siderosis, and contrast
enhancement along the right inferior parietal, posterior
temporal, and occipital lobes, which may be secondary to amyloid
angiopathy in this age group. However, no signs of parenchymal
amyloid angiopathy are identified. Inflammatory and neoplastic
etiologies are not usually associated with siderosis. Follow-up
MRI with and without contrast is recommended to assess
stability.
RECOMMENDATION(S): Follow-up brain MRI with and without
contrast in ___
months for reassessment of the right inferior parietal,
posterior temporal, and occipital leptomeningeal abnormality.
If clinically warranted, correlation with CSF studies could also
be considered.
CXR
IMPRESSION:
No focal consolidation.
Findings are suggestive of COPD.
TTE
CONCLUSION:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
The visually estimated left ventricular ejection fraction is
>=60%. Left ventricular cardiac index is normal (>2.5 L/min/m2).
There is no resting left ventricular outflow tract gradient with
no change with Valsalva. No ventricular septal defect is seen.
Normal right ventricular cavity size with normal free wall
motion. There is a normal ascending aorta diameter for gender.
The aortic valve leaflets (?#) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are not well seen. The tricuspid valve leaflets
appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Mild symmetric left ventricular hypertrophy with normal cavity
size and global biventricular systolic function. Technically
suboptimal to exclude regional wall motion abnormalities. Mild
pulmonary artery systolic hypertension.
Brief Hospital Course:
___ female with a history of atrial fibrillation on
Eliquis, carotid stenosis s/p carotid stent/bypass, HTN,
dyslipidemia, previous colectomy with ileostomy (for colonic
pseudoobstruction), prior cholecystectomy/appendectomy, and
prior R hip replacement who was transferred to ___ from ___
___ for evaluation of a non-displaced C1 fracture after a
fall from her toilet, no surgical intervention indicated as per
ACS/ortho-spine, patient subsequently transferred to the
medicine service for syncope work-up, found to have UTI with an
otherwise unremarkable syncope work-up.
# Possible syncopal episode - Patient reportedly fell and hit
her head after getting up in the middle of the night to urinate,
she had been sitting on the toilet. There was no prodrome,
patient was unsure whether she lost consciousness or rather just
fell asleep while urinating. Telemetry did not reveal any
underlying cardiac arrhythmia. Troponin was negative and
electrocardiogram did not reveal any ischemic changes. TTE
performed ___ was largely reassuring (LVEF 60%, suymmetric LVH,
mild PAH). An infectious workup was sent and demonstrated that
patient had a possible urinary tract infection as below, she did
endorse some urinary frequency. MRI C-spine findings did show a
possible C1-2 level epidural enhancement (? mass such as
schwannoma), patient subsequently underwent MRI brain which was
less conspicuous though did show leptomeningeal FLAIR
hyperintensity with siderosis and contrast enhancement along the
right inferior parietal, posterior temporal, and occipital
lobes, which may be secondary to amyloid angiopathy in this age
group . Unlikely to be the cause of your possible syncope,
though patient will need repeat MRI to ensure stability to
___.
# Leukocytosis with neutrophilic predominance - Possibly
reactive iso recent fall, though infectious work-up was sent and
was notable for inflammatory UA, urine culture growing >1000CFU
Staph aureus. Patient remained afebrile and hemodynamically
stable. CRP was 3.0. Blood cultures pending at time of discharge
along with urine culture sensitivities. Patient was started on
ceftriaxone, transitioned to bactrim at time of discharge to
complete a five day course.
# Non-displaced C1 fracture - Ortho-spine and ACS evaluated
patient, no acute surgical intervention indicated. No
contraindication to systemic anticoagulation. Patient will need
to continue wearing ___ hard collar at all times except when
eating/cleaning with plan for follow-up in ___ in 6
weeks. ___ was consulted, patient was up and walking
independently without any concerns. Patient was discharged with
a small prescription for oxycodone for breakthrough pain.
# Minimal nonspecific probable epidural enhancement anterior to
right midbrain at C1-2 level anterior to the tectorial membrane
on MRI C-spine. Follow-up MRI did not show such conspicuous
findings in this area though did have the leptomeningeal FLAIR
hyperintensity with siderosis and contrast enhancement as
mentioned above. Patient will need repeat MRI brain in ___.
# Hypertension - Patient said that BPs have not been well
controlled as an outpatient, not currently on any anti-HTNs.
Previously it seems that she was on lisinopril/HCTZ,
spironolactone, and verapamil. Medications were changed during
ICU stay last year for colonic pseudoobstruction. BPs may have
been
acutely elevated iso recent fall and pain. SBPs initially
170-180s. Started amlodipine 5mg qd ___ with subsequent
improvement, SBPs 120-160s at time of discharge.
# Normocytic anemia - No clinical concern for bleeding after
recent trauma. Labs showed iron sat 15.6%, patient was
administered IV ferric gluconate x1. Hemolysis labs and B12
unremarkable.
# Thrombocytosis - Most likely reactive, though could be caused
by iron deficiency anemia.
# Atrial fibrillation - Noted to be in sinus rhythm.
- Rate control: Continued home metoprolol succinate 50mg qd with
holding parameters
- AC: Continued apixaban 5mg BID
# Dyslipidemia
# Peripheral vascular disease, history of carotid stenosis with
stent/bypass ___ ago)
- Continued home pravastatin
- Continued home aspirin
# Colectomy with ileostomy iso colonic pseudoobstruction (failed
reversal earlier this year)
- Continued home loperamide
# GERD
- Continued home famotidine
TRANSITIONAL ISSUES
=================
[] Please follow-up pending urine and blood cultures
[] Patient was discharged on bactrim for UTI treatment, will
complete 5-day course of antibiotics on ___
[] ___ collar should be worn for 6 weeks at all times except
when eating or cleaning
[] Patient will need follow-up in ___ in 6 weeks
[] Patient was started on amlodipine 5 mg daily for blood
pressure control, continue to titrate as needed
[] Patient was noted to have iron deficiency this admission,
should discuss outpatient investigation for possible
gastrointestinal sources of bleeding, CBC should be repeated at
next PCP ___
[] MRI brain this admission showed probable chronic small vessel
ischemic disease and leptomeningeal FLAIR hyperintensity with
siderosis and contrast enhancement along the right inferior
parietal, posterior temporal, and occipital lobes;
**she will need repeat MRI brain to ensure stability in ___
months**
[] TTE this admission showed mild symmetric left ventricular
hypertrophy with normal systolic function, mild pulmonary artery
systolic hypertension
.
.
.
.
Time in care: >30 minutes in discharge-related activities on the
day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Famotidine 40 mg PO BID
5. Pravastatin 40 mg PO QPM
6. LOPERamide 2 mg PO BID
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*50 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every eight
(8) hours Disp #*3 Tablet Refills:*0
4. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 2 Days
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tab-cap by
mouth twice a day Disp #*3 Tablet Refills:*0
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Famotidine 40 mg PO BID
10. LOPERamide 2 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==============
C1 Non-displaced fracture
Syncope
Urinary tract infection
Hypertension
Secondary Diagnoses
================
Atrial fibrillation
Discharge Condition:
___ J collar must be worn at all times except when
eating/cleaning. The collar should be worn for 6weeks.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You had a fall at home and were found to have a bone fracture
in your neck.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You were evaluated by the orthopedic surgeons and there was no
need for surgery.
-You were transferred to the general medicine service in order
to investigate causes of what caused you to fall at home.
-An ultrasound of your heart which was reassuring.
-An MRI of your brain did not reveal any mass or bleeding,
though you will need a repeat MRI in ___ to assess for
stability.
-You were found to have a urinary tract infection and were
started on antibiotics.
-Given that your blood pressure was quite high, you were started
on a new medication to help lower it (amlodipine).
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to wear your neck collar at all times except
when eating or cleaning. You will need to continue wearing the
neck brace for 6 weeks.
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10544855-DS-5 | 10,544,855 | 22,153,262 | DS | 5 | 2128-11-03 00:00:00 | 2128-11-04 06:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Vicodin
Attending: ___
___ Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
The patient is a ___ female with ESRD on HD MWF and s/p
cholecystectomy presenting as transfer from OSH with concern for
cholangitis.
The patient reports ongoing epigastric pain over the past
several months with associated nausea and vomiting. On the day
of presentation, she reports feeling weak and lightheaded,
especially with standing. She missed her regularly scheduled HD
session. She denies any fevers, chills, diarrhea, constipation,
chest pain, or shortness of breath. She was evaluated at an OSH
and treated with zosyn for concern of cholangitis. She was
transferred to ___ for consideration of ERCP.
Per OMR notes, the patient has been experiencing chronic
abdominal over the the last six months, with associated poor PO
intake, nausea and intermittent vomiting. She endorses a 40 lbs
in the last six months. No change in bowel habits or blood in
the stool. She experienced a recent episode of acute
pancreatitis of unclear origin, thought secondary to amiodarone.
As part of a work-up over the last six months, she has
undergone CT and MRCP; findings included a common bile duct
dilated to 1.6 cm with mild dilation in the intrahepatic ducts
with no signs of choledocholithiasis. She had an upper endoscopy
done in ___ that was normal. A gastric emptying study was
normal. A colonoscopy in ___ was normal.
Upon presentation to ED, 99.0 49 77/40 18 95% RA. Labs were
significant for HCT 25.7 (baseline). ALT 24, AST 27, AP 291,
Tbili 0.3, Alb 2.1. RUQ ultrasound shows dilated common bile
duct at 15 mm with accompanying central intrahepatic ductal
dilatation. Patient is known to have ductal dilatation to 16 mm.
No obstructing lesion was seen. Patient was given dilaudid 1 mg
IV X 1. She was given 500 cc NS. On transfer, VS: 98.9 66 84/43
16 99% RA.
Past Medical History:
Polycystic Kidney Disease
CRI, baseline creatinine 2.6
Hypertension
Gout
Hyperlipidemia
Paroxysmal atrial fibrillation
migraine
.
s/p hysterectomy
s/p laparoscope cholecystectomy
s/p tubal ligation
Social History:
___
Family History:
Father had polycystic kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.2 BP: 74/49 P: 73 R: 18 O2: 97%RA
General: Well appearing female in no acute distress
HEENT: Mucous membranes slightly dry
Neck: JVP non elevated
CV: S1/S2 Regular Rate and Rhythm, no murmurs/gallops
appreciated
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/ronchai
Abdomen: Soft, tender in epigastrum, no rebound or guarding,
normoactive bowel sounds
Ext: Warm, 2+ pitting edema in ___, RUE fistula, +thrill
DISCHARGE EXAM:
VS: 98.4 97/53 70 14 100%RA
General: Well appearing female in no acute distress
HEENT: Mucous membranes moist
Neck: JVP not elevated
CV: Regular Rate and Rhythm, no murmurs/gallops appreciated
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/ronchai
Abdomen: Soft, moderately tender in epigastrum, no rebound or
guarding, normoactive bowel sounds
Ext: Warm, ___ pitting edema in ___, RUE fistula, +thrill
Pertinent Results:
ADMISSION LABS
___ 01:15AM BLOOD WBC-6.9 RBC-2.08* Hgb-8.1* Hct-25.7*
MCV-123*# MCH-38.9*# MCHC-31.6 RDW-15.8* Plt ___
___ 01:15AM BLOOD Neuts-64.5 ___ Monos-5.5 Eos-1.1
Baso-0.4
___ 01:15AM BLOOD Glucose-81 UreaN-18 Creat-4.3*# Na-144
K-3.6 Cl-102 HCO3-29 AnGap-17
___ 05:40AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.5*
___ 01:15AM BLOOD Albumin-2.1*
___ 07:52AM BLOOD Lactate-0.8
RUQ ULTRASOUND ___:
IMPRESSION: Dilated common bile duct at 15 mm with accompanying
central
intrahepatic ductal dilatation. Per the GI note in OMR, the
patient is known to have ductal dilatation to 16mm. No
obstructing lesion is seen, suggesting sphincter of Oddi
dysfunction as a potential etiology correlate with MRCP or ERCP.
___ ERCP:
Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome
A severe diffuse dilation was seen at the biliary tree with the
CBD measuring 15 mm.
No filling defects were noted. No discrete stricture was noted.
The intrahepatics appeared to be normal. Clips of previous
cholecystectomy were noted.
Given the clinical presentation and the very dilated CBD, a
sphincterotomy was performed
Several balloon sweeps were performed. No stone/sludge were
noted.
Excellent flow of bile was noted.
Brief Hospital Course:
The patient is a ___ year-old female with ESRD on HD MWF and s/p
cholecystectomy presenting as transfer from OSH with concern for
cholangitis.
# EPIGASTRIC PAIN/NAUSEA: The patient was admitted with her
baseline chronic epigastric pain. MRCP recently showed a dilated
CBD up to 1.6 cm with mild intrahepatic dilation, without signs
of choledocholithiasis. She was previously evaluated by the
advanced endoscopy team who felt that she had sphincter stenosis
or sphincter of Oddi dysfunction to explain her dialted CBD.
There was plan for outpatient ERCP and sphincterotomy. Less
concern for cholangitis in this acute setting given normal LFTs
as above, and her hypotension was likely her baseline. Given her
inpatient status, advanced endoscopy pursed ERCP on this
admission. She had no filling defects found but did have known
biliary dilation. She therefore underwent sphincterotomy
without complication. She was kept NPO, on gentle IVF given her
CKD and her diet was advanced without difficulty the following
day. She had improvement in her chronic pain after the
procedure.
# HYPOTENSION: The patient preseneted to the ED complaining of
weakness and her baseline abdominal pain (see below) and was
found to be hypotensive. Per review her outpatinet records, the
patient has chronically low blood pressures in the ___
systolic, and has been mentating well. She received a 500cc
bolus in the ED with some symptomatic improvement. She may have
had a component of hypovolemia in the setting of poor PO intake,
but, her pressures most likely reflect her baseline. There was
less concern for infection, more specifically cholangitis given
her normal LFTs, afebrile, no leukocytosis, and normal lactate.
She tolerated MAPs in the ___, mentating well. Checking blood
pressures in her thighs gave higher readings, likely more
consistent with actual pressures and her BP was in the 90-100's
in her thighs at the time of discharge.
CHRONIC ISSUES
# ESRD on HD: Currently on ___ schedule, however missed her HD
session on the day of presentation. Had HD the ___ of
admission, and was continued on her regular dialysis schedule.
She was continued on her home sinacalcet. Her sevelamer was
held in the setting of low phos and poor PO intake.
# Gout: Currently asymptomatic. Her home meds were continued.
# Paroxysmal Atrial fibrillation: CHADS2 = 1. Currently in sinus
rhythm. Her metoprolol was held initial given the concern
initially for hypotension but subsequently restarted.
TRANSITIONAL ISSUES:
- ___ Blood cultures pending at the time of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Aspirin 162 mg PO DAILY
5. Niacin ___ mg PO DAILY
6. Cranberry Concentrate *NF* (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg Oral daily
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Cinacalcet 60 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. biotin *NF* 5000 mcg Oral daily
12. melatonin *NF* 10 mg Oral QHS
13. HYDROmorphone (Dilaudid) 2 mg PO Frequency is Unknown
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Cinacalcet 60 mg PO DAILY
3. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
4. Pantoprazole 40 mg PO Q24H
5. Metoprolol Succinate XL 25 mg PO DAILY
6. biotin *NF* 5000 mcg Oral daily
7. Cranberry Concentrate *NF* (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg Oral daily
8. melatonin *NF* 10 mg Oral QHS
9. Niacin ___ mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Bile duct obstruction
End stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having abdominal pain.
You were going to get an ERCP as an outpatient and we decided to
do it here instead. Your ERCP showed dilation of your biliary
tree and a sphincterotomy was performed to open up your bile
ducts. Because of this procedure, you should avoid NSAIDs,
blood thinners, and aspirin for the next 5 days.
You were initially in the ICU because of low blood pressures,
but when it was determined that you chronically have low blood
pressures, you were transferred to the general medicine floor.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Followup Instructions:
___
|
10545108-DS-14 | 10,545,108 | 23,215,512 | DS | 14 | 2180-11-15 00:00:00 | 2180-11-15 16:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Right sided weakness, Aphasia
Major Surgical or Invasive Procedure:
TEE
LP
History of Present Illness:
HPI: Ms. ___ is a ___ w/ PMH of HTN, T2DM, hyperlipidemia,
prior TIA and a recent kidney transplant in ___ currently on
Plavix who endorses syncopal episode preceded by sudden onset
lightheadedness one week ago. At that time she was hospitalized
and later discharged with the syncopal episode being attributed
to dehydration due to frequent diarrhea, attributed to
consequences of post-transplant immunosuppresion and/or
medications. She endorses being asymptomatic during the week
until yesterday evening, when upon attempting to enter the
shower
she again experienced lightheadedness and fainted. She does not
remember what occurred in the intervening period between the
fainting episode and being on the ambulance, except that she
stated that she could feel herself getting progressively
lightheaded and losing consciousness. She denies nausea,
diplopia
or other symptoms associated with the lightheadedness.
Past Medical History:
End-Stage Renal Disease status post Renal Transplant in ___
Type II diabetes
Hypertension
Hyperlipidemia
Transient Ischemic Attach in ___
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Patient is awake and lethargic
HEENT: No scleral icterus or cervical lymphadenopathy
Lungs: Breathing without using accessory muscles of respiration
Cardiac: Deferred
Bowel: Soft, non-tender
Skin: Deferred
Neurologic Examination:
Mental Status: Patient was awake and somewhat lethargic,
oriented
to self and hospital. Could not complete months of the year
backwards or days of the week backwards. Fluent speech with
comprehension during conversation. Responses to commands delayed
at times, some difficulty with word-finding.
Cranial Nerves: PERRLA 2cm, full extraocular eye movements with
no nystagmus, sensation to light touch intact in face, endorses
no hearing loss bilaterally, slightly decreased strength of
facial muscles on the right side, tongue protrudes midline, ___
strength sternocleidomastoid muscle.
Strength: ___ deltoid, biceps, triceps, interosseous muscles,
iliopsoas muscle.
Reflexes: Deferred
Gait: Deferred
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, white plaques on tongue
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, 3+ SEM
LUNGS: RLL crackles otherwise CTAB, breathing comfortably
without
use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ str in all extr, SLTI
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 08:45AM ALT(SGPT)-<5 AST(SGOT)-6 LD(LDH)-188 ALK
PHOS-102 TOT BILI-0.8
___ 08:45AM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-2.5*
MAGNESIUM-1.9 CHOLEST-169
___ 08:45AM %HbA1c-7.0* eAG-154*
___ 08:45AM TRIGLYCER-147 HDL CHOL-36* CHOL/HDL-4.7
LDL(CALC)-104
___ 08:45AM TSH-1.3
___ 08:45AM tacroFK-8.2
___ 08:45AM WBC-7.3 RBC-2.87* HGB-8.7* HCT-27.3* MCV-95
MCH-30.3 MCHC-31.9* RDW-15.1 RDWSD-52.5*
___ 08:45AM PLT COUNT-149*
___ 03:45PM CRP-6.7*
___ 05:55AM BLOOD WBC-4.6 RBC-2.70* Hgb-8.3* Hct-26.4*
MCV-98 MCH-30.7 MCHC-31.4* RDW-14.7 RDWSD-53.1* Plt ___
___ 05:55AM BLOOD Glucose-188* UreaN-18 Creat-1.5* Na-145
K-4.3 Cl-109* HCO3-22 AnGap-14
___ 08:45AM BLOOD %HbA1c-7.0* eAG-154*
___ 06:43AM BLOOD tacroFK-9.3
TEE
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium/right atrial appendage. There is
a small patent foramen ovale visualized with color Doppler.
There are simple atheroma in the aortic arch with
no atheroma in the descending aorta to 30 cm from the incisors.
The aortic valve leaflets (3) appear
structurally normal. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is no
aortic valve stenosis. There is trace aortic regurgitation. The
mitral valve leaflets appear structurally normal
with no mitral valve prolapse. There is moderate anterior mitral
annular calcification. A LARGE, highly mobile
echodensity, measuring 3.5 cm in length and up to 0.4 cm in
width, is seen on the left ventricular side of the
mitral valve. This mass is attached to the base of the anterior
mitral leaflet at an area of anterior mitral
annular calcification and is highly mobile in the LVOT,
intermittently prolapsing throught the aortic valve.
Differential diagnosis includes thrombus and papillary
fibroelastoma. Endocarditis cannot be ruled out but
seems much less likely. No abscess is seen. There is trivial
mitral regurgitation. The pulmonic valve leaflets
are not well seen. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is physiologic
tricuspid regurgitation. There is no pericardial
effusion.
IMPRESSION: Large, serpentine, highly mobile mass in the LVOT
attached to the base of the
anterior mitral leaflet on an area of mitral annular
calcification, intermittently prolapsing through
the aortic valve.
MR ___ w/o contrast
1. No evidence of acute infarction, hemorrhage or intracranial
mass.
2. Unchanged patchy and partially confluent white matter lesions
in the
cerebral hemispheres bilaterally, likely a sequela of chronic
microangiopathy.
No white matter lesions to suggest the presence of PRES.
3. Indeterminate 14 x 7 x 13 mm left parotid gland lesion.
Further evaluation
with a dedicated ultrasound and possible tissue sampling is
recommended.
RECOMMENDATION(S): Indeterminate left parotid gland lesion for
which
evaluation with a dedicated ultrasound is recommended on a
nonemergent basis.
TTE
The left atrium is SEVERELY dilated. The right atrium is
moderately enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 77 % (normal 54-73%).
Left ventricular cardiac index is normal (>2.5 L/min/m2). There
is no left ventricular outflow tract gradient at
rest or with Valsalva. Normal right ventricular cavity size with
normal free wall motion. Tricuspid annular plane
systolic excursion (TAPSE) is normal. The aortic sinus diameter
is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal
with a normal descending aorta diameter. There
is no evidence for an aortic arch coarctation. The aortic valve
leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is a centrally directed jet of
trace aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. A LARGE 1.8 cm
long highly mobile) echodensity is seen on
anterior mitral annulus in the left ventricular outflow tract
most c/w a THROMBUS (Fibroelastoma also in the
differential, but less likely given its appearance). There is
severe mitral annular calcification. There is minimal
functional mitral stenosis from the prominent mitral annular
calcification. There is mild [1+] 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 physiologic
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial pericardial
effusion.
IMPRESSION: Large highly mobile echodensity attached to the
anterior mitral annulur calcification
c/w thrombus (or fibroelastoma), but not causing obstruction.
Minimal mitral stenosis due to
prominent mitral annular calcification. Mild symmetric left
ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
No structural cardiac cause of
syncope identified.
Brief Hospital Course:
Ms. ___ is a ___ w/ PMH of HTN, T2DM, hyperlipidemia, prior
TIA in ___ and a recent kidney transplant in ___ currently on
Plavix who presented after experiencing a syncopal episode ___
___ while trying to get into the shower, found to have
hypoglycemia w labile blood sugars, and LV thrombus vs.
fibroelastoma as part of TIA workup, transferred to medicine
from neurology service for further management of her diabetes,
hypertension, and possible LV thrombus. She declined cardiac
surgery, so was started on warfarin w lovenox bridge. Her blood
sugars remained within reasonable limits.
#LV Mass
LV thrombus vs. fibroelastoma seen on TTE and TEE. Cardiology
and C-surg were consulted. Given the size and location of mass,
she was recommended to have surgical removal of this mass. Given
her recent surgeries, she declined to pursue surgery at this
time. She was started on empiric anticoagulation with heparin
gtt and transitioned to warfarin with lovenox bridge on
discharge. INR goal ___. Recommend repeat TTE in 4 weeks with
re-evaluation for cardiac surgery at that time.
#T2DM
#Syncope
Hypoglycemia to ___ likely the cause of her stroke-like
symptoms, caused by double dose of bolus insulin without eating.
Seen by ___ diabetes team for additional education regarding
pump.
#Hypertension
No hypertensive urgency or emergency. Sounds like baseline is
130s-160s at home, so not far off baseline. Can gradually
titrate to goal over several days to weeks. Increased amlodipine
to 10 mg daily.
#Renal Transplant
ESRD ___ HTN/T2DM s/p LURT on ___ at ___. Baseline
Cr is 1.7-1.8. Tacro uptitrated to 4 mg BID for goal ___.
Continued acyclovir 400 mg bid, clotrimazole troche daily, MMF
500 mg BID. Tacro level to be drawn ___.
#H/o TIA
Previously on Plavix, discontinued after initiating therapeutic
anticoagulation
TRANSITIONAL ISSUES:
======================
[] Patient found to have LV thrombus vs. papillary
fibroelastoma. She declined cardiac surgery at this time. She
can be scheduled for re-evaluation if amenable to surgical
intervention with ___ cardiac surgery department, or with
another cardiac surgeon of her choice.
[] Recommend repeat TTE in 4 weeks to evaluate size of this LV
thrombus vs. fibroelastoma
[] Given location, size of potential existing intra-cardiac
thrombus, would favor anticoagulation w/ Coumadin w/ goal INR
___ over DOAC with lovenox bridge
[] Discharged on 5 mg warfarin daily w lovenox bridge. She will
have INR drawn ___ with PCP office, who should then manage
her warfarin dosing and future INR checks
[] Patient seems to have incorrectly given herself an extra
bolus of insulin causing her syncopal event. Please continue to
discuss the safety of the insulin pump with her
[] Tacrolimus level 9.3 on discharge at 4 mg bid. Repeat level
to be drawn ___ with results sent to Dr. ___ to follow up
and adjust dosing prn
[] Plavix discontinued with initiation of warfarin. Please
ensure patient is no longer taking Plavix or aspirin while
antioagulated.
[] Indeterminate 14 x 7 x 13 mm left parotid gland lesion.
Further evaluation
with a dedicated ultrasound and possible tissue sampling is
recommended.
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
Medications on Admission:
Tacrolimus 3 mg twice daily
CellCept 500 mg twice daily
Clotrimazole 10 mg lozenge daily until ___
Acyclovir 400 mg twice daily
Citalopram 20 mg every morning
Plavix 75 mg daily
Rosuvastatin 10 mg daily
Cranberry capsules 200 mg twice daily
Calcium and vitamin D daily 500/200
Ferrous gluconate 324 daily
Eye vitamins Preservision Areds 2 1 capsule BID
Ativan 0.5mg PRN QHS
propranolol Cr 60mg daily
Vitamin D 2000IU daily
Magnesium 250mg daily
Amlodipine 2.5mg daily *this medication was recently started*
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC EVERY 12 HOURS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC every twelve (12) hours Disp
#*14 Syringe Refills:*1
2. Warfarin 5 mg PO DAILY16
RX *warfarin 2.5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Tacrolimus 4 mg PO Q12H
RX *tacrolimus 1 mg 4 capsule(s) by mouth twice a day Disp #*240
Capsule Refills:*0
5. Acyclovir 400 mg PO Q12H
6. Citalopram 20 mg PO DAILY
7. Clotrimazole 1 TROC PO DAILY
8. Ferrous GLUCONATE 324 mg PO DAILY
9. LORazepam 0.5 mg PO QHS:PRN anxiety
10. Magnesium Oxide 250 mg PO DAILY
11. Mycophenolate Mofetil 500 mg PO BID
12. Rosuvastatin Calcium 10 mg PO QPM
13. Vitamin D ___ UNIT PO DAILY
14. HELD- Propranolol 60 mg PO DAILY This medication was held.
Do not restart Propranolol until told to by your doctor
15.Outpatient Lab Work
ICD-10 Z86.718
INR
Please send results to:
Name: ___.
Phone: ___
Fax: ___
16.Outpatient Lab Work
tacrolimus, basic metabolic panel
ICD-10 code ___
Please send results to:
Name: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoglycemia
LV thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You presented to ___ because you were having
symptoms of confusion, lightheadedness, slurred speech, and
weakness.
You were initially admitted to neurology service. You had a
brain MRI which showed no acute stroke. An EEG showed no
evidence of seizure. You also had an ultrasound of your heart,
which showed a blood clot in your heart. Cardiology was
consulted and you were started on a blood thinner for this clot.
Given your fluctuating blood sugar levels, you were transferred
to the medicine service.
You should have your blood drawn on ___ at your PCP ___.
You should follow up with the results with Dr. ___ and with
Dr. ___.
You should use the lovenox injections until your INR (blood
thinner level) is at a stable level from the warfarin. Dr.
___ one of her staff members will adjust your warfarin
dose based on your INR level. You may need frequent blood tests
for this until this is at a stable dose.
Be well!
Your ___ Care Team
Followup Instructions:
___
|
10545214-DS-21 | 10,545,214 | 25,407,743 | DS | 21 | 2191-10-15 00:00:00 | 2191-10-18 08:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx diverticulitis with septic shock ___, psychiatry
attending at ___ sudden onset chills today at 4:30pm that
feel very similar to his episode of sepsis ___ years ago. Called
his PCP's office and was instructed to check his temperature at
home; he continued to experience shaking chills and had temps to
103 at home. No localizing s/s, ROS negative including no
headache, photophobia, neck stiffness, chest discomfort,
shortness of breath, cough, sputum production, nausea, vomiting,
diarrhea, abdominal pain, rash. No new medications. Started
prozac again 2 weeks prior (has been on and off this medication
for over a decade). No new exposures, odd foods or sick
contacts.
Past Medical History:
___ syndrome
Diverticulitis
Sinusitis
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS 100.5 100/70 82 20 95%RA
GEN Alert, oriented, no acute distress, diaphoretic
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
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM
VS Tm 102 (tc 98.7) 100/62 58 18 99%RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales
CV RRR normal S1/S2, no mrg
ABD soft NT ND
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 08:02PM BLOOD WBC-12.0*# RBC-5.57 Hgb-15.9 Hct-47.9
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.8 Plt ___
___ 08:02PM BLOOD Neuts-83.8* Lymphs-9.1* Monos-3.6 Eos-3.3
Baso-0.3
___ 07:00AM BLOOD Parst S-NEGATIVE
___ 08:02PM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-137
K-4.5 Cl-100 HCO3-24 AnGap-18
___ 08:02PM BLOOD ALT-23 AST-32 AlkPhos-56 TotBili-1.2
___ 08:02PM BLOOD Lipase-47
___ 08:02PM BLOOD Albumin-4.6
___ 11:54PM BLOOD Lactate-1.9
___ 08:09PM BLOOD Lactate-2.6*
CXR ___:
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Lungs
are clear. No
pleural effusion, pulmonary vascular congestion, or pneumothorax
is present.
There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 07:18AM BLOOD WBC-7.2 RBC-4.40* Hgb-12.7* Hct-38.6*
MCV-88 MCH-28.8 MCHC-32.8 RDW-13.9 Plt ___
___ 07:00AM BLOOD Neuts-75* Bands-0 Lymphs-12* Monos-13*
Eos-0 Baso-0 ___ Myelos-0 NRBC-1*
___ 07:18AM BLOOD Glucose-106* UreaN-11 Creat-1.1 Na-139
K-4.3 Cl-108 HCO___-26 AnGap-9
___ 12:50PM BLOOD HIV Ab-NEGATIVE
Brief Hospital Course:
___ w/h/o diverticulitis w septic shock presents with sudden
onset rigors and temp to 103, no localizing signs.
#Fever. Patient admitted for fever of unknown origin. Initial vs
were 102.2 133 ___ 97%. Patient was enrolled in the COMMIT
trial, received ~6L of NS. BPs fluctuated between 120 and 100
systolic; patient remained asymptomatic. Labs notable for
leukocytosis to 12 with mild left shift, lactate of 2.6. Blood
and urine cultures were sent, and patient received one dose
vancomycin and ceftriaxone empirically. On arrival to the floor,
patient reported drenching sweats, no chills. CT scan was
deferred as patient had no localizing GI symptoms to suggest
diverticulitis. Fluids were continued, antibiotics discontinued.
Leukocytosis resolved, repeat lactate normalized to 1.9. Patient
agreed to HIV testing; lyme titers and babesia smear also sent;
these were pending at time of discharge and have since returned
normal. Pt continued to spike intermittent fevers to 101, but as
he still exhibited no localizing symptoms and had no
leukocytosis, no bands, he was judged to likely be suffering
from a viral infection. He was sent home in stable condition on
hospital day 2 to follow up with his PCP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluoxetine 20 mg PO DAILY
2. Lorazepam 0.5 mg PO DAILY:PRN anxiety, insomnia
3. mometasone *NF* 50 mcg/actuation NU 2 sprays in both nostrils
BID
4. Cialis *NF* (tadalafil) 10 mg Oral daily PRN intercourse
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Lorazepam 0.5 mg PO DAILY:PRN anxiety, insomnia
3. Cialis *NF* (tadalafil) 10 mg Oral daily PRN intercourse
4. mometasone *NF* 50 mcg/actuation NU 2 sprays in both nostrils
BID
Discharge Disposition:
Home
Discharge Diagnosis:
Fever, presumed viral illness.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___ was a pleasure taking care of you here during
your stay at ___ ___. You were
admitted for fever. You were given IV fluids, and one dose of
antibiotics. Blood cultures and urine cultures were negative,
and your chest X-ray was clear. After two nights continued to be
intermittently febrile, but with no elevated white blood cell
count. Presumed diagnosis was a viral illness. You were sent
home in stable condition to follow up with your PCP.
Followup Instructions:
___
|
10545650-DS-21 | 10,545,650 | 29,282,604 | DS | 21 | 2173-11-17 00:00:00 | 2173-11-20 11:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lithium / Sulfa (Sulfonamide Antibiotics) / Neomycin / latex
Attending: ___.
Chief Complaint:
R knee swelling
Major Surgical or Invasive Procedure:
___ Aspiration of R knee
History of Present Illness:
This is a ___ female who has had recurrent issues with pain and
swelling of her right knee since injury in ___ when she tripped
over a phone charger cord in early ___ and presented to the
___
___ ED. Per patient report, at that time, initial
radiographs demonstrated a soft tissue fluid collection around
her knee and CT was negative for fracture. The fluid collection
was eventually aspirated. Since that time, Ms ___ states
that the fluid has re-accumulated and required repeat aspiration
at least 6 times, most recently about 1 month ago, at which time
area was injected with lido with epi and cortisone. She has also
undergone ___. The re-accumulation typically begins over the
right patella and spreading upward along the medial thigh. She
was recently seen in clinic by ___ after being referred for
possible sclerotherapy. She was scheduled for ___ guided drainage
on ___, but developed worsening pain so presented to the ED.
She has only been taking tylenol for pain over the past ___
months. She denies any recent fevers, chills ,dizziness,
lightheadedness, difficulty ambulating.
In the ED initial vitals were: 6 98.7 92 120/93 18 97%
- Labs were not done
- Patient was given 1 tab vicodin PO, 5mg morphine.
On arrival to the floor, patient's pain had completely resolved
following IV morphine in the ED.
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:
NIDDM
HTN
HPL
hypothyroidism
PAD
Venous insufficiency
CAD
osteoarthritis of right knee (TKR planned)
Bipolar
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION
=====================================
Vitals - T: 97.9 BP: 130/72 HR: 78 RR: 02 sat:
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese, soft, mild LLQ tenderness to deep palpation,
otherwise nontender. no rebound or guarding
EXTREMITIES: moving all extremities well. R knee with large
effusion tracking up to anterior thigh. Some overlying
hyperpigmentation, but not frankly erythematous or warm.
bilateral varices
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE
=====================================
Vitals - 97.6; 98.1; 63-67; 111/68; 18; 98/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABDOMEN: soft, mild LLQ tenderness to deep palpation, otherwise
nontender. no rebound or guarding
EXTREMITIES: R knee with effusion, mildly tender to palpation.
Effusion tracks up to medial thigh, firm in this area. Some
overlying hyperpigmentation, but not erythematous or warm. Mild
pitting edema to bilateral ankles, mild chronic venous changes
to mid-tibia bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: moving all extrermities
SKIN: warm and well perfused
Pertinent Results:
LABS ON ADMISSION:
___ 07:55AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.0
___ 07:55AM BLOOD Glucose-125* UreaN-26* Creat-1.0 Na-140
K-4.2 Cl-103 HCO3-30 AnGap-11
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD WBC-6.3 RBC-3.70* Hgb-11.1* Hct-35.1*
MCV-95 MCH-29.9 MCHC-31.5 RDW-14.2 Plt ___
LABS ON DISCHARGE: none
Brief Hospital Course:
This is a ___ F with history of DM2, PAD, HTN, bipolar disorder
and recent issues with recurrent R knee fluid collection here to
undergo aspiration and possible sclerotherapy by ___.
ACUTE ISSUES
========================
# R knee fluid collection: On ___ eval, collection thought to be
serous rather than hemorrhagic and plan was for drainage and
subsequent sinogram to evaluate anatomy in preparation for
possible sclerotherapy. She has been holding aspirin in
preparation for this procedure. Patient remained afebrile,
without leukocytosis. Pain well-controlled during admission with
tylenol TID. During the sinogram, there appeared to be
communicationg with the joint and therefore sclerotherapy could
not be performed. 700cc hemorrhagic fluid were drained and an
ace bandage was placed on knee with plans for follow up with ___
clinic.
CHRONIC ISSUES
=========================
# Type 2 DM: Held glipizide, SSI in house
# Bipolar disorder: continue bupropion, lamotrigine
TRANSITIONAL ISSUES
=========================
- Follow-up with ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. GlipiZIDE 5 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. LaMOTrigine 150 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Lorazepam 0.5 mg PO DAILY:PRN anxiety
9. TraMADOL (Ultram) 75 mg PO TID:PRN pain
10. Furosemide 20 mg PO DAILY:PRN leg swelling
11. Metoprolol Tartrate 50 mg PO BID
12. Gabapentin 400 mg PO TID
13. Pravastatin 80 mg PO DAILY
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Gabapentin 400 mg PO TID
3. LaMOTrigine 150 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Pravastatin 80 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Furosemide 20 mg PO DAILY:PRN leg swelling
12. GlipiZIDE 5 mg PO DAILY
13. Lorazepam 0.5 mg PO DAILY:PRN anxiety
14. TraMADOL (Ultram) 75 mg PO TID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Right knee hematoma
SECONDARY DIAGNOSIS:
Diabetes mellitus type II
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank ___ for letting us participate in your care at ___
___. ___ were scheduled for a procedure to drain your
right knee on ___, but ___ presented to the ED earlier due to
pain. Your pain was well-controlled while ___ were in the
hospital with Tylenol, and ___ underwent the procedure without
any complications.
Followup Instructions:
___
|
10545650-DS-23 | 10,545,650 | 25,999,590 | DS | 23 | 2174-01-09 00:00:00 | 2174-01-09 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lithium / Sulfa (Sulfonamide Antibiotics) / Neomycin / latex /
Vicodin
Attending: ___.
Chief Complaint:
Right foot pain
Major Surgical or Invasive Procedure:
Incision and drainage of right foot abscess ___ and ___
History of Present Illness:
Ms. ___ is a ___ year old F with PMH of T2DM, CAD, PAD, and
reports of a recent right ankle fracture on ___ with air
cast in place now who presents with complaint of right foot and
knee pain. Pt states she has "cellultitis and edema" of the
right foot. Pt reports that she was sitting on the edge of her
bed and fell off the edge of the bed twisting her ankle. She was
seen in urgent care and was found to have nondisplaced R lateral
malleolar fracture. The brace is causing more pressure and pain
on R knee where hematoma is located. She also reports worsening
R foot erythema for which she was seen by her PCP ___ ___ who
recommend continuing the levofloxacin and monitoring.
Of note she was recently hospitalized from ___ until
___ when she presented with warmth/redness/tenderness at
right thigh percutaneous drain site and was found to have an
infected thigh hematoma. Pt fell and hit her right knee in ___, which caused hematoma that was unsuccessfully drained
multiple times. Recently had right thigh drain placed by ___ on
___, and felt initially was improving with decreased swelling
in the leg. She had an MRI thigh/knee was done to ensure no
communication of the thigh cavity with the joint space which did
not show any evidence of communication with the joint space.
Cultures of the thigh grew GNRs and GPCs (pairs/chains) and pt
was treated with vancomycin and unasyn. The cultures grew mixed
bacterial flora with sensitivities to levofloxacin. She had
drainage with sclerotherapy treatment and drain removal with
interventional radiology on ___. She was discharged on
levofloxacin with planned 14 day course on ___.
In the ED initial vitals were: 10 97.6 68 106/60 18 97% RA
- Labs were significant for Cr 1.4, WBC 5.9 with 74% PMNs.
- She had x-ray of the rightknee/ankle which showed...
- Patient was given Ibuprofen 800 mg, IV Morphine Sulfate 2 mg,
IV Vancomycin 1000 mg, and IVF 1L NS.
Vitals prior to transfer were: 97.4 65 118/48 16 96% RA
On the floor, pt reports that she does not have right foot pain
at rest. It is only present with ambulation. She denies fevers,
chills. or night sweats.
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:
NIDDM
HTN
HPL
hypothyroidism
PAD
Venous insufficiency
CAD
osteoarthritis of right knee (TKR planned)
Bipolar
CKD stage III (baseline Cr 1.3-1.4 in Atrius records most
recently)
Social History:
___
Family History:
Mother died of cervical cancer, father, smoker, died of lung
cancer. Does not know of any other family history. Sister in
good health, as are sons.
Physical Exam:
==== PHYSICAL EXAM ON ADMISSION ====
Vitals - T:98.0 BP:98/74 HR:76 RR:18 02 sat:99%RA
GENERAL: NAD
HEENT: brusing on face EOMI, PERRL, anicteric sclera, pink
conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: right foot with dorsal warmth, swelling and
erythema which I outlined, ttp over erythematous area. Swelling
over the right lateral malleolous. Right thigh without heali
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: venous stasis changes over bilateral shins
==== PHYSICAL EXAM ON DISCHARGE ====
Vitals - Tm 98.6 BP: 108/57 HR 60 RR 18 02 sat: 95-98% RA, ___
99-172
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: right foot with residual warmth and erythema on
dorsal aspect, now s/p I&D by podiatric surgery. TTP over
erythematous area. Right thigh percutaneous drain site intact,
no erythema.
PULSES: 1+ DP pulses bilaterally
Pertinent Results:
On admission:
___ 12:10AM BLOOD WBC-5.9 RBC-3.43* Hgb-9.8* Hct-30.9*
MCV-90 MCH-28.7 MCHC-31.9 RDW-16.0* Plt ___
___ 12:10AM BLOOD Neuts-74.0* Lymphs-16.3* Monos-5.6
Eos-3.1 Baso-1.0
___ 12:10AM BLOOD Glucose-125* UreaN-35* Creat-1.4* Na-141
K-4.2 Cl-106 HCO3-27 AnGap-12
___ 12:14AM BLOOD Lactate-0.6
In the interim:
___ 07:15AM BLOOD Glucose-157* UreaN-40* Creat-2.1* Na-140
K-4.2 Cl-103 HCO3-25 AnGap-16
___:
___ 06:00AM BLOOD WBC-4.4 RBC-3.59* Hgb-10.1* Hct-32.7*
MCV-91 MCH-28.0 MCHC-30.7* RDW-15.9* Plt ___
___ 06:00AM BLOOD Glucose-148* UreaN-33* Creat-1.1 Na-141
K-4.2 Cl-106 HCO3-27 AnGap-12
MICROBIOLOGY:
Blood cultures (___): NGTD.
IMAGING and other studies:
R foot, X-ray 3 views (___):
IMPRESSION:
No fracture or dislocation.
R Tib/Fib X-ray (___):
IMPRESSION:
No fracture or dislocation.
R foot ultrasound, soft tissue (___):
IMPRESSION:
There is a 4.2 x 3.5 x 0.9 cm fluid collection along the dorsum
of the right foot with mixed echogenic contents concerning for
possible abscess. There is no gas seen in subcutaneous soft
tissues.
Brief Hospital Course:
___ year old F with PMH of T2DM, CAD, PAD who presents with
complaint of right foot and knee pain, found to have cellulitis
affecting dorsum of right foot with accompanying abscess at that
location.
# Right foot cellulitis: Pt with reported history of
non-displaced right malleolar fracture on ___ after a fall
who presented with worsening erythema overlying the right dorsum
of the foot concerning for cellulitis. XRays of right
tib/fib/foot in-house were negative for fracture. Received IV
vancomycin in ED. Was subsequently switched to doxycycline for
PO MRSA coverage. RLE U/S revealed a 4.2x3.5x0.9cm fluid
collection and the patient underwent I&D with Podiatric Surgery
on ___. Her pain was managed with tramadol, tylenol and
oxycodone. The patient has been performing partial weight
bearing of right foot with unna boot.
# ___: The patient had an elevated creatinine on admission (1.4
on ___ which rose to a peak of 2.1. This was determined to be
pre-renal in origin given the elevated BUN/Cr ratio. She
received 1L NS volume repletion and her creatinine trended down
to her baseline of 1.1 by ___.
# Polymicrobial thigh hematoma: Pt is s/p percutaneous drainage
of right thigh and was found to have an infected polymicrobial
thigh hematoma. She is currently on levofloxacin for this
infection, with a planned 14 day course scheduled to end on
___.
# Recent Falls: Pt with report of multiple recent falls. She
denies dizziness or lightheadedness but notes that she has
decreased feeling in her feet. Etiology of her falls is likely
diabetic peripheral neuropathy.
==== TRANSITIONAL ISSUES ====
- Patient is to complete her course of levofloxacin on ___.
- Patient is to complete her course of doxycycline on ___.
- Patient's lasix was stopped during this admission due to
kidney injury on presentation and concern for orthostasis
leading to falls; need may be reassesed as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. Gabapentin 400 mg PO TID
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. LaMOTrigine 150 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Lorazepam 0.5 mg PO DAILY:PRN anxiety
9. Metoprolol Tartrate 50 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 80 mg PO DAILY
12. TraMADOL (Ultram) 75 mg PO TID:PRN pain
13. GlipiZIDE 5 mg PO DAILY
14. Furosemide 20 mg PO DAILY:PRN leg swelling
15. Docusate Sodium 100 mg PO BID constipation
16. Senna 8.6 mg PO BID constipation
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN
breakthrough pain
18. Levofloxacin 750 mg PO Q24H
19. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Docusate Sodium 100 mg PO BID constipation
4. Gabapentin 400 mg PO TID
5. LaMOTrigine 150 mg PO DAILY
6. Levofloxacin 750 mg PO Q24H
The last day you should take this medication is ___.
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN
breakthrough pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*28 Tablet Refills:*0
12. Pravastatin 80 mg PO DAILY
13. Senna 8.6 mg PO BID constipation
14. TraMADOL (Ultram) 75 mg PO TID:PRN pain
RX *tramadol [Ultram] 50 mg 1.5 tablet(s) by mouth three times a
day Disp #*28 Tablet Refills:*0
15. Doxycycline Hyclate 100 mg PO Q12H
The last day you should take this medication is ___.
16. GlipiZIDE 5 mg PO DAILY
17. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Cellulitis of right foot
Secondary Diagnosis:
Abscess of right foot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ for evaluation of right
foot and knee pain. You were found to have cellulitis affecting
your right foot and received intravenous antibiotics for this
infection. You were also found to have a fluid collection /
abscess of the right foot which was drained by the Podiatry
team. You will receive a total of 10 days of antibiotic therapy
for your cellulitis.
Regarding your preexisting thigh infection, your outpatient
antibiotics (levoquin / levofloxacin) were continued while
inpatient. You will complete your course as an outpatient.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10545740-DS-6 | 10,545,740 | 25,939,582 | DS | 6 | 2153-04-06 00:00:00 | 2153-04-07 08:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
pain crisis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ 9 weeks pregnant w/sickle cell recently discharged from ___
presents with full body pain consistent with prior sickle cell
crisis. Pain started yesterday, is constant, worse in hips, low
back and legs. She reports having weekly pain crisis while she
is pregnant. She was just discharged from ___ with pain crisis
on ___.
In ED pt given cefepime, dilaudid, 1Lns, lorazepam
ROS: +as above, otherwise reviewed and negative
Past Medical History:
PE in ___ on lovenox
Sickle cell disease
- c/b acute chest and avasular necrosis
Social History:
___
Family History:
+sickle cell
Physical Exam:
ADMISSION
Vitals: T:98.8 BP:154/61 P:75 R:18 O2:95%ra
PAIN: 10
General: moderate distress due to pain
Lungs: clear anteriorly
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
DISCHARGE
VS: T:98 HR:83 BP:102/60 RR: 16 94%ra
PAIN: 4
Gen: NAD, sitting comfortably in bed
CV: RRR nl s1s2, II/VI soft systolic murmur ULSB
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Neuro: alert, speech fluent, moving all extremities, follows
commands
Skin: warm, dry no rashes
MSK: full rom of bilateral hips but with moderate pain
Pertinent Results:
___ 10:45PM GLUCOSE-106* UREA N-6 CREAT-0.5 SODIUM-132*
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-18* ANION GAP-19
___ 10:57PM LACTATE-3.2*
___ 10:45PM ALT(SGPT)-31 AST(SGOT)-68* LD(___)-858* ALK
PHOS-98 TOT BILI-2.6*
___ 10:45PM LIPASE-34
___ 10:45PM ALBUMIN-4.3 CALCIUM-10.4* PHOSPHATE-2.8
MAGNESIUM-1.6
___ 10:45PM WBC-17.2* RBC-2.12* HGB-7.1* HCT-20.8* MCV-98
MCH-33.7* MCHC-34.3 RDW-19.9*
___ 10:45PM NEUTS-64.1 ___ MONOS-5.8 EOS-1.2
BASOS-0.6
___ 10:45PM PLT COUNT-473*
___ 10:45PM ___ PTT-27.0 ___
___ 06:35AM BLOOD WBC-7.6 RBC-2.37* Hgb-7.2* Hct-21.6*
MCV-91 MCH-30.5 MCHC-33.4 RDW-18.2* Plt ___
___ 06:35AM BLOOD Glucose-91 UreaN-5* Creat-0.3* Na-138
K-3.8 Cl-105 HCO3-23 AnGap-14
___ 06:20AM BLOOD LD(___)-723* TotBili-1.5
PELVIC US ___ FINDINGS:
Examination is limited secondary to patient intolerance.
Allowing for this, the ovaries are normal in appearance. The
right ovary measures 3.8 x 2.6 x 2.9 cm. The left ovary measures
2.7 x 1.9 x 0.9 cm. Waveforms could not be obtained secondary
to the limitations as described above. There is an intrauterine
live fetus with a heart beat measuring 179 beats per minute.
Limited views of the uterus are unremarkable. The cervix is
unremarkable. There is no pelvic free fluid.
IMPRESSION: Live intrauterine pregnancy.
Brief Hospital Course:
___ 10 weeks pregnant w/sickle cell recently discharged from ___
presents with full body pain consistent with prior sickle cell
crisis.
Sickle Cell Disease: with acute pain crisis, hemolysis with
worsening acute on chronic anemia. She was initially placed on
Dilaudid PCA but requested transition to morphine PCA. She was
continued on her MS ___. Pain was improving significantly but
worse again today. Received 2 units pRBC on ___, hemoglobin
increased appropriately and is stable. Empiric ceftriaxone
started ___ due to increasing fever curve, no localizing signs
of infection but she is developing some chest pain. No
consolidation on CXR but possible early acute chest syndrome.
Has chronic bilateral AVN of her hips without prior therapy, low
likelihood for infection in hips given bilateral pain and good
ROM. Given worsening symptoms will sent hemoglobin
electrophoresis to determine % Hgb S, with plan that if very
elevated discuss with hematology performing exchange transfusion
which she has required in the past. However pt's symptoms
started to improve and she was able to transition off of PCa to
her home oral pain regimen before electrophoresis resulted. She
completed a 5 day course of ceftriaxone for fevers without clear
source. She received IV and PO hydration as well as Incentive
spirometer and supplemental O2.
Prior DVT: cont lovenox
Pregnancy: 10 weeks pregnant, had some mild white vaginal
discharge which is new. OBGYN evaluated, low concern for pelvic
infection, pelvic ultrasound showing no evidence of tubo-ovarian
abscess. GC/chlamydia cultures negative.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Famotidine 20 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Hydroxyurea 1000 mg PO QHS
5. Morphine SR (MS ___ 15 mg PO Q8H
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Enoxaparin Sodium 40 mg SC DAILY
8. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 50 mg SC Q12H
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
2. Famotidine 20 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Morphine SR (MS ___ 15 mg PO Q8H
RX *morphine 15 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Prenatal Vitamins 1 TAB PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Sickle cell crisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a sickle cell crisis. You were treated
with IV pain medications and fluids. You also had fevers and
were treated with antibiotics for possible acute chest syndrome.
OBGYN evaluated you and found no significant abnormalities. You
should follow up closely with your primary care physician,
hematologist and OBGYN doctors.
Followup Instructions:
___
|
10545967-DS-14 | 10,545,967 | 27,498,545 | DS | 14 | 2186-05-20 00:00:00 | 2186-05-20 15:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric and bilateral flank pain
Major Surgical or Invasive Procedure:
open thoracoabdominal repair
History of Present Illness:
Ms. ___ is a ___ year old female smoker who was transferred
to the Emergency Department from ___ for evaluation of
symptomatic thoracoabdominal aortic aneurysm. She reports onset
of epigastric and bilateral flank pain about 1 week ago. The
pain
is constant and has worsened in severity since its onset. She
denied any associated GI or GU symptoms and has been tolerating
a
diet without issue. She has never had pain like this previously.
She initially presented to ___ for evaluation this
morning, where her imaging revealed a 6cm thoracoabdominal
aortic
aneurysm. Her workup, which included evaluation for
pancreatitis,
gall stones, kidney stones, or acute coronary syndrome was
otherwise negative. She was transferred to ___ for
vascular surgery evaluation.
In the Emergency Department, she is afebrile and hemodynamically
stable. She continues to report epigastric pain. On exam, she is
tender to palpation in the epigastrium and has a palpable
pulsatile mass. Her OSH imaging was reviewed with radiology who
agreed that there were no findings concerning for impending
rupture.
Past Medical History:
PMH:
bilateral tinnitis
PSH:
lumbar surgery
C section
appendectomy
panniculectomy
Social History:
___
Family History:
Family History:
Father with CAD
Mother with lung cancer
Physical Exam:
Admission Exam:
Vitals: T 99.5, HR 77, BP 123/82, RR 18, SPO2 99% RA
General: AAOx3, non-toxic appearing
CV: RRR, no murmur
Pulm: normal rsepiratory effort, CTA bilaterally
GI: Abdomen soft, non-distended, tender to palpation in
epigastrium without rebound or guarding, palpable pulsatile mass
Extremities: warm and well perfused
Pulses: R: p/p/p/p L: p/p/p/p
Discharge Exam:
Vitals: 24 HR Data (last updated ___ @ 811)
Temp: 97.9 (Tm 98.2), BP: 182/49 (149-182/49-67), HR: 70
(62-70), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery: Ra,
Wt: 132.2 lb/59.97 kg
GENERAL: [x]NAD [x]A/O x3 []intubated/sedated []abnormal
CV: [x]RRR []irregularly irregular []no MRG []Nl S1S2
[]abnormal
PULM: []CTA b/l [x]no respiratory distress []abnormal
ABD: [x]soft []Nontender [x]appropriately tender
[]nondistended []no rebound/guarding []abnormal
WOUND: [x] left thoracoabdominal incision c/d/i, staples in
place, no wound drainage or erythema, former CT sites c/d/I no
drainage
EXTREMITIES: Bilateral lower extremity ___ strength
PULSES: R: p/p L: p/p
Pertinent Results:
Admission Labs:
======================
___ 06:15PM BLOOD WBC-8.1 RBC-4.06 Hgb-13.4 Hct-40.4
MCV-100* MCH-33.0* MCHC-33.2 RDW-12.8 RDWSD-46.9* Plt ___
___ 06:15PM BLOOD Neuts-58.5 ___ Monos-11.0 Eos-1.9
Baso-0.7 Im ___ AbsNeut-4.73 AbsLymp-2.22 AbsMono-0.89*
AbsEos-0.15 AbsBaso-0.06
___ 06:15PM BLOOD ___ PTT-29.9 ___
___ 06:15PM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-140
K-4.9 Cl-104 HCO3-21* AnGap-15
___ 06:15PM BLOOD ALT-13 AST-18 AlkPhos-85 TotBili-0.7
___ 02:41AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9
Interval Labs:
=====================
___ 01:48PM BLOOD WBC-17.1* RBC-2.51* Hgb-7.7* Hct-23.7*
MCV-94 MCH-30.7 MCHC-32.5 RDW-14.2 RDWSD-49.1* Plt ___
___ 09:51AM BLOOD WBC-18.4* RBC-3.42* Hgb-10.3* Hct-31.0*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.6 RDWSD-48.6* Plt ___
___ 06:15PM BLOOD WBC-16.5* RBC-3.73* Hgb-11.3 Hct-34.2
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.6 RDWSD-48.8* Plt ___
___ 02:24PM BLOOD Neuts-79.2* Lymphs-17.9* Monos-1.1*
Eos-0.8* Baso-0.1 Im ___ AbsNeut-7.12* AbsLymp-1.61
AbsMono-0.10* AbsEos-0.07 AbsBaso-0.01
___ 02:29AM BLOOD ___ PTT-30.2 ___
___ 02:31AM BLOOD ___ PTT-28.5 ___
___ 03:06AM BLOOD Glucose-97 UreaN-17 Creat-0.6 Na-136
K-4.6 Cl-100 HCO3-28 AnGap-8*
___ 02:50AM BLOOD Glucose-84 UreaN-15 Creat-0.6 Na-137
K-4.6 Cl-102 HCO3-20* AnGap-15
___ 01:24AM BLOOD ALT-57* AST-59* LD(LDH)-374* AlkPhos-607*
TotBili-0.5
___ 02:39AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
___ 03:17PM BLOOD Type-ART Temp-36.9 pO2-75* pCO2-34*
pH-7.46* calTCO2-25 Base XS-0
___ 01:35AM BLOOD Type-ART pO2-66* pCO2-26* pH-7.52*
calTCO2-22 Base XS-0
___ 03:18AM BLOOD freeCa-1.22
Discharge Labs:
=========================
___ 06:13AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.8* Hct-34.0
MCV-95 MCH-30.1 MCHC-31.8* RDW-13.4 RDWSD-46.4* Plt ___
___ 06:13AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-138
K-4.3 Cl-102 HCO3-27 AnGap-9*
___ 04:50AM BLOOD Calcium-8.7 Phos-4.5 Mg-1.8
Microbiology:
========================
___ 2:12 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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
___ 5:17 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:25 am URINE Site: CLEAN CATCH Source:
Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Imaging/Studies:
============================
___ CTA Torso
IMPRESSION:
1. Thoracoabdominal aortic aneurysm measuring maximum transverse
___ of
4.6 x 4.1 cm (ap x tv, 3:36) in the thorax and maximum
transverse ___
of 5.6 x 6.1 cm (ap x tv, 3:84) in the abdomen with noncalcified
and calcified
mural plaques. There is no evidence of dissection, intramural
hematoma, or
penetrating ulcer.
2. The aorta and the major vessels in the abdomen pelvis are
patent. Note is
made of a separate origin of the left gastric artery originating
from the
aorta. There is mild-to-moderate narrowing of the origin of the
celiac
artery.
3. Probable fibroid uterus.
4. 3 mm lung nodule in the right upper lobe and 3 mm subpleural
nodule in the
superior segment of the right lower lobe.
5. Retroperitoneal lymph nodes measuring up to 1.1 cm in short
axis,
nonspecific in etiology, could be reactive.
For incidentally detected multiple solid pulmonary nodules
smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an
optional CT
follow-up in 12 months is recommended in a high-risk patient.
___ TTE
IMPRESSION: Mildly dilated ascending and descending thoracic
aorta. Normal biventricular
cavity sizes and regional/global biventricular systolic
function. No valvular pathology or
pathologic flow identified. High normal estimated pulmonary
artery systolic pressure.
___ MRI Cervical Thoracic
IMPRESSION:
1. Limited examination due to patient motion, within this
limitation, there is
evidence of multilevel degenerative changes throughout the
cervical spine,
more significant from C3-C4 through C6-C7 levels. There is no
evidence of
spinal cord signal abnormality throughout the cervical spine.
2. A small fluid collection about the proximal descending
thoracic aorta is
likely secondary to recent repair. Attention on follow-up
recommended.
3. Bilateral pleural effusions, small on the right and large on
the left. The
left effusion appears loculated with at least partial collapse
of the left
upper and lower lobes.
4. Mild multilevel degenerative changes throughout the thoracic
spine with no
evidence of abnormalities throughout the thoracic spinal cord.
5. Multilevel, multifactorial degenerative changes throughout
the lumbar
spine, more significant at L3-L4 and L4-5 levels.
6. 1.8 x 1.1 cm right thyroid lobe cyst. If not previously
known, non urgent
thyroid ultrasound recommended for further evaluation.
RECOMMENDATION(S): 1.8 x 1.1 cm right thyroid lobe cyst.
Ultrasound follow
up recommended.
___ College of Radiology guidelines recommend further
evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5
cm in patients age ___ or ___, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___ EGD
Findings: Esophagus: Grade A esophagitis with no bleeding was
seen in the distal esophagus
Normal mucosa was noted in the whole stomach
A single superficial 1.5cm ulcer was found in the duodenal bulb
and sweep. A visible vessel suggested recent bleeding. Two
endoclips were successfully applied to the duodenal bulb and
sweep for the purpose of hemostasis
Impressions:
Grade A esophaghitis in the distal esophagus
Normal Mucosa in the whole stomach
Ulcer in teh duodenal bulb and sweep (endoclip)
Recommendations:
Start highd ose IV PPI BID
Trend hgb
Recommend outpatient EGD in x2-3months to evaluate esohpagitis
Brief Hospital Course:
Ms. ___ is a ___ year old female smoker who was transferred
to the Emergency Department from ___ on ___ for
evaluation of a
6cm symptomatic type II found on CT. She was afebrile and
hemodynamically stable with SBP of 120s. There was no evidence
concerning for acute or impending aneurysm rupture on imaging.
So the patient was transferred to the ICU admission for
monitoring and blood pressure control pending aneurysm repair.
She was medically cleared for surgery. On ___ she underwent an
open thoracoabdominal aortic aneurysm repair. There were no
complications during the procedure. She was transferred from the
OR to the CVICU still intubated. Remainder of hospital course
discussed by systems below.
Hospital Course
[]Neuro: Post operatively pt was weaned from sedation and
extubated. She had a normal neurological exam. POD2 she endorsed
being unable to move her legs, the left was worst than the
right. Pt was immediately placed on rescue protocol with goal
ICP pressure less than 10mmhg goal draining 10cc per hour, with
MAP above 90. Neurology was consulted with recommended an MRI
which was negative for cord ischemia. Patient slowly regained
strength in both her legs. POD8 spinal drain capped, and removed
the following day without issue. Leg strength on exam noted to
have improved significantly. Prior to leaving CVICU patient was
working with ___ and ambulating independently. On arrival to VICU
continued to demonstrate appropriate lower
extremity strength. Pain was controlled on Tylenol PO dilaudid
and gabapentin.
- discharged on tramadol (20 tablets), and gabapentin
[]CV: Pt was hemodynamically stable through POD1. Her Hct was 48
post operatively With the start of the rescue protocol she
maintained a MAP 90-110. She was transfused twice to keep HgB
>12 per rescue protocol. POD3 pt went into afib with RVR. With
meoprol 5mg x2 and amio bolus/ggt her RVR resolved. Vascular
medicine recommended she continue amio and digoxin for her Afib.
POD 6 her MAPs fell to ___ and she was restarted back on neo.
POD 6 She resumed her atorvastatin. Remained intermittently on
neo to maintain MAP>80, and was fully weaned off by POD11. On
arrival to VICU, patient was maintained in permissive
hypertension. Regarding her paroxysmal atrial fibrillation,
digoxin was discontinued and amiodarone weaned to 200 daily.
Toprol started for rate control. Following comfort with
normalizing blood pressures, would consider switching to coreg.
- Amiodarone 200 mg qd x 30d
- Toprol 25 qd
- eliquis 5mg bid
- Follow up with outpatient cardiology scheduled ___ w/ Dr.
___. Will plan to discuss continuation of eliquis + amio,
?holter for afib.
- Follow up hypertension, inpt cardiology recommended starting
coreg instead of toprol.
[]Pulm: Extubated uneventfully in CVICU, Post operatively
patient required O2 via NC to maintain SaO2 of 100%.
Transitioned to room air shortly thereafter and has remained
stable.
[]FEN/GI: Patient was resumed on regular diet. POD10 Hgb
9.8->7.3, episode of melena, GI consulted for EGD which was
notable for grade a esophagitis and 1.5 cm duodenal ulcer now
s/p clipping for hemostasis. Hgb thereafter has remained stable.
Patient to remain on twice daily dosing of ppi x4 weeks, once
daily thereafter. GI team okay with starting anticoagulation for
afib. H. Pylori ag pending at discharge.
- follow up ___ mo for outpatient EGD to evaluate esophagitis
- PPI bid
- f/u pylori ag
- follow up scheduled for ___ with Dr. ___
[]Endo: Pt on SSI throughout hospital course. Pt found to have a
1.1cm R thyroid cyst found on her CTA. TSH wnl
- outpatient PCP/Endo follow up
[]Heme: Pt was transfused twice to keep Hg>/=12.0 per protocol.
She continued on SQH for DVT ppx. Pt with afib throughout
hospital course and CHADVAS score is 2 so patient started on
(elliquis) before discharge.
[]GU: Pt with foley throughout CVICU course, removed on POD9,
voided without issue. Treated for urinary tract infection
POD3-6(see below). ___ during hospital course resolved s/p IVF.
[]ID: Pt with elevated WBC on POD2. UA significant for UTI so
patient placed on Ceftriaxone for E.coli UTI completed ___ (3d
course). Subsequent urine analysis + culture without evidence of
infection. At time of discharge she did not endorse dysuria,
frequency, or hesitancy.
Transitional Issues:
====================
- Follow up with outpatient cardiology scheduled ___ w/ Dr.
___. Will plan to discuss continuation of eliquis + ___,
?___ for afib.
- Follow up hypertension, inpt cardiology recommended starting
coreg if no longer allowing permissive hypertension in light of
recent spinal ischemia.
- Follow up ___ mo for outpatient EGD to evaluate esophagitis
(scheduled for ___ with Dr. ___
- Patient needs PCP, ensure she has made arrangements
- Follow up to be scheduled with vascular surgery
- 1.1cm R thyroid cyst found on her CTA. TSH wnl
- f/u pylori ag
- New meds: tramadol (20 tablets), and gabapentin 300 bid,
pantoprazole 40 bid, eliquis 5 bid, Toprol 25, amiodarone 200 qd
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Amiodarone 200 mg PO DAILY Duration: 27 Days
Take once daily for one month total, you received your first
doses in the hospital.
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*27
Tablet Refills:*0
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*1
4. Gabapentin 300 mg PO BID
This medication may make you drowsy. Avoid driving until effects
are observed.
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*40 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q12H Duration: 30 Days
Please take this medication twice daily until ___, then take
once daily.
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
7. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Take ___ to full tablet every 6 hours as needed for pain. Do not
drive while taking this medication.
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Thoracoabdominal aneurysm
Spinal ischemia
Gastric Ulcer
Esophagitis
Acute Kidney Injury
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after for
repair of an aneurysm located in an artery within your abdomen.
To perform this procedure, an incision was made across your
abdomen and back to visualize and repair the defect. Following
the procedure, you were admitted to the intensive care unit for
continued monitoring. We discovered that you temporarily had
weakness of your legs. You were started on a resuscitation
protocol, and your symptoms resolved. While we were monitoring
you, we noticed that you briefly had an irregular heart rhythm.
The cardiology team was consulted, and you were started on
medications to help maintain a normal heart rhythm.
Additionally, while in the ICU you had a bleeding ulcer that was
discovered within your stomach. A procedure was performed by the
gastroenterology team where the bleeding was stopped. After
several days of stability in the ICU, you were transferred to
the floor service where you continued to demonstrate
improvement. On ___, we felt you were safe for discharge home.
Please note changes to your medications as listed on the
attached documents.
Please plan on attending follow up primary care, cardiology, and
gastroenterology.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
MEDICATIONS
Before you go home, your nurse ___ give you information about
new medications and will review all the medications you should
take at home. Be sure to ask any questions you may have. If
something you normally take or may take is not on the list you
receive from the nurse, please ask if it is okay to take it.
DIET
It is normal to have a decreased appetite. Your appetite will
return over time.
Follow a well balance, heart-healthy diet, with moderate
restriction of salt and fat.
Eat small, frequent meals with nutritious food options (high
fiber, lean meats, fruits, and vegetables) to maintain your
strength and to help with wound healing.
BOWEL AND BLADDER FUNCTION
You should be able to pass urine without difficulty. Call you
doctor if you have any problems urinating, such as burning,
pain, bleeding, going too often, or having trouble urinating or
starting the flow of urine. Call if you have a decrease in the
amount of urine.
You may experience some constipation after surgery because of
pain medicine and changes in activity. Increasing fluids and
fiber in your diet and staying active can help. To relief
constipation, you may talk a mild laxative. Please take to
your pharmacist for advice about what to take.
SMOKING
If you smoke, it is very important that you STOP. Research
shows smoking makes vascular disease worse. This could increase
the chance of a blockage in your new graft. Talk to your
primary care physician about ways to quit smoking.
Followup Instructions:
___
|
10546009-DS-4 | 10,546,009 | 29,545,275 | DS | 4 | 2168-10-28 00:00:00 | 2168-10-28 09:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
unable to give
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Asked to evaluate this ___ year old white male with unknown
past medical history for bi-frontal sdh. Per ED, the pt was
intoxicated and being asked to leave a party when he was punched
in the face and fell backwards striking his head with witnessed
LOC. He was brought to the hospital for evaluation.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
O: T: 97.6 BP:135 /67 HR:72 R 15 O2Sats___
Gen: WD/WN, comfortable, NAD at rest / on stretcher in hard
collar
HEENT: Pupils: ___ EOMi grossly
Neck: in collar
Extrem: Warm and well-perfused./ bruising to bilateral tricep
regions
Neuro:
Mental status: Lethargic/ difficult to arouse / non cooperative
with exam.
Orientation: non participating / states "stop it" or " alright"
to most questions.
Recall: unable
Language: Speech fluent / one - two word statements .
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to2
mm bilaterally. Visual fields uanblet to test.
III, IV, VI: Extraocular movements grossly intact bilaterally
without nystagmus.
V, VII: Facial strength and sensation unable to assess. no
obvious facial
VIII: Hearing intact to voice.
IX, X: Palatal elevation unable to assess
XI: Sternocleidomastoid and trapezius uanble to assess .
XII: Tongue appears midline
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
CT:Bi frontal sdh / L>R, sulcal effacement on the left out of
proportion to sdh
On Discharge:
A&OX3
PERRL
EOMS intact
face symmetrical
L periorbital ecchymosis
full motor
No pronator drift
Pertinent Results:
CT HEAD W/O CONTRAST ___
1. Interval increased conspicuity of a 2.4 x 1.3 cm left frontal
hemorrhagic contusion.
2. Stable-appearing thin left frontoparietal and right frontal
subdural
hematomas with subfalcine extension.
3. Stable effacement of the left lateral ventricle and focal
markings,
without significant interval increase in mass effect.
4. Surgical staples over a known right occipital subgaleal
hematoma and
laceration.
___ Ct maxillary/sinus - 1. Comminuted and depressed
anterolateral fracture of the left maxillary
sinus with associated hemorrhage within the sinus.
2. Nondisplaced anterior nasal spine fracture.
3. Mildly comminuted minimally displaced left nasal bone
fracture.
4. Trace paranasal sinus disease.
___ CT head -
1. No significant interval change in appearance of left frontal
intraparenchymal hematoma, left frontoparietal subdural
hematoma, or right
frontal subdural hematoma with subfalcine extension.
2. Stable effacement of the left lateral ventricle without shift
of normally
midline structures or central herniation.
3. No new intracranial hemorrhage or acute large vascular
territorial
infarction.
Brief Hospital Course:
___ y/o M +EOTH presents s/p assault. Patient was seen to have
b/l SDH as well as left maxillary sinus, anterior nasal spine
and left nasal bone fractures. He was admitted to the
neurosurgery service for further evaluation and monitoring. On
repeat head CT, patient was seen to have blossoming of L frontal
contusion. He remained neuro intact on examination. Plastics
evaluated patient for facial fractures and determined no surgery
was necessary, he is to follow up as an outpatient. In the
afternoon, patient complained of worsening headache that was
unrelieved with pain medication, repeat head CT was done and
showed increase in size of L frontal contusion with surrounding
edema. He continues to be neuro intact.
Now DOD, he is afebrile, VSS, and neurologically stable. He was
evaluated by ___ and they recommended home without ___. His pain
was controlled on dilaudid. He was discharged home on ___ and
will follow up with Neurosurgery in 4 weeks with a repeat Head
CT.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral SDH
L frontal contusion
Cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10546460-DS-7 | 10,546,460 | 26,964,111 | DS | 7 | 2187-07-11 00:00:00 | 2187-07-16 01:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A ___ PMH depression, HTN presenting s/p 10ft fall from ladder
onto deck, found to be unconscious. He was initially seen at OSH
and found to have occipital lac/hematoma, bruising left anterior
chest wall. Neurosurgery is consulted due to concern for dens
fracture from OSH CT scan read. Denies neck pain, bowel or
bladder incontinence. Denies recent history of trauma. Reports
fall ___ yrs ago that caused herniated L spine discs that have
been treated nonoperatively. Other injuries include 8 rib
fractures left posterior, 3 rib fx right anterior, small apical
pneumothorax, no hemothorax. He has an 8 inch laceration on the
back of the head, closed by the trauma team.
Past Medical History:
Depression, HTN, bipolar disorder, lumbar herniated discs
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
T 98, HR 70, BP 117/69, RR 18, POx 95% RA
Gen: WD/WN, moderate painful distress from L rib fractures
HEENT: Pupils: 2mm bilat, EOMs intact, PERRLA
Neck: in c-collar
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Discharge Physical Exam:
Vitals: T 98.4, BP 116/73, HR 73, RR 18, O2 Sat 94% (on RA)
General: Awake, alert, NAD
HEENT: Mucus membranes moist, atraumatic; laceration to left
occiput with staples in place
CV: +RRR, +S1/S2, no RMG
Resp: Normal WOB, +CTAB, no wheezes or crackles
GI: Abdomen soft, non-distended, non-TTP; small abrasion to LLQ
Extremities: Warm, well-perfused
Pertinent Results:
Lab Values:
___ 04:25PM BLOOD WBC-23.7* RBC-4.47* Hgb-14.2 Hct-42.5
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.4 RDWSD-46.8* Plt ___
___ 04:25PM BLOOD ___ PTT-35.0 ___
___ 04:44PM BLOOD Glucose-128* Lactate-2.2* Creat-1.1
Na-139 K-4.0 Cl-105 calHCO3-22
___ 07:25AM BLOOD WBC-13.1* RBC-3.71* Hgb-11.8* Hct-36.0*
MCV-97 MCH-31.8 MCHC-32.8 RDW-13.2 RDWSD-47.1* Plt ___
___ 07:25AM BLOOD Glucose-84 UreaN-25* Creat-1.1 Na-139
K-4.3 Cl-103 HCO3-25 AnGap-11
___ 07:25AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1
Images:
TRAUMA #3 (PORT CHEST ONLY) ___:
Left posterior fifth and sixth left rib fractures. No
visualized pneumothorax or pleural effusion on this supine film.
CT HEAD W/O CONTRAST ___:
1. No evidence of acute intracranial process or hemorrhage.
2. No acute fracture or traumatic dislocation in the cervical
spine.
3. Multilevel, multifactorial degenerative changes throughout
cervical as
described in detail above.
CHEST (PA & LAT) ___:
Comparison to ___. Known left-sided rib fractures
of stable
appearance. The current radiograph shows no evidence for the
presence of a pneumothorax. Borderline size of the heart. Mild
elongation of the
descending aorta. Small retrocardiac atelectasis.
CHEST (PORTABLE AP) ___:
Lungs are low volume with mild pulmonary vascular congestion.
Cardiomediastinal silhouette is stable. There is no pleural
effusion. No
pneumothorax. The known left-sided rib fractures are unchanged.
Brief Hospital Course:
This is a ___ year old male, with a PMH significant for
depression, HTN, bipolar disorder, and lumbar herniated discs.
He presented to ___ from OSH after a 10ft fall. He sustained a
posterior scalp laceration, and imaging demonstrated left-sided
___ rib fractures, and a small left pneumothorax. He was
admitted to the acute care surgery/trauma service for further
management. There was also a question of a type 2 odontoid
fracture, but this was ruled out following a second read of OSH
imaging. He was cleared by the neurosurgery team from C-collar
and with no need to follow up.
The patient was originally ordered for a dPCA, but he was not
following directions well on using it after repeated teaching
done by nurses and surgery team. Thus, his dPCA was discontinued
on HD1 and he was switched to oral analgesics. Repeat CXR
demonstrated resolution of the pneumothorax. The patient was
tolerating a regular diet and voiding without issue. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
He was seen by physical therapy, who cleared him to go home with
no need for further services. However, the patient expressed
interest in home ___ and home physical therapy, and these
services were arranged for him by Case Management. 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 on oral pain medication. The patient was discharged
home with ___ and home ___. Home ___ will provide medication
assistance/reconciliation. He received a limited prescription of
oxycodone, based on CPS recommendations, for three days
duration. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. He will follow up in ___ clinic in two
weeks. He will follow up with his PCP in two weeks. We recommend
he follow up with his chronic pain physician soon after
discharge for evaluation of his chronic pain and prescriptions
as needed for his home oxycodone regimen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. LamoTRIgine 200 mg PO QHS
3. OxyCODONE (Immediate Release) 10 mg PO QAM
4. OxyCODONE (Immediate Release) 5 mg PO QPM
5. OxyCODONE (Immediate Release) 10 mg PO QHS
6. amLODIPine 10 mg PO DAILY
7. ClonazePAM 0.5 mg PO QID
8. Valsartan 160 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Citalopram 40 mg PO DAILY
11. Atorvastatin 40 mg PO QHS
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
Please do not exceed 3gm in a 24 hour period. Alternate with
ibuprofen for pain control.
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Please take with food.
3. Lidocaine 5% Patch 1 PTCH TD QAM
On for 12 hours. Off for 12 hours.
RX *lidocaine [Lidocare] 4 % Please apply to affected area. once
a day Disp #*14 Patch Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Please take lowest effective dose and wean as tolerated.
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*36 Tablet Refills:*0
7. amLODIPine 10 mg PO DAILY
8. Atorvastatin 40 mg PO QHS
9. Citalopram 40 mg PO DAILY
10. ClonazePAM 0.5 mg PO QID
11. Ferrous Sulfate 325 mg PO DAILY
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. LamoTRIgine 200 mg PO QHS
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Valsartan 160 mg PO DAILY
16. HELD- OxyCODONE (Immediate Release) 10 mg PO QHS This
medication was held. Do not restart OxyCODONE (Immediate
Release) until This medication was held. Do not restart
OxyCODONE (Immediate Release) until discussion with your PCP.
You are on a different pain regimen for your acute pain.
17. HELD- OxyCODONE (Immediate Release) 10 mg PO QHS This
medication was held. Do not restart OxyCODONE (Immediate
Release) until This medication was held. Do not restart
OxyCODONE (Immediate Release) until discussion with your PCP.
You are on a different pain regimen for your acute pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Scalp laceration
Left ___ rib fractures
Small left pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ to be evaluated after you fell and sustained
injuries, including scalp laceration, left-sided ___ rib
fractures and a small left pneumothorax (when air gets into the
space between your lungs and chest wall). There is no surgical
intervention for your rib fractures and your pneumothorax will
resolve on it's own. You have been monitored and you have been
breathing well on room air. You are tolerating a regular diet,
ambulating, voiding without issue, and your pain has been
controlled on oral pain medications. You are ready to be
discharged home to continue your recovery. Please follow the
instructions below:
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 driving or
operating heavy machinery while taking pain medications.
* Your injury caused left-sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10546797-DS-20 | 10,546,797 | 26,399,210 | DS | 20 | 2186-11-23 00:00:00 | 2186-11-23 14:55:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, edema, aflutter
Major Surgical or Invasive Procedure:
___ Transesophageal Echocardiogram
History of Present Illness:
___ yo M with PMH of HTN, HL, DM, COPD, VSD s/p repair,
paroxysmal SVT who presents from clinic c/o body swelling and
persistent SOB/DOE after being treated for a COPD exaceration.
Patient presented to PCP ___ ___ with complaints of SOB,
cough w/ sputum production, fatigue, wheezing, without
associated fever. Was not having trouble sleeping at the time.
Combivent and Proair helping. Diagnosed with bronchitis/COPD
exacerbation and treated with 3 days of prednisone (40mg daily)
and amoxicillin (today is day#8). Symptoms improved some for
___, however cough, SOB/DOE, and swelling of face, abd, and
extremities developed since then and have significantly worsened
over the last ___, with patient unable to lie flat ___
orthopnea. Patient represented to clinic and was sent to ED for
further work up. He denies fever, chills, CP, palpitations,
lightheadedness, dizziness, sweats, sinus pain or pressure,
earache or sore throat. He has had only 3 cigarettes in the past
3 days. Per atrius records, Wt Readings from Last 5 Encounters:
___ : 228 lb (103.42 kg), ___ : 201 lb (91.173 kg),
___ : 200 lb 6.4 oz (90.901 kg), ___ : 201 lb (91.173
kg), ___ : 196 lb (88.905 kg). Patient was 188lbs in
___. It appears he has gained 40lbs since ___, mostly in
the last ___. Patient notes symptoms clearly developed in
last 10days.
Describes history of intermittent rare (every few years)
episodes of lightheadedness that last for less than two minutes.
Not associated with palpitations. Work up for paroxysmal SVT
included an EKG which captured an atrial tachycardia (rate 150).
Also showed RBBB, nml PR interval and lateral Twave inversions.
Subsequent Holter monitor showed sinus rhythm with multiplt PACs
and several episodes of SVT. The longest episode lasting for 97
beats at a rate of 188bpm. No further work up. Noted to have a
normal echo/EF in ___ without issues with VSD.
In the ED, initial vitals were 97.5, 156, 135/65, 22, 95%RA.
Patient was noted to be in atrial flutter unresponsive to
diltiazem 30mg PO, started on dilt ggt (no bolus given low BPs).
Peak Flow 140. Given combivent, ipratropium nebs, and solumedrol
125mg. Labs significant for Na+ 126, K+ 5.0, Cr 0.7, glucose
236, Mg 1.4 (repleted w/ 400mg in ED), WBC 7.8 (N 77.6%), Hct
40.5, MCV 103. BNP 439, neg trop. CXR showed pulmonary venous
hypertension or slight congestion with a suspected right-sided
pleural effusion. Patchy right basilar opacity is probably
compatible with associated atelectasis, although an infectious
process is hard to exclude. Vitals on transfer were 131, 21,
119/93, 96%3L NC.
On arrival to the floor, patient without pain, breathing
tolerable, though with notable wheeze. No CP or other pain.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain.
Notes recent bursistis of right hip, which has resolved in the
last week.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: RBBB, paroxysmal SVT
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
3. OTHER PAST MEDICAL HISTORY:
TOBACCO DEPENDENCE (___), MARIJUANA ABUSE, possible
cocaine use
HYPERCHOLESTEROLEMIA
AMBLYOPIA
COPD
HYPERTENSION
CONGENITAL VENTRICULAR SEPTAL DEFECT s/p correction
Obesity
DM (Diabetes Mellitus), Type 2
Colonic polyp
-cognitive deficit - poor medication complaince. Has ___
manager ___ who comes twice a month
-diastolic congestive heart failure, new onset ___
-atrial flutter, on anticoagulation for possible left atrial
appendage thrombus on TEE (started ___
Social History:
___
Family History:
GF with heart problem later in life. Father with "brain cancer"
in late ___, died in early ___. Mother - ___. Believes
sister is healthy.
Physical Exam:
Admission Exam:
VS: T97.5, 146/98, 131, 22, 94%2L ___ 284
Admission Weight: 232lbs, 103.4kg
GENERAL: WDWN obese elderly man breathing somewhat rapidly but
with minimal accessory muscle involvement Speaking full
sentences.
HEENT: NCAT. Sclera anicteric. PERRL. No xanthalesma.
NECK: Supple with JVP of 9cm.
CARDIAC: tachy, regular, hard to discern any subtle heart sounds
___ wheezing and rales. midline sternotomy scar from previous
cardiac surgery.
LUNGS: Resp minimally labored, minimal abd accessory muscle use.
crackles ___ way up lung posteriorly, wheezes throughout. No
rhonchi.
ABDOMEN: Obese. Soft, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c. 3+ peripheral edema. ___ digit on both
hands foreshortened but with normal joints.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ ___ 1+
Left: DP 1+ ___ 1+
Discharge Exam:
VS: 97.9, 107/54, 77, 18, 94%RA
Daily Wt: 92.8kg (Admission Weight: 103.4kg)
GENERAL: WDWN obese elderly man breathing comfortably with
minimal accessory muscle involvement Speaking full sentences on
RA.
NECK: Supple with JVP not elevated.
CARDIAC: RRR, nml s1/s2, slight systolic aortic murmur without
radiation midline sternotomy scar from previous cardiac surgery.
LUNGS: Resp minimally labored, minimal abd accessory muscle use.
CTAB. No rales or rhonchi.
ABDOMEN: Obese. Soft, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c. ___ peripheral edema. ___ digit on both
hands foreshortened but with normal joints.
PULSES:
Right: DP 1+ ___ 1+
Left: DP 1+ ___ 1+
Pertinent Results:
Admission Labs:
___ 10:10AM BLOOD WBC-7.8 RBC-3.95* Hgb-12.9* Hct-40.5
MCV-103* MCH-32.8* MCHC-32.0 RDW-14.1 Plt ___
___ 10:10AM BLOOD Neuts-77.6* Lymphs-14.4* Monos-6.7
Eos-0.8 Baso-0.6
___ 10:10AM BLOOD ___ PTT-35.5 ___
___ 10:10AM BLOOD Glucose-236* UreaN-22* Creat-0.7 Na-126*
K-6.1* Cl-92* HCO3-24 AnGap-16
___ 10:10AM BLOOD proBNP-439*
___ 10:10AM BLOOD cTropnT-<0.01
___ 10:10AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.8 Mg-1.4*
___ 11:12AM BLOOD K-5.0
Digoxin Level: ___ 03:30PM BLOOD Digoxin-1.0
Discharge Labs:
___ 07:06AM BLOOD WBC-6.8 RBC-4.28* Hgb-14.1 Hct-44.0
MCV-103* MCH-32.9* MCHC-32.0 RDW-13.8 Plt ___
___ 07:06AM BLOOD ___ PTT-46.8* ___
___ 07:06AM BLOOD Glucose-149* UreaN-22* Creat-0.8 Na-131*
K-4.9 Cl-91* HCO3-32 AnGap-13
___ 07:06AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.7
Imaging:
___ CXR: Findings suggesting pulmonary venous hypertension
or slight
congestion with a suspected right-sided pleural effusion.
Patchy right
basilar opacity is probably compatible with associated
atelectasis, although
an infectious process is hard to exclude.
___. No evidence of pulmonary embolism.
2. Right pleural effusion with adjacent atelectasis; trace left
pleural
effusion and left basilar atelectasis.
3. Findings suggesting right heart decompensation.
___ TEE: No spontaneous echo contrast is seen in the body of
the left atrium. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A probable thrombus is seen in the left
atrial appendage. No spontaneous echo contrast is seen in the
body of the right atrium or right atrial appendage. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium or the right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is a small pericardial effusion.
IMPRESSION: IMPRESSION: A possible thromus at the entry of the
___, near the mitral valve. No other clot was seen in the LA,
RA/RAA. Mild MR.
___ TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The right ventricular cavity is mildly dilated
with borderline normal free wall function. 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. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Suboptimal image quality due to body habitus. Mild
symmetric LVH. Left ventricular systolic function is probably
normal, a focal wall motion abnormality cannot be excluded. The
right ventricle is not well seen but is probably mildly dilated
and hypokinetic. No significant valvular abnormality. Normal
estimated pulmonary artery systolic pressure.
___ CXR: The heart is mildly enlarged and there is some mild
pulmonary
vascular re-distribution and small bilateral pleural effusions.
However,
compared to the prior exam, the appearance of the lungs has
improved and the effusions are slightly smaller. IMPRESSION:
Persistent but slightly improved CHF.
Brief Hospital Course:
___ yo M with PMH of HTN, HL, DM, recent COPD exacerbation,
congenital VSD s/p repair, paroxysmal SVT who presented in new
congestive heart failure and atrial flutter, found to have a
possible left atrial appendage thrombus.
# New Acute Diastolic Congestive Heart Failure: Patient was
admitted with reportedly acute onset CHF (BNP 439, Na+ 126).
Differential initially included nephrotic syndrome or cirrhosis
(however, albumin 4.0) as well as lymphatic disease (however,
edema is pitting). No history concerning for ACS, TnT negative
x1.
Given his history of atrial tachycardia and that fact that he
was admitted in ___ with rates in the 150s, tachyarrhythmia
induced myopathy causing CHF was considered. Alternatively,
COPD exacerbation and frequent albuterol use may have acutely
triggered tachycardia which in itself may have caused acute
diastolic CHF without cardiomyopathy. Patient has a history of
congenital VSD s/p repair in ___ (age ___, however echo this
admission did not show any issues with VSD repair, nor did it
suggest significant LVH or reduced EF. Patient was diuresed with
intermittent doses of lasix 100mg IV, and subsequently
autodiuresed significantly. Not discharged on lasix daily given
his continued autodiuresis (2liters negative a day). Kidney
function stable at Cr 0.8. Admission Weight: 103.4kg. Discharge
Weight: 92.8kg.
# Aflutter/paroxysmal SVT: Patient has a known history of
paroxysmal SVT, worked up previously with ECG and Holter
monitor. HR in clinic the morning of admission was 92bpm.
Current aflutter likely triggered by fluid overload, albuterol
use, and stress on the heart, as well as low magnesium. Patient
was initially controlled in the ___ on diltiazem 15mg/hr and
digoxin IV was loaded. TEE showed a possible left atrial
appendage thrombus, so heparin ggt was continued, while patient
became therapeutic on warfarin (goal ___. Patient was
transitioned to diliazem and digoxin PO, and weaned off dilt
ggt. Baseline heart rate remained in ___, however given bursts
of HR in 150s with exertion, metoprolol succinate 50mg daily was
initiated. Plan is to continue anticoagulation with warfarin for
___ weeks, to recheck ___ and consider cardioversion if thrombus
has resolved at that time. Given that this is his first
presentation of aflutter and CHF history suggests acute
decompensation (in 10days), this was thought to be instigated by
COPD exacerbation. If in follow up after patient is cardioverted
out of aflutter, patient appears to be in CHF or if he developed
recurrent aflutter, endocardial ablation should be considered at
that time. SW was consulted given patient's history of
noncompliance ___ cognitive issues and importance on
anticoagulation regimen over the next month.
Chronic Issues:
# Diabetes: HgbA1c 7.7% on ___. Maintained on HISS
inhouse. On discharge, glipizide and metformin were continued.
Actos was discontinued given that is can instigate acute CHF
exacerbations.
# Congenital VSD s/p repair: Repaired at age ___ at ___.
Echo this admission showed nml EF without VSD issues.
# Hyperlipidemia: Simvastatin 40mg daily was discontinued and
Pravastatin 80mg daily was started given diltiazem initiation.
ASA 81 for prevention of heart disease was continued.
# Hypertension: Patient was started on diltiazem for atrial
flutter, with good blood pressure control. Lisinopril was held
initially, given normal blood blood pressures on diltiazem. On
discharge, lisinopril was restarted at 5mg daily.
# COPD Exacerbation: Prior to admission patient was treated for
COPD exacerbation with steroids and antibiotics. Chest CT
showed CHF exacerbation, no other signs of acute process. WBC
7.8. Transient increase in WBC to 12.2 likely due to
administration of solumedrol 125mg in the ED the day prior. He
completed his 10 day antibiotic course of Amoxicillin 500mg Q8h
inhouse. Given persistent (per the patient, "smoker's") cough,
repeat CXR was performed and showed improvement in CHF, again no
signs of other acute process. With diuresis, patient reported
his cough improved, and was better than it has been in the past
several years. Ipratropium and levalbuterol were administered
prn for wheezing. Albuterol was avoided given atrial
tachycardia.
# Macrocytosis: MCV 103, hct was low-normal (37-40). RDW is
normal. No reported history of ETOH abuse. Deferred to
outpatient work up.
Transitional Issues:
#CODE: Full Code
#EMERGENCY CONTACT: HCP, Nurse ___ Manager ___:
___. Sister ___ ___, cell
___, Work voicemail: ___.
- Macrocytosis work up
- Diabetes regimen, given Actos was discontinued this admission.
___ need insulin, however this was deferred inhouse given many
medication changes being made and patient's issues with
medication compliance at baseline.
- monitoring of electrolytes given patient has been started on
lasix. Daily weights with a goal weight of 188lbs (85.5kg),
which was his weight in ___. Patient is currently
autodiuresing, so does not require lasix daily. However, if
patient's urine output decreases and he remains above his dry
weight of 188pounds with stable kidney function (normal
creatinine), please dose lasix 40mg PO daily.
- Close cardiology follow up with plans for repeat TEE prior to
cardioversion.
- INR monitoring, goal ___. On warfarin 5mg daily.
- Discharged on lisinopril 5mg (home dose was 10mg), given
aflutter and additional new cardiac medications (metoprolol
succ, diltiazem).
Medications on Admission:
Amoxicillin 500 mg TID for 10 days (day#8 of 10 today)
Simvastatin 80 mg Tablet take ___ tablet daily
Pioglitazone (ACTOS) 30 mg daily
Ascorbic Acid (VITAMIN C) 500 mg Tablet daily
Glipizide 10 mg Oral Tablet Extended Rel 24 hr BID
Metformin 1,000 mg Oral Tablet,ER ___ 24 hr 1 PO BID
Lisinopril 10 mg daily
Ipratropium-Albuterol (COMBIVENT) ___ mcg/Actuation
Inhalation Aerosol inhale 2 puffs by mouth FOUR TIMES DAILY
Albuterol Sulfate (PROAIR HFA) 90 mcg HFA 2 puffs Q4-6 hours prn
Cholecalciferol, Vitamin D3, 1,000 unit Capsule daily
ASPIRIN EC 81MG daily
Discharge Medications:
1. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO once a
day.
2. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO twice a day.
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Combivent ___ mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
6. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: You
will be instructed on how many pills to take daily based on
monitoring of your blood levels. Start by taking 2tabs daily.
Disp:*60 Tablet(s)* Refills:*0*
9. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. diltiazem HCl 360 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:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for weight greater than 188lbs: Goal weight: 188lbs or
85.5kg.
Disp:*30 Tablet(s)* Refills:*0*
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
14. pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Atrial Flutter
Acute Diastolic Congestive Heart Failure
Atrial Appendage Thrombus
Secondary Diagnosis:
COPD exacerbation
Diabetes
HTN
HL
Macrocytosis
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 admitted because your heart was going
abnormally fast and was noted to be in a rhythm called "Atrial
Flutter". Because on your echocardiogram, we were concerned for
a clot in one of the chambers of your heart, and so we were not
able to cardiovert (electrically shock) you out of this rhythm.
We are controlling this fast rhythm with medications
(metoprolol, diltiazem and digoxin) and giving you blood
thinners (coumadin) which should help to dissolve the clot. You
should follow up with a cardiologist in one month for reimaging
and if your clot is gone, you will be scheduled for electrical
cardioversion to correct your abnormal heart rhythm.
Additionally, you were noted to be in heart failure as a result
of your heart not working well with this fast abnormal heart
rhythm. This caused a lot of fluid accumulation in your body. An
echocardiogram showed no significant abnormality of your heart
muscle. We started you on diuretic medications (medications to
get the extra fluid off your body) which will improve these
symptoms. You should follow up with a cardiologist for this as
well.
The following changes were made to your home medication regimen:
START Lasix 40mg daily if your weight is above 188pounds.
Currently you are urinating without medications. You do not need
to make Lasix if you are urinating a lot daily and continuing to
lose weight without this medication.
START Coumadin 5mg daily.
START Diltiazem 0.25mg daily.
START Digoxin 0.25mg daily.
START Metoprolol Succinate 50mg by mouth daily.
DECREASE Lisinopril to 5mg daily.
STOP Simvastatin.
START Pravastatin 80mg daily.
STOP Actos. You will need to follow up with your PCP for further
diabetes management. Actos can worsen heart failure, so you
should no longer take this medication.
Taking your medications and making your follow up appointments
are extremely important as it is important to monitor and treat
this irregular heart rhythm and blood clot.
Followup Instructions:
___
|
10546797-DS-21 | 10,546,797 | 26,168,892 | DS | 21 | 2191-03-13 00:00:00 | 2191-03-18 16:03:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
glycopyrrolate
Attending: ___.
Chief Complaint:
DOE, leg swelling
Major Surgical or Invasive Procedure:
-Cardioversion
History of Present Illness:
Mr. ___ is a ___ y/o male with chronic COPD, CHF, and PAF
presenting with signs of a CHF exacerbation, including 10 lb
weight gain, DOE, swelling, and CXR findings demonstrating
pulmonary congestion, as well as atrial flutter 2:1.
He was admitted to ___ ___ years ago for similar symptoms,
including swelling and weight gain concerning for a CHF
exacerbation. On that admission, he also had his first episode
of atrial flutter for which he was started on warfarin and
digoxin. It was thought that the atrial flutter was precipitated
by his COPD and CHF exacerbations at the time. The plan was to
anticoagulate and consider cardioversion as an outpatient in ___
weeks because he was found to have a atrial appendage thrombus
on TEE. However, he never had a recurrence of aflutter or any
other heart failure exacerbation symptoms, so he was not
cardioverted. He was managed with torsemide 20 mg daily.
He reports that his torsemide dose was decreased from 20 to 10
mg daily 8 weeks ago. In the last two weeks, he has had new
onset of lower extremity swelling, shortness of breath, and
general discomfort. He has gained 10 lbs in the last 2 weeks,
and he reports a dry weight of 192 lbs. He can only walk 1 block
before becoming dyspneic, although at baseline he can walk 1.5
miles per day. He sleeps on 3 pillows, which is unchanged from
prior, and he has a chronic sporadic cough which is unchanged as
well. He denies any fevers, chills, chest pain, dysphagia, and
muscular weakness. No recent dietary changes.
He denies any recent palpitations. He continues to take his
warfarin regularly and has his INR checked in a ___ clinic.
In the ED initial vitals were: 97.9, HR 120, BP 102/74, RR 24,
O2 96% NC
EKG: Atrial flutter, rate 138, 2:1 AV block
Labs/studies notable for: WBC 7.8, Hgb 12.5, INR 4.7, proBNP
832, Na 129, K 5.5, Cr 1.0, MB 5, trop negative x2, Mg 1.5, UA
wnl
Patient was given: Treated for a COPD exacerbation with duonebs
and methylprednisolone 125 mg x1. Diuresed with furosemide 40 mg
x1. Rate controlled for PAF with diltiazem 20 mg PO and dilt
drip at 10 mg/hr.
Vitals on transfer: HR 72, BP 87/61, O2 98%
On arrival to the CCU: Patient is a&ox3, speaking in full
sentences. Confirms HPI as above.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: RBBB, paroxysmal SVT
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
3. OTHER PAST MEDICAL HISTORY:
TOBACCO DEPENDENCE (___), MARIJUANA ABUSE, possible
cocaine use
HYPERCHOLESTEROLEMIA
AMBLYOPIA
COPD
HYPERTENSION
CONGENITAL VENTRICULAR SEPTAL DEFECT s/p correction
Obesity
DM (Diabetes Mellitus), Type 2
Colonic polyp
-cognitive deficit - poor medication complaince. Has case
manager ___ who comes twice a month
-diastolic congestive heart failure, new onset ___
-atrial flutter, on anticoagulation for possible left atrial
appendage thrombus on TEE (started ___
Social History:
___
Family History:
GF with heart problem later in life. Father with "brain cancer"
in late ___, died in early ___. Mother - ___. Believes
sister is healthy.
Physical Exam:
ADMISSION EXAM:
VS: T 97.9 BP 108/41 HR 86 RR 24 O2 SAT 94$ RA
GENERAL: Obese male, oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Distant heart sounds due to habitus. Regular rate. Normal
S1, S2. No murmurs, rubs, or gallops.
LUNGS: Significant expiratory wheezing, mild crackles in the
bases.
ABDOMEN: Obese, non-tender, slightly firm, no organomegaly
EXTREMITIES: Warm, well perfused. 2+ pitting edema of the lower
extremities
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
VS: 97.7 100s/50s ___ 18 92% RA. Ambulatory sats: 88-93%
GENERAL: Obese male, oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Distant heart sounds due to habitus. Regular rate. Normal
S1, S2. No murmurs, rubs, or gallops.
LUNGS: Diminished breath sounds, mild crackles
ABDOMEN: Obese, non-tender, slightly firm, no organomegaly
EXTREMITIES: Warm, well perfused. 2+ pitting edema of the lower
extremities
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
___ 12:15PM BLOOD WBC-7.8 RBC-3.96* Hgb-12.5* Hct-39.6*
MCV-100* MCH-31.6 MCHC-31.6* RDW-13.3 RDWSD-49.0* Plt ___
___ 12:15PM BLOOD ___ PTT-51.9* ___
___ 12:15PM BLOOD Glucose-324* UreaN-23* Creat-1.0 Na-129*
K-7.0* Cl-90* HCO3-30 AnGap-16
___ 06:40AM BLOOD ALT-33 AST-24 LD(LDH)-201 AlkPhos-138*
TotBili-0.3
___ 12:15PM BLOOD CK-MB-5 proBNP-832*
___ 12:15PM BLOOD Calcium-9.4 Phos-3.7 Mg-1.5*
___ 12:26PM BLOOD Lactate-1.8 K-5.5*
DISCHARGE LABS:
___ 04:37AM BLOOD WBC-8.1 RBC-3.76* Hgb-11.8* Hct-37.1*
MCV-99* MCH-31.4 MCHC-31.8* RDW-13.2 RDWSD-47.7* Plt ___
___ 04:37AM BLOOD ___ PTT-40.4* ___
___ 04:37AM BLOOD Glucose-166* UreaN-19 Creat-1.0 Na-128*
K-4.5 Cl-86* HCO3-34* AnGap-13
___ 04:37AM BLOOD ALT-31 AST-23 LD(LDH)-246 AlkPhos-141*
TotBili-0.3
___ 04:37AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.7
Studies:
Echo ___:
Mild spontaneous echo contrast is present in the left atrial
appendage. The right atrial appendage ejection velocity is
depressed (<0.2m/s). No thrombus is seen in the right atrial
appendage No atrial septal defect is seen by 2D or color
Doppler. LV systolic function appears depressed. There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
with mild global free wall hypokinesis. There are simple
atheroma in the descending thoracic aorta to 35 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. No mitral valve abscess
is seen. Mild (1+) mitral regurgitation is seen. There is no
abscess of the tricuspid valve. The estimated pulmonary artery
systolic pressure is normal. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality at 0 and 30 degrees. Mild
left atrial appendage spontaneous echo contrast without discrete
thrombus identified. Depressed biventricular systolic function.
Mild mitral and tricuspid regurgitation.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with chronic COPD, CHF, and PAF
who presented with 10 lb weight gain, DOE, swelling, and CXR
findings demonstrating pulmonary congestion concerning for a
heart failure exacerbation as well as atrial flutter 2:1.
# Acute on chronic CHF exacerbation (HFpEF): LVEF > 55% on ___
echo with mild RV cavity dilation. Presented with weight gain,
DOE, orthopnea, swelling, and CXR demonstrating pulmonary
congestion, with elevated BNP. Likely etiology of current
exacerbation is recent decrease in his home torsemide dose
causing fluid retention, along with contributions from his rapid
aflutter causing decreased cardiac output. Dry weight (according
to pt) of 192 lbs. He was diuresed aggressively with IV Lasix
and eventually transitioned to torsemide 40 mg PO as a home
dose. He had over 6L diuresis on this admission. On his most
recent echo on ___, the study demonstrated a depressed
LVEF perhaps caused by tachycardia induced cardiomyopathy. On
discharge, his volume overload had mostly resolved. We continued
his home lisinopril 5 mg, spironolactone 12.5 mg daily, and
metop xl 50 mg daily.
# Aflutter 2:1/afib: First diagnosed with paroxysmal atrial
flutter in ___ during an admission for CHF -- managed as an
outpatient with metoprolol xl 50 mg daily. In the ED on this
admission, he was found to be in aflutter 2:1. He received a
dilt bolus followed by dilt drip, with rate control to the ___.
Upon admission to the CCU, he was anticoagulated with heparin
gtt and warfarin. He was loaded with amiodarone IV and PO for
rate control. He was also managed with metoprolol tartrate.
Despite this, he had RVR to the 140s. He received a
TEE/cardioversion on ___ with return to NSR, but then he again
converted into afib/flutter with RVR on ___. As his INR briefly
dropped to subtherapeutic range, he needed a repeat TEE before
another cardioversion. An ablation was considered, but as he was
intermittently in Afib, it was decided to first try another
cardioversion. He had a repeat TEE/cardioversion on ___, and
converted successfully into NSR. On discharge, he was in NSR and
therapeutic on warfarin. His discharge INR was 2.5, and his
discharge warfarin dose was 4 mg daily. His amiodarone should be
titrated as described in the transitional issues.
# CAD: Has multiple risk factors for CAD, including smoking,
diabetes, and hyperlipidemia. No recent left heart cath on
record. Recent echo showing regional wall motion abnormalities
suggests possible ischemic etiology. We continued his aspirin,
statin, metoprolol, and lisinopril. ___ need a stress test as an
outpatient.
# COPD: He has baseline COPD, but there was minimal concern that
he was having an active COPD exacerbation. He received his home
COPD medications (ipratropium inhaler and nebs). There was some
concern that his high doses of metoprolol were worsening his
COPD, we slightly decreased his metoprolol before discharge.
# Recent cataract surgery: continued home eye drops
# Hyperlipidemia - continued home pravastatin 80 mg daily
# Hypothyroidism - continued home levothyroxine 25 mg po daily
Transitional Issues:
[]Discharged on Torsemide 40 mg po qd
[]Will need labs next week- chem 10, coags on ___
[]Amiodarone started. Will need 400 mg tid through ___, 400 mg
daily for the following 7 days, then 200 mg daily for the next
___ days.
[]Follow up with Dr. ___ your PCP
# CODE: Full code (confirmed)
# CONTACT/HCP: ___ (friend and HCP), ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO DAILY16
2. Lisinopril 5 mg PO DAILY
3. Torsemide 10 mg PO DAILY
4. ofloxacin 0.3 % ophthalmic QID
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
6. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES QID
7. exenatide microspheres 2 mg/0.65 mL subcutaneous every 7 days
8. Ipratropium Bromide MDI 2 PUFF IH BID
9. Ipratropium Bromide Neb 1 NEB IH Q12H
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Magnesium Oxide 400 mg PO DAILY
12. SITagliptin 50 mg oral DAILY
13. Pravastatin 80 mg PO QPM
14. Metoprolol Succinate XL 50 mg PO DAILY
15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
16. Spironolactone 12.5 mg PO DAILY
17. GlipiZIDE XL 10 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
19. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO TID Duration: 3 Days
RX *amiodarone 200 mg 2 tablet(s) by mouth As directed Disp #*90
Tablet Refills:*0
2. Amiodarone 400 mg PO DAILY Duration: 7 Days
3. Amiodarone 200 mg PO DAILY Duration: 14 Days
4. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
5. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. exenatide microspheres 2 mg/0.65 mL subcutaneous every 7
days
8. GlipiZIDE XL 10 mg PO BID
9. Ipratropium Bromide MDI 2 PUFF IH BID
10. Ipratropium Bromide Neb 1 NEB IH Q12H
11. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES QID
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Lisinopril 5 mg PO DAILY
14. Magnesium Oxide 400 mg PO DAILY
15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
16. Metoprolol Succinate XL 50 mg PO DAILY
17. ofloxacin 0.3 % OPHTHALMIC QID
18. Pravastatin 80 mg PO QPM
19. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
20. SITagliptin 50 mg oral DAILY
21. Spironolactone 12.5 mg PO DAILY
22. Vitamin D ___ UNIT PO DAILY
23.Outpatient Lab Work
Atrial fibrillation I48.91
Please check chem-10 and ___ on ___ and fax results to
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Atrial flutter, CHF exacerbation
Secondary: DM
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 ___ because you were having fast heart
rates in an abnormal rhythm called Atrial flutter. You also were
found to have a heart failure exacerbation which means that you
had fluid in your lungs. We successfully cardioverted you so
that your heart is now in a normal rhythm. We also successfully
removed the fluid as well. Please pay attention to the
medications we are prescribing you on discharge because there is
a new medication Amiodarone and some medications have changed
slightly.
All the best,
Your care team at ___
Followup Instructions:
___
|
10546797-DS-23 | 10,546,797 | 25,410,386 | DS | 23 | 2194-04-08 00:00:00 | 2194-04-08 23:45:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
glycopyrrolate / Trulicity
Attending: ___.
Chief Complaint:
COPD with acute exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male with a history of COPD, diastolic CHF, Type 2
Diabetes, Atrial Flutter on Coumadin, who presents with COPD
exacerbation. The patient reports that his symptoms began 3 days
prior to admission when he developed cough, progressive dyspnea.
He went to his atrius pulmonologist, Dr. ___ felt the
patient was ill, and started him on prednisone and doxycycline 1
day prior to admission. He had taken his second dose the morning
of admission.
Of note the patient is on 2L of home oxygen, but this is only
used for ambulation. The day of presentation he was evaluated by
his case manager nurse, who noted he was dyspneic and sent him
in. He also notes some additional pulmonary edema. Patient
denies fever, chills, chest or abdominal pain, nausea, vomiting
or diarrhea.
Patient reports at baseline he can actually ambulate comfortably
a reasonable distance (I used walking around 12R as an example)
and he said no problem while using oxygen. He reports his
ambulatory sat as being around 94% while doing so, but currently
he is ___.
He also notes some right wrist pain that radiates to his right
side particulary while typing on a computer. He has not seen a
specialist for this at ___ yet.
Initial vitals in the ___ ED: 97.4, 82, 113/86, 20 92%2L. His
initial PEF was 125, which improved to 150 with nebs. The
patient received 3 albuterol nebs, along with his home insulin.
He had a chest x-ray which was unrevealing. He also had an EKG
which to my eye appears unchanged versus his baseline.
Past Medical History:
RBBB
paroxysmal ST
Hyperlipidemia
amblyopia
COPD
Primary Hypertension
congenital ventricular septal defect s/p correction at age ___
obesity
Type 2 Diabetes
cognitive deficit with hx of poor medication compliance
HFpEF
Atrial Fibrillation/flutter
Social History:
___
Family History:
GF with heart problem later in life. Father with "brain cancer"
in late ___, died in early ___. Mother - ___.
Physical Exam:
Admission exam:
===============
VSS: 98.6, 126/70, 80, 20, 92%2LNC
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: Poor air movement B/L, Phlegm sounds b/l all lung fields,-
fremitus, - wheezes, - crackles
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, 1+ pitting edema to knee b/l
NEURO: CAOx3, Motor ___ ___ Flex/Ext/ Finger Spread
.
.
Discharge exam:
===============
Vital signs:
___ 0717 Temp: 97.7 PO BP: 123/63 HR: 63 RR: 18 O2 sat: 96%
O2 delivery: 2___ FSBG: 150
___ 0928 HR: ambulatory: 89-100 RR: ambulatory: 22 O2 sat:
ambulatory: 89-92% O2 delivery: ___
___ 0944 O2 sat: ___ O2 delivery: RA
Gen: NAD
Neuro: awake, alert, conversant with clear speech
Pulm: lungs with moderate expiratory wheezing throughout, mildly
prolonged expiratory phase, however normal WOB with no accessory
muscle use or pursed-lip breathing and no conversational dyspnea
Cards: RR, no m/r/g appreciated, 1+ pitting edema of b/l ___: soft, non-tender to palpation, BS+
Psych: calm, cooperative
Pertinent Results:
Admission labs:
===============
___:37PM BLOOD WBC-11.8* RBC-3.90* Hgb-12.7* Hct-38.9*
MCV-100* MCH-32.6* MCHC-32.6 RDW-14.1 RDWSD-51.6* Plt ___
___ 12:37PM BLOOD Neuts-88.5* Lymphs-3.5* Monos-6.5
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.41* AbsLymp-0.41*
AbsMono-0.77 AbsEos-0.01* AbsBaso-0.02
___ 02:02PM BLOOD ___ PTT-38.6* ___
___ 12:37PM BLOOD Glucose-330* UreaN-34* Creat-1.4* Na-136
K-5.2 Cl-94* HCO3-25 AnGap-17
___ 12:37PM BLOOD proBNP-435*
___ 12:37PM BLOOD Calcium-9.3 Phos-3.0 Mg-1.6
___ 02:57PM BLOOD O2 Flow-2 pO2-48* pCO2-46* pH-7.41
calTCO2-30 Base XS-3 Intubat-NOT INTUBA Comment-NASAL ___
___ 02:40PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
Imaging:
========
CHEST (PA & LAT) Study Date of ___ 2:21 ___
IMPRESSION: Mild atelectasis in the lower lungs. Top-normal
heart size. Otherwise unremarkable.
Discharge labs:
================
___ 07:10AM BLOOD WBC-8.9 RBC-3.66* Hgb-11.9* Hct-36.9*
MCV-101* MCH-32.5* MCHC-32.2 RDW-13.9 RDWSD-51.2* Plt ___
___ 07:10AM BLOOD Glucose-75 UreaN-33* Creat-1.4* Na-142
K-3.8 Cl-95* HCO3-28 AnGap-19*
___ 07:10AM BLOOD Albumin-4.1
___ 07:10AM BLOOD ___ PTT-34.5 ___
Brief Hospital Course:
# COPD exacerbation:
-treated with pred 40 and nebs with clinical improvement
-weaned back to usual supplemental O2 (room air at rest, 2L NC
with ambulation)
-extended pred treatment for 2 more days, last day will be
___
-advised patient enroll in outpatient pulmonary rehab (if this
is available to him) given his significant burden of COPD and
now an acute exacerbation requiring hospitalization.
# Possible cervical radiculopathy
On initial presentation he described "some right wrist pain that
radiates to his right side particularly while typing on a
computer." His symptoms and exam findings were felt to be most
likely consistent with a lower cervical radiculopathy (initially
he describes a C8 dermatome distribution of symptoms that is
positionally dependent, but also some thoracic symptoms).
-recommend re-evaluation in ___ weeks with PCP; if symptoms
still present and no telling findings on exam, could consider
pursuing additional imaging studies
.
.
.
Greater than 30 minutes in discharge-related activities today.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation. (patient could not recount his
medications)
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Amiodarone 200 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Torsemide 30 mg PO DAILY
5. Aspirin EC 81 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Spironolactone 12.5 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 3 mg PO DAILY16
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. PredniSONE 40 mg PO DAILY
16. Bydureon (exenatide microspheres) 2 mg/0.65 mL subcutaneous
Administer 2mg subcutaneously once weekly
17. exenatide microspheres 2 mg subcutaneous weekly
18. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
19. Metoclopramide 10 mg PO Q8H:PRN nausea
20. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation Inhale 1 puff twice daily
21. Glargine 20 Units Breakfast
Discharge Medications:
1. Glargine 20 Units Breakfast
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
SOB/wheezing
5. Amiodarone 200 mg PO DAILY
6. Apixaban 5 mg PO BID
7. Atorvastatin 40 mg PO QPM
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
12. Metoclopramide 10 mg PO Q8H:PRN nausea
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. PredniSONE 40 mg PO DAILY Duration: 2 Days
Last dose will be on ___
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
16. semaglutide 1 mg/dose (2 mg/1.5 mL) subcutaneous 1X/WEEK
17. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation DAILY
18. Spironolactone 12.5 mg PO DAILY
19. Torsemide 30 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21.Outpatient Physical Therapy
Outpatient pulmonary rehabilitation
ICD-10 Code: ___
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation w/ acute on chronic hypoxia
Possible cervical radiculopathy
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Gen: NAD
Neuro: awake, alert, conversant with clear speech
Pulm: lungs with moderate expiratory wheezing throughout, mildly
prolonged expiratory phase, however normal WOB with no accessory
muscle use or pursed-lip breathing and no conversational dyspnea
Cards: RR, no m/r/g appreciated, 1+ pitting edema of b/l ___: soft, non-tender to palpation, BS+
Psych: calm, cooperative
Discharge Instructions:
Mr. ___,
You were admitted to the hospital with worsening shortness of
breath and cough due to a COPD exacerbation. We believe this
COPD exacerbation was triggered by an upper respiratory
infection, perhaps a cold, you had that preceded it. You were
treated here with steroids and nebulizers and your breathing and
cough improved. Please take prednisone for 2 more days (last day
will be ___. You can use the albuterol nebulizer as
needed to help you with shortness of breath and wheezing, but if
you find that you have to use it more than 3 times in a day, you
should seek medical attention.
Given that you had an exacerbation of COPD, we recommend that
you enroll in outpatient pulmonary rehabilitation to maximize
your lung function and decrease your risk of hospitalization in
the future.
It was a pleasure caring for you and we wish you a full and
speedy recovery.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10547408-DS-14 | 10,547,408 | 29,435,430 | DS | 14 | 2162-08-30 00:00:00 | 2162-08-30 10:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cephalosporins / Penicillins / betalactam / Carbapenems
Attending: ___.
Chief Complaint:
abdomianl pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o nonverbal F w/ cerebral palsy with
quadriparesis reliant on a G-J tube (placed ___ by ___ for
nutrition with PMHx of SBO and constipation who p/w one day of a
bilious G-J tube leak and abdominal pain with concerning for
recurrent SBO.
Two days ago, ___ caretakers @ her group home noticed she
was acting moody, different form her baseline. Earlier today,
her aid, who was interviewed in the ED by her bedside, noticed a
dark green fluid soaking her G/J drain sponge 2x, witnessed
patient had a new non-productive cough and gagging. Patient was
brought to PCP's office (___), who sent her to
the ___ ED per ___ abdominal pain on exam, G-J leak, and
small red macules surrounding the G-J drain.
Patient has 2 bowel movements today, once this AM and once while
in the ED. Patient has not urinated today, but was receiving
tube feeds as usual via her J-tube @ 115 cc/hr continuous
throughout the day. Patient relies on J-tube for all
nutritional
and fluid intake and G-tube for all medications.
On admission to the ED, patient was tachycardic to 140 and
afebrile at 96.6F. In the ED, ___ G-tube was put to
suction and put out 1500 cc of bilious non-bloody fluid. Patient
was then disimpacted in ED, stool was soft.
Past Medical History:
Past Medical History: (From ___ medical records and
caregiver at ___
___:
-non-verbile, responds to commands, communicates with eye
movements
- all nutrition via continuous J-tube @ 115cc/hr
- O2 requirement overnight @ 2L
Cerebral Palsy w/ quadriparesis and mental retardation
Osteoporosis
Hip and Femoral Fractures ___ years ago
h/o GI-Bleeds (Last ___ years ago)
h/o SBO
Constipation
h/o seizures (Last ___ years ago)
h/o aspiration PNA
CHF
HTN
Past Surgical History:
Bilateral Hip Repair ___ years ago)
___ implant
SBR for SBO
Multiple G-J and G-tube placements
Social History:
___
Family History:
Non constributory
Physical Exam:
At ___:
99.2/98.4 95 135/91 19 98%RA
General: Awake and alert, responsive to questions per her
baseline
Cardiac: RRR
Resp: CTA b/l - sating well on room air
Abdomen: soft, non distended, non tender, no rebound or guarding
Extremities: consistent with CP diagnosis
Pertinent Results:
1. Fluid-filled dilated loops of small bowel, with a transition
point in the
mid abdomen, and distal decompression consistent with small
bowel obstruction.
No evidence of closed loop obstruction or bowel wall edema.
2. Large amount of fecal loading, with significant distention of
the rectum up
to 12 cm.
3. Large hiatal hernia. Congenital malrotation. Gastrojejunal
tube
terminating in the right lower quadrant.
4. Cholelithiasis without evidence of cholecystitis.
Brief Hospital Course:
Ms. ___ is a ___ with a history of CP, s/p recently placed GJ
tube by ___, presented with leakage around GJ tube site,
abdominal pain, and leukocytosis. Abdominal CT showed a possibel
transition point consistent with a small bowel obstruction. ___
was consulted who did not feel there was any intervention to be
done on their part. Therefore, she was admitted to ___ for
management of a possibel small bowel obstruction, but more
significantly a very large fecal load in her rectum and large
colon. Her gtube was placed to gravity and she received several
enemas to clear out her colon. She was disimpacted in the ED
with little resolution, as the CT scan was taken after the
attempted disimpaction. Therefore, she was placed on a standing
regimen of colace, mineral oil, through her jtube, and fleet
enemas. She was adequately resuscitated with fluids. She was
hypernatremic for a few days because of probably dehydration and
she was given free water flushes through her jtube and her
maintenance fluids were increased. Her electrolytes then
normalized. Her white count, after her initial one in the ED,
normalized as well. Her pain decreased and her abdominal exam
continued to improve. AFter her pain was resolved, her tubefeeds
were resumed. She tolerated those well. Her gtube continued to
put out quite a bit, possibly because she was not restarted on
her reglan during the hospital stay. Therefore, the plan at
discharge will be to continue the gtube to gravity for
decompression, no tube feeds were seen refluxing into the
stomach, and once her reglan is restarted and her output
decreased, her gtube can be capped. She can continue on her home
tubefeed regimen with the addition of some stool softeners and
more aggressive bowel regimen as needed. Given the extent of the
dilation of her rectum with stool, she most likely has a very
chronic process of severe constipation.
Her mother and aunt were called during her hospital stay with
updates, alogn with communication to the group home as needed.
All questions were answered and she was stable for discharge on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Diazepam 5 mg PO TID
3. Metoclopramide 10 mg PO TID
4. PHENObarbital 64.8 mg PO BID
5. Ranitidine 150 mg PO BID
6. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Miconazole Powder 2% 1 Appl TP TID
RX *miconazole nitrate [Antifungal Cream] 2 % 1 Appl Topical
three times a day Refills:*0
2. Mineral Oil ___ mL PO Q6H
RX *mineral oil 15 cc Jtube Q6 hours Refills:*0
3. PHENObarbital 64.8 mg PO BID
4. Ranitidine 150 mg PO BID
5. Cetirizine 10 mg PO DAILY
6. Diazepam 5 mg PO TID
7. Lisinopril 2.5 mg PO DAILY
8. Metoclopramide 10 mg PO TID
9. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium [Stool Softener] 50 mg/5 mL 10 mL by mouth
twice a day Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Senexon] 8.8 mg/5 mL 5 mL Jtube twice a day
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for abdominal pain and constipation.
You recovered well and your pain was resolved. You will eb
discharged with a small bowel regimen to be continued. You can
continue tubefeeds through your Jtube and keep your gtube to
gravity in order to decompress, until the output remains low and
then it can be capped.
Discharge instructions:
Please come to the ED or call the clinic if you experience any
of the following:
-fevers, chills
-abdominal pain
-redness or drainage aroudn drain site
Thank you,
Your ___ Surgery Team
Followup Instructions:
___
|
10548280-DS-19 | 10,548,280 | 23,716,183 | DS | 19 | 2187-02-17 00:00:00 | 2187-02-17 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
High bp medication / Percocet / codeine / Klonopin / lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
History of Present Illness:
___ woman who underwent elective cholecystectomy ___ at ___
w/ Dr ___. Since that time she has had nausea, NBNB emesis,
epigastric/RUQ/right back pain, feels pressure, and
chills/weakness. No true fevers, no change in BMs (specifically
no light stools or blood in stool). She notes that her urine was
slightly orange prior to surgery and has continued to be so. She
came in due to worsening pain and feeling that she was
dehydrated. Not taking any pain medications postop anymore.
Past Medical History:
OB/GynHx: SVD x2, fibroids
PMH: anemia, depression, migraines, HTN
PSH: TAB via D&C, tubal ligation, hysteroscopy and polypectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
VS: T 98.4 Pulse 80 BP 114/71 RR 18 O2 sat 98% RA
GEN: NAD AAOx3
Resp: CTAB no wheeze/crackles
CV: RRR no MRG
GI: soft, nontender, nondistended
Extrem: warm, well perfused
Wound: CDI, no erythema or drainage
Pertinent Results:
___ 05:58AM BLOOD WBC-5.6 RBC-4.29 Hgb-13.2 Hct-38.0 MCV-89
MCH-30.8 MCHC-34.7 RDW-14.6 RDWSD-47.2* Plt ___
___ 09:45AM BLOOD WBC-6.9 RBC-4.34 Hgb-12.9 Hct-39.0 MCV-90
MCH-29.7 MCHC-33.1 RDW-14.5 RDWSD-47.8* Plt ___
___ 05:58AM BLOOD Glucose-110* UreaN-5* Creat-0.7 Na-137
K-2.7* Cl-95* HCO3-27 AnGap-18
___ 07:40PM BLOOD Glucose-102* UreaN-7 Creat-0.7 Na-136
K-3.2* Cl-97 HCO3-27 AnGap-15
___ 09:45AM BLOOD Glucose-89 UreaN-9 Creat-0.7 Na-137 K-3.6
Cl-98 HCO3-22 AnGap-21*
___ 05:58AM BLOOD ALT-506* AST-245* LD(___)-206
AlkPhos-267* TotBili-3.9* DirBili-2.4* IndBili-1.5
___ 05:54AM BLOOD ALT-554* AST-395* LD(LDH)-276*
AlkPhos-261* TotBili-8.1* DirBili-5.9* IndBili-2.2
___ 09:45AM BLOOD ALT-563* AST-436* AlkPhos-217*
TotBili-10.3*
___ 01:10AM BLOOD ALT-608* AST-470* AlkPhos-250*
TotBili-10.1* DirBili-7.3* IndBili-2.8
___ 05:58AM BLOOD Lipase-274*
___ 05:54AM BLOOD Lipase-566*
___ 01:10AM BLOOD ___
Brief Hospital Course:
Ms. ___ is ___ ___ woman who underwent elective
cholecystectomy ___ at ___
with Dr ___. Since that time she has had nausea, NBNB emesis,
epigastric/RUQ/right back pain, feels pressure, and
chills/weakness. No true fevers, no change in BMs (specifically
no light stools or blood in stool). She notes that her urine was
slightly orange prior to surgery and has continued to be so. She
came in due to worsening pain and feeling that she was
dehydrated.
On presentation ___ her labs were significant for elevated
LFTs (ALT 608, AST 470, AP 250, TBili 10.7, D Bili 7.3) and
elevated lipase to ___.
She was admitted and managed with no diet by mouth, IV fluids,
IV antibiotics (Unasyn) and a scheduled ERCP with sphincterotomy
to evaluate the patency of her common bile duct. Of note, no
stones were seen but a small amount of sludge was evacuated. The
common bile duct, common hepatic duct, right and left hepatic
ducts, biliary radicles and cystic duct were filled with
contrast and well visualized with no defects. A sphincterotomy
was performed at the 12o'clock position without
post-sphincterotomy bleeding.
On ___ she was started on a clear liquid diet, which she
tolerated well. Her electrolytes were repleted x2, and her LFTs
were notable for a downtrend. On ___ she was advanced to
regular diet, denied pain, was ambulating independently, and her
labs were notable for further downtrending LFTs (ALT 506, AST
245, AP 267, TBili 3.9, D Bili 2.4). She was prescribed
ciprofloxacin as an outpatient per GI recommendations and was
instructed to keep her post-operative follow up appointment with
Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 300 mg PO DAILY
2. ClonazePAM 1 mg PO BID
3. Ibuprofen 600 mg PO Q8H:PRN Pain
4. Duloxetine 120 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
7. LaMOTrigine 50 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Amlodipine 5 mg PO DAILY
10. Calcium Carbonate 500 mg PO QID:PRN reflux
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [___] 500 mg 1 tablet(s) by mouth twice
a day Disp #*10 Tablet Refills:*0
2. Amlodipine 5 mg PO DAILY
3. BuPROPion 300 mg PO DAILY
4. ClonazePAM 1 mg PO BID
5. Duloxetine 120 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. LaMOTrigine 50 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
Discharge Disposition:
Home
Discharge Diagnosis:
Obstructed common bile duct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after underwent elective
cholecystectomy ___ at ___ with Dr ___. Since that time
at home you experienced nausea, vomiting, epigastric/RUQ/right
back pain, and
chills/weakness. You did not have fevers >101.5, and no change
in BMs (specifically no light stools or blood in stool). You
came in due to worsening pain and feeling that you were
dehydrated.
Once in the hospital, your labs showed elevated liver function
and pancreas labs. You underwent ERCP to evaluate/open up your
common bile duct, and you were found to have sludge but no
stones in your bile duct.
You have recovered from the procedure, your labs are all
improving, and are now ready to be discharged to home. Please
follow the recommendations below to ensure a speedy and
uneventful recovery:
1. Follow the post-operative instructions you received at
discharge from your last admission. Keep your post-operative
appointment.
2. If you have remaining sterisrips, follow your previous
post-operative instructions. The edges of Steri-Strips usually
start curling at about ___ days. The paper strips should be
removed at 14 days. Rarely patients are sensitive to the glue on
Steri-Strips in which case please remove the strips and inform
us as we may need to use something else to keep the incision
intact.
3. Avoid strenuous exercise after your surgery. Resume physical
activity when site of surgery does not hurt without pain
medication performing said activity.
4. You can perform all your activities of daily living. AVOID
lifting weights heavier than 30lbs for a total duration of 2
weeks after surgery. Please note chronic cough, chronic
constipation, excessive lifting of heavy weights and weight gain
predispose to development of hernia at the site of incisions
5. Avoid excessive fat in your diet for the first two weeks as
some patients may develop loose stool and some abdominal
discomfort while the body gets used to an absent gallbladder.
6. Call the GI office at ___ if you have any of the
following:
A. A fever higher than 101 degrees.
B. If the skin around the incision or incision is very red,
painful, swollen; looks infected
C. Jaundice ( yellowing of eyes, mucous membranes) or persistent
nausea and vomiting
Followup Instructions:
___
|
10548551-DS-7 | 10,548,551 | 21,557,830 | DS | 7 | 2116-03-29 00:00:00 | 2116-04-04 21:31:00 |
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:
Laparascopic Cholecystectomy
History of Present Illness:
___ presenting with epigastric pain. Reports that a sharp
epigastric pain woke him up from sleep at 1 AM this morning,
lasting one hour. He attempted to make himself vomit but could
not. Denies nausea and vomiting. He continued to have
intermittent epigastric pain for the rest of the night, lasting
a few minutes at a time. Denies fevers, chills, urinary
symptoms. Last meal at 9 pm. + flatus, + loose BM at 2 AM. He
has never befor had pain like this. He does take ___ excedrin
pills a day for migraines. Denies alcohol use. RUQ U/S in the ED
demonstratred cholelithiasis, non-distended gallbladder is
nondistended without gallbladder edema or pericholecystic fluid
collection. CBD was normal 2mm. His LFTs and white count were
normal. The patient was offered elective surgery but was in
significant pain and opted to have a laparoscopic
cholecystectomy as soon as possible so he was consented and
added on for OR fore the same day.
Past Medical History:
PMH - migraines
PSH - none
Social History:
___
Family History:
Hyperlipidemia, Hypertension
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: 97.8, 66, 119/82, 19, 98% RA
Gen - NAD
Heart - RRR
Lungs - CTAB
Abdomen - soft, non-distended, TTP epigastric area > RUQ, no
rebound, no guarding, negative ___ sign, no masses
Extrem - no edema
PHYSICAL EXAM ON DISCHARGE
VS: 98, 79, 121/81, 18, 99% RA
Gen - NAD
Heart - RRR
Lungs - CTAB
Abdomen - soft, non-distended, non-tender, no rebound, no
guarding, negative, active BS
Extrem - no edema
Pertinent Results:
ADMISSION LABS
144 109 21
-------------< 99
3.4 23 1.3
ALT: 29 AP: 68 Tbili: 0.4 Alb: 4.8
AST: 34
Lip: 35
7.2 ___ > 14.7 < 316
45.2
N:60.9 L:28.4 M:6.2 E:3.2 Bas:1.3
U/A neg
Brief Hospital Course:
The patient was admitted on ___ under the acute care
surgery service for management of his acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy on ___. Please see operative report for
details of this procedure. The patient tolerated the procedure
well and was extubated upon completion. He we subsequently taken
to the PACU for recovery after which he was transferred to the
surgical floor hemodynamically stable.
The patient's vital signs were routinely monitored and he
remained afebrile and hemodynamically stable. He was initially
given IV fluids postoperatively, which were discontinued when he
began tolerating PO's. His diet was advanced postoperatively,
which he tolerated without abdominal pain, nausea, or vomiting.
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 received discharge teaching and
follow-up instructions and verbalized understanding of and
agreement with the discharge plan.
Medications on Admission:
1. Topamax 50mg BID
2. imitrex ___ PRN
3. vitamin D
4. excedrin PRN
Discharge Medications:
1. Topamax 50mg BID
2. imitrex ___ PRN
3. vitamin D
4. excedrin PRN
5. Docusate Sodium 100 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lap Chole
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:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 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.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10548633-DS-13 | 10,548,633 | 25,805,539 | DS | 13 | 2149-07-10 00:00:00 | 2149-07-10 13:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of HIV and
Burkitt's lymphoma s/p right neck excisional biopsy and 3 cycles
of R-CODOX-M and 1 cycle of R-IVAC who presents with fever.
He was doing well until last night. He had trouble sleeping and
also felt warm. He took his temperature and it was 102 using two
different thermometers. He did not take any tylenol or
ibuprofen.
He notes constipation for which he took milk of magnesia,
headache, and back pain. He had neulasta shot last week and
reports body aches. He took Benadryl for itching on his legs. He
notes dizziness with walking. He has poor PO intake. He feels
like he is neutropenic. He feels like his breathing is faster
than usual. He denies abdominal pain, cough, shortness of
breath,
nausea/vomiting, and diarrhea.
On arrival to the ED, initial vitals were 99.5 118 115/77 19
100%
RA. No exam documented. Labs were notable for WBC 0.3 (ANC 10),
H/H 9.8/27.6, Plt 9, Na 138, K 3.9, BUN/Cr ___, and lactate
1.5. Blood cultures were sent. CXR showed patchy right basilar
opacity. Patient was given cefepime 2g IV, oxycodone 5mg PO, and
Tylenol 1g PO, and 1L NS. Prior to transfer vitals were 102.9
120
112/61 26 97% RA.
On arrival to the floor, patient reports tired. He denies vision
changes, weakness/numbness, cough, hemoptysis, chest pain,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
He was in his usual health until ___, when he noticed
an enlarging lymph node in his right neck. He was initially
treated with antibiotics. However, it did not decrease in size.
He then was sent to a dentist, where odontogenic infection was
suspected, and several teeth were removed. However the lymph
node
continued to grow. Due to progressively enlarging lymph node, he
presented to ___ in ___. He underwent excisional biopsy of right cervical
lymph node on ___ where 90% of the mass was removed.
The mass was around his carotid artery. The pathology showed an
aggressive B-cell lymphoma, with differential being diffuse
large
B cell lymphoma versus Burkitt's lymphoma. He also had a bone
marrow biopsy and CT torso that was negative. His
parents live in ___, so his care was discussed with the
oncology team at ___, and he flew back from ___. He
then
presented to the ___ ED for admission to initiate treatment.
Treatment History:
- ___: C1D1 R-CODOX-M
- ___: C2D1 R-CODOX-M
- ___: C3D1 R-CODOX-M
- ___: C1D1 R-IVAC
PAST MEDICAL HISTORY:
- HIV
- Hydrocele at age ___
- Adenoidectomy at age ___
Social History:
___
Family History:
Paternal great grandmother with breast cancer. No
family history of leukemia or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 101.4, BP 124/70, HR 119, RR 18, O2 sat 94% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear. Right neck incision well
healing, minimal erythema.
CARDIAC: Tachycardic, regular rhythm, 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, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.7 PO BP: 120/76 HR: 85 RR: 18 O2 sat: 95%
O2 delivery: RA
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear. Right neck incision well
healing
CARDIAC: Regular rate and rhythm, 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, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN III-XII
intact aside from mild rightward deviation of tongue. Strength
full throughout. Sensation to light touch intact.
SKIN: ~2mm milldy erythematous nodule over back without
extension
of erythema. Not tender and no active drainage. Seems improving.
Additional scattered folliculitis over back.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:40PM BLOOD WBC-0.3* RBC-3.11* Hgb-9.8* Hct-27.6*
MCV-89 MCH-31.5 MCHC-35.5 RDW-11.8 RDWSD-37.8 Plt Ct-9*
___:25AM BLOOD ___ PTT-29.6 ___
___ 08:40PM BLOOD Glucose-109* UreaN-16 Creat-1.2 Na-138
K-3.9 Cl-99 HCO3-22 AnGap-17
___ 08:40PM BLOOD ALT-51* AST-35 LD(LDH)-188 AlkPhos-188*
TotBili-1.2
___ 08:40PM BLOOD Albumin-4.6 Calcium-9.3 Phos-4.0 Mg-1.9
___ 08:46PM BLOOD Lactate-1.5
DISCHARGE LABS:
===============
___ 07:50AM BLOOD WBC-14.5* RBC-2.48* Hgb-7.8* Hct-22.5*
MCV-91 MCH-31.5 MCHC-34.7 RDW-12.0 RDWSD-40.0 Plt Ct-96*
___ 07:50AM BLOOD Glucose-125* UreaN-5* Creat-1.0 Na-143
K-3.3* Cl-106 HCO3-22 AnGap-15
___ 07:50AM BLOOD ALT-26 AST-24 LD(LDH)-446* AlkPhos-149*
TotBili-0.4
___ 07:50AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8
MICROBIOLOGY:
=============
___: Stool CDiff - Positive
___: Blood Culture - PND
___ Urine Culture - Negative
___ Blood Culture x 2 - Pending
IMAGING:
========
CXR ___
Impression: Patchy right basilar opacity which may represent
developing pneumonia.
Brief Hospital Course:
PRINICIPLE REASON FOR ADMISSION:
Mr. ___ is a ___ male with history of HIV and
Burkitt's lymphoma s/p right neck excisional biopsy and 3 cycles
of R-CODOX-M and 1 cycle of R-IVAC who was admitted with febrile
neutropenia and sepsis.
# Febrile Neutropenia:
# Sepsis:
# CDiff colitis
# Folliculitis
CXR initially with possible right sided pneumonia, and he was
noted to have folliculitis over his back. He was started on
vancomycin and cefepime. Subsequently found to have CDiff
colitis and is now on po vancomycin as well.
Sepsis physiology resolved, and we continued
vancomcyin/cefepime/po vancomycin until his ANC recovered and he
was afebrile x48 hours. We then transitioned to po cephalexin to
finish folliculitis treatment x7 days, though ___. He will then
continue po vancomycin x14 days through ___. He will follow
up with Dr. ___ week.
# ___'s Lymphoma
Continued prophylaxis with acyclovir and dapsone. PET-CT planned
for ___ will need to be rescheduled. Follow-up with outpatient
Oncologist next ___. Had 1% blasts on peripheral smear in
setting of count recovery; discussed with his outpatient
oncologist, likely effect from Neulasta and will monitor.
# Chronic headache: Improved with IVF
# HIV: Continued Dolutegravir and Descovy
# Anemia: Likely chemotherapy-induced. Currently stable.
# Thrombocytopenia: Likely secondary to chemotherapy. Transfused
1 bag platelets on arrival
# GERD: Continued ranitidine
# Constipation: Bowel regimen
# Billing: >30 minutes spent coordinating and executing this
discharge plan
TRANSITIONAL ISSUES:
- Will need to reschedule PET-CT (was scheduled for ___
- Con't cephalexin through ___ days po vancomycin after completing Keflex, through ___
- Please note - 1% blasts on CBC differential in setting of
count recovery from Neulasta - would monitor
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Cetirizine 10 mg PO DAILY:PRN allergies
3. Dapsone 100 mg PO DAILY
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
6. Lorazepam 0.5-1 mg PO QHS:PRN
anxiety/nausea/vomiting/sleeping
7. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
8. Ranitidine 150 mg PO DAILY
9. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 4 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth q6 hours Disp #*14
Capsule Refills:*0
2. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*35 Capsule Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Cetirizine 10 mg PO DAILY:PRN allergies
5. Dapsone 100 mg PO DAILY
6. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
7. Dolutegravir 50 mg PO DAILY
8. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
9. Lorazepam 0.5-1 mg PO QHS:PRN
anxiety/nausea/vomiting/sleeping
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
12. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Sepsis
# Fever and neutropenia
# CDiff colitis
# Folliculitis
# Burkitt's lymphoma
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 admitted with fever and neutropenia. We
started you on antibiotics, and ultimately found you had CDiff
colitis. You also had folliculitis on your back. Your fevers
improved and your blood counts recovered. Please continue you
oral cephalexin to treat your folliculitis through ___.
You will then need to finish 14 more days of oral vancomcyin
through ___. Please follow up with Dr. ___ as scheduled.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10548962-DS-11 | 10,548,962 | 25,716,961 | DS | 11 | 2140-07-11 00:00:00 | 2140-07-11 15:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lantus / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with a history of hypertension,
diabetes, lacunar stroke, and CNS lymphoma who is presenting
with increasing combativeness at her nursing home (The ___ in
___. Over the past six months, she has had progressive
decline in her mental status, with increasingly difficulty
remembering people's names. While at the nursing home in
___, she has also started to become combative,
intermittently acting aggressively towards staff. Over the last
few days, however, she has gotten more somnolent. Her daughter
was interviewed in the emergency room and she said that Ms
___ has not had any abdominal pain, fevers, chills, cough,
nausea, vomiting over the last few days. A UA performed in the
ED was positive; a head CT revealed progressive changes on CT
scan. She was admitted to the floor for further management.
Past Medical History:
Past Oncological History: She was initially transferred from
___ on ___ with worsening mental
status change and possible 1-cm intrapontine hemorrhage. The
patient was sleepy in bed and could not communicate
intelligently. She was transferred to ___
___ on ___. She underwent a stereotaxic brain
biopsy on ___, and then started high-dose methotrexate
on ___.
(1) a stereotaxic brain biopsy by ___, M.D., Ph.D.
on
___,
(2) s/p 5 induction cycles and 1 maintenance cycle of high-dose
methotrexate starting ___ to ___,
(3) ___ Bloody nipple discharge,
(4) ___ Right breast biopsy showed grade II invasive ductal
carcinoma, ER/PR positive and Her-2 neg and left breast
intermediate nuclear grade and LCIS,
(5) ___ Repeat biopsy at ___ confirmed findings,
(6) ___ CT torso showed multiple bilateral breast nodules,
and
(7) ___ Received briefly anastrozole 1 mg daily.
Other Past Medical History:
(1) Hypertension
(2) Asthma
(3) Diabetes type 2
(4) Osteoarthritis
(5) Cervical, lumbar spondylosis
(6) Depression
(7) Left lacunar infact (___)
(8) s/p knee surgery
(9) s/p right hip pinning
Social History:
___
Family History:
Unknown. Her health care proxy is her daughter, ___, at
___.
Physical Exam:
Physical Exam:
97.7 140/72 72 18 99%RA
GEN: Alert, oriented to name only. No acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: prolonged exp phase, no wheeze
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: No lower leg edema
DERM: No active rash
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
___ 01:00PM BLOOD WBC-12.3*# RBC-4.06* Hgb-11.7* Hct-35.5*
MCV-88 MCH-28.9 MCHC-33.0 RDW-14.6 Plt ___
___ 06:40AM BLOOD WBC-7.2 RBC-3.52* Hgb-10.3* Hct-30.5*
MCV-87 MCH-29.2 MCHC-33.8 RDW-14.0 Plt ___
___ 06:00AM BLOOD Glucose-149* UreaN-16 Creat-0.9 Na-141
K-3.9 Cl-98 HCO3-29 AnGap-18
___ 06:40AM BLOOD ALT-21 AST-19 AlkPhos-57 TotBili-0.3
___ 06:00AM BLOOD Mg-1.9
___ 06:00AM BLOOD mthotrx-0.09
___ 06:40AM BLOOD mthotrx-0.18
___ 05:30PM BLOOD mthotrx-0.38
___ 06:30AM BLOOD mthotrx-0.27
___ 06:05AM BLOOD mthotrx-1.5
==================================
Radiology
==================================
Echocardiogram ___
Findings
LEFT ATRIUM: LA not well visualized.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC was not
visualized. The RA pressure could not be estimated.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Aortic valve not well seen. No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR. ___ (>250ms) transmitral E-wave decel time.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size is normal. with
grossly normal free wall contractility. The aortic valve is not
well seen. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Global biventricular size
is normal, and function is vigorous, though assessment of
regional wall motion could not be made based on this study.
Valves were not well seen, though no obvious valve disease is
detected by doppler.
No prior exams for comparison.
MRI head ___
FINDINGS:
Portions of the examination are markedly limited secondary to
patient motion.
Within these confines:
In comparison with the MR head ___, there is increase
in T2/FLAIR
hyperintensity involving the deep and periventricular bifrontal
white matter
with areas of right greater than left nodular enhancement and
questionanle
slow diffusion concerning for recurrent lymphoma. There is also
new T2/FLAIR
hyperintensity involving the left thalamus without enhancement.
Other
scattered foci and confluent areas of high T2/FLAIR signal are
nonspecific.
There is no evidence of acute intracranial hemorrhage.
Ventricular,
cisternal, and sulcal prominence may be a function of
age-related parenchymal
volume loss. Flow voids of the major intracranial vessels
appear maintained.
There is a polyp or mucous retention cyst within the left
maxillary sinus.
The remaining paranasal sinuses demonstrate normal signal.
There is fluid
signal within the mastoid air cells bilaterally. The the sella
turcica,
craniocervical junction, and orbits appear grossly unremarkable.
A left
frontal burr hole is again seen. A nasal septal defect is
noted.
IMPRESSION:
New increasing bifrontal signal abnormality with right greater
than left
nodular enhancement concerning for recurrent lymphoma.
New T2/FLAIR hyperintensity involving the left thalamus without
enhancement.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
___ year old female with history of CNS lymphoma, invasive ductal
carcinoma, hypertension, diabetes,lacunar stroke, urinary tract
infection and pneumonia. Has had increasing somnolence
(preceeded by agitation) at nursing home admitted with new
changes on head CT and a positive UA. She was started on
ciprofloxacin on admission and her mental status improved over
the next day. She now appears to be back to her baseline, which
is alert and interactive but sometimes confused. She had an
indwelling Foley on admission. She did not seem to have a clear
indication for this, so it was removed and she was able to
urinate freely. The changes noted in her head CT from the ER
were followed up with an MRI of the head. This study showed
findings concerning for recurrent lymphoma. Dr. ___ a
family meeting with patient and her daughter ___, who is HCP.
It is not clear that the patient understands her disease process
and most decisions were made through ___. Given the long
disease free interval from her initial lymphoma diagnosis, a
brain biopsy would be recommended. Patient and daughter decided
they did not want this. Dr. ___ the imaging and felt
that it was most consistent with recurrent lymphoma. The patient
also has a history of early stage breast cancer which was not
surgically resected but treated with anti-hormonal treatment
(anastrazole). The possibility of the brain lesion being due to
breast cancer metastasis was entertained, but imaging
characteristics were felt to be more consistent with lymphoma.
The decision from family meeting was to start high dose
methotrexate and follow response on imaging. The patient had a
foley placed again for accurate urine monitoring. She had an
echocardiogram which was unremarkable. She was planned for
staging CT prior to treatment, but refused to go for the test.
Decision was made to proceed with treatment and she had her
urine alkalinized to pH >9.0. She received 3.5g/m2 methotrexate
on ___. Leucovorin rescue was started 24h afterward. urinary
alkalinization was maintained until her methotrexate level was
0.09 on the day of discharge. Another attempt at CT scanning was
made and she is now agreeable. Her foley catheter was removed
prior to discharge to reduce risk for UTI. She will return to ___
___ for admission for cycle #2 of high dose methotrexate on
___. the remainder of her problem list from admission is
listed below:
# Diarrhea: concern for cdiff given cipro earlier in stay. cdiff
testing negative
# UTI: s/p 3 days cipro
# Er/Pr positive breast cancer: has been treated with
anastrazole, no surgery per past discussions. no symptoms of
metastatic disease, planned for f/u staging/surveillance CT
prior to DC, f/u as outpatient or at next admission.
# Hypertension: Continue lisinopril.
# Diabetes Mellitus: Poorly controlled. Continued on home
glipizide 5 mg po bid. Changed metformin ER to regular metformin
to facilitate crushing/administration. Continued SC insulin.
# Perineal Rash: Treated with antifungal cream.
# FEN: Ground diabetic diet (tolerated without coughing today);
thickened nectar liquids.
# Code Status: DNR/DNI (confirmed with HCP/daughter on ___.
# ___:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
Medications on Admission:
Lactulose 30 mL PO/NG PRN
Fluoxetine 40 mg PO/NG DAILY
Docusate Sodium 200 mg PO/NG DAILY
Lisinopril 10 mg PO/NG DAILY
Insulin SC (per Insulin Flowsheet)
Omeprazole 20 mg PO DAILY
Acetaminophen 650 mg PO/NG Q8H
fluoxetine 40 mg capsule
1 capsule(s) by mouth once a day (Prescribed by Other Provider)
___
gabapentin 100 mg capsule
2 capsule(s) by mouth three times a day (Prescribed by Other
Provider; Dose glipizide 5 mg tablet
hydrocodone 5 mg-acetaminophen 500 mg tablet
1 Tablet(s) by mouth q4 hours as needed for pain (Prescribed by
Other
lisinopril 10 mg tablet
1 Tablet(s) by mouth daily (Prescribed by Other Provider)
___
metformin [Fortamet]
Fortamet 1,000 mg tablet,extended release
Singulair 10 mg tablet
omeprazole 20 mg capsule,delayed release
sitagliptin [Januvia]
Januvia 100 mg tablet
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H wheeze/SOB
2. Docusate Sodium 100 mg PO BID
3. Fluoxetine 40 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Gabapentin 200 mg PO TID
6. GlipiZIDE 5 mg PO BID
7. Lisinopril 10 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Senna 1 TAB PO BID:PRN constipation
10. Acetaminophen 650 mg PO Q8H
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
12. Lactulose 30 mL PO PRN if no bowel movement all day
13. anastrozole 1 mg Oral daily
14. azelastine 0.15 % (205.5 mcg) NU daily
15. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
urinary tract infection
recurrent CNS lymphoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital from your nursing home after
being increasingly more agitated and combative and then later
more somnolent. You were found to have a urinary tract infection
that was treated with ciprofloxacin and resolved. Your alertness
improved after the infection was treated. You also had a CT scan
and MRI of the brain which found what is most likely a
recurrence of your lymphoma. After discussion with you and your
daughter, we decided to begin treatment with methotrexate
chemotherapy. You tolerated this well and are now being
discharged back to your nursing home. You will need to return in
2 weeks for the next cycle of chemotherapy.
Followup Instructions:
___
|
10549079-DS-14 | 10,549,079 | 27,157,030 | DS | 14 | 2131-03-26 00:00:00 | 2131-03-26 12:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
elbow pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presented to the ED yesterday with right elbow pain,
swelling, redness. Pain and redness started ___, worse with
movement or touch, with decreased range of motion due to pain,
tingling in the third through fifth digits occasionally. No
fevers. No improvement with ice, minimal improvement with aleve.
Saw PCP for this on ___ and was noted to have olcecranon
bursitis. Told to take naproxen and follow up with ortho next
week for possible drainage however pain worsened and elbow
became acutely red swollen and warm on ___ and so pt presented
to the ED.
In ED pt given CefazoLIN and oxycodone for presumed septic
bursitis/cellulitis but there was no improvement in pain or
reddness after 2 doses of abx so pt seen by ortho who felt that
there was no evidence of septic arthritis treat with antibiotics
for cellulitis outpatient vs inpatient at ED discretion. Pt
received a total of 4 doses of cefazoLIN and 2 doses of bactrim.
On repeat exam erythema had spread beyond demarkated areas so pt
given vancomycin and admitted for further IV abx.
On arrival to the floor pt reports worsened erythema. No BM in 2
days. No nausea or fever. Works in ___ so has frequent
injuries but no significant trauma prior to bursitis.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
chronic low back pain
depression
erectile dysfunction
Social History:
___
Family History:
Father Cancer
Mother ___ heart disorder
Paternal Uncle Cancer; Cancer - Ovarian
Sister Cancer
Physical ___:
Vitals: T:98 BP:125/71 P:91 R:18 O2:97%ra
PAIN:
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: R olcecranon bursitis painful to light touch, also with
edema and warmth and erythema extending upper inner arm and down
forearm
Neuro: alert, follows commands
Discharge exam:
AF, VSS
right elbow with minimal-moderate amount of edema/erythema
localized only to the olecranon; resolution of prior extension;
passive ROM intact, active ROM improved but limited by pain
Pertinent Results:
___ 03:00PM GLUCOSE-86 UREA N-14 CREAT-0.6 SODIUM-138
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 03:00PM LACTATE-1.1
___ 03:00PM WBC-11.6* RBC-4.43* HGB-14.5 HCT-42.7 MCV-96
MCH-32.8* MCHC-34.0 RDW-12.5
___ 03:00PM NEUTS-77.5* LYMPHS-12.8* MONOS-7.5 EOS-1.6
BASOS-0.6
___ 03:00PM PLT COUNT-220
___ 05:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 05:34PM URINE RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE
EPI-0
___ 05:34PM URINE COLOR-Yellow APPEAR-Clear SP ___
XR Elbow ___ Preliminary FINDINGS:
No acute fracture or dislocation is identified. Mild
degenerative changes are seen within the elbow joint including
an enthesophyte at the insertion of the triceps upon the
olecranon. A joint effusion is not identified. There is soft
tissue swelling noted about the ulnar and posterior aspect of
the elbow without evidence for subcutaneous emphysema. No
radiopaque foreign body or soft tissue calcification is seen. No
concerning lytic or sclerotic osseous abnormalities
demonstrated.
Brief Hospital Course:
___ presents with right elbow pain, swelling, redness
consistent with bursitis and overlying cellulitis.
Active issues:
1. Bursitis complicated by cellulitis - no e/o septic arthritis
given lack of systemic symptoms and good ROM of joint. Treated
with various abx in the ED with minimal improvement, so switched
to IV vanc. Treated with IV vancomycin x 48 hours and switched
to keflex and bactrim upon d/c. MRSA not likely, however, given
rapid improvement with vancomycin, decided to continue coverage
for both strep and MRSA. He will complete a total of 7 days, 5
days remaining of abx on discharge. Pain treated with naproxen,
flexeril prn, and oxycodone prn.
Chronic issues:
1. Depression - continued home meds
Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 500 mg PO Q12H
2. Viagra (sildenafil) 100 mg oral prn
3. Cyclobenzaprine 5 mg PO TID:PRN muscle spasms
4. BuPROPion (Sustained Release) 300 mg PO QAM
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Cyclobenzaprine 5 mg PO TID:PRN muscle spasms
RX *cyclobenzaprine 5 mg one tablet(s) by mouth every 8 hours
Disp #*20 Tablet Refills:*0
3. Naproxen 500 mg PO Q12H
4. Viagra (sildenafil) 100 mg oral prn
5. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg one capsule(s) by mouth every 6 hours Disp
#*20 Capsule Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg one tablet(s) by
mouth twice daily Disp #*10 Tablet Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
This causes sedation; do not drink or drive or operate machinery
while taking
RX *oxycodone-acetaminophen 5 mg-325 mg one tablet(s) by mouth
every four hours Disp #*25 Tablet Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg one capsule by mouth twice daily
Disp #*20 Capsule Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg one capsule(s) by mouth twice daily
Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Olecranon bursitis
Cellulitis
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 a bursitis of your right elbow complicated
by overlying cellulitis (skin infection). You were given several
antibiotics in the emergency room and admitted for IV
antibiotics. You received IV vancomycin for 48 hours with
marked improvement in your symptoms. You are being discharged
on two oral antibiotics to take for the next 5 days. In
addition, you are being discharged on the muscle relaxant to
take as needed, oxycodone to take as needed for pain, and stool
softeners to help prevent constipation while taking the pain
medications.
Please return to the ED or to your PCP if any worsening
swelling, redness, difficulty moving your elbow, fevers, chills.
Followup Instructions:
___
|
10549196-DS-11 | 10,549,196 | 27,146,002 | DS | 11 | 2157-07-22 00:00:00 | 2157-07-22 12:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin
Attending: ___.
Chief Complaint:
hypernatremia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ male history of IDDM, previous NSTEMI, DVT,
hemiplegia and hemiparesis, esophageal ulcer with bleeding and
previous hemorrhage, underlying kidney disease, and CVA with
reportedly right-sided deficits of hemiplegia and hemiparesis,
demented and oriented to self at baseline who presents for
concern of abnormal lab work from his care facility at ___ and ___ notable for elevated white blood cell
count of 11.6, sodium 149, potassium 4.2 glucose 502 ___s
creatinine 1.8.
Per ED, patient speaks ___ and ___. Patient is
full code. No recent falls and no inability to obtain home
insulin per nursing facility report.
Per the ED staff, the patient was unable to express ROS/hx due
to
confusion, dementia, metabolic encephalopathy. Patient
reportedly receives most of his care at ___
although he has been seen at ___.
Per med rec at bedside, not on blood thinners.
Per ED, he has a G tube. They noted he appeared to have dry
mucus membranes, left-sided hand contractures and atrophy,
distended belly, mild right upper quadrant tenderness otherwise
nontender abdomen, no pedal edema with feet warm well perfused
2+
capillary refill and no apparent diabetic ulcers. Stage II to
severe decubitus ulcer.
Past Medical History:
BACKACHE NOS
CHRONIC KIDNEY DISEASE, STAGE 3 (MODERATE)
ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED
ENTEROSTOMY MALFUNCTION
ERYTHEMA INTERTRIGO
GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED
HYPERKALEMIA
HYPERTENSIVE CHRONIC KIDNEY DISEASE W STG 1-4/UNSP
IRON DEFICIENCY ANEMIA, UNSPECIFIED
MV COLLISION ___
___ MEDICAL PROCEDURES CAUSE ABN REACT/COMPL, W/O
PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EM
PRESSURE ULCER OF SACRAL REGION, STAGE 2
PRSNL HX OF TIA (TIA), AND CEREB INFRC W/O RESID D
SPRAIN LUMBAR REGION
SPRAIN OF NECK
SPRAIN SHOULDER/ARM NEC
SPRAIN THORACIC REGION
TYPE 2 DIABETES MELLITUS W DIABETIC CHRONIC KIDNEY
TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA
UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANC
IDDM, previous NSTEMI, DVT, hemiplegia and hemiparesis,
esophageal ulcer with bleeding and previous hemorrhage,
underlying kidney disease, and CVA with reportedly right-sided
deficits of hemiplegia and hemiparesis
s/p j-tube, Glucerna 1.5 cal 70 ml/hr x15 hours
Duodenal ulcer c/b GIB
CVA
Right upper extremity DVT (u/s during hospitalization in ___
___ did not
show any clots)
Sacral stage II ulcers
CKD
s/p j-tube, Glucerna 1.5 cal 70 ml/hr x15 hours
Social History:
___
Family History:
unable to ascertain
Physical Exam:
Afebrile, VS reviewed in POE
GENERAL: Awake, answers questions with simple answers
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation bilaterally
GI: Abdomen distended but not rigid, bs normal, tympanitic.
MSK: bilateral hand contractures, gross muscle wasting,
SKIN: No rashes or ulcerations noted
NEURO: Awake, oriented to self, that he is in a hospital
Pertinent Results:
___ 06:30AM BLOOD WBC-9.3 RBC-3.03* Hgb-7.7* Hct-25.2*
MCV-83 MCH-25.4* MCHC-30.6* RDW-21.4* RDWSD-62.6* Plt ___
___ 05:38AM BLOOD Glucose-95 UreaN-7 Creat-0.8 Na-143 K-3.5
Cl-107 HCO3-25 AnGap-11
Brief Hospital Course:
#Hypernatremia: ___ male history of previous NSTEMI,
esophageal ulcer
with bleeding and previous hemorrhage, CVA with residual
hemiplegia and hemiparesis, dementia, CKD, HTN, iron deficiency
anemia, stage 2 sacral pressure ulcer, T2DM, PEG-J on Glucerna,
right upper extremity DVT (u/s during hospitalization in ___
___ did not show any clots) previously on Coumadin now dc'd s/p
UGIB and colitis treated at ___ who presented with
hypernatremia. This resolved with IVF. It was likely secondary
to osmotic diuresis due to uncontrolled diabetes.
#Ileus: The patient was not having bowel movements and developed
abdominal distension. #CT Chest W/O Contrast and CT Abd & Pelvis
W/O Contrast findings.
"4.5 cm long focal area of either adherent stool versus mild
irregular wall thickening is demonstrated within the sigmoid
colon. Further evaluation can be obtained with intravenous
contrast enhanced CT or MR, or sigmoidoscopy, as an underlying
mass cannot be excluded in this region." KUB on ___ showed a
distended sigmoid colon. Tube feeds were stopped and the bowels
rested. He began having bowel movements again, and tube feeds
were advanced to goal. Repeat KUB showed improvement. IV iron
was administered instead of oral to avoid worsening. Atropine
PRN was stopped.
Further recommendations: Obtain contrast enhanced CT or MR as an
outpatient to see if finding was stool related to ileus
#Diabetes Mellitus, type 2: Per ___ discharge summary, he
was recently started on Levemir as he was found to have lactic
acidosis due to metformin. He presented with hyperglycemia. This
improved with fluids and insulin administration. DKA was not
present. His blood glucose control has been better on Lantus 7 U
BID here. Levemir should be equivalent, but adjustments may be
required based on total intake (some oral intake with dysphagia
diet in addition to TF)
#2.4 cm hypodense lesion in the spleen is indeterminate,
potentially a hemangioma or cyst.
# Right upper extremity DVT (u/s during hospitalization in
___
___ did not show any clots) previously on Coumadin now dc'd s/p
UGIB treated at ___
# History of previous NSTEMI: not currently on ASA due to
previous bleeding according to previous documentation, c/u
statin.
# GI Bleed - continue PPI (changed to lanzoprazole)
# Iron deficiency anemia: IV iron was used in place of enteric
iron. The patient did not require transfusion. Resume PO iron on
___ to avoid exacerbating ileus
# CKD: Cr 0.8
Appropriately dose meds, avoid nsaids, nephrotoxins
# HTN
c/u amlodipine, reduce lisinopril to 10 mg for renal protection
# Hx stage 2 sacral pressure ulcers and unstageable right heel
ulcer
-Continue wound care
Diet: small meals of puree/nectar thick liquids w/ 1:1
supervision/feed assist
-continued nutrition via alternative means as needed
2. Medications: via non-oral means
3. Aspiration Precautions:
-HOB > 30 degrees
-Oral care: TID
-upright and fully alert
-small bites/sips
-alternate liquids and solids
Glucerna 1.5 @ 80 mL/hr
x16 hrs, providing ___ kcal, 106 g protein, and 972 mL free
water. Free water 200 mL q4h.
The patient was seen and examined on the day of discharge. He
was having bowel movements and tolerating tube feeds without
difficulty. He denied pain.
I spent > 30 minutes preparing this discharge spent arranging
future care and preparing information for transfer to extended
care facility
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO/NG DAILY
2. Atorvastatin 80 mg PO QPM
3. Sucralfate 1 gm PO TID
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Docusate Sodium 100 mg PO BID
6. Escitalopram Oxalate 10 mg PO DAILY
7. Ferrous GLUCONATE 324 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Lactobacillus acidophilus 1 cap po DAILY
10. LiquiTears (polyvinyl alcohol) 1.4 % ophthalmic (eye) TID
11. Lisinopril 40 mg PO DAILY
12. Mirtazapine 15 mg PO QHS
13. Nystatin Oral Suspension 5 mL PO QID
14. Polyethylene Glycol 17 g PO DAILY
15. TraZODone 50 mg PO QHS
16. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
17. Senna 8.6 mg PO BID:PRN constipation
18. Levemir (insulin detemir) 100 unit/mL subcutaneous BID
19. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
20. Atropine Sulfate 1% 1 DROP SL PRN uincreased secretaion
21. Bisacodyl 10 mg PR QHS:PRN constiatpion
22. Psyllium Powder 1 PKT PO DAILY:PRN constiatpiuon
23. Milk of Magnesia 30 mL PO DAILY:PRN constiuaption
24. Ondansetron 4 mg PO Q4H:PRN nausea, secretion
Discharge Medications:
1. Multivitamins W/minerals 15 mL NG DAILY
2. Lisinopril 10 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Bisacodyl 10 mg PR QHS:PRN constiatpion
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. Docusate Sodium 100 mg PO BID
9. Escitalopram Oxalate 10 mg PO DAILY
10. Lactobacillus acidophilus 1 cap po DAILY
11. Levemir (insulin detemir) 100 unit/mL subcutaneous BID
7 U BID
12. LiquiTears (polyvinyl alcohol) 1.4 % ophthalmic (eye) TID
13. Milk of Magnesia 30 mL PO DAILY:PRN constiuaption
14. Mirtazapine 15 mg PO QHS
15. Nystatin Oral Suspension 5 mL PO QID
16. Ondansetron 4 mg PO Q4H:PRN nausea, secretion
17. Polyethylene Glycol 17 g PO DAILY
18. Psyllium Powder 1 PKT PO DAILY:PRN constiatpiuon
19. Senna 8.6 mg PO BID:PRN constipation
20. Sucralfate 1 gm PO TID
21. TraZODone 50 mg PO QHS
22. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
23. HELD- Ferrous GLUCONATE 324 mg PO DAILY This medication was
held. Do not restart Ferrous GLUCONATE until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypernatremia
Ileus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for elevated sodium levels and
elevated blood sugar. These problems were complicated by a
slowing of your bowels. We treated and sodium and blood sugar
and allowed your bowels to rest. They appear to working better
now, so we restarted your tube feeds.
Instructions:
- Do not restart your oral iron supplement until ___
- Reduce your lisinopril to 10 mg daily
- Continue Levemir twice daily. You have currently been using 7
U in the morning and evening. This may need to be adjusted.
- Stop using atropine as this can slow your bowels down
- Use lansoprazole in place of omeprazole as this can be
administered through your feeding tube.
Followup Instructions:
___
|
10549280-DS-3 | 10,549,280 | 21,232,447 | DS | 3 | 2115-07-31 00:00:00 | 2115-07-31 14:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R arm pain
Major Surgical or Invasive Procedure:
___ - ORIF of R ulna
History of Present Illness:
___ shot around 8pm earlier tonight in the right forearm with a
9mm. Patient reports someone knocked down the door of her house
& fired 2 rounds at her. One struck her right forearm, & the
other grazed her abdomen. She felt immediate pain in the
forearm, + numbness & tingling. She initially presented to
___, and was susquently transferred for furhter
managment. Since arrival to the ED, the numbness/ tingling has
resolved. Her pain remains well controlled while she rests the
arm. Last PO intake was 8am
Past Medical History:
Bipolar
Schizoaffective
Depression
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is a healthy appearing female, NAD, a&o
x 3
Vitals: VSS
Right upper extremity:
1cm entrance wound over the raidal borader of the forearm just
proximal to the elbow. No gross contamination. Slow sanguinous
ooze from the wound. Exit wound: 1.5 cm wound over the posterior
medial border of the forearm, porximal to the elbow. Slow
sanguinous ooze from the wound. No gross contamination
Compartments soft
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Pertinent Results:
___ 09:00PM GLUCOSE-79 UREA N-6 CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15
___ 09:00PM estGFR-Using this
___ 09:00PM WBC-14.6* RBC-5.17 HGB-15.7 HCT-47.0 MCV-91
MCH-30.4 MCHC-33.4 RDW-12.9
___ 09:00PM NEUTS-82.8* LYMPHS-12.5* MONOS-4.0 EOS-0.4
BASOS-0.2
___ 09:00PM PLT COUNT-388
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with R ulnar fracture. Patient was taken to the
operating room and underwent ORIF of the R ulna. Patient
tolerated the procedure without difficulty and was transferred
to the PACU, then the floor in stable condition. Please see
operative report for full details.
Musculoskeletal: prior to operation, patient was ___ RUE.
After procedure, patient's weight-bearing status was
transitioned to ___ RUE, ROMAT. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by IV
narcotics and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood for acute
blood loss anemia.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #2, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on mechanical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
Trazodone
lithium
seroquel
Prazosin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*50 Tablet Refills:*0
2. Lithium Carbonate CR (Eskalith) 450 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*35 Tablet
Refills:*0
4. Perphenazine 12 mg PO QHS
5. Perphenazine 2 mg PO TID:PRN agitation
6. Prazosin 2 mg PO QHS
7. TraZODone 200 mg PO HS
8. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
R ulna fracture
Discharge Condition:
At the time of discharge, Ms ___ was ambulating, A&Ox3,
tolerating a regular diet and pain was controlled without
nausea.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- No weight bearing through the right upper extremity. Range of
motion as tolerated. Wear the splint when sleeping or
ambulating.
Followup Instructions:
___
|
10549546-DS-25 | 10,549,546 | 26,068,185 | DS | 25 | 2197-01-22 00:00:00 | 2197-01-22 17:41:00 |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a PMHx of insulin
dependent diabetes who presents for evaluation of worsening
shortness of breath.
He started getting SOB a couple of weeks ago. It is worse with
exertion. It has been getting progressively worse to the point
where his activity was very limited by his dyspnea. No chest
pain. Rare palpitations when he feels he does not get enough air
that is associated with anxiety. +Orthopnea. +PND. ___ swelling
and abdominal swelling.
In the ED initial vitals were: 98.4 75 135/76 22 91% Nasal
Cannula
EKG showed sinus rhythm with rate of 77, no ST-T wave changes
Labs/studies notable for: Normal CBC, coags, and Chem 7. ProBNP
136. Lactate 1.6. Trop-T 0.02.
A CTA of the chest showed no PE, mild centrilobular emphysema,
diffuse mild bronchial wall thickening.
Patient was given:
___ 21:30 SL Buprenorphine-Naloxone (8mg-2mg) 1 TAB
___ 21:30 TD Nicotine Patch 21 mg
Vitals on transfer: 98.6 87 ___ 94% Nasal Cannula
ROS: Per HPI. In addition, denies DVT, PE, CVA. No fevers or
chills. Mild cough (smoker's)
Past Medical History:
Alcohol abuse (no etoh ___
Cellulitis
COPD
DM2 (c/b nephropathy, retinopathy
HTN
HLD
OSA
morbid obesity
rhinitis
osteoarthritis
Social History:
___
Family History:
Positive for lung cancer in his mother and father, positive for
diabetes in his grandfather and brother,positive for CAD in
several aunts and uncles, positive for hypertension in his
brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T=98.4 BP=136/74 HR=83 RR=18 O2 sat=91 on 2L NC
GENERAL: Well appearing, obese male in NAD
HEENT: Anicteric sclera, Dry MM
NECK: JVP to 1-2 cm above the clavicle while upright
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: Distant breath sounds. CTA b/l. Non-labored breathing
ABDOMEN: Firm, protuberant, non-tender
EXTREMITIES: Warm and well perfused, 2+ Edema to upper shins
bilaterally
DISCHARGE PHYSICAL EXAM:
=======================
VS: 98.8 ___ 18 88-95% RA
24 hr: 1304/5050
Weight: 130.4<-132.1 kg <-134.1 <- 137.1
Tele: Sinus rhythm, 60s-80s, frequent PACs
GENERAL: well appearing man, sitting up in bed in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple w/JVP 10cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, Resp were unlabored, no
accessory muscle use. Poor air movement w/no expiratory wheezes
or crackles.
ABDOMEN: Obese abdomen, non tender to palpation
EXTREMITIES: Warm and well perfused, ___ pitting edema to knee
in RLE, ___ pitting edema to knee in LLE, 2+ DP pulses
Pertinent Results:
ADMISSION LABS:
===============
___ 07:45PM GLUCOSE-237* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-11
___ 07:45PM cTropnT-0.02*
___ 07:45PM proBNP-136
___ 07:45PM LACTATE-1.6
___ 07:45PM WBC-8.3 RBC-4.86 HGB-14.1 HCT-45.2 MCV-93
MCH-29.0 MCHC-31.2* RDW-15.8* RDWSD-53.7*
___ 07:45PM NEUTS-58.6 ___ MONOS-12.3 EOS-2.7
BASOS-0.2 IM ___ AbsNeut-4.86 AbsLymp-2.14 AbsMono-1.02*
AbsEos-0.22 AbsBaso-0.02
___ 07:45PM ___ PTT-36.6* ___
PERTINENT LABS:
===============
Troponin 0.02->0.02
Arterial Blood Gas ___: PCO2 70, pH 7.33 pO2 62
Venous blood gases: pH 7.32->7.39->7.40
pCO2: 80->75->71
DISCHARGE LABS:
===============
___ 07:20AM BLOOD WBC-6.5 RBC-5.38 Hgb-15.7 Hct-49.8 MCV-93
MCH-29.2 MCHC-31.5* RDW-15.2 RDWSD-51.2* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-265* UreaN-35* Creat-1.0 Na-137
K-4.0 Cl-90* HCO3-37* AnGap-14
___ 07:20AM BLOOD ALT-25 AST-22 AlkPhos-74
___ 07:20AM BLOOD Calcium-9.9 Phos-5.6* Mg-2.1
___ 10:02AM BLOOD ___ pO2-43* pCO2-71* pH-7.40
calTCO2-46* Base XS-14
Micro
================
Blood Culture ___: pending
IMAGING AND OTHER STUDIES:
===========================
___ CXR PA/LAT:
Compared with prior radiographs on ___, there is new
peribronchial cuffing, vascular enlargement and increase in
heart size, compatible with new mild pulmonary edema.There is no
focal consolidation. No pleural effusion or pneumothorax is
seen.
___ CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild emphysema with diffuse mild bronchial wall thickening
which may
reflect airways inflammation/infection.
___ EKG: Sinus rhythm. Left axis deviation. Non-specific ST-T
wave changes. Compared to the previous tracing of ___
inferior Q waves are no longer apparent.
___ ECHO: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). 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 mild aortic valve stenosis
(valve area 1.2-1.9cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
mild aortic stenosis and pulmonary hypertension is detected;
other findings are similar.
___ Lower Extremity Doppler:
No evidence of deep venous thrombosis in the right or left lower
extremity veins. Extensive subcutaneous edema throughout
bilateral lower extremities.
Brief Hospital Course:
Patient is a ___ with IDDM who presents with worsening SOB
concerning for new onset congestive heart failure.
#Acute Diastolic Heart Failure: Patient presented with Given ___
edema and abdominal swelling, BNP may be falsely normal given
obesity and with diastolic failure which would likely have lower
wall stress. Other possibility that was considered was isolated
R sided failure from pulmonary HTN from poorly controlled
respiratory disease. His last TTE was in ___ with normal EF at
that time, confirmed with current TTE. He also had mild-moderate
emphysema seen on CTA of the chest, with significant smoking hx,
concerning for an COPD exacerbation. He was treated with IV
Lasix drip with symptomatic improvement, along with nebulizer
treatments and tiotropium inhaler. Patient was initially
breathing in low 90% on ___, weaned down to 2L NC, then
subsequently off oxygen and on room air. He also received CPAP
treatments at night. He may warrant outpatient evaluation of
ischemia as a precipitant; cardiology follow up is scheduled
with Dr. ___. His daily weights were monitored and
discharge weight was 130.4kg. Patient requested discharge prior
to being diuresed to euvolemia. He was discharged on Torsemide
40mg PO daily and Metoprolol XL 100mg daily with close
cardiology follow up.
#COPD: Pulmonary workup in ___ showed obstructive and
restrictive disease. Patient is not on any COPD medications at
home, or on home oxygen.
During admission, patient treated with Albuterol nebulizer
treatments as needed, along with Spiriva inhaler daily. He was
able to be weaned off O2 prior to discharge. Discharged home on
Spiriva daily with appointments for repeat PFT's and pulmonology
follow up. Patient was also counseled on smoking cessation and
was discharged with nicotine patches.
#SVT: Patient had symptomatic SVT runs up to HR 150s, each time
breaking with vagal maneuvers. Patient experienced palpitations
during these episodes. Patient had no episodes of SVT in 48 hour
prior to discharge and no further intervention was needed. The
patient will be followed closely by cardiology as outpatient and
knows to call Dr. ___ he develops palpitations at home.
#Insulin Dependent Diabetes Mellitus: Patient on 70/30 50U QAM
and QPM at home with metformin 500 BID. Metformin was held, and
patient was continued to home 70/30 with HISS.
#History of opioid abuse: Patient continued on home
Buprenorphine-Naloxone
TRANSITIONAL ISSUES:
=====================
-Discharge Weight: 130.4kg
-Medications ADDED during this hospitalization: Torsemide 40mg
daily, Metoprolol Succinate 100mg daily, Spiriva daily, Nicotine
patch daily.
-Patient should get have labs drawn at ___ on ___
___. Order is in.
-Patient has cardiology f/u with Dr. ___ at ___
on ___ @ 4pm.
-Patient has COPD, based on PFT's in ___. Patient scheduled
for repeat PFT's at ___ on ___ @830 and has
pulmonology f/u on ___ @ 10:40AM
-Patient would benefit from continued smoking cessation
counseling. Discharged with nicotine patches.
-CODE: Full
-CONTACT: ___ (Wife) ___ (h) ___ (c)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. MetFORMIN XR (Glucophage XR) 500 mg PO BID
3. 70/30 50 Units Breakfast
70/30 50 Units Bedtime
4. Naproxen 440 mg PO Q12H:PRN pain
Discharge Medications:
1. 70/30 50 Units Breakfast
70/30 50 Units Bedtime
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. MetFORMIN XR (Glucophage XR) 500 mg PO BID
5. Naproxen 440 mg PO Q12H:PRN pain
6. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch every 24 hours Disp #*30
Patch Refills:*0
7. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap IH
daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Acute Diastolic Heart Failure
Secondary Diagnosis:
-COPD
-Diabetes Type II, insulin dependent
-History of Opioid Abuse
-Chronic Hip and Knee pain
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 ___ on ___ after experiencing
worsening shortness of breath along with lower leg and abdominal
swelling. You were treated for heart failure with a medication
called Lasix, which helps take fluid off your body. Please go to
___ to get labs checked on ___, they already have the
prescription for this. Please follow up with Dr. ___ on
___ at the appointment scheduled for you.
We also believe your COPD contributed to your trouble breathing.
You were given nebulizer treatments while in the hospital, and
ordered for CPAP which is a machine that can help you breathe
better at night. You will have repeat pulmonary function testing
on ___ at ___. You should NOT use inhaler on the
morning of this appointment.
You should continue taking all of your prescribed medications
(except Spiriva the morning of lung testing) and attend
appointments with both Cardiology and Pulmonology (see
appointments below).
We wish you the ___,
Your ___ Care Team
Followup Instructions:
___
|
10549546-DS-26 | 10,549,546 | 29,362,575 | DS | 26 | 2197-07-26 00:00:00 | 2197-07-26 23:14:00 |
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 and lower extremity swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ with PMH significant for T2DM, HFpEF
(60-65%), AFib on Xarelto, OSA on CPAP, and history of substance
abuse who presents to the ED for DOE and ___ swelling.
Patient has not been taking his medications for the past two
weeks (except for his suboxone). He has felt progressively worse
since he stopped taking his medications (he stopped due to
family stress at home). He reports dyspnea on exertion beginning
around the time he stopped taking his medications. He notes that
recently he is only able to walk ___ steps before becoming SOB
and having to rest. He also reports new orthopnea, PND and
bendopnea in the last 2 weeks. He has taken to sleeping upright
in his recliner with his CPAP because he cannot catch his
breath. He estimates that he has gained 15 lbs in the last 2
weeks. Most of this seems to be fluid which is mainly in his
abdomen and lower extremities bilaterally although he notes that
the RLE is larger than the left. He also reports a nonproductive
cough. He denies recent sick contacts and received the flu shot
this year.
Past Medical History:
Alcohol abuse (no etoh ___
Cellulitis
COPD
DM2 (c/b nephropathy, retinopathy)
HFpEF
HTN
HLD
AFIB
OSA
morbid obesity
rhinitis
osteoarthritis
tobacco abuse
Social History:
___
Family History:
Positive for lung cancer in his mother and father, positive for
diabetes in his grandfather and brother,positive for CAD in
several aunts and uncles, positive for hypertension in his
brother.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
GENERAL: Pleasant morbidly obese gentleman, well-appearing, in
no distress.
HEENT: no conjunctival pallor or scleral icterus, MMM
NECK: JVP not visible ___ habitus
CCARDIAC: Distant heart sounds, irregularly irregular, no
murmurs rubs or gallops.
PULMONARY: Quiet breath sounds, no w/r/r.
ABDOMEN: Morbidly obese but soft. Normal bowel sounds and
non-tender, no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis or clubbing. trace
to 1+ edema in dependent areas (below level of knee). Stasis
dermatitis noted bilaterally. No wounds or weeping of the skin.
SKIN: Without rash, stasis changes as noted
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
___ 05:50AM BLOOD WBC-8.6 RBC-5.54 Hgb-16.3 Hct-51.5*
MCV-93 MCH-29.4 MCHC-31.7* RDW-14.1 RDWSD-47.5* Plt ___
___ 05:50AM BLOOD ___ PTT-44.1* ___
___ 05:50AM BLOOD Glucose-248* UreaN-22* Creat-0.8 Na-137
K-4.0 Cl-92* HCO3-37* AnGap-12
___ 02:15PM BLOOD Glucose-282* UreaN-14 Creat-0.9 Na-135
K-4.5 Cl-95* HCO3-33* AnGap-12
___ 05:50AM BLOOD Calcium-9.6 Phos-3.6 Mg-1.7
___ 02:15PM BLOOD Albumin-3.4* Calcium-9.1 Phos-3.3# Mg-1.6
___ 02:15PM BLOOD ALT-25 AST-24 AlkPhos-95 TotBili-0.4
___ 02:15PM BLOOD Lipase-32
___ 06:32AM BLOOD CK-MB-5 cTropnT-<0.01
___ 09:30PM BLOOD CK-MB-6 cTropnT-<0.01
___ 02:15PM BLOOD cTropnT-<0.01
___ 02:15PM BLOOD CK-MB-6 proBNP-196*
___ 03:45PM BLOOD D-Dimer-618*
___ 02:15PM BLOOD TSH-1.0
___ CTA:
IMPRESSION:
1. No pulmonary embolism or acute aortic process.
2. Emphysema diffuse bronchial wall thickening likely reflecting
small airways
disease, difficult to exclude superinfection with reactive hilar
and
mediastinal lymph nodes. Air trapping also noted.
3. Partially imaged perihepatic ascites for which clinical
correlation is
advised.
___ TTE:
IMPRESSION: Mild symmetric left ventricular hypetrophy with
preserved systolic function. Mild right ventricular dilation and
systolic dysfunction. Mild aortic stenosis. Mild pulmonary
artery systolic hpyertension.
Brief Hospital Course:
___ with PMH significant for T2DM, HFpEF (60-65%), AFib on
Xarelto, OSA on CPAP, COPD and history of substance abuse who
presents with hypoxia and tachycardia found to have heart
failure exacerbation, CAP and COPD exacerbation now diuresed
almost 15L, completed antibiotics/prednisone. Being discharged
on torsemide 40mg qd with DC weight of 130.9kg.
#HFpEF: presented decompensated, last EF 60-65%. Received IV
Lasix 40mg x1 in ED with mild improvement. BNP on admission was
196. Additionally, admission weight was 143.6kg, weight at last
CHF discharge was ~130kg. Cardiac echo showed preserved EF, with
mild AS, mild PAH, and global RV free wall hypokinesis. He was
diuresed aggressively on a furosemide gtt, though developed a
mild contraction alkalosis with this, diuresis reduced to
torsemide 40mg po qd (double home dose). On this regimen, he
remained about ___ neg per day. Discharge weight 130.9kg.
Although he likely still has some fluid to diurese, he is
scheduled for ___ clinic f/u on ___, where he will get
appropriate titration of his medications. It is likely the
diuretic regimen will be able to be reduced at this upcoming
appointment.
#Afib/flutter with RVR: had a few episodes of SVT versus RVR. He
received adenosine and IV diltiazem on one occasion, with
improvement. PO diltiazem was added to his metoprolol regimen.
Likely trigger was decompensated CHF and possible pneumonia.
Diltiazem weaned off on ___, but patient experiencing HR in
100s-130s on morning of ___, so discharged on both metoprolol XL
200mg qd and diltiazem 30mg bid, with plan for close follow up
in ___ clinic. His xarelto was continued. TSH 1.0.
#HYPOXIA: The dominant contributor for his hypoxia was CHF
exacerbation with pulmonary edema, secondary contributors were
COPD exacerbation +/- CAP. CTA chest ruled out PE. Area of
bronchial thickening and air bronchogram seen in right middle
lobe of CTA chest suggestive of infectious process despite no
leukocytosis, fever or increased sputum production. Patient
completed a 5 day course of levofloxacin and prednisone.
Diuresis also as above. He was saturating >89% on RA at the time
of DC. He also resumed his home tiotropium inhaler. He continued
his CPAP for OSA overnight throughout his hospitalization.
#T2DM: poorly controlled on admission, patient was transitioned
to glargine 100 units sc daily (from home 45BID of 70/30) plus
home dosage of metformin on discharge.
#SUBSTANCE ABUSE: continued home suboxone while inpatient.
TRANSITIONAL ISSUES:
#TORSEMIDE DOSE: Negative ___ per day on torsemide 40mg every
morning, during HF follow-up appointment consider cutting back
to home dose of torsemide 20mg based on exam.
#INSULIN: Switched BID 70/30 in favor to glargine since ___
required bid injection thus more diabetic supplies, which
patient is having difficulty affording. Continued on home dose
metformin on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. 70/30 40 Units Breakfast
70/30 40 Units Dinner
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO BID
5. Nicotine Patch 21 mg TD DAILY
6. Torsemide 20 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Rivaroxaban 20 mg PO DINNER
Discharge Medications:
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. Glargine 100 Units BreakfastMax Dose Override Reason: dose
needed given clinical needs
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 100 Units
before BKFT; Disp #*3 Vial Refills:*0
RX *insulin syringe-needle U-100 29 gauge x ___ use with
glargine once a day Disp #*30 Syringe Refills:*0
3. MetFORMIN XR (Glucophage XR) 500 mg PO BID
4. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Rivaroxaban 20 mg PO DINNER
6. Tiotropium Bromide 1 CAP IH DAILY
7. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth every morning Disp #*60
Tablet Refills:*0
8. Atorvastatin 40 mg PO QPM
RX *diltiazem HCl 30 mg 1 (One) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
9. Diltiazem 30 mg PO BID
RX *diltiazem HCl 30 mg 1 (One) tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Milk of Magnesia 30 mL PO BID
RX *magnesium hydroxide ___ Milk of Magnesia] 400 mg/5 mL
30 mL by mouth twice a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Heart failure with preserved ejection fraction
COPD exacerbation
Pneumonia
Atrial fibrillation
Secondary diagnoses:
T2DM
Substance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ for a heart failure
exacerbation . We believe your heart was unable to properly pump
blood forward because you were not taking your medications as
directed. As a result, you started to build up fluid in your
lungs and legs. This fluid in your lungs made it difficult for
you to breathe. On top of this, you likely had an exacerbation
of your COPD or a small pneumonia that also made it tough to
breathe.
While you were here, we gave you IV diuretics to help take off
fluid from your body until you were close to your previous
discharge weight of 130 kg. You were also given a course of
steroids and antibiotics to help treat the COPD exacerbation and
pneumonia. By the time of discharge, your weight was 130.9kg.
While this is close to your previous weight, we still believe
that you have some fluid left to diurese.
While admitted, you also had a bout of atrial fibrillation with
fast heart rate that was treated with medications. You are being
discharged on an increased dosage of metoprolol (200mg) as well
as 30mg diltiazem 2x a day. This will help control your heart
rates.
For your heart failure, please take your medications as
directed, follow a low salt diet, and see your heart specialist
on ___.
Please make sure to weigh yourself each day. If you have any
warning signs as listed below, please call your PCP.
Thank you for letting us take care of you,
___ Medicine
Followup Instructions:
___
|
10549672-DS-20 | 10,549,672 | 20,392,277 | DS | 20 | 2140-07-14 00:00:00 | 2140-07-14 14:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Demerol / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a pleasant ___ year-old woman with a history of
hypertension, hypothyroidism and basal cell carcinoma. The
patient communicated to her daughter early in the morning of
___ that she got up in the middle of night, possibly to go to
the bathroom, and sustained a fall. The patient could not
recall the events on interview today. Per her daughter, the
patient said
she was able to crawl to her bed to get up and phone her
daughter about the fall.
Mrs. ___ was brought to ___ by her son.
The patient was noted to be at her baseline at that time,
ambulating with a cane. OSH CT scanning showed bilateral SDH:
Left SDH subacute with a max width of 0.3cm; Right SDH acute in
nature (0.7cm). She suffered a lip laceration that was sutured
at the OSH. Lastly, she was noted to have a non-displaced nasal
bone fracture. The patient was transported to ___ for further
evaluation and management.
Mrs. ___ states that she was admitted to ___ in ___ut hasn't fallen since today. However, with
further prompting, she acknowledged she fell a month and a half
ago. As mentioned above, she uses a cane at baseline due to
instability.
Past Medical History:
Hypertension, hypothyroidism, basal cell carcinoma
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
T: 97.7 HR: 80 BP: 132/65 RR: 16 O2Sats: 100% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact. Nose swollen, dried blood at nares.
Ecchmosis of upper lip area.
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.
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
On discharge:
T: AVSS
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact. Nose swollen, dried blood at nares.
Ecchmosis of upper lip area.
Neuro:
Mental status: Oriented to person, place and time. Has periods
of confusion and agitation.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
On discharge:
AAO x 3, no pronator drift. Strength ___ throughout.
Pertinent Results:
___ Non-contrast head CT (OSH):
bilateral SDH: Left SDH subacute with a max width of 0.3cm;
Right SDH acute in nature (0.7cm). No midline shift.
Ventricles
patent.
___ ECG
Sinus rhythm. Left axis deviation. Non-specific lateral ST-T
wave flattening. Delayed R wave transition. No previous tracing
available for comparison.
___ ECG
Sinus rhythm. Baseline artifact. Left axis deviation.
Non-specific lateral
ST-T wave changes. Borderline low limb lead voltage. Compared to
the previous tracing of ___ there is increase in the
baseline artifact and sinus arrhythmia. Otherwise, no diagnostic
interim change.
___ Echo
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal. Quantitative (biplane) LVEF = 57%. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
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 structural cardiac cause of syncope seen. Normal
global and regional biventricular systolic function. Mild mitral
regurgitation.
___ Carotid U/S
Right ICA 40% stenosis.
Left ICA<40% stenosis.
___ Non-contrast head CT:
1. Stable small, left greater than right, subdural hematomas
without mass
effect on subjacent brain parenchyma. No new hemorrhage.
2. Chronic pan-sinusitis, similar to ___.
Brief Hospital Course:
Mrs. ___ was admitted to the Neurosurgery service after she
was found to have bilateral subdural hematomas s/p mechanical
fall. Due to a questionable syncopal episode, she was admitted
to the inpatient ward for further workup, in addition to ongoing
neurologic checks. Mrs. ___ was noted to have a urinary
tract infection based on urinalysis. She was given ceftriaxone
in the ED and started on a three-day course of ciprofloxacin
thereafter. She was eating a regular diet without issue. The
Plastic Surgery service was asked to see the patient for her
nasal bone fracture. Based on their evaluation, there was no
intervention required.
Both physical and occupational therapy were asked to see the
patient on ___. Physical and occupational therapy were
unanimous in their recommendations that the patient would best
be served with rehab. Ms. ___ had a syncopal work up that
included a carotid series which showed that the right internal
carotid arteries were 40% stenotic while the left internal
carotid arteries were less than 40% stenotic. She also had an
echocardiogram which showed mild mitral regurgitation with no
mechanical cause for her syncopal episode. Ms. ___
electrocardiogram showed sinus rhythm with periods of sinus
arrhythmia.
On ___, Mrs. ___ was discharged to a rehabilitation
facility. She was afebrile, hemodynamically and neurologically
stable. She completed her three-day course of ciprofloxacin.
The patient was instructed to follow up with Dr. ___ in
___ clinic with a non-contrast head CT prior to her
appointment.
Medications on Admission:
Synthroid, amlodipine, calcium 600 + D3, MVI
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Amlodipine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Senna 1 TAB PO BID
7. Famotidine 20 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral subdural hematomas
Urinary tract infection
Discharge Condition:
Mental Status: Oriented x3, but has periods of confusion and
agitation.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
o Take your pain medicine as prescribed.
o Exercise should be limited to walking; no lifting, straining,
or excessive bending.
o 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.
o Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Followup Instructions:
___
|
10549680-DS-17 | 10,549,680 | 21,268,144 | DS | 17 | 2167-02-09 00:00:00 | 2167-02-18 20:52:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ homeless M with hx of EtOH abuse, COPD, and PE/DVT, presents
with 10 months of shortness of breath. Patient was brought to
___ by ambulance after reportedly being found on park bench
with 2 pints of EtOH. After becoming sober, patient reported a
10 month history of progressive SOB, stating that he cannot walk
more than a few blocks without becoming short of breath. Also
reports 10 months of nonpositional chest pain, that does not
radiate, and is not associated with any heart palipitations or
exacerbated with activity.
Patient reports that he has been in and out of various hospitals
over the past year for various medical problems. Also reports
that he has had the PNA three times in the past year which were
treated with antibiotics. Was recently treated at ___
___, reporting that he had a heart attack, although he
states that he cannot remember what they did for him. According
to ___ records, patient was admitted ___ for a COPD
exacerbation. Patient has a history of PE dx in ___ and was on
coumadin but was recently transitioned to lovenox due to
supratherapeutic INRs.
In the ED, initial VS were 98 100 132/94 17 100% RA. CBC, chem7
were wnl, and trop was negative x1. EKG was wnl. CXR showed mild
pulmonary vascular congestion and bibasilar atelectasis. CTA
showed nearly completely occlusive thrombus in the lobar branch
supplying the left lower lobe with an appearance suggestive of
chronic thrmbosis. Patient was given lovenox ___ x2.
On arrival to the floor, patient reports shortness of breath as
above, unchanged. Also complains of CP as above, unchanged.
Complains of some leg tenderness, states that bilaterally below
the knees calves always tender and its because of DVTs.
All other 10-system review negative in detail.
Past Medical History:
COPD
DVT/PE
?Pyschiatric ___ records mention bipolar disorder)
EtOH Abuse
Social History:
___
Family History:
Reports multiple family member with DVT/PE. Mother, brother,
uncle (has filter), sister
Physical ___ Physical Exam:
VS - 97.8 125/83 95 22 99RA
General - Lying in bed. NAD
HEENT - MMM, OP clear.
Neck - supple, full ROM
CV - RRR, no murmurs or gallops. JVP not elevated
Lungs - +wheezing, no rhonchi or crackles.
Abdomen - soft, nontender, nondistended.
Ext - TTP of bilateral ankles and calves. No edema or erythema.
+DP pulses
Neuro - cooperative with exam
Discharge Physical Exam:
VS - 97.8 135/93 91 20 96RA
General - Lying in bed. NAD
HEENT - MMM, OP clear.
Neck - supple, full ROM
CV - RRR, no murmurs or gallops. JVP not elevated
Lungs - +mild wheezing, no rhonchi or crackles. breath sounds
present bilaterally
Abdomen - soft, nontender, nondistended.
Ext - TTP of bilateral ankles and calves. No edema or erythema.
+DP pulses
Neuro - no focal deficits. ___ strength throughout
Pertinent Results:
Admission Labs:
___ 08:26AM BLOOD WBC-6.6 RBC-4.50* Hgb-13.2* Hct-40.8
MCV-91# MCH-29.3 MCHC-32.3 RDW-14.4 Plt ___
___ 08:26AM BLOOD Neuts-57.7 ___ Monos-7.5 Eos-4.0
Baso-1.4
___ 08:26AM BLOOD ___ PTT-38.7* ___
___ 08:26AM BLOOD Glucose-77 Creat-0.9 Na-144 K-3.7 Cl-108
HCO3-24 AnGap-16
___ 08:26AM BLOOD cTropnT-<0.01
Discharge Labs:
___ 05:50AM BLOOD WBC-6.0 RBC-4.58* Hgb-13.2* Hct-41.2
MCV-90 MCH-28.9 MCHC-32.1 RDW-14.4 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-141
K-3.6 Cl-107 HCO3-25 AnGap-13
Imaging:
EKG ___ NSR
CXR ___ Mild pulmonary vascular congestion and bibasilar
atelectasis.
CTA ___ IMPRESSION:
1. Eccentric thrombus in the lobar branch supplying the left
lower lobe has a CT appearance suggestive of chronic thrombosis.
The thrombus extends and completely occludes all the segmental
branches to the left lower lobe with the exception of the branch
supplying the posterobasal segment which is partially occluded.
These branches are smaller than expected, also supporting
chronicity.
2. 4 mm nodule in the left upper lobe should be followed in 6
months.
3. Small focus of ground-glass opacity in the right lower lobe
may represent aspiration versus infection. Malignancy is also
possible, therefore this should also be followed.
4. Emphysema.
5. Fatty liver
Brief Hospital Course:
Mr. ___ is a ___ yo homeless M with hx of EtOH abuse, COPD,
and PE/DVT(heterozygous for prothrombin mutation), found down
acutely intoxicated and brought to ___ ED, and admitted for
management of chronic shortness of breath ___ chronic PE.
ACTIVE ISSUES:
# DVT/PE, SOB, Chest Pain: CTA in the ED showed a large left
main pulmonary embolus. His PE/DVT history is somewhat unclear,
but briefly, through patient history and prior hospital records,
he was diagnosed with a large left main thrombus in ___,
which by ___ report was stable in ___, and in
comparison to our CTA findings this admission, is unchanged.
Patient has been on lovenox after reportedly being
subtherapeutic on warfarin. According to records, this patient
has a history of medical noncompliance but patient states that
he has been compliant with his lovenox. In the ED, patient was
afebrile, HD stable, had normal ekg, CBC and Chem7 were wnl, CXR
was negative for PNA and trop x1 was negative. Here on the
floor, patient didn't complain of any new symptoms, just his
chronic SOB/CP due to his known PE and COPD. Given his known
chronic DVT/PE history, IVC filter was considered. Hematology
was consulted, and they felt that an IVC filter had many more
risks than benefits in this patient so they recommended keeping
him on his current regimen of 150 mg lovenox QD. Upon discharge,
pateint was afebrile and HD stable.
# EtOH abuse: According to patient and prior records, has never
had an episode of withdrawal. Patient was monitored closely the
night of admission using CIWA. Patient did not have any
withdrawal symptoms and did not require any treatment for this
during this hospitalization.
TRANSITIONAL ISSUES
- should f/u with pcp in one to two weeks
- right lower lobe ground-glass opacity - recommend re-imaging
to monitor for stability
- fatty liver identified on imaging - recommend further work-up
as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing or SOB
2. Albuterol-Ipratropium 1 PUFF IH Q6H
3. Enoxaparin Sodium 150 mg SC DAILY Start: ___, First
Dose: Next Routine Administration Time
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Topiramate (Topamax) 50 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing or SOB
2. Albuterol-Ipratropium 1 PUFF IH Q6H
3. Enoxaparin Sodium 150 mg SC DAILY Start: ___, First
Dose: Next Routine Administration Time
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Topiramate (Topamax) 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: shortness of breath
Secondary: DVT/PE, chronic
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 care for you here at ___
___. As you know, you were hospitalized for shortness of
breath. We believe that your shortness of breath is caused by
your underlying COPD as well as your pulmonary embolus, which is
a blood clot in your lungs. In order to treat these conditions,
please take the medications that you have been perscribed, in
particular, the lovenox well help to ensure that the blood clot
in your lung does not get bigger. Please continue to take your
albuterol-ipratropium inhaler, which should also help with your
breathing.
We feel that your alcohol consumption may be contributing to
your blood clots in the legs and lungs. It is in your best
interest to refrain from alcohol completely. At the very least,
cutting back on the amount and frequency of alcohol consumption
would be to your benefit.
Please follow up with your primary care doctor in one week.
Please contact your doctor immediately if you ___ fever
(>100.4), worsening or severe shortness of breath, worsening or
severe chest pain, or with any other symptoms that concern you.
Followup Instructions:
___
|
10549680-DS-18 | 10,549,680 | 20,286,039 | DS | 18 | 2168-01-05 00:00:00 | 2168-01-08 12:04:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
___ homeless male w/ PMH sig for COPD, tobacco abuse, DVT/PE
(prothrombin mutation, on Lovenox) who p/w cough, productive
green sputum, subjective fevers, and worsening shortness of
breath over the last few weeks.
The patient has been non-ambulatory and in a wheelchair. Last
year, he underwent a left pateloplasty at ___ and
for the past 8 months he has been unable to flex or extend his
left knee. He has had some wound dehiscence of the left knee in
the past few months and has been seen and treated with some
bedside debridement and dressing changes by plastic surgery dept
at ___.
Over the past few weeks, he has noted feeling warm, having
sweats, and having shortness of breath on exertion while in his
wheelchair. He has a chronic cough, especially in the morning.
However, it has been worsening over the past week, productive of
greenish sputum. He felt unable to take a full breath and came
to the ED. His review of systems was also positive for a 55lb
unintentional wt loss over the past 6 months.
In the ED, initial vitals: 98.4 101 100/63 20 92% RA. It was
also found that his left knee wound had dehisced with notable
purulent drainage. He was initially admitted to RDU (appeared
intoxicated) but he was deemed to be more acutely ill with
tachypnea, 88% O2 sat on RA, increased to 92 on NC. He was
treated for a COPD flare (wheezy diffusely, also with crackles
per report) -> Azithromycin (methylpred x1, nebs x1) initially
but given lactate of 2.8, decision was made to give
Levofloxacin, Vanco, and Cefepime. Labs notable for negative
serum/urine tox screen, +EtOH, WBC 11, BNP 537, lactate 2.8. CXR
without consolidation, evidence of emphysema. He was seen by
ortho for his left knee wound, and the patient was transferred
to the MICU.
Past Medical History:
-COPD
-DVT/PE ___, on ?lifelong AC w/ Lovenox (h/o noncompliance to
monitoring while on Coumadin, h/o supratherapeutic INR)
-Prothrombin mutation
-?Pyschiatric: ___ records mention bipolar
disorder/depression
-EtOH abuse: 1 pint of per day
-Tobacco abuse
-L patella fracture with a patella button and extensor mechanism
rupture s/p extensor mechanism repair w/ allograft
-Diverticulosis
-GI bleed in ___- ___
-Osteoarthritis
-Hyperlipidemia
-PTSD
-Gender identity
Social History:
___
Family History:
Reports multiple family member with DVT/PE. Mother, brother,
uncle (has filter), sister
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 37.1, HR 86, BP 123/73, 24, 94% on 2L NC
GENERAL: Alert, oriented, no acute distress, asking to go to
sleep
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Diminished breath sounds bilaterally, faint bibasilar
crackles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; left knee with dressing, pink with granulation tissue, no
erythema or drainage
SKIN: warm and dry
NEURO: AAO x 3
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tm 98.2, BP: 123/72, P: 62, R: 20, O2: high 90's on 1 L,
___ % on RA. GLucose 97.
GENERAL: Alert, oriented, no acute distress, asking to go to
sleep
HEENT: Sclera anicteric, tongue dry, but buccal gutters moist,
oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation B/L on anterior and posterior chest
with patient lying sideways (did not "like" to sit up) No
wheezing or stertor noted.
CV: Regular rate and rhythm, normal S1 S2 over aortic, pulmonic,
tricuspid or mitral valves, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses radial and DP pulses B/L, no
clubbing, cyanosis or edema; left knee with dressing.
NEURO: AAO x 3, CNII-XII intact, no gross motor or sensory
deficits.
Pertinent Results:
ADMISSION LABS
==============
___ 07:31PM BLOOD WBC-11.6*# RBC-5.26 Hgb-14.0 Hct-45.3
MCV-86 MCH-26.6* MCHC-30.9* RDW-16.1* Plt ___
___ 07:31PM BLOOD Neuts-55.2 ___ Monos-3.4 Eos-3.0
Baso-0.9
___ 07:31PM BLOOD Glucose-97 UreaN-11 Creat-1.1 Na-142
K-3.2* Cl-105 HCO3-21* AnGap-19
___ 07:31PM BLOOD Lipase-37
___ 07:31PM BLOOD proBNP-537*
___ 07:31PM BLOOD cTropnT-<0.01
___ 07:31PM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2
___ 07:31PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:30PM BLOOD pO2-60* pCO2-36 pH-7.35 calTCO2-21 Base
XS--4 Comment-TESTS ADDE
___ 08:45PM BLOOD Lactate-2.8*
___ 08:45PM URINE Color-Straw Appear-Clear Sp ___
___ 08:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
NOTABLE LABS
============
___ 09:00PM BLOOD Type-ART pO2-498* pCO2-29* pH-7.41
calTCO2-19* Base XS--4
DISCHARGE LABS
==============
___ 07:50AM BLOOD WBC-9.8 RBC-5.08 Hgb-13.4* Hct-42.6
MCV-84 MCH-26.3* MCHC-31.4 RDW-15.6* Plt ___
___ 07:50AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-142
K-3.4 Cl-105 HCO3-26 AnGap-14
___ 07:50AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0
MICRO
=====
MRSA SCREEN (Final ___: No MRSA isolated.
Blood cultures pending.
STUDIES
=======
___ PFTs:
Moderate obstructive ventilatory defect with a mild to moderate
gas exchange defect. Lung volumes are within normal limits. The
FVC is likely underestimated due to an early termination of
exhalation. There are no prior studies available for comparison.
___ ECHO: Normal biventricular cavity sizes with
preserved regional and low normal global biventricular systolic
function. Mild mitral regurgitation. High normal estimated PA
systolic pressure.
___ CT chest without contrast:
1. SIMILAR CT APPEARANCE OF SOLID 4 MM AND 5 MM LEFT LUNG
NODULES.
APPROXIMATELY ___ YEAR STABILITY IS SUGGESTIVE OF A BENIGN
ETIOLOGY.
2. MIXED ATTENUATION RIGHT LOWER LOBE 12 MM OPACITY ALSO APPEARS
UNCHANGED. CONSIDER ADDITIONAL ___ YEAR FOLLOWUP CT TO EXCLUDE AN
INDOLENT LUNG ADENOCARCINOMA, WHICH MAY BE VERY SLOWLY GROWING.
3. ENLARGED PULMONARY ARTERIES SUGGESTIVE OF PULMONARY ARTERIAL
HYPERTENSION, AND CORONARY ARTERY CALCIFICATIONS
4. MILD EMPHYSEMA, FINDINGS SUGGESTIVE OF RESPIRATORY
BRONCHIOLITIS, AND CHRONIC BRONCHITIS.
___ CXR (PA and lateral):
Clear lungs with no evidence of pneumonia.
___ XR left knee:
1. Postoperative/posttraumatic changes involving the patella as
described above. Comparison to old films would be helpful the
status to this is an interval change.
2. Osteoarthritis.
___ ECG:
Sinus tachycardia. Non-specific inferolateral ST segment
flattening. Compared to the previous tracing of ___ no
interval diagnostic change.
Brief Hospital Course:
___ homeless male w/ PMH sig for COPD, tobacco and alcohol
abuse, DVT/PE (on Lovenox) who p/w cough, productive green
sputum, subjective fevers, and worsening shortness of breath
over the last few weeks.
ACUTE ISSUES
============
# Dyspnea: Patient initially saturating at 92% on room air which
may be his basline given history of COPD, however he dropped to
88% and given his elevated lactate, there was concern for a
pneumonia. CXR shows no focal consolidation. Also diffuse
wheezing on exam. Patient has history of COPD although is likely
mild given CT findings and the fact that he is not on home
oxygen. The patient responded very quickly to steroids (Day 1:
___, 5-day course). He received one dose of azithromycin ___,
500mg IV), but this was discontinued. This may be too quick for
treatment of COPD exacerbation. He was weaned from BiPAP within
a few hours and transferred to the floor. The patient also had a
CT scan of the chest which showed similar appearance of 4mm and
5mm left lung nodules, unchanged mixed attenuation of RLL 12mm
opacity ___ year follow-up recommended) as well as enlarged
pulmonary arteries suggestive of pulmonary hypertension and mild
emphysema. An ECHO only showed slight MR and high normal PA
pressures. PFTs demonstrated a moderate obstructive ventilatory
defect with a mild to moderate gas exchange defect. The etiology
for his shortness of breath may result from recurrent
thromboemboli in the setting of decreased mobility, prothrombin
mutation, and prior DVT/PE. Before discharge, he was weaned from
2L NC to room air with O2 saturation >90%. He should be
scheduled for follow-up with pulmonology through his PCP at
___.
# L Knee Wound: Patient is s/p extensor mechanism repair w/
allograft after suffering patellar fx and extensor injury.
Orthopedics saw patient and recommended no acute intervention
with weight bearing as tolerated. He was also seen by plastics
who thought the wound looked improved from prior and recommended
to continue bactracin with daily dressing changes. Knee x-rays
showed stable post-surgical changes.
CHRONIC ISSUES
==============
# DVT/PE: Patient is on lifelong anticoagulation given history
of DVT/PE in the setting of prothrombin mutation. He was
continued on Lovenox ___ daily.
# EtOH Abuse: Patient presented with etoh of 294. He was placed
on the ___ protocol but did not require any benzos. He was
given thiamine and folate supplementation.
# Tobacco Abuse: Nicotine patch PRN, encouraged cessation.
# Homelessness: Patient is planning to return to his current
shelter when medically stable for discharge.
TRANSITIONAL ISSUES
===================
# The pt changes his dressing himself. Pt was provided some
dressing supplies at discharge.
# ___ follow-up CT chest is recommended for mixed attenuation
in RLL 12mm opacity to exclude an indolent lung adenocarcinoma.
# The patient should be scheduled for follow-up in pulmonology
through his PCP at ___.
# Emergency contact: ___ (Mother) ___
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 150 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze
3. Escitalopram Oxalate 20 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Omeprazole 20 mg PO DAILY
6. Meclizine 25 mg PO TID:PRN dizziness
7. Nicotrol NS (nicotine) 10 mg/mL nasal daily
Discharge Medications:
1. Enoxaparin Sodium 150 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inhaled once daily Disp #*3 Capsule Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate 90 mcg 1 puff every ___ hrs Disp #*4
Inhaler Refills:*0
6. Bacitracin Ointment 1 Appl TP ASDIR with daily dressing
changes
RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram
apply to knee as directed Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multiple] 1 tablet(s) by mouth onec
daily Disp #*60 Tablet Refills:*0
8. Nicotrol (nicotine) 10 mg/mL inhalation q2 hours prn Nicotine
Cravings
RX *nicotine [Nicotrol] 10 mg 1 daily as needed Disp #*20
Cartridge Refills:*0
9. Meclizine 25 mg PO TID:PRN dizziness
10. Omeprazole 20 mg PO DAILY
11. PredniSONE 40 mg PO DAILY
take on ___
RX *prednisone 20 mg 2 tablet(s) by mouth once Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
1. Chronic obstructive pulmonary disease
2. Non-healing wound of the left knee
SECONDARY DIAGNOSES
===================
1. Deep vein thrombosis
2. Alcohol abuse
3. Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were recently admitted for shortness of breath and
subjective fevers. Because of you were not providing enough
oxygen to your blood, you were initially brought to the
intensive care unit (ICU), where you were placed on BiPap. Your
shortness of breath quickly improved and you were weaned off
supplementary oxygen altogether shortly after leaving the ICU.
We had pulmonary function tests, an echocardiogram, and a chest
CT performed to evaluate the cause of your shortness of breath.
One possible explanation would be recurrent clots reaching the
lungs. For this reason, the lovenox will be continued. You also
have two nodules in your left lung that did not show any change
and a repeat chest CT is recommended in one year. You should be
scheduled to see a pulmonologist as an outpatient by your PCP at
___. Your left knee wound was also evaluated by
orthopedics and plastic surgery. You may bear weight on the knee
as tolerated and you should continue with bacitracin on the
wound and daily dressing changes.
We wish you all the best!
Your ___ care team
Followup Instructions:
___
|
10549741-DS-19 | 10,549,741 | 24,324,360 | DS | 19 | 2145-03-12 00:00:00 | 2145-03-12 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right abdominal pain
Major Surgical or Invasive Procedure:
___: cystoscopy, basket extraction of ureteral calculus,
right ureteral stent placement
History of Present Illness:
Ms. ___ is a pleasant ___ female who presented with 1 month
of dysuria and sudden onset right abdominal pain that started
just prior to presentation to the ED. She underwent a CT scan
that demonstrated a 4mm right UVJ calculus with corresponding
hydronephrosis and a urinalysis was concerning for infection.
Past Medical History:
Glaucoma
Hypertension
Social History:
___
Family History:
Denies GU history
Physical Exam:
GEN: NAD, AAO, resting comfortably
PULM: nonlabored breathing, normal chest rise
ABD: obese, soft, NT, ND
EXT: WWP
Pertinent Results:
___ 12:12 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
___ 05:35AM BLOOD WBC-8.5 RBC-5.17 Hgb-11.3 Hct-37.7
MCV-73* MCH-21.9* MCHC-30.0* RDW-15.7* RDWSD-40.9 Plt ___
___ 05:35AM BLOOD Glucose-101* UreaN-22* Creat-0.9 Na-145
K-4.0 Cl-107 HCO3-23 AnGap-15
Brief Hospital Course:
Ms. ___ was admitted to the urology service from the ED for
management of her urinary tract infection and right UVJ
calculus. She was started empirically on IV ceftriaxone and
administered IVF. She was monitored over the course of the
evening on day of admission and was afebrile and hemodynamically
stable. Her urine was strained and there was no evidence of
stones so on the day following admission she was counseled about
right ureteral stent placement. She was brought to the OR where
she underwent cystoscopy, basket extraction of right ureteral
calculus, and right ureteral stent placement. Please see
operative report for full details. She recovered well in the
immediate post operative period. Prior to discharge she was
afebrile, hemodynamically stable, voiding without difficulty,
pain was controlled, and tolerating a diet. She was discharged
with a course of ciprofloxacin with instructions to follow up as
scheduled for stent removal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY
2. Lisinopril 30 mg PO DAILY
3. Tizanidine 2 mg PO QHS:PRN muscle spasm
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H UTI Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*10 Tablet Refills:*0
3. Oxybutynin 5 mg PO TID:PRN bladder spasms
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth every 8 hours
as needed Disp #*15 Tablet Refills:*0
4. Phenazopyridine 100 mg PO TID:PRN dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*15 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO QHS Duration: 5 Days
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*5
Capsule Refills:*0
6. Lisinopril 30 mg PO DAILY
7. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY
8. Tizanidine 2 mg PO QHS:PRN muscle spasm
Discharge Disposition:
Home
Discharge Diagnosis:
Right ureteral calculus
Discharge Condition:
GEN: NAD, resting comfortably
MENTAL: AAO, no focal deficits
AMB: amb independently at baseline
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 your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-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.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
Followup Instructions:
___
|
10549991-DS-15 | 10,549,991 | 25,992,371 | DS | 15 | 2168-09-12 00:00:00 | 2168-09-12 18:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
L foot ulcer infection
Major Surgical or Invasive Procedure:
___ - Vascular angiogram with stent placement
___ - Ulcer debridement and bone excision in operating room
History of Present Illness:
Patient is ___ M with PMH type I diabetes, CVA, PVD who
presents as a direct admit for cellulitis.
He was seen at the ___ office today for follow-up care of
a wound on his left TMA. Per clinic notes: "Vascular examination
revealed nonpalpable pedal pulses bilaterally. Dermatological
examination shows a small punctate ulceration laterally over the
fifth metatarsal stump. There was noted to be some mild edema
and erythema of the foot. The base of the ulceration had small
amount of purulent drainage."
On arrival to the floor, patient reports that he is here fore
his foot. He is somewhat of a poor historian and cannot answer
most questions. He states that his L foot has been hurting for
maybe ___ mo, he isn't sure. He denies fevers/chills, N/V, SOB,
CP/dizziness, abd pain, constipation/diarrhea, numbness or
weakness.
Per discussion with his brother, ___, patient has memory
problems from CVA. He has had pain in his foot for a couple of
weeks.
Past Medical History:
PVD
Diabetes since age ___
HTN
CVA ___ years ago s/p car accident
Perioperative occipital lobe stroke ___
PAST SURGICAL HISTORY:
___ Balloon angioplasty of left superficial femoral
artery.
___ Redo left below-knee popliteal to posterior tibial
artery bypass with right basilic arm vein
RLE fem ___ ___
Debridement right ___ toe ___
Left hallux amputation ___
LLE bypass x 2 (___)
RLE knee surgery ___ years ago
Gastric ulcer surgery
Social History:
___
Family History:
Father deceased. + FHx diabetes. Unsure of other FHx.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.0 PO 180 / 69 89 18 95 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, + dentures
NECK: supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: L foot with areas of erythema on shin (nontender),
1+ edema b/l, L foot with TMA, wrapped in clean bandage
SKIN: Multiple scars on upper extremities.
DISCHARGE PHYSICAL EXAM
========================
VS: 97.8PO 115 / 63 78 16 98 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, MMM, + dentures
NECK: supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: L foot with areas of erythema on shin (nontender)
outlined in skin marker, improved, L foot with transmetatarsal
amputation, incision on lateral aspect of forefoot with sutures
in place, no erythema and minimally tender.
SKIN: Multiple scars on upper extremities.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 12:30AM BLOOD WBC-9.1 RBC-4.13* Hgb-11.7* Hct-35.2*
MCV-85 MCH-28.3 MCHC-33.2 RDW-13.0 RDWSD-40.4 Plt ___
___ 12:30AM BLOOD Glucose-338* UreaN-22* Creat-0.9 Na-134
K-3.7 Cl-96 HCO3-26 AnGap-16
___ 12:30AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.9
___ 12:30AM BLOOD CRP-83.4*
DISCHARGE LAB RESULTS
=====================
___ 05:31AM BLOOD WBC-10.6* RBC-4.07* Hgb-11.6* Hct-34.7*
MCV-85 MCH-28.5 MCHC-33.4 RDW-13.6 RDWSD-41.8 Plt ___
___ 05:31AM BLOOD Glucose-40* UreaN-24* Creat-1.1 Na-139
K-3.7 Cl-100 HCO3-25 AnGap-18
___ 12:30AM BLOOD ALT-18 AST-20 AlkPhos-94 TotBili-0.2
___ 08:10AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0
IMAGING/STUDIES
===============
___ L Foot XRay:
Status post trans phalangeal amputations of the first through
fifth toes. No definite erosion to suggest osteomyelitis.
___ Arterial Study:
Evidence of moderate to severe ischemia bilateral lower
extremities, worse on the left.
___ Ultrasound Vein Mapping:
The great saphenous veins have been harvested bilaterally. The
small saphenous veins are patent and with diameters as above.
Please see digitized image on PACS for formal sequential
measurements.
___ MRI:
Soft tissue edema along the lateral fifth proximal phalanx, with
adjacent bone marrow edema, hypointense T1 bone marrow signal
and enhancement of the fifth proximal phalanx and metatarsal
head. No cortical irregularity, erosion or soft tissue sinus
tract extending to bone is seen. No significant fifth MTP joint
effusion. Marrow edema is relatively intense, but the
differential diagnosis includes prominent reactive marrow edema
versus osteomyelitis of the fifth metatarsal head and proximal
fifth phalanx. No localized fluid collection or abscess.
Relatively large soft tissue hemangioma in the plantar soft
tissues of the forefoot, detailed above. This corresponds to
phleboliths seen on the ___ radiographs.
___ L Foot XRay:
Status post resection of distal fifth metatarsal with expected
postoperative findings.
Brief Hospital Course:
Patient is ___ M with PMH type I diabetes, CVA, PVD who
presents as a direct admit for infected L foot ulcer. He
underwent an angiogram and stent placement to increase blood
flow to the LLE. An MRI was concerning for osteomyelitis, so the
patient was taken to the OR by podiatry for wound debridement
and bone excision. He was continued on IV vancomycin and PO
ciprofloxacin. The treatment course will depend on the bone
pathology results.
#Infected L foot ulcer:
#Osteomyelitis:
The patient presented with an infected left foot in the setting
of three months of increasing pain. Xray with possible
osteomyelitis. Vascular angiogram performed on ___ and stent
was placed to improve vascular flow in the left lower extremity.
The angiogram showed poor perfusion in the L lower extremity.
MRI with evidence of osteomyelitis. The patient was started on
IV vanc/flagyl/cipro ___ which were then stopped in an
attempt to have the patient off of antibiotics for 48 hours to
get culture data when patient went to the OR for debridement.
The podiatry team performed a debridement in the OR on ___.
Unfortunately, no intra-op cultures were sent, and the specimen
was only sent for pathology. Per ID, the plan was to empirically
continue treating for osteomyelitis for a 6 week course. If bone
pathology demonstrates clear margins, treatment will stop after
2 weeks of IV therapy. Day 1 = ___. Patient should follow-up
with ___ OPAT, Podiatry, and vascular surgery.
# ___: Patient had a Cr of 1.3 (baseline 1.0). Resolved with
IVF. Likely prerenal in the setting of being NPO for procedure.
Lisinopril and HCTZ held given ___ and ___ in the
hospital.
#Peripheral vascular disease: The patient was evaluated by the
vascular team and a stent was placed as above. He was continued
on home aspirin and Plavix.
#T1DM complicated by diabetic neuropathy: Patient was diagnosed
with T1DM at age ___. Home regimen is 36U of Lantus at bedtime,
Humalog 5U, 2U, 4U with breakfast, lunch, dinner respectively.
His blood sugars were difficult to control when he was NPO for
procedures. Please continue to monitor blood sugars closely.
#HTN: Continued home amlodipine, atenolol. Held home lisinopril,
HCTZ as above given ___ and normotension.
#CVA: Patient has short-term memory problems and difficulty
expressing himself from a CVA. He was continued on aspirin,
plavix, and atorvastatin.
#GERD: Continued home ranitidine.
#Depression: Continued home citalopram.
#Glaucoma: Continued home latanoprost and timolol.
TRANSITIONAL ISSUES:
====================
#Osteomyelitis
- ID follow-up (ID will contact patient to schedule.)
- Podiatry follow-up (Scheduled.)
- Will be discharged on IV vancomycin and PO ciprofloxacin.
- Follow-up bone pathology. If clean margins, patient only needs
2 weeks of IV antibiotics, otherwise, he will need 6 weeks of IV
antibiotics. (Day 1 = ___.
#PVD
- Vascular follow-up (Scheduled)
#HTN
- home lisinopril and HCTZ held given normotension and ___.
Please restart as needed.
#T1DM
- Patient discharged on home regimen. Please monitor blood
sugars closely.
#CODE: Full
#CONTACT: ___ (brother/HCP) ___ Mother
(___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. aspirin 325 mg oral DAILY
4. amLODIPine 5 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Citalopram 10 mg PO DAILY
7. lisinopril-hydrochlorothiazide ___ mg oral BID
8. Ranitidine 150 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Timolol Maleate 0.5% 1 DROP BOTH EYES QHS
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Vytorin ___ (ezetimibe-simvastatin) ___ mg oral DAILY
13. Glargine 36 Units Bedtime
Humalog 5 Units Breakfast
Humalog 2 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 g IV Q12 hours Disp #*14 Vial Refills:*5
3. Glargine 36 Units Bedtime
Humalog 5 Units Breakfast
Humalog 2 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. amLODIPine 5 mg PO DAILY
5. aspirin 325 mg oral DAILY
6. Atenolol 25 mg PO DAILY
7. Citalopram 10 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Gabapentin 100 mg PO TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Ranitidine 150 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES QHS
13. Vitamin D 1000 UNIT PO DAILY
14. Vytorin ___ (ezetimibe-simvastatin) ___ mg oral DAILY
15. HELD- lisinopril-hydrochlorothiazide ___ mg oral BID
This medication was held. Do not restart
lisinopril-hydrochlorothiazide until you are told to do so by
your primary care doctor.
16.___
ICD10:M86
Diagnosis: Osteomyelitis L foot
Prognosis: good
___: 13 mo.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis:
- Infected left foot ulcer
- Osteomyelitis
Secondary Diagnosis:
- Type 1 DM
- Peripheral vascular disease
- CVA
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 at ___.
Why did you come to the hospital?
================================
- You came to the hospital because your podiatrist thought that
your foot was infected.
What did we do for you?
==================
- We gave you strong antibiotics to help treat the infection.
- You had a stent placed in one of the blood vessels of your leg
to help with blood flow.
- You went to the operating room to have your wound cleaned out
by the podiatry team. They also sent a piece of bone to the
pathology lab to see if it was infected.
What do you need to do?
==================
- It is important that you continue taking your antibiotics as
prescribed.
- You should follow-up with your podiatrist.
- You should also follow-up with the infectious disease team.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team.
Followup Instructions:
___
|
10550508-DS-21 | 10,550,508 | 21,135,562 | DS | 21 | 2120-05-07 00:00:00 | 2120-05-08 19:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Lipitor
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ F with h/o NSCLC s/p RML lobectomy in ___,
CAD s/p stent ___ and recent diagnosis of melanoma admitted
with dyspnea after she was noted to be short of breath at a
pre-op evaluation. Much of below HPI abstracted from Pulmonary
consult note and confirmed by me.
Per pumonary consult note, she carries a diagnosis of COPD and
has been undergoing cardiac and pulmonary workup (pulmonary
workup here and cardiac workup at ___ for progressive dyspnea
x ___ year. She was initially seen by pulmonary on ___ when she
was started Symbicort and an ENT c/s was recommended for vocal
cord evaluation. She had transient improvement with Symbicort.
She also had a TTE showing signs of diastolic dysfunction and
was started on lasix on ___. During her ENT evaluation, she was
found to have a nasal mass and underwent local exision on ___
and pathology revealed malignant melanoma.
On day of admission, patient was found to be dyspneic at pre-op
evaluation and was sent to the ED; however, she felt her
breathing was at baseline (gets SOB after walking a few feet at
b/l). Chronic cough is unchanged. Per pulmonary note, she
reports negative ___ dopplers at ___ a few days ago.
In the ED, initial VS were 98.7 60 153/57 20 100%2L though she
was also noted to be tachypneic to the 40's. She received
azithromycin 250mg, prednisone 40mg, as well as nebulizer
treatments with some iprovement. She was seen by the pulmonary
service, who felt symptoms were not consistent with COPD
exacerbation but rather a manifestation of her multifactorial
chronic process +/- pulmonary edema. She was admitted for
further work-up.
On arrival to the floor, patient is tachypnic but denies CP,
palpitations, lightheadedness, abd pain, n/v.
REVIEW OF SYSTEMS: As per HPI
Past Medical History:
Recent diagnosis of malignant melanoma
COPD
NSCLC s/p RML lobectomy ___
CAD s/p stent ___
Social History:
___
Family History:
- Mom died of kidney failure
- Dad died of leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
================================
VS - RR 32
General: Tachypneic, does become SOB mid-sentence, remarkably
NAD
HEENT: NC/AT
Neck: JVD 8-10 cm
CV: RRR, S1 S2
Lungs: Faint bibasilar rales otherwise CTAB, no retractions, no
accessory muscle use
Abdomen: Soft, NT, ND
GU: Deferred
Ext: 1+ pitting edema to knee b/l
Neuro: Alert, oriented
DISCHARGE PHYSICAL EXAM:
================================
VS: 98.0 139/84 (SBPs 120-150) 89 95%RA
General: Awake, alert. Not tachyneic. Still speaks in
short-burst phrases, soft voice.
HEENT: MMM.
CV: RRR, S1 S2
Lungs: CTA b/l, no retractions, no accessory muscle use
Abdomen: Soft, NT, ND
Ext: trace to 1+ pitting edema b/l in feet and pre-tibial.
Neuro: Alert, oriented
Pertinent Results:
LABS:
==========================
___ 03:15PM BLOOD WBC-7.2 RBC-4.16* Hgb-12.1 Hct-37.1
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.3 Plt ___
___ 03:15PM BLOOD Neuts-58.4 ___ Monos-6.9 Eos-3.1
Baso-0.5
___ 03:15PM BLOOD ___ PTT-31.6 ___
___ 03:15PM BLOOD Glucose-91 UreaN-21* Creat-1.0 Na-139
K-4.5 Cl-100 HCO3-29 AnGap-15
___ 03:15PM BLOOD CK(CPK)-46
___ 03:15PM BLOOD CK-MB-2
___ 03:15PM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:55AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1
___ 03:25PM BLOOD Type-ART pO2-113* pCO2-28* pH-7.56*
calTCO2-26 Base XS-4 Intubat-NOT INTUBA
___ 09:14AM BLOOD ___ pO2-64* pCO2-45 pH-7.41
calTCO2-30 Base XS-2 Comment-GREEN TOP
___ 03:15PM BLOOD Lactate-2.1*
___ 06:45AM BLOOD WBC-8.8 RBC-4.44 Hgb-13.1 Hct-39.5 MCV-89
MCH-29.6 MCHC-33.3 RDW-15.4 Plt ___
___ 06:45AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-140
K-4.5 Cl-93* HCO3-33* AnGap-19
IMAGING:
==========================
CXR (___):
FINDINGS: The patient is s/p right upper lobectomy, better
evaluated in prior chest CT. The lungs are well expanded,
without focal opacities.
Cardiomediastinal and hilar contours are unremarkable. Mild
cardiomegaly ispresent. A slight prominence of the aortic knob
represents an aortic nipple, likely from a traversing vessel,
better seen in prior chest CT. There is no pleural effusion or
pneumothorax.
IMPRESSION: Mild cardiomegaly. No acute cardiopulmonary
process.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
==============================================
___ woman with a history of progressive dyspnea, CAD,
COPD and (recently diagnosed) melanoma who was referred to ED
from pre-op evaluation with dyspnea.
ACTIVE ISSUES:
==============================================
# Dyspnea: Patient had been at a pre-operative evaluation (for
upcoming melanoma surgery) and was noted to be tachypneic. She
was sent to the ED for further evaluation. Upon presentation she
had a RR of ___ but saturating well on room air (>95%).
Venous blood gas was significant for a pH of 7.56 and PCO2 of
28. EKG showed no acute changes, troponin was negative x2. CXR
showed no acute process; remaining labs were normal. She was
seen by pulmonary in the ED who thought this was not COPD and
her symptoms were likely due to volume overload. Patient
reported ___ year of chronic dyspnea, especially on exertion.
Even walking to the bathroom made her tachypneic and dyspneic.
She had recently been started on PO Lasix 20mg daily for
progressive ___ edema. ECHO ___ showed EF >55% with some
increased left ventricular filling pressure; PA pressure could
not be determined. Upon arrival to the floor she had resting
tachypnea (RR ___ and ___ ___ edema. Her lungs sounded clear.
She had had b/l US of her LEs on ___ at OSH, which were
negative for DVT. She was diuresed with IV lasix, with about
1.5L net removed over the course of 2 days. Her discharge weight
was 173 lb (presumed dry wt as Cr bumped). She had some
improvement in her breathing status; she had normal RR at rest,
though still became tachypneic with activity. At all times
during her stay she mainatined O2 saturations above 93%. She was
clinically stable, and discharged on Lasix 20mg daily. Follow-up
was in place with Pulmonology and her PCP. At time of discharge
Cardiology was notified and was working on a discharge follow-up
appointment for her to evaluate her cardiac function as a
contributor to her dyspnea. Of note she was taking amlodipine
prior to admission; this was held due to potential contribution
to her ___, the medication was not restarted upon
discharge.
# Acute decompensated diastolic heart failure: She had an ECHO
___ with increased left ventricular filling pressure
(PCWP>18mmHg) and normal EF. Please see above for hospital
course and planned cardiology follow-up.
# Positive UA: Upon admission patient had a dirty UA and
>100,000 e coli on urine culture. However she was completely
asymptomatic and thus no treatment was given.
TRANSITIONAL ISSUES:
==============================================
- Stopped amlodipine ___ edema)
- Follow-ups in place with Pulm; PCP and ___ call pt with
appointments.
- Consider right heart cath as outpatient to rule out Pulm HTN.
- Discharge weight was 173 lb (presumed dry wt as Cr bumped)
- Referred for home ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Lovastatin 20 mg oral daily
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Citalopram 5 mg PO DAILY
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
6. Amlodipine 2.5 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Citalopram 5 mg PO DAILY
4. Lovastatin 20 mg ORAL DAILY
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
6. Furosemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dyspnea
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 care for you here at ___
___. You were admitted on ___ for shortness of
breath. This was thought to partially be due to too much fluid.
You were given medication to take off fluid, with some
improvement in your symptoms. Please continue your water pill
after discharge.
You will need to have continued evaluation for your shortness of
breath as the cause is not completely clear. We have scheduled
an appointment with your pulmonologist. You will also be called
with primary care and cardiology appointments to help facilitate
further investigation (please see below).
We stopped a medication for your blood pressure (amlodipine)
because it can cause leg swelling. It is important to follow-up
with your Primary Care doctor in the next week for a blood
pressure check.
Again, it was a pleasure to meet you and take care of you.
-Your ___ team
Followup Instructions:
___
|
10550621-DS-22 | 10,550,621 | 23,210,691 | DS | 22 | 2172-07-07 00:00:00 | 2172-07-07 17:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Afib/flutter with RVR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with recent diagnosis of
carcinoid lung mass with mets, atrial fibrillation on lovenox,
idiopathic cardiomyopathy (EF 45%), recently hospitalized for
initiation of chemotherapy (with carboplatin/etoposide, day#1
___, now presenting from rehab with afib with
RVR. She noticed palpitations today at rehab and asked to be
evaluated. She was noted to be in rapid Afib with rates 150s.
Aside from palpitations, she denies symptoms of associated chest
pain, shortness of breath, nausea, lightheadedness. She was sent
to ___ ED for further evaluation.
.
She was diagnosed with Afib in ___ with the workup resulting
in her neuroendocrine lung cancer diagnosis during ___
hospitalization. Cancer was diagnosed when TTE showed ___ vs
external compression. Subsequent CT showed large mediastinal
mass. Afib has been difficult to control since middle of
___, thought to be related to mass effect from tumor. She
had been on sotalol, switched to dronedarone, then back to
sotalol, which was changed to diltiazem and metoprolol during
recent hospitalization in ___. She has been flipping in and
out of atrial fibrillation frequently in the last few months but
notes improved control of afib since that hospitalization. Can
feel palpitations with rates >140s. She was transitioned from
dabigatran to enoxaparin during that hospitalization in setting
of biopsy and was kept on enoxaparin in case she might need a
repeat procedure.
.
In the ED inital vitals were as follows: 97.4 140 90/64 18 100%
RA.
500cc NS bolus given which brought HR down to 108. She was then
given diltiazem 5mg IV push with BP 92/60, bringing HR down to
96. During ED stay, systolic BPs ranged 87-104, appeared to have
lower systolics with elevated HRs. She received another 10mg IV
diltiazem with 30mg po diltiazem in the ED as well as magnesium
repletion and total 2L IVF. She denied any chest pain, shortness
of breath. ECG showed Afib with NA NI, new ST depression lateral
leads; repeat EKG unchanged. CXR with stable right effusion vs
elevation of right hemidiaphragm. Troponin negative x1. Labs
also significant for WBC 1.3, Hct 35.3, Na 131. Vitals in ED
prior to transfer to floor were as follows: 104/66 114,afib 22
97% on 2L NC.
.
On arrival to the ICU, she feels overall well. Denies
palpitations currently. She does report generalized fatigue,
progressive since starting chemotherapy, worse in the last two
days, such that she needs to use a walker at Rehab to help her
move around. She denies fevers, chills, chest pain, shortness of
breath beyond her baseline. Her cough is unchanged from
baseline, no sputum production. No headache. Has very decreased
appetite for several days.
.
Review of systems:
(+) Per HPI . Groin rash.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Patient developed new onset atrial fibrillation in beginning
of ___, initial TTE showed slightly depressed LVEF of 45%,
initially thought to be due to her chronic alcohol use. Her
atrial fibrillation worsened despite uptitration of medication
(sotalol and dronedarone) and her repeat TTE showed ___
___ vs. extrinsic mass compressing on ___. She was admitted
for evaluation and her biopsy showed neuroendocrine tumor
consistent with typical carcinoid.
- CT scan showing metastases to bone, lymph nodes and possibly
liver.
.
PAST MEDICAL HISTORY:
Atrial fibrillation ___ (diagnosed ___
Idiopathic Cardiomyopathy, LVEF 45% (diagnosed ___
Osteopenia
GERD
BPPV
Cataracts s/p lens replacements
Social History:
___
Family History:
Mother with MI at age ___, son with ___, daughter with breast CA
Physical Exam:
Physical Exam:
Vitals: T: 97.8 BP: 97/52 P: 110 R: 24 O2: 96% on 2L
General: Alert, oriented, thin woman in no acute distress
HEENT: Sclera anicteric, pale conjunctiva, dry mucus membranes,
oropharynx clear
Neck: JVP ~9cm
Lungs: Decreased breath sounds in Right lower base posteriorly,
no wheezes, rales, rhonchi
CV: Irregular rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley ; erythematous groin rash
Ext: warm, well perfused, 1+ peripheral edema
DISCHARGE PHYSICAL EXAM:
Vitals: 97.4, 108/60, 108, 22, 94% RA
General: Alert, oriented, thin woman in no acute distress
HEENT: Sclera anicteric, pale conjunctiva, dry mucus membranes,
oropharynx clear
Neck: JVP ~9cm
Lungs: Decreased breath sounds over right base and mid-lunk; no
wheezes, rales, rhonchi
CV: Irregular rhythm, no murmurs or rubs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley; erythematous groin rash
Ext: warm, well perfused, 1+ peripheral edema
Pertinent Results:
___ 03:00PM BLOOD WBC-1.3*# RBC-4.07* Hgb-10.9* Hct-35.3*
MCV-87 MCH-26.8* MCHC-31.0 RDW-19.3* Plt ___
___ 02:30AM BLOOD WBC-1.0* RBC-3.47* Hgb-9.3* Hct-29.5*
MCV-85 MCH-26.9* MCHC-31.6 RDW-19.2* Plt Ct-89*
___ 07:35AM BLOOD WBC-1.5* RBC-3.72* Hgb-10.0* Hct-32.7*
MCV-88 MCH-26.8* MCHC-30.5* RDW-19.2* Plt Ct-78*
___ 08:20AM BLOOD WBC-2.3*# RBC-3.73* Hgb-10.0* Hct-32.4*
MCV-87 MCH-26.7* MCHC-30.8* RDW-19.5* Plt Ct-71*
___ 08:25AM BLOOD WBC-5.0# RBC-3.68* Hgb-10.2* Hct-32.1*
MCV-87 MCH-27.6 MCHC-31.6 RDW-20.1* Plt Ct-68*
___ 08:30AM BLOOD WBC-8.5# RBC-3.59* Hgb-9.9* Hct-31.3*
MCV-87 MCH-27.6 MCHC-31.7 RDW-21.0* Plt Ct-63*
___ 08:15AM BLOOD WBC-6.4 RBC-3.64* Hgb-9.8* Hct-31.5*
MCV-87 MCH-26.8* MCHC-31.0 RDW-21.0* Plt Ct-60*
___ 08:33AM BLOOD WBC-8.5 RBC-3.76* Hgb-10.5* Hct-32.9*
MCV-88 MCH-27.9 MCHC-31.9 RDW-20.6* Plt Ct-76*
___ 08:15AM BLOOD Neuts-67 Bands-3 Lymphs-11* Monos-11
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-3* Promyel-1* NRBC-1*
___ 07:35AM BLOOD ___ ___
___ 08:20AM BLOOD ___ ___ 08:25AM BLOOD ___ ___
___ 03:00PM BLOOD Glucose-114* UreaN-7 Creat-0.4 Na-131*
K-3.9 Cl-94* HCO3-29 AnGap-12
___ 02:30AM BLOOD Glucose-93 UreaN-6 Creat-0.4 Na-133 K-3.7
Cl-100 HCO3-25 AnGap-12
___ 07:35AM BLOOD Glucose-99 UreaN-7 Creat-0.4 Na-132*
K-3.9 Cl-97 HCO3-26 AnGap-13
___ 08:20AM BLOOD Glucose-91 UreaN-6 Creat-0.4 Na-130*
K-3.4 Cl-95* HCO3-25 AnGap-13
___ 08:25AM BLOOD Glucose-141* UreaN-7 Creat-0.5 Na-130*
K-3.2* Cl-94* HCO3-29 AnGap-10
___ 08:30AM BLOOD Glucose-82 UreaN-4* Creat-0.5 Na-129*
K-4.0 Cl-98 HCO3-25 AnGap-10
___ 08:15AM BLOOD Glucose-79 UreaN-4* Creat-0.6 Na-133
K-3.8 Cl-99 HCO3-30 AnGap-8
___ 08:33AM BLOOD Glucose-78 UreaN-7 Creat-0.5 Na-134 K-3.8
Cl-97 HCO3-30 AnGap-11
___ 08:20AM BLOOD ALT-31 AST-23 LD(LDH)-188 AlkPhos-120*
TotBili-0.6
___ 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:30AM BLOOD TSH-5.3*
___ TTE:
A large, ovoid mass is present in the posterior mediastinum
abutting the posterior wall of the left atrium and resulting in
extrinsic compression (erosion/infiltration into the wall of the
left atrium is possible but cannot be diagnosed or excluded on
the basis of this study). The mass measures approximately 7 cm
in its long axis and 5 cm in its short axis. Pulmonary vein
compression cannot be excluded but is possible based on the
location of the mass, as well as the pulmonary hypertension,
right ventricular enlargement, and tricuspid regurgitation. No
prior echocardiographic study is available for comparison.
The left atrium is normal in size. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF 65%). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
The right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with depressed free wall
contractility. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate (___) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. The mitral
valve leaflets are elongated. There is moderate bileaflet mitral
valve prolapse. Mild to moderate (___) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Tricuspid valve prolapse is present. Moderate to severe [3+]
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.] There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
___ yo F with atrial fibrillation and lung carcinoid tumor with
neuroendocrine features, presenting with palpitations, admitted
to ICU for control of rapid Afib/Aflutter.
# Atrial fibrillation/ Aflutter:
Hemodynamically stable with HR in ___ and SBPs ___ on
arrival after IV Diltiazem and IVF were administered. We
continued enoxaparin for anticoagulation. She was restarted on
her home dose of metoprolol and diltiazem was increased to 90mg
QID, which was not tolerated. She was transferred to the floor
where her rate control faltered; eventually she was loaded with
amiodarone with conversion to sinus rhythm per electrophysiology
recommendations. Her diltiazem was discontinued and her
metoprolol was lowered. She will be fitted with a cardionet
device for arrhythmia monitoring while at rehab (prescription
sent and address of rehab noted).
# Hypoxia
Mild hypoxia on presentation with 2L O2 requirement, perhaps in
the setting of receiving IVFs in the ED. She did not appear to
be grossly fluid overloaded on exam. A CXR showed a significant
mass present in the right lung with a small effusion present.
She was weaned off 02 prior to discharge from the ICU and
remained on room air throughout the admission.
# Lung carcinoid tumor with neuroendocrine features:
Followed by Dr. ___ at ___ and Dr. ___.
She was started last week on carboplatin and etoposide,
presented on day#1 ___. Allopurinol was continued. She had a
repeat TTE that better clarified her cardiac sequelae from this
tumor; she is noted to have a normal EF but could have
compression of the pulmonary veins. She will be readmitted on
___ for her second cycle of chemo along with radiation.
# Neutropenia- On admission the pt's ANC was 130. She did not
have any signs of acute infection. Blood and urine cultures were
sent. She was continued on Neupogen at her home dose and placed
on neutropenic precautions. By the time of discharge, her
counts had recovered for many days.
Transitional Issues:
- readmission on ___ for chemo/radiation
- cardionet measurements/fitting and delivery to rehab (to be
worn while at rehab)
- requests a ___ PCP and cardiologist; appointments not made
due to her planned readmission in a few days, at which point
follow-up appointments should be made.
Medications on Admission:
- filgrastim 300 mcg/0.5 mL - for 10 days (from discharge
___
- allopurinol ___ mg Tablet daily
- multivitamin daily
- omeprazole 20 mg Capsule x 2 tabs daily
- enoxaparin 100 mg/mL Syringe sq daily
- calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable PO
QID PRN acid reflux.
- Diltia XT 240 mg Capsule,Ext Release Degradable daily
- Toprol XL 100 mg Tablet Extended Release 24 hr daily
- docusate sodium 100 mg Capsule PO BID
- codeine sulfate 30 mg Tablet PRN cough.
- benzonatate 100 mg Capsule PO TID prn cough
- senna 8.6 mg Tablet Sig: ___ Tablets PO BID prn constipation
- acetaminophen 325 mg Tablet x 2 tabs PO Q6H PRN pain/fever
- dextromethorphan-guaifenesin ___ mg/5 mL Syrup PRN cough
- nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical BID
- ranitidine HCl 150 mg Tablet BID PRN heartburn
- bisacodyl 10 mg Suppository PRN constipation
- Fleet Enema ___ gram/118 mL Enema PRN constipation
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day PRN constipation
- Ensure Liquid TID with meals
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q24 ().
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for reflux.
6. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for cough.
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
11. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five
(5) ML PO Q4H (every 4 hours) as needed for cough.
12. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical BID
(2 times a day).
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): with meals.
16. Ensure Liquid Sig: One (1) PO three times a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Atrial fibrillation/atrial flutter with rapid ventricular rate
Typical lung carcinoid with neuroendocrine features
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___.
You were admitted for atrial fibrillation/atrial flutter with
rapid ventricular rate. We attempted to control your rhythm
with the previously prescribed medications, but eventually
switched to another medication called amiodarone. This
medication was successful at converting you back into a normal
rhythm with a normal rate.
You will be readmitted next week ___ for planned
chemotherapy and radiation therapy.
Please note the following changes to your medication list:
START amiodarone 200mg by mouth three times per day with meals
(for heart rate/rhythm)
START dronabinol 5mg by mouth twice per day (for appetite)
DECREASE toprol XL from 100mg to 75mg daily (decreased due to
change to amiodarone)
STOP diltiazem (you were switched to amiodarone)
STOP neupogen
STOP milk of magnesia
STOP fleet enema
STOP ranitidine
Otherwise please take all medications as prescribed.
Followup Instructions:
___
|
10550641-DS-10 | 10,550,641 | 22,663,532 | DS | 10 | 2129-05-12 00:00:00 | 2129-05-12 16:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Lipitor / Decadron
Attending: ___.
Chief Complaint:
Altered mental status, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male known to the Neurosurgery service following
recent admission and diagnosis of a ___ mass in the setting of
a lung mass, now s/p left occipital craniotomy for tumor
resection on ___ re-presents with fever and altered mental
status. He was recently discharged on ___.
Past Medical History:
- PVD - Angioplasty x 3
- HTN
- Hyperlipidemia
- Gout
- Solidtary kidney by birth
- CKD stage III
- Appenectomy
- Tonsillegtomy
- Left cataract surgery
Social History:
___
Family History:
Mother deceased: ___ disease
Father deceased: CHF
Sister alive ___, unknown history
No additional family history known
Physical Exam:
ON ADMISSION
============
O: T: 98.4 HR 74 BP 153/73 RR20 Sat 96% 3L NC
Gen: lethargic
HEENT: soft fluctuat fluid collection at the incision site.
Incision is healed well without erythema
Extrem: right knee and right leg edema.
Neuro:
Mental status: lethargic, minimally verbal, opens eyes to voice
Orientation: Oriented to person only
Language: minimally verbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields unable to test
III, IV, VI: Extraocular movements appear intact but unable to
test
V, VII: Facial strength appears intact. unable to test sensation
VIII: Hearing intact to voice.
IX, X: Palatal elevation unable to test.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. mild tremor in bilat
UE,
right greater than left
Grips full bilaterally but pt does not follow a full motor exam.
Grips billet to command, shows 2 fingers bilaterally
Wiggles toes bilaterally
Does not lift legs off bed to command
Sensation: unable to test but responds to light touch
bilaterally
Coordination: unable to test
ON DISCHARGE
============
Gen: awake
HEENT: soft fluctuant fluid collection at the incision site.
Incision is well healed without erythema
Extrem: right knee and right leg edema.
Neuro:
Mental status: opens eyes to voice, confused
Orientation: Oriented to person only
Language: expressive dysphasia, perseverating, hallucinating
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. RIGHT hemianopsia
III, IV, VI: Extraocular movements appear intact but unable to
test
V, VII: Facial strength appears intact. unable to test sensation
VIII: Hearing intact to voice.
IX, X: Palatal elevation unable to test.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. mild tremor in bilat
UE,
right greater than left
Grips full bilaterally but pt does not follow a full motor exam.
Grips billet to command, shows 2 fingers bilaterally
Wiggles toes bilaterally
At least antigravity in all 4 extremities
Sensation: responds to light touch bilaterally
Coordination: unable to test
Pertinent Results:
Please see OMR for pertinent imaging & labs
___ 06:00AM BLOOD WBC-12.3* RBC-3.36* Hgb-10.2* Hct-31.6*
MCV-94 MCH-30.4 MCHC-32.3 RDW-13.2 RDWSD-44.9 Plt ___
___ 06:00AM BLOOD Neuts-74.3* Lymphs-8.7* Monos-10.1
Eos-1.5 Baso-0.9 Im ___ AbsNeut-9.16* AbsLymp-1.07*
AbsMono-1.25* AbsEos-0.19 AbsBaso-0.11*
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-95 UreaN-26* Creat-0.7 Na-146
K-3.8 Cl-104 HCO3-27 AnGap-15
CFS
-------------
TUBE #2
CSF
Chemistry Protein
111 Glucose
38
TUBE #1
CSF WBC
1265 RBC
5
Poly
78 Lymph
4 Mono
18 EOs
Comments: CSF TNC: Hazy And Colorless
CSF TNC: Clear Supernatent
CSF TNC: Reported To And Read Back By
___ TNC: ___ ___ On ___
___ 2:15 am CSF;SPINAL FLUID TUBE #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 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..
FLUID CULTURE (Final ___: NO GROWTH.
---------------
___ 5:52 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
-----------
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
----------------
___ 6:10 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
---------------
Brief Hospital Course:
#Altered mental status/Fever/aseptic meningitis/metabolic
encephalopathy/metastatic neuroendocrine tumor to the ___
On ___, Mr. ___ was admitted to the Neuro ICU with altered
mental status. LP in the ED had elevated protein, low glucose
and high opening pressure. Cultures were sent. He was noted to
have a mass on his neck on admission felt to be lymphadenopathy.
MRI was performed which did not show abscess. His wound was
noted to have purulent drainage and he was started on empiric
vancomycin, cefepime and ampicillin. Infectious disease was
consulted. Ampicillin was discontined on ___ per ID. He was
placed on EEG on ___ which was negative for seizure. He had
leukocytosis on admission which downtrended. He was transferred
to ___ on ___. Repeat MRI was stable and negative for clear
abscess but there was concern for ventriculitis ___ he had a
fever to 101.2 with WBC up trending, urine cultures and blood
cultures were sent and were all negative. Repeat CXR was done
and was negative. His family was consented for PICC line ___.
Placement of PICC was deferred in setting of elevated WBC with
unknown source. CSF culture was negative. Due to continued
fevers, worsening altered mental status, and continuing
elevation of WBC a family discussion was had regarding
additional surgical procedures verse CMO, after thorough
discussion, the patient was transitioned to CMO care with
Palliative care consult on ___. The patient's case was
re-discussed at ___ TUmor Conference on ___ and consensus
was that given the negative cultures, the profound
encephalopathy that the patient developed aseptic meningitis
with poor prognosis due to disease progression. All invasive
intervention were stopped per family's request as the patient
transitioned to CMO. Over ___ to ___ the patient
gradually improved, still confused, with expressive aphasia, non
lethargic anymore so the family asked for guidance in whether
the CMO status should be reversed or continue care. With the
involvement of Palliative Care, Hem/Onc, ID, nursing and
neurosurgery as discussed with Dr. ___ family
meeting took place on ___ where the family was presented
with the grim prognosis due to the pathology of the tumor
(neuroendocrine tumor, STAGE IV metastatic lesion possibly due
to lung). After hearing different opinions the family elected to
proceed with hospice care option and continue CMO status.
#Dysphagia
Due to altered mental status, the patient was made NPO on
admission. NGT was attempted to be placed on ___ for tube
feeding, but was unsuccessful as the patient non-compliant with
placement. SLP evaluated and recommended puree consistency with
thin liquids and 1:1 feeding. Family was consented ___ for PEG
placement for nutrition supplementation, however NGT was placed
over concern for patient self d/c'ing PEG. Tube feeds were
started ___. Given CMO status on ___ and repeat family meeting
on ___ to agree to hospice, the Dobhoff was removed and the
patient was allowed to eat to comfort.
#Bilateral lower extremity DVT's
On admission, the patient was found to have b/l DVT's and was
started on heparin drip with PTT goal of 50-70. Given CMO the
family elected to stop needle sticks with SQH and PTT checks,
and after discussion with Dr. ___ (patient's son)
elected to start Xarelto po for DVT and PE prophylaxis. ___
acknowledged the fact that there is a possibility for ___
hemorrhage while on anticoagulation. ___ discussed with his
mother ___ who also agreed on the patient being discharged
on Xarelto 20mg daily for patient compliance and minimal
medications since he is CMO status. It was also explained that
this medication provides prophylaxis protection but does not
guarantee that a PE or a DVT will not happen or expand.
Palliative care / hospice team to re-assess need for
anticoagulation. Per their request and after discussing with Dr
___ will discharge the patient on Xarelto and Hospice may
decide for continuation after discussion with the patient and
family and agree.
#Pain
Patient appeared to be in pain with movement on ___. MRI L
spine was ordered to evaluate for spinal metastasis. The patient
was moving to much in the scan so MRI was not obtained with
contrast, but non-enhanced scan was found to be negative for
metastasis. IV morphine and po oxycodone PRN were given
#Gout
On prior admission patient was found have gout flair in right
knee. Rheumatology had been consulted and colchicine started.
___ Rheumatology was consulted for updated recommendations for
persistent redness and swelling in right knee and new redness of
right ankle. Colchicine was titrated up per their
recommendation.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN fever or pain, Allopurinol
50 mg PO DAILY, Colchicine 0.3 mg PO DAILY, Docusate Sodium 100
mg PO BID, Heparin 5000 UNIT SC BID, Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime, Senna 17.2 mg PO QHS,
Valproic Acid ___ mg PO Q8H, amLODIPine 10 mg PO DAILY, Aspirin
81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO/PR Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6h Disp
#*20 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*3
Suppository Refills:*0
3. Gabapentin 100 mg PO DAILY
RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*3
Capsule Refills:*0
4. Haloperidol 0.5 mg PO Q6H:PRN agitation
RX *haloperidol 0.5 mg 1 tablet(s) by mouth every 6h Disp #*12
Tablet Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8h as needed
Disp #*9 Tablet Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4h Disp #*22
Tablet Refills:*0
7. Rivaroxaban 20 mg PO ONCE Duration: 1 Dose
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*3 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 tab by mouth twice daily Disp #*6 Tablet
Refills:*0
9. Colchicine 0.6 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily Disp
#*3 Tablet Refills:*0
10. Allopurinol 50 mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic neuroendocrine tumor to the ___
Lung lesion
Fever, resolved
Altered mental status
Aseptic meningitis
Toxic-metabolic encephalopathy
Bilateral lower extremity DVT
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) other than what is being prescribed
for you at discharge.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10551080-DS-14 | 10,551,080 | 23,942,108 | DS | 14 | 2186-12-08 00:00:00 | 2186-12-10 21:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Dislodged PEG tube
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with history of G-tube
placement for esophagela squamous cell carcinoma and failure to
thrive ___ at OSH. This morning his homeless shelter/nursing
home staff found that the tube was no longer in place. The
patient states that he felt it went into his stomach. He was
seen
at OSH where foley catheter was placed easily through his G-tube
tract. CT Abd/Pelvis was performed and was believed to show
portions of the catheter within loops of small bowel but also
extraluminal and within the peritoneum, suggesting bowel
perforation. The patient was thus transferred to ___ for
further care.
The patient denies any abdominal pain, fevers, hematochezia,
melena, nausea or vomiting. He recently completed a course of
vancomycin for pneumonia.
ROS:
(+) per HPI, as well as weight loss and cough
(-) Denies fevers, chills, night sweats, chest pain, shortness
of
breath, edema, vomiting, pruritis, hematemesis, melena, BRBPR,
dysphagia, easy bruising, dizziness, syncope, urinary frequency
or dysuria
Past Medical History:
Past Medical History: Esophageal squamous cell carcinoma,
depression, vitamin D deficiency, BPH, hypernatremia, htn, CKD,
gout
Past Surgical History: None
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam:
Vitals: 98.9 86 130/72 18 100% RA
GEN: A&O, NAD
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, non-tender, non-distended. PEG in place, functioning.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 03:57AM GLUCOSE-96 UREA N-62* CREAT-3.1* SODIUM-143
POTASSIUM-5.6* CHLORIDE-105 TOTAL CO2-21* ANION GAP-23*
___ 03:57AM estGFR-Using this
___ 03:57AM URINE HOURS-RANDOM
___ 03:57AM URINE HOURS-RANDOM
___ 03:57AM URINE UHOLD-HOLD
___ 03:57AM URINE GR HOLD-HOLD
___ 03:57AM WBC-4.9 RBC-3.16* HGB-8.9* HCT-26.7* MCV-84
MCH-28.0 MCHC-33.2 RDW-16.6*
___ 03:57AM NEUTS-66 BANDS-3 LYMPHS-12* MONOS-14* EOS-2
BASOS-0 ___ METAS-1* MYELOS-2*
___ 03:57AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-OCCASIONAL
___ 03:57AM PLT SMR-NORMAL PLT COUNT-364
___ 03:57AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
___ 03:57AM URINE RBC-5* WBC-9* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 03:57AM URINE MUCOUS-RARE
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of esophageal
squamous cell carcinoma undergoing chemoradiotherapy and
failure to thrive status post G-tube placement at outside
hospital on ___. The patient was in his usual state of
health until ___ when presented to emergency department
after the homeless shelter/nursing home staff found that the
G-tube was no longer in place. A CT abdomen/pelvis performed at
the emergency department demonstrated that portions of the
catheter were intraluminal within loops of small bowel but there
were portions which appear extraluminal and within the
peritoneum, suggesting a bowel perforation. The patient was
admitted for observation and follow of foreign body migration
within the GI tract.
A foley catheter was placed in the G-tube site to keep patency
of the tract. On hospital day 1 a new gastrostomy tube was
placed at the bedside by the gastroenterologist service and a
series of abdominal X rays were obtained to evaluate migration
of G-tube through GI tract. A fluoroscopy study confirmed new G
tube placement. The patient was kept NPO and IV fluids while
passage of the G-tube was achieved through the rectum on
hospital day 2. Tube feeding at goal rate and home medications
were resumed.
During the hospital stay, vital signs were routinely monitored
and patient remained afebrile and hemodynamically stable. He was
voiding adequate amounts of urine without difficulty.
At the time of discharge, the patient was afebrile and
hemodynamically stable. The patient was tolerating her tube
feeding and voiding without assistance. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Doxazosin 4 mg PO HS
2. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
3. Famotidine 20 mg PO DAILY
4. Lidocaine Viscous 2% 15 mL PO TID:PRN Esophageal irritation
5. Metoprolol Tartrate 25 mg PO BID
6. Mirtazapine 15 mg PO QHS
7. Ondansetron 4 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Doxazosin 4 mg PO HS
2. Famotidine 20 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Mirtazapine 15 mg PO QHS
5. Ondansetron 4 mg PO Q8H:PRN Nausea
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
7. Lidocaine Viscous 2% 15 mL PO TID:PRN Esophageal irritation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Squamous cell carcinoma of the esophagus
Failure to thrive s/p PEG placement
PEG disloged s/p replacement at bedside
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 ___ after your PEG tube have gotten
dislodged. You underwent several images of your abdomen to watch
out for signs of perforation until the PEG tube was passed out.
In addition, a new PEG tube was placed at the bedside by the
gastroenterology service. The functionality of the new PEG tube
was confimed via a contrast study. You were started back on your
tube feeeding, home meds and are ready for being discharged back
to your nurse facility.
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.
Followup Instructions:
___
|
10551350-DS-16 | 10,551,350 | 23,461,070 | DS | 16 | 2147-01-23 00:00:00 | 2147-01-30 18:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
drug overdose
stiffness, muscle pain
delirium
Major Surgical or Invasive Procedure:
Liver ultrasound
MRI neck
TTE
History of Present Illness:
___ with asthma, depression and polysubstance use, ?IVDU,
transferred from ___ after overdosing on Opana
(oxymorphone-hydrocholoride) and alcohol for troponemia,
transaminitis, leukocytosis, lactic acidosis and rhabdomyolysis.
Pt reports taking 2 Opana pills and 30 beers on day before
presentation, and being found on the ground by his mother the
next day, then delirious and in severe diffuse pain, but worst
at his neck and R shoulder. He was brought in by ambulance to ___
___ he was noted to be afebrile but with lactate of 4.2,
WBC 20.8, Trop 1.88, elevated LFTs, and normal EKG without
ischemic change. He was given one dose azithromycin and
cefepime, and put on banana bag, ASA and Motrin.
He was transferred for eval of high troponemia to ___ where
repeat labs showed reduction in troponins to 0.24, CKMB 85, with
mild hyperkalemia 5.2, ___ with Cr 1.7, and significantly
elevated CK ___, WBC 16.7, ALT/AST 207/443, Tbili 0.7, and
lactate 1.7. CXR showed evidence of ?atelectasis/aspiration.
Urine tox neg. He was given 4L NS, albuterol neb x 2, vancomycin
1gm, and on the floor, maintenance fluids at 150cc/hr.
Cardiology evaluated him and felt that given his normal EKG, the
elevated troponins likely represented leak in setting of
systemic stress. They recommended echo if pt should become
symptomatic or EKG show changes.
On the floor, pt was afebrile and hemodynamically stable,
intermittently on 2L or RA. He reported diffuse stiffness, deep
seated muscular pain not elicted by palpation, and dyspnea,
wanting to use his Symbicort, stating that albuterol nebs do not
help.
Past Medical History:
-depression
-polysubstance abuse since age of ___
- asthma
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals - ___ 138/90 (114-138) 90 ___ 98% on 2L
GENERAL: comfortably sleeping, but requested lights to remain
off, and asked for a limited exam.
HEENT: Atraumatic/normocephalic, PERRL, MMM, good dentition
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no mrg
LUNG: ?bibasilar crackles, breathing well without use of
accessory muscles, good air movement
ABDOMEN: NTND, +BS, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: deferred
DISHCARGE PHYSICAL EXAM
=========================
Vitals: 98.1 ___ 18 97/RA
GENERAL: sitting up in his chair
HEENT: MMM, pt reports numbness at his R ear
NECK: nontender supple neck, no LAD
LUNG: diminished breath sounds in R lung base, no wheezing
ABDOMEN: NTND, +BS, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: decreased strength in bilat UEs, but R>L. Sensation
improving although still with subjective decreased sensation.
Pertinent Results:
ADMISSION LABS
___ 06:10PM BLOOD WBC-16.7* RBC-4.62 Hgb-14.1 Hct-42.0
MCV-91 MCH-30.5 MCHC-33.5 RDW-12.7 Plt ___
___ 06:10PM BLOOD Neuts-77.4* Lymphs-13.4* Monos-8.6
Eos-0.2 Baso-0.4
___ 06:10PM BLOOD Plt ___
___ 06:10PM BLOOD Glucose-206* UreaN-33* Creat-1.7* Na-137
K-5.2* Cl-106 HCO3-21* AnGap-15
___ 06:10PM BLOOD ALT-209* AST-443* ___
AlkPhos-43 TotBili-0.7
___ 06:10PM BLOOD CK-MB-85* MB Indx-0.3
___ 06:10PM BLOOD cTropnT-0.24*
___ 06:10PM BLOOD Albumin-4.3 Calcium-7.5* Phos-2.9 Mg-2.8*
___ 06:24PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 07:20AM BLOOD Glucose-76 UreaN-9 Creat-0.8 Na-141 K-3.9
Cl-106 HCO3-24 AnGap-15
___ 07:20AM BLOOD ALT-303* AST-268* CK(CPK)-1230*
AlkPhos-74 TotBili-0.6
___ 07:20AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8
CK
CK(CPK)
___ 07:20 1230
___ 07:00 3098
___ 07:15 7875
___ 07:05 ___
___ 20:47 ___
___ 14:13 ___
___ 07:22 ___
___ 21:15 ___
___ 13:11 ___
___ 05:25 ___
___ 00:10 ___
___ 18:10 ___
CPK ISOENZYMES cTropnT
___ 21:15 0.16
___ 13:11 0.16
___ 05:25 0.23
___ 00:10 0.23
___ 18:10 0.24
MICRO:
Hep B: immunized
Hep C: negative
HIV: negative
UA ___: Prot 100, Large Blood but 17 RBCs, few bact
Urine tox neg
IMAGING:
___ C spine film
FINDINGS:
Disc spaces are preserved. Normal alignment. No prevertebral
soft tissue
swelling is seen. No fracture is seen. Odontoid view is not
provided.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is substantial
opacification in the retrocardiac region on the lateral view.
This most likely is on the right on the frontal projection, and
is consistent with a lower lobe pneumonia. The dense streak of
the opacification at the left base has cleared.
___ Liver ultrasound:
1. Unremarkable appearance of the liver.
2. Bilateral pleural effusions. No ascites
3. Splenomegaly
4. No gallstones. Thickened gallbladder wall most likely due to
third spacing as the gallbladder is not distended.
___ MRI soft tissue/neck: IMPRESSION:
Limited examination. No definite signs of discitis or
osteomyelitis seen. No intraspinal fluid collections seen. No
cord compression identified. Soft tissue swelling in the
posterior suboccipital soft tissues and minimal prevertebral
soft tissue increased signal could be related to trauma. If
clinical concern persists, a repeat examination can be obtained
with sedation.
___ TTE: Conclusions
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%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis seen.
Normal biventricular regional/global systolic function. Normal
left ventricular diastolic function. No clinically significant
valvular abnormalities noted.
___ Chest PA and Lat:
IMPRESSION:
Linear opacity at the left lung base present on prior
examination now more conspicuous and may reflect atelectasis
although superimposed aspiration cannot be excluded.
___ EKG: SR at 73 bpm, sm non-pathologic q waves inferiorly
Brief Hospital Course:
PRIMRARY REASON FOR ADMISSION:
___ with asthma, depression, polysubstance abuse transferred
from ___ with rhabdomyolysis and transaminitis in the
setting of alcohol and opana overdose and found to have
pnuemonia.
ACTIVE ISSUES:
# Rhabdomyolysis: The patient presented after being down in the
setting of polysubstance use. CK peaked at ___ and trended
down with aggressive IVF rescucitation with goal urine output >
200cc/hr. His CK trended down to 1230 by discharge. He should
have this rechecked by his PCP to confirm full resolution of CK
elevation.
# Troponemia: The patient had a peak troponin of 0.24 on
admisison. Cardiology evaluated him in the ED and felt that this
was likely in the setting of systemic stress. He remained
asymptomatic with an unchanged EKG and troponins trended down.
# Transaminitis: The patient had elevated AST and ALT. Liver and
gallbladder ultrasound showed normal parenchyma with no stones
or ascites. HIV was negative with negative HepC and HepB
serologies consistent with immunization. Etiology likely either
from alcohol or muscle breakdown given elevated AST. This will
require further monitoring by his outpatient providers and
additional testing if persistently elevated.
# Asthma: The patient was using his home symbicort, and taking
multiple times throughout the day. He was instructed on the
proper use of this medication repeatedly by multiple providers.
He was given albuterol for symptom control while inpatient and
will be prescribed an inhaler at discharge. He would benefit
from continued education about his asthma and asthma treatments.
# Pneumonia: He continued to report shortness of breath and CXR
was concerning for right lower lobe pneumonia. He was started
on levofloxacin and clindamycin for 7 days to treat for both HAP
and possible aspiration (day 1: ___
# Neck and shoulder pain, decreased sensation of his fingers:
The patient reported decreased sensation on his left fingers
that waxed and waned. He had an MRI of the cervical spine that
showed no definite signs of discitis or osteomyelitis, no
intraspinal fluid collections, or cord compression. It noted
soft tissue swelling in the posterior suboccipital soft tissues
and minimal prevertebral soft tissue increased signal could be
related to trauma. Prior to discharge, he underwent c spine
plain films that showed preserved disc spaces, normal alignment
and no prevertebral soft tissue swelling and his symptoms
improved throughout the course of his admission.
# Polysubstance abuse: Notable for narcotics, alcohol, and
cocaine. He received lorazepam on both CIWA and ___ scales.
Social Work was consulted and discussed possible options for
treatment although the patient refused.
# Anxiety: The patient reported using substances to control his
anxiety. He was evaluated by Psychiatry who felt his overdose
was not a suicide attempt. He continued to refuse rehab but
there was no psychiatric contraindication to discharge. He will
be discharged with
TRANSITIONAL ISSUES:
- Would benefit greatly from alcohol and drug cessation
counseling/rehabilitation
- Would benefit from therapy and evaluation by a psychiatric
professional for treatment of his substance induced mood
disorder, alcohol use disorder, depression and anxiety.
- Will need to continue levofloxacin + clindamycin for 7 days
(to treat HAP and possible aspiration). Day 1: ___
- CK trended down to 1230 by discharge. LFTs: ALT 303 AST 268
- Will need repeated education about appropriate use of his
inhalers. He was using his symbicort inhaler multiple times a
day. He will be given a prescription for albuterol inhaler.
- Will need repeat labs (CK, LFTs) in 1 week to make sure
continue to downtrend
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Symbicort (budesonide-formoterol) unknown unit inhalation BID
Discharge Medications:
1. Symbicort (budesonide-formoterol) 2 puffs INHALATION BID
Maximum 4 puffs per day
2. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Clindamycin 450 mg PO Q8H
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every eight (8)
hours Disp #*21 Capsule Refills:*0
6. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
7. Outpatient Lab Work
Please obtain CK, AST, ALT, AlkP and Cr and fax results to Dr.
___ at ___. ICD 9: 728.88 Rhabdomyolysis
8. Lorazepam 1 mg PO DAILY:PRN anxiety
RX *lorazepam 1 mg 1 tablet by mouth daily Disp #*4 Tablet
Refills:*0
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate 90 mcg ___ puff every six (6) hours Disp
#*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- rhabdomyolysis
- transaminitis
- polysubstance abuse
- asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted on ___ after drinking a large volume of
alcohol and taking opana. You were on the ground for a long
time and because of this had a very dangerous medical problem
called 'rhabdomyolysis'. You were given lots of IV fluids to
help flush the muscle breakdown products out into your urine.
You were monitored carefully and the measure of these prodcuts
in your blood trended down.
You also reported having trouble breathing that felt like your
asthma. You were found to have a pneumonia, for which you will
need to take two antibiotics (levofloxacin and clindamycin) for
7 days. Also, you were not using your symbicort inhaler
correctly, as this should be used AT MOST 4 puffs a day. You
were given a prescription for an albuterol inhaler which you can
use every 6 hours.
It is very important that you get help for your very dangerous
alcohol use and anxiety.
We wish you the best,
-- Your ___ Medicine Team--
Followup Instructions:
___
|
10551514-DS-11 | 10,551,514 | 20,321,021 | DS | 11 | 2167-07-15 00:00:00 | 2167-07-15 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
parastoma hernia s/p reduction at bedside
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMHx for T4N2M0 rectal cancer s/p laparoscopic LAR with
diverting loop ileostomy on ___ who presents to the ___ with
abdominal pain with findings significant for parastomal hernia.
Patient states that he was doing well post-operatively and has
returned to a normal functional status. However this ___, patient
states that he had a sudden urge of abdominal pain and noticed
that his diverting ileostomy has herniated out about 8cm.
Patient
denies fever/chills, nausea/vomiting.
Past Medical History:
chronic headaches
Social History:
___
Family History:
1. Maternal aunt with gynecologic cancer.
2. Maternal aunt with liver cancer.
3. No colorectal cancer, which he is aware.
Physical Exam:
Neuro: NAD, A&Ox3
CV: RRR
Pulm: nl breathing effort
GI: reduced parastomal hernia, nonTTP, nondistended, soft
GU: voiding without difficulty
Ext: warm, pulses intact
Pertinent Results:
___ 06:07PM ___ PTT-30.0 ___
___ 06:07PM PLT SMR-LOW PLT COUNT-124*
___ 06:07PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:07PM NEUTS-62 BANDS-0 ___ MONOS-13 EOS-3
BASOS-0 ___ MYELOS-0 AbsNeut-4.46 AbsLymp-1.58
AbsMono-0.94* AbsEos-0.22 AbsBaso-0.00*
___ 06:07PM WBC-7.2# RBC-4.48* HGB-13.8 HCT-39.2* MCV-88
MCH-30.8 MCHC-35.2 RDW-15.9* RDWSD-48.9*
___ 06:07PM ALBUMIN-4.8 CALCIUM-9.7 PHOSPHATE-4.1
MAGNESIUM-2.0
___ 06:07PM LIPASE-121*
___ 06:07PM ALT(SGPT)-53* AST(SGOT)-57* ALK PHOS-148* TOT
BILI-0.5
___ 06:07PM GLUCOSE-119* UREA N-22* CREAT-0.9 SODIUM-138
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18
___ 06:13PM LACTATE-1.9
___ 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Brief Hospital Course:
Mr ___ presented to ___ with parastomal hernia on ___ s/p
reduction at bedside. He tolerated the procedure well without
complications. An imaging study of his rectum revealed no
leakage. His stoma showed no signs of intussusception after
prolapse reduction, with good output and function. After a brief
and uneventful stay in the hospital, he was discharged home on
___. At discharge, he was tolerating a regular diet,
passing flatus, functioning ielostomy, voiding, and ambulating
independently. He was seen by stoma/ostomy nurses for teaching
and education prior to discharge. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[x] None
Social Issues Causing a Delay in Discharge:
[x] No social factors contributing in delay of discharge.
Medications on Admission:
capecitabine
capecitabine 500 mg tablet
3 tablet(s) by mouth Q12H for 14 days with each cycle of
___
___,
___ Tablet11 ___
entecavir
entecavir 0.5 mg tablet
1 tablet(s) by mouth ___
Renewed___,
___ Tablet11 ___
ondansetron HCl
ondansetron HCl 8 mg tablet
1 tablet(s) by mouth every eight (8) hours as needed for low
grade ___
___,
___ Tablet11 ___
prochlorperazine maleate [Compazine]
Compazine 10 mg tablet
1 tablet(s) by mouth four times a day as needed for low grade
___
___,
___ Tablet11 ___
Sort by Drug Class
Discharge Medications:
1. Entecavir 0.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
parastoma hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ have a ileostomy. The most common complication from a new
ileostomy placement is dehydration. The output from the stoma is
stool from the small intestine and the water content is very
high. The stool is no longer passing through the large intestine
which is where the water from the stool is reabsorbed into the
body and the stool becomes formed. ___ must measure your
ileostomy output for the next few weeks. The output from the
stoma should not be more than 1200cc or less than 500cc. If ___
find that your output has become too much or too little, please
call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
Followup Instructions:
___
|
10551570-DS-14 | 10,551,570 | 29,142,147 | DS | 14 | 2131-11-18 00:00:00 | 2131-11-18 16:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
? Endocarditis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F PMH with h/o active IV heroin use presenting complaining
of rash since ___ as well as chills and intermittent chest
pain, nonexertional for one week. Denies sob. Her chest pains
last for seconds prior to dissipating. She first developed the
rash around ___ and it started out as blisters. She was
concerned that it was MRSA which she had before which was
treated as o/p with oral antibiotics. She went to an urgent
care where she was told that she had MRSA and was given a week
of clindamycin. She continued to develop new lesions which
turned into painful erythematous ulcers. She felt feverish in
this time but never took her temperature. She has lost 40 lbs in
the past two months. She developed diffuse muscle pain and
chills and feels very fatigued. She last took IV heroin
yesterday- 1 gm. No foreign travel. She has dogs but no other
pets. She has episodes of emesis 3x per week, sometimes bilious
but never with blood.
In ER: (Triage Vitals: 7 | 97.3 |150 | 133/68 | 22 94% RA )
Meds Given: vancomycin
Fluids given: 1L
Radiology Studies:CXR
consults called: none
Past Medical History:
Long QTC syndrome s/p SQ link monitoring system placement
Social History:
___
Family History:
Mother with ___
Physical Exam:
ADMISSION EXAM:
==============
Vitals: 98.0 PO 105 / 65 101 18 96 RA
CONS: NAD, comfortable appearing
HEENT: ncat anicteric MMM
CV: s1s2 rrr soft flow murmur
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
back:
GU:no CVAT
MSK:No spinal tenderness, no clear joint effusions or tenderness
no c/c/e 2+pulses
SKIN: diffuse groups of erythematous ulcers all over her body
including torso, back, L inner thigh, R armpit, stomach. All are
crusted over and not oozing.
Mechanic hands and ? ___ lesions at her fingers
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
===============
Pertinent Results:
ADMISSION LABS:
==============
___ 10:25PM COMMENTS-GREEN
___ 10:25PM LACTATE-1.4
___ 10:20PM GLUCOSE-108* UREA N-8 CREAT-0.8 SODIUM-137
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
___ 10:20PM estGFR-Using this
___ 10:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:20PM WBC-6.9 RBC-5.14 HGB-13.4 HCT-40.9 MCV-80*
MCH-26.1 MCHC-32.8 RDW-13.0 RDWSD-37.2
___ 10:20PM NEUTS-52.9 ___ MONOS-12.7 EOS-2.5
BASOS-0.4 IM ___ AbsNeut-3.65 AbsLymp-2.17 AbsMono-0.88*
AbsEos-0.17 AbsBaso-0.03
___ 10:20PM PLT COUNT-317
DISCHARGE LABS:
===============
MICRO:
=====
Blood culture ___ x3: pending but NGTD
IMAGING:
========
CXR ___:
The cardiomediastinal contours are within normal limits. The
bilateral hila are unremarkable. The lungs are clear without
focal consolidation. There is no evidence of pulmonary vascular
congestion. There is no pneumothorax or pleural effusion.
IMPRESSION:
No acute cardiopulmonary process.
TTE ___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. No mitral valve abscess
is seen. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis or
pathologic flow. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
___ 07:00AM BLOOD WBC-5.2 RBC-4.24 Hgb-11.2 Hct-34.5
MCV-81* MCH-26.4 MCHC-32.5 RDW-13.2 RDWSD-38.4 Plt ___
___:00AM BLOOD Glucose-108* UreaN-4* Creat-0.6 Na-141
K-3.9 Cl-107 HCO3-28 AnGap-10
___ 07:00AM BLOOD Calcium-8.9 Mg-2.1
___ 07:35AM BLOOD HBsAg-Negative
___ 07:00AM BLOOD CRP-36.4*
___ 10:20PM BLOOD CRP-48.8*
___ 07:35AM BLOOD HIV Ab-Negative
___ 10:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
The patient is a ___ year old female with h/o active IV drug use
who presents with subjective fevers, weight loss, and rash
# Subjective fevers/weight loss/myalgias: Unclear cause of
symptoms, but given history of IVDU c/f underlying infectious
process such as endocarditis vs. transient bacteremia. TTE done
on ___ negative for vegetations or abscesses. HIV and
hepatitis
serologies negative. She was monitored for fevers while
admitted and did not have any fever or leukocytosis.
# Rash: pt presenting with scattered ulcerating bleeding rash as
noted above. Seen by dermatology who felt that this is likely
c/w self-inflicted etiology exacerbated by likely itchiness from
opiate use. She was started on Muprocin cream followed by
duoderm or mepilex border to areas of erosion.
# IVDU: ___ reported active use. She was started on low dose
methadone for withdrawal symptoms. She was also seen by ___ who
helped provide her with resources for ongoing sobriety. Pt
stated that she has a plan to take her already prescribed
suboxone that is in the possession of her mother to manage
cravings if they develop after discharge. She stated her goal
was to not take any suboxone or methadone and to be free from
medications and drugs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
resume your previously prescribed dose
2. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % 1 application twice a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
IV drug abuse
skin rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fever and a skin rash. You were evaluated
for infection and we did not find any suggestion of infection at
this time. The dermatologists evaluated your skin and
recommended a topical treatment.
You were evaluated by the social worker to help give you
resources in order to help with getting sober.
Please continue to avoid drug use/abuse as this can lead to
infection and death amongst other things.
We wish you luck!
Followup Instructions:
___
|
10551762-DS-18 | 10,551,762 | 21,643,358 | DS | 18 | 2142-10-08 00:00:00 | 2142-10-16 08:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / ___
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with a history of cardiomyopathy (EF ___,
nonischemic) s/p BiV pacer ___ with improved EF to 30%,
hypertension, who presents for evaluation of low back pain but
was found in triage to be hypoxemic to 86% RA.
He was seen in the emergency department on ___ with back pain
after a fall at home; he was noted to have midline tenderness to
palpation without any numbness, weakness, or bowel/bladder
problems or other neurologic symptoms; he had an x-ray which
showed compression fractures in the lumbar spine. He was given
acetaminophen and Flexeril and discharged home. He states that
he has had significant back pain unrelieved by the medications
he was given and thus came back to the hospital.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- sCHF (LVEF ___
3. OTHER PAST MEDICAL HISTORY:
- Biventricular dilatation
- Moderate to severe pulmonary HTN
- Tonsilectomy
- C5 disc herniation
- Bilareral hip replacements.
- H/o Alcohol abuse
Social History:
___
Family History:
Patient is adopted, but believes his biological mother may have
had CAD.
Physical Exam:
ADMISSION EXAM:
VS: ___ ___ Temp: 98.5 PO HR: 60 RR: 20 O2 sat: 97% O2
delivery: Ra
GENERAL: NAD, lying comfortably in bed eating dinner, in no
acute distress.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD. JVP at 12cm
CV: Rhythm regular, S1 and S2, with a ___ systolic ejection
murmur at the lower left sternal border
PULM: Diminished at bases bilaterally with faint crackles.
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ edema to mid thighs bilaterally.
MSK: Mild tenderness to palpation over lumbar spine.
NEURO: Strength and sensation intact in ___ LEs. Strength ___
bilaterally limited slightly by pain.
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-12.9* RBC-4.48* Hgb-11.4* Hct-38.9*
MCV-87 MCH-25.4* MCHC-29.3* RDW-16.9* RDWSD-53.9* Plt ___
___ 06:45PM BLOOD Neuts-86.9* Lymphs-5.2* Monos-6.7
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.22* AbsLymp-0.67*
AbsMono-0.87* AbsEos-0.01* AbsBaso-0.03
___ 06:45PM BLOOD ___ PTT-38.6* ___
___ 06:45PM BLOOD Glucose-98 UreaN-30* Creat-1.0 Na-139
K-5.2 Cl-99 HCO3-29 AnGap-11
___ 06:45PM BLOOD TotProt-7.1 Albumin-3.7 Globuln-3.4
Calcium-9.3 Phos-3.5 Mg-2.0 Iron-36*
___ 06:45PM BLOOD CK-MB-3 ___
___ 06:45PM BLOOD cTropnT-0.03*
___ 06:45PM BLOOD CK(CPK)-51
___ 06:45PM BLOOD calTIBC-450 Ferritn-27* TRF-346
___ 06:45PM BLOOD PEP-NO SPECIFI FreeKap-42.7* FreeLam-23.6
Fr K/L-1.81*
IMAGING:
CHEST XRAY ___: Right pleural effusion, with a loculated
appearance with subjacent consolidation which could represent
atelectasis and/or pneumonia. Cardiomegaly with hilar
congestion.
DISCHARGE LABS:
Brief Hospital Course:
___ man with a history of cardiomyopathy (EF ___,
nonischemic) s/p BiV pacer ___ with improved EF to 30%,
hypertension, who presents for evaluation of low back pain but
was found in triage to be hypoxemic to 86% RA.
In the hospital, his chest xray was notable for right pleural
effusion with a consolidation suggestive of pneumonia and
cardiomegaly with hilar congestion. He was thought to have CAP
and started on Ceftriaxone and Azithromycin. He was volume
overloaded on exam (JVP to the angle of the mandible, ___ lower
extremity edema), and it was presumed that his infection was the
trigger of his acute on chronic HFrEF and hypoxemic respiratory
failure.
ACUTE ISSUES:
#Hypoxemic respiratory failure
#Acute on chronic HFrEF
#Community acquired PNA:
Likely multifactorial with mild HF exacerbation as well as
underlying PNA. Observed cough during interview with mild
leukocytosis and CXR fairly convincing for underlying PNA.
Treated with CTX and Azithro. For HF exacerbation, likely
triggered by infection. Low concern for ischemia given lack of
sx or EKG changes. Received IV Lasix and was put on a Lasix
drip. BID Lasix 120mg.
- CTX
- Azithromycin
- Diuresed with 120IV Lasix, Lasix gtt
- Daily weights
- Is and Os
- TTE: xxxxx
- PRELOAD: Diuresis as above
- AFTERLOAD: Lisinopril 20mg PO daily
- NHBK: Fractionate home to 25mg PO tartrate Q6 (not holding
given mild HF exacerbation)
# back pain s/p fall: Known compression fracture. Pain well
controlled with lidocaine patch and Tylenol. No red flag sx for
cord compression currently.
- Tylenol standing 1G Q8
- Lidocaine patch
#Normocytic anemia: Slightly below baseline with no signs of
active bleeding at this time, negative guiac in ED. Iron studies
suggestive of iron deficiency anemia.
- Iron PO
#Proteinuria: No history of diabetes, rhematologic disease or
malignancy to explain proteinuria. Few RBCs on UA as well.
Concern for potential MM with normocytic anemia, recent
fracture, and proteinuria (although Cr seems to be ok).
- SPEP, serum free light chains: xxxxx
CHRONIC ISSUES:
#Atrial fibrillation:
-Metoprolol Tartrate 25 mg PO/NG Q6H
-Dabigatran Etexilate 150 mg PO BID
#Hypertension: Continue home ACE, BB
- Lisinopril 20 mg PO/NG DAILY
TRANSITIONAL ISSUES:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 150 mg PO BID
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Torsemide 80 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Systolic heart failure exacerbation
Community Acquired pneumonia
Presumed COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU IN THE HOSPITAL?
You came in with back pain after a recent fall and were found to
have a low oxygen saturation and fluid in your legs.
WHAT HAPPENED IN THE HOSPITAL?
You were found to have pneumonia and were treated with IV
antibiotics. This infection likely caused your heart to not pump
as effectively, causing buildup of fluid in your lungs and body.
You were given medications to help you urinate to remove the
excess fluid.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
You should follow-up with your doctor.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you! We wish you the very best!
Sincerely,
___
Dear Mr. ___,
Followup Instructions:
___
|
10551762-DS-19 | 10,551,762 | 26,213,658 | DS | 19 | 2143-08-03 00:00:00 | 2143-08-06 11:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Darvon
Attending: ___.
Chief Complaint:
Scrotal Swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with HFrEF, now
recovered ___ nonischemic cardiomyopathy with BiV pacer ___,
COPD on 2L home O2, HTN who presents with scrotal swelling.
Patient was in his usual state of health until:
___, 1 week PTA: Running to get front door when he tripped on a
wire and fell, landing on his L flank and hit his head. No LOC.
No blurry vision. No LH beforehand.
___, 4 days PTA: Noticed swelling of his scrotum. No redness or
pain. Urinating w/o difficulty
___, 2 days PTA: Began having difficulty urinating, only small
dribbles coming out and lots of leaking. No dysuria.
___: Presented to ED due to inability to see penis and
inability
to urinate more than just drops. ED Initial Vitals: T 97.4, HR
76, BP 168/99, RR 16, O2 91%2L. Taking diuretics as prescribed,
has not missed any doses. No cough. No fever, URI complaints.
Foley placed. Gave 80mg IV Lasix
On the floor, he reports that his legs are somewhat swollen.
Denies any changes in medication. Has been eating a lot more
fast
food lately.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- sCHF (LVEF ___
3. OTHER PAST MEDICAL HISTORY:
- Biventricular dilatation
- Moderate to severe pulmonary HTN
- Tonsilectomy
- C5 disc herniation
- Bilareral hip replacements.
- H/o Alcohol abuse
Social History:
___
Family History:
unknown as he is adopted.
Physical Exam:
Admission:
VS: T 97.4, BP 162/79, HR 64, RR 19, O2 96%3L
GENERAL: Well-appearing man, NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP 14
CARDIAC: Normal rate, regular rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly. No pitting edema of abdomen.
GU: Scrotum massively edematous, foley in place.
EXTREMITIES: Warm, well perfused; mildly cool peripherally but
warm thighs. Pitting edema to thighs.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge:
24 HR Data (last updated ___ @ 351)
Temp: 97.3 (Tm 98.5), BP: 127/66 (60-127/40-66), HR: 76
(61-76), RR: 18 (___), O2 sat: 92% (91-99), O2 delivery: 2L,
Wt: 155.2 lb/70.4 kg
Weight yesterday: ~157
Fluid Balance:-740 cc
GEN: NAD.
NECK: JVP to jaw at 30 degrees iso severe TR
PULM: CTAB
BACK: No sacral edema
EXT: Warm, well perfused. trace ___ edema. Lateral aspect of left
shin with ~___rythematous patch with central healing
ulceration. Slightly warm to palpation. No pain to palpation.
Pertinent Results:
Admission labs:
___ 11:00AM BLOOD WBC-7.0 RBC-4.32* Hgb-10.6* Hct-38.9*
MCV-90 MCH-24.5* MCHC-27.2* RDW-18.0* RDWSD-58.6* Plt ___
___ 11:00AM BLOOD Glucose-89 UreaN-26* Creat-1.0 Na-139
K-4.7 Cl-98 HCO3-31 AnGap-10
___ 07:22AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.8
Discharge Labs:
___ 06:33AM BLOOD WBC-8.9 RBC-4.32* Hgb-10.7* Hct-38.6*
MCV-89 MCH-24.8* MCHC-27.7* RDW-17.6* RDWSD-57.1* Plt ___
___ 06:33AM BLOOD Glucose-75 UreaN-41* Creat-0.9 Na-136
K-5.2 Cl-97 HCO3-29 AnGap-10
___ 06:33AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.3
Studies:
CT Head
1. No acute intracranial process.
2. Stable chronic small vessel ischemic disease and involutional
changes.
Scrotal US
1. Limited study in the setting of extensive bilateral scrotal
edema.
2. Lack of continuous forward diastolic flow is seen in the
right
intratesticular arterial waveforms, likely technical due to
extensive
overlying scrotal edema. Otherwise, normal color flow and
echotexture within
both testes.
3. Small bilateral hydroceles, unchanged.
CXR
1. Mild pulmonary edema with small left pleural effusion, new in
the interval,
and unchanged loculated right pleural effusion with calcified
fibrothorax.
2. Severe enlargement of the cardiac silhouette size, increased
from prior,
potentially due to lower lung volumes, though a pericardial
effusion is not
excluded.
3. Patchy opacities in lung bases may reflect atelectasis,
though infection or
aspiration is not excluded.
ECHO
The left atrial volume index is SEVERELY increased. The right
atrium is markedly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is >15mmHg. There is moderate symmetric left
ventricular hypertrophy with a small cavity. There is normal
regional and
global left ventricular systolic function. Overall left
ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection fraction is 80%. There is no
resting left ventricular outflow tract gradient. Moderately
dilated right ventricular cavity with SEVERE global free wall
hypokinesis. Tricuspid annular plane systolic excursion (TAPSE)
is depressed. Intrinsic right ventricular systolic function is
likely
lower due to the severity of tricuspid regurgitation. There is
abnormal interventricular septal motion c/w right ventricular
pressure and volume overload. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a mildly dilated
descending aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is an eccentric,
inferolateral directed jet of mild [1+] mitral regurgitation.
Due to the Coanda effect, the severity of mitral regurgitation
could be UNDERestimated. The pulmonic valve leaflets are normal.
There is mild pulmonic regurgitation. The tricuspid valve
leaflets appear structurally normal. There is SEVERE [4+]
tricuspid
regurgitation. Due to acoustic shadowing, the severity of
tricuspid regurgitation may be UNDERestimated. There is SEVERE
pulmonary artery systolic hypertension. In the setting of at
least moderate to severe tricuspid regurgitation, the pulmonary
artery systolic pressure may be UNDERestimated. There is a small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade. In the presence of
pulmonary artery hypertension, typical echocardiographic
findings of tamponade physiology may be absent.
Brief Hospital Course:
___ year-old man with HFpEF, now recovered ___ nonischemic
cardiomyopathy with BiV pacer ___, COPD on 2L home O2, HTN
who presented with scrotal edema, found to have acute heart
failure exacerbation. He was started on IV Lasix, ultimately
with drip as high as 10 mg/hr, and diuresed to a dry weight of
70.4 kg (155.2 lb). Course was complicated by metabolic
alkalosis, hypotension and ___ secondary to overdiuresis but
this improved by the time he was discharged. He will be
discharged on an oral diuretic regimen of 20 mg torsemide with
several home medications held with plan to reinitiate at
adjusted doses in outpatient setting.
TRANSITIONAL ISSUES:
======================
[ ] Likely was not taking prescribed diuretics (had been
prescribed 80mg torsemide daily). Reduced diuretic dose to 20 mg
PO torsemide on discharge. Patient's weights will need to be
followed closely and diuretic dose adjusted as needed.
[ ] Was last seen by cardiology in ___. Previously
followed by ___. F/u was arranged with HF NP and Dr.
___ the most recent note from Dr. ___ suggested
f/u with Dr. ___ at the time of discharge.
[ ] Consider right heart cath for further workup of pulmonary
hypertension now that he is euvolemic. The patient did not want
to stay in the hospital for further procedures
[ ] Aldactone held at discharge due to episodes of hypotension,
please resume as an outpatient if BPs stable at follow-up visit.
[ ] Lisinopril stopped prior to discharge due to hypotension.
Was tolerating it well on admission so please reinitiate at low
dose with uptitration as tolerated. Would favor adding back
lisinopril before aldactone.
[ ] Patient's metoprolol succinate decreased from 100 mg to 50
mg at discharge given concern that metoprolol contributing to
hypotension, severe tricuspid regurgitation, and right heart
dysfunction. Patient with biventricular pacing, will need to
evaluate for degree BiV pacing percentage in outpatient device
clinic given recent reduction of dose. Remote transmission was
arranged with the device clinic for ___
[ ] Patient given script for shower chair. Please ensure that he
is able to get this as an outpatient
[ ] ASA held at discharge given no CAD seen on last coronary
angiogram.
[ ] Patient instructed to do daily weights at home.
Discharge weight: 70.4 kg (155.2 lb)
Discharge Cr: 0.9
Discharge diuretics: torsemide 20 mg PO daily
# CODE STATUS: Full, confirmed
# CONTACT: Cousin ___ (___)
ACTIVE ISSUES:
=============
# Acute on Chronic HFpEF with recovered LVEF
TTE with hyperdynamic systolic function and worsened TR and
dilated right ventricular cavity with SEVERE global free wall
hypokinesis. Exacerbation was felt to be secondary to medication
non-compliance as his pharmacy reports that he last filled his
torsemide in ___ for an 84 day supply. He endorses
medication compliance however. He was started on IV Lasix,
ultimately with drip as high as 10 mg/hr, and diuresed to a dry
weight of 70.4 kg (from admission weight of 86.3kg) , and Cr of
0.9. For the majority of his hospitalization he was continued on
home regimen of Lisinopril 20mg qd Metoprolol Succinate 100mg
qd; Spironolactone 50mg qd but in the setting of hypotension his
lisinopril and aldactone were held. Metoprolol succinate dosage
was decreased on discharge given concern that it metoprolol was
contributing to patient's hypotension, severe TR and RH
dysfunction with plan for close follow up in device clinic to
evaluate for percentage BiV pacing.
___. Likely secondary to overdiuresis. Improved with holding
diuretic and gentle hydration (500cc IVF). Cr 0.9 on discharge.
#Hypotension, secondary to hypovolemia in the setting of
overdiuresis. Patient was asymptomatic but BPs were as low as
___. Improved with 500cc of IVF and holding diuretic.
Medication adjustments as above.
#Metabolic alkalosis, Bicarb climbed to 41 in the setting of
aggressive diuresis. Bicarb improved to normal with
acetazolamide.
#Severe pulmonary HTN. Found on ECHO. Would benefit from RHC
once euvolemic. Declined during this hospitalization.
# Atrial Fibrillation. Continued home dabigatran and metoprolol.
Metoprolol dose reduced from 100 mg to 50 mg on discharge as
above. Rates were well controlled during hospitalization.
# COPD. Held home umeclidinium-vilanterol as nonforumlary, but
resumed at discharge. He did have significant wheezing on exam
during his hospitalization and was treated with PRN nebulizer
treatments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Dabigatran Etexilate 150 mg PO BID
5. Torsemide 80 mg PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. albuterol sulfate 90 mcg/actuation inhalation Q4H dyspnea
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Torsemide 20 mg PO DAILY
3. albuterol sulfate 90 mcg/actuation inhalation Q4H dyspnea
4. Dabigatran Etexilate 150 mg PO BID
5. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
6. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until your PCP says to
7. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until your PCP says to
reinitiate
8.shower chair
ICD10: W19.XXXA fall
___ 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
======================
Acute on chronic HFpEF with recovered LVEF
Scrotal edema
Acute kidney injury
Metabolic alkalosis
Hypotension secondary to hypovolemia
Secondary diagnoses
====================
Hypertension
COPD
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 of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had too much
fluid in your body.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you a medication called lasix through the IV to remove
the excess fluid from your body. You lost 35 pounds of water
while you were here.
- You had a little bit of kidney injury while you were here but
that got better by the time you left the hospital
- Your blood pressures were very low after we removed all of the
excess fluid but these improved after we changed around you
medications
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- It's very important to take your torsemide every day at home
so that you can prevent fluid build up
- Weigh yourself every day and write down the weight on a piece
of paper. If your weight goes up by more than 3 lbs in one day
then call your doctor as you might need more of the torsemide.
Bring a log of your weights to your follow-up appointments.
- It's very important to follow a low salt diet at home to
prevent fluid build up again.
- We changed the doses of some of your medicines. Your doctor
___ increase them again with time.
- We arranged for you to see a new cardiologist who specializes
in congestive heart failure. Please see below for your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10551922-DS-13 | 10,551,922 | 22,048,759 | DS | 13 | 2188-09-11 00:00:00 | 2188-09-15 09:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with no significant PMHx presented to the
___
clinic for evaluation of pancytopenia on ___ and was found
to
have pancytopenia and peripheral smear findings concerning for
likely acute promeylocytic leukemia in setting of low
fibrinogen.
She was referred to Hematology/Oncology by her primary care
physician after two CBCs ___ and ___ showed
pancytopenia. The CBC was done as part of an evaluation for
"tired legs" while climbing stairs for 2 months time.
She felt well until ___ when she began having
heavy, irregular menses characterized by prolonged bleeding for
7
to 10 days. She also noted that she felt sweaty and hot at night
(no true temps) intermittently at home over the past several
weeks-months but attributed this to getting older/possibly
menopause. Endorses bruising more easily in this time period as
well. But otherwise no e/o bleeding or bruising. Currently she
reports having intermittent diarrhea due to what she thinks is
from yogurt consumption and that she may be lactose intolerance.
Diarrhea is nonbloody. No melena. NO cough, SOB, sore throat,
rhinorrhea, headaches, diplopia.
ED COURSE:
T 98.1 HR 78 BP 147/72 --> 107/78 RR 20 100%RA
Labs with WBC 500 ANC 140, Plts 66, Hct 26.1. UA with mod blood.
INR 1.1. Fibrinogen 102. Uric acid 5.1. LDH 171.
In the ED, she received: oral Retinoic Acid *NF* (tretinoin) 40
mg ___ 17:20).
Review of Systems: No HA/rhinorrhea/fevers/rashes/abd pain/chest
pain/dysuria/hematuria/melena all other 10 point ROS neg other
than Per HPI
On arrival to the floor she is calm and has no complaints.
Past Medical History:
None
Social History:
___
Family History:
No known FHx of hematologic disease. Aunt had breast cancer.
Grandfather with another unknown cancer which developed in his
___.
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.4 122/76 89 16 99%RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: no JVD. no LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, doe shave small healing bruises over
thighs and excoriation over forelegs but no blistering lesions
or
rashes
NEURO: A&Ox3.
DISCHARGE EXAM
VS: 97.7 77-107 120/62 18 99% RA
GEN: NAD, ambulating around room and unit
HEENT: No JVD
CV: RRR, S1 and S2, no m/r/g
PULM: CTAB, no wheezes, crackles, rhonchi
CHEST: Port-site on right upper chest mildly tender to
palpation, no erythema or drainage
ABD: BS+, soft, NT, ND
EXT: No cyanosis, clubbing, or edema
NEURO: Grossly intact
SKIN: Few small ecchymoses on bilateral ___
___ Results:
==Admission Labs==
___ 11:16AM BLOOD WBC-0.5*# RBC-2.51*# Hgb-9.1*# Hct-26.1*#
MCV-104*# MCH-36.3*# MCHC-34.9 RDW-14.0 RDWSD-51.8* Plt Ct-66*#
___ 11:16AM BLOOD Neuts-28* Bands-0 Lymphs-60* Monos-1*
Eos-0 Baso-5* ___ Metas-1* Myelos-0 Promyel-0 Blasts-5*
NRBC-1* Other-0 AbsNeut-0.14* AbsLymp-0.30* AbsMono-0.01*
AbsEos-0.00* AbsBaso-0.03
___ 11:16AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Burr-1+ MacroOv-OCCASIONAL Tear Dr-OCCASIONAL
___ 11:16AM BLOOD ___ PTT-28.2 ___
___ 11:16AM BLOOD ___
___ 11:16AM BLOOD UreaN-13 Creat-0.7 Na-139 Cl-103 HCO3-24
AnGap-16
___ 11:16AM BLOOD TotProt-7.7 Albumin-4.9 Globuln-2.8
Calcium-10.6* Phos-3.3 Mg-2.1 UricAcd-5.1 Iron-242*
___ 11:16AM BLOOD ALT-12 AST-15 LD(LDH)-171 CK(CPK)-237*
AlkPhos-72 TotBili-0.7
___ 11:16AM BLOOD calTIBC-319 ___ Ferritn-416* TRF-245
___ 11:16AM BLOOD 25VitD-26*
___ 11:16AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative
___ 11:16AM BLOOD HCV Ab-Negative
___ 08:59PM BLOOD pH-7.41 Comment-GREEN TOP
___ 08:59PM BLOOD freeCa-1.11*
DISCHARGE LABS
==============
___ 12:00AM BLOOD WBC-2.6* RBC-1.94* Hgb-7.1* Hct-21.4*
MCV-110* MCH-36.6* MCHC-33.2 RDW-20.9* RDWSD-79.9* Plt ___
___ 12:00AM BLOOD Neuts-60.3 ___ Monos-7.1 Eos-4.7
Baso-0.0 NRBC-1.2* Im ___ AbsNeut-1.54* AbsLymp-0.69*
AbsMono-0.18* AbsEos-0.12 AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-36.3 ___
___ 12:00AM BLOOD ___ 12:40AM BLOOD QG6PD-9.1
___ 12:40AM BLOOD Ret Aut-2.3*
___ 12:00AM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
___ 12:00AM BLOOD ALT-208* AST-85* LD(LDH)-183 AlkPhos-53
TotBili-0.3
___ 12:00AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1
___ 12:00AM BLOOD ALT-20 AST-19 LD(LDH)-248 AlkPhos-71
TotBili-0.2
IMAGING
=======
CXR ___ PA and LAT
No acute abnormality
TTE ___
IMPRESSION: Preserved biventricular regional/global systolic
function. Mild-moderate tricuspid regurgitation with mild
pulmonary artery systolic hypertension.
Liver and gallbladder U/S ___
Normal abdominal ultrasound
Unilateral upper extremity veins U/S
IMPRESSION:
Acute DVT noted at the basilic vein extending over a distance of
3 to 4 cm as detailed above.
MICROBIOLOGY
============
C. diff assay ___: negative
BCx ___ x2: negative, final
Brief Hospital Course:
BRIEF SUMMARY
=============
Ms. ___ is a ___ female with no significant past medical
history who presented to ___ clinic for evaluation of
pancytopenia and fatigue who was found to have acute
promyelocytic leukemia (APML). She was started on ATRA, arsenic,
and prednisone per the ___ ___ protocol. Her ATRA and
arsenic were stopped for a few days and then reintroduced at 50%
doses for a few days due to LFT elevations. Both agents were
returned to full dose and she tolerated them well. Her course
was also complicated by a right arm DVT associated with a PICC
line. The PICC was removed and a port-a-cath was placed. She
started on enoxaparin (1.5 mg/kg SQ daily) and will likely need
anticoagulation for three months. She was also treated with
vancomycin for possible superimposed cellulitis however this was
discontinued due to low suspicion for infection.
ACUTE ISSUES
============
# APML - The pt presented after a clinic visit to evaluate
pancytopenia with a bone marrow biopsy suggestive of APML. The
decision was made to treat per ___ et al. ___
___ with ATRA/arsenic trioxide/prednisone. Pt
got first dose of ATRA in ED on ___ and second dose ___
on the floor. She also got 2 U cryoprecipitate on admission.
Her first dose of arsenic was on ___. Day 1 of treatment
was therefore declared ___.
On ___, given her LFTs, ATRA was held ___ - ___
(D12-19). Given that her LFTs remained elevated, ATO was held
___ - ___ (D16-19). On ___ both ATRA and ATO were
restarted at 50% dosages according to the ___ ___
protocol. She was transitioned to full dose ATO on ___
(D21). Prior to completing her cycle, her LFTs began to increase
again, however her T.bili remained normal. The decision was made
to complete her cycle without stopping her medications given
that she was nearly finished. She also got daily ECGs, as
arsenic can prolong the QTc. She tolerated treatment well
without evidence of maturation syndrome. She received
prophylaxis.
# RUE DVT: On ___, her RUE was found to be erythematous and
edemadous at the site of her PICC line. Her PICC line was
removed and a right chest Port-A-Cath was placed. She had a RUE
US with Doppler that demonstrated a RUE DVT. She was started on
therapeutic enoxaparin (55 mg SC BID) on ___. She was also
started on empiric vancomycin on ___ to cover for possible
RUE cellulitis. After several days of vancomycin therapy, it was
felt that she did not have an infection so this was
discontinued. She was discharged on enoxaparin 1.5 mg/kg SQ
daily with instructions to complete a 3-month course.
# Transaminitis: Pt found to have LFT elevations on ___.
This was felt to be due to medications. Fluconazole was stopped
and micafungin was started, and then given that LFTs remained
elevated micafungin was stopped. This did not result in
resolution of her transaminits, so ATRA/ATO were held as
described above. She had a RUQ US that was normal. Her ATRA/ATO
was restarted as above, and she experienced worsening LFTs on
___ but these mediations were not stopped given that she only
had two more days of her cycle.
Transitional Issues:
====================
-Pt started on enoxaparin on ___ for treatment of RUE DVT
and will likely require anticoagulation for three months
-Patient will need to complete a 9-day prednisone taper
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Centrum Complete (multivitamin-iron-folic acid) ___ mg-mcg
oral DAILY
2. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) oral DAILY
3. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Tretinoin (ATRA-All Transretinoic Acid) 40 mg PO QPM )
( )
RX *tretinoin (chemotherapy) 10 mg 3 capsules (30 mg) by mouth
qam, and 4 capsules (40 mg) po qpm Disp #*210 Capsule Refills:*0
2. Enoxaparin Sodium 80 mg SC DAILY
RX *enoxaparin 80 mg/0.8 mL 80 mg SQ once daily Disp #*30
Syringe Refills:*0
3. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
4. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone [Mepron] 750 mg/5 mL 1500 mg by mouth daily Disp
___ Milliliter Milliliter Refills:*0
5. PredniSONE 10 mg PO DAILY
RX *prednisone 5 mg 2 tablet(s) by mouth for one day, then 1 t
daily for 3 days, then ___ t daily for 3 days, then stop Disp
#*7 Tablet Refills:*0
6. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
7. Centrum Complete (multivitamin-iron-folic acid) ___ mg-mcg
oral DAILY
8. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 1 tablet ORAL DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Ranitidine 150 mg PO BID
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Acute Promyelocytic Leukemia (APML)
Right Upper Extremity Deep Vein Thrombus (PICC associated)
Right Upper Extremity Cellulitis
Secondary Diagnoses:
Pancytopenia
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with acute promyelocytic leukemia (APML). You were treated with
all-trans retinoic acid (ATRA) and arsenic. You also received
prednisone (a steroid), which you will be tapering at home.
Your treatment was briefly interrupted because of your liver
tests, but therapy was resumed at full dose. You also had a
blood clot in your right arm near your PICC line. The PICC line
was removed and a Port-A-Cath was placed. You were also started
on enoxaparin (Lovenox) to treat the clot and will continue to
use this once daily for three months. Please continue to take
your ATRA as instructed and come to all of your appointments.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10552385-DS-13 | 10,552,385 | 23,156,605 | DS | 13 | 2164-04-01 00:00:00 | 2164-04-01 17:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Ultram
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission Labs
-----------------
___ 06:03PM BLOOD WBC-5.7 RBC-4.44 Hgb-12.5 Hct-39.8 MCV-90
MCH-28.2 MCHC-31.4* RDW-13.0 RDWSD-42.9 Plt ___
___ 06:03PM BLOOD Plt ___
___ 06:03PM BLOOD Glucose-82 UreaN-9 Creat-0.8 Na-141 K-4.4
Cl-102 HCO3-23 AnGap-16
___ 06:03PM BLOOD ALT-15 AST-18 AlkPhos-107* TotBili-0.3
___ 06:03PM BLOOD Albumin-4.7
___ 08:15AM BLOOD TSH-5.0*
___ 08:15AM BLOOD Free T4-1.1
___ 09:20PM URINE Blood-LG* Nitrite-NEG Protein-20*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-NEG
Discharge Labs
-----------------
___ 07:00AM BLOOD WBC-4.6 RBC-3.68* Hgb-10.5* Hct-32.7*
MCV-89 MCH-28.5 MCHC-32.1 RDW-13.1 RDWSD-42.5 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-91 UreaN-6 Creat-0.7 Na-140 K-4.1
Cl-106 HCO3-23 AnGap-11
___ 07:00AM BLOOD ALT-11 AST-15 AlkPhos-84 TotBili-0.2
___ 07:00AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.9 Mg-2.0
___ 04:06PM URINE Blood-SM* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.5
Leuks-NEG
Imaging
-----------
CT PELVIS WITH CONTRAST
IMPRESSION:
1. No acute findings in the pelvis.
2. Normal CT appearance of the right and left ovaries.
3. Sigmoid colonic diverticulosis.
TVUS
IMPRESSION:
Normal uterus and right ovary. The left ovary is not
identified.
Brief Hospital Course:
___ is a ___ year old female with a pmhx of
___'s thyroiditis, migraines, asthma and anxiety who
presented to the ED for evaluation of 5 days of lower
abdominal/pelvic pain of unclear etiology with an unremarkable
CT of the pelvis and TVUS but likely secondary to Mittelschmerz.
We controlled her symptoms and discharged her once she was able
to tolerate a PO diet.
TRANSITIONAL ISSUES:
====================
[ ] She may benefit for consideration of OCP/IUD to help prevent
painful periods which should further be discussed during future
outpatient appointments
[ ] Please check a repeat TSH/free T4 during her next follow up
appointment
ACUTE ISSUES:
=============
#Lower abdominal/pelvic pain
#Dysmenorrhea
She presented with persistent abdominal/pelvic pain with
unremarkable workup including CT abdomen/pelvis, TVUS at ___
and overall normal labs upon admission here with no
leukocytosis, normal LFT's, lipase, pregnancy test and a
relatively normal TVUS and pelvic exam making any acute process
unlikely. Given that her left ovary was not visualized on the
TVUS we repeated a CT of the pelvis which showed normal
appearance of the right and left ovaries with no acute processes
in the pelvis. Her association of pain with mensuration is
likely ___ Mittelschmerz vs. ruptured ovarian cyst vs.
endometriosis/adenomysosis/fibroid uterus. We controlled her
symptoms wand discharged her once she once she was able to
tolerate a PO diet.
[ ] She may benefit for consideration of OCP/IUD to help prevent
painful periods which should further be discussed during future
outpatient appointments.
CHRONIC ISSUES:
===============
#Hashimito's Thyroiditis
Her TSH/T4 was checked with a TSH value of 5.0 and a free T4 of
1.1. She did report not taking her thyroid medications during
the days preceding her hospitalization due to her nausea.
Continued home levothyroxine
[ ] Please check a repeat TSH/free T4 during her next follow up
appointment
#Aniety
She reports taking Benadryl at home for anxiety attacks. She
required no Benadryl during her stay here. We also started her
on Ramelteon to help with insomnia while in the hospital.
#Migraines
She reports a history of very infrequent migraines and takes OTC
migraine medictions when experiencing one. She reported no
migraines during her stay here.
CORE MEASURES
=============
#CODE: Full code, presumed.
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. SUMAtriptan succinate 50 mg oral DAILY:PRN
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
4. DiphenhydrAMINE 12.5 mg PO DAILY:PRN Anxiety
Discharge Medications:
1. Acetaminophen 500 mg PO BID PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 1
tablet(s) by mouth BID PRN Disp #*30 Tablet Refills:*0
2. Ibuprofen 400 mg PO BID PRN Pain - Mild
RX *ibuprofen [IBU] 400 mg 1 tablet(s) by mouth BID PRN Disp
#*60 Tablet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Duration: 7 Days
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H PRN Disp #*21
Tablet Refills:*0
4. DiphenhydrAMINE 12.5 mg PO DAILY:PRN Anxiety
5. Levothyroxine Sodium 50 mcg PO DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
7. SUMAtriptan succinate 50 mg oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
----------
Intractable Abdominal Pain
Secondary
----------
Anxiety
Migraines
___'s Thyroiditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you had severe
abdominal pain and were not eating or drinking secondary to the
pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- While you were in the hospital we ran a number of lab and
imaging tests which did not explain the cause of your abdominal
pain. We also gave you medications to help control your pain and
nausea and made sure you were able to tolerate a diet.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10552928-DS-21 | 10,552,928 | 23,925,782 | DS | 21 | 2137-01-16 00:00:00 | 2137-01-16 11:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
found down, unresponsive.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old male that was found down by friends with
positive alcohol level. He is unable to recall the event but
there is a questionable history of assault. GCS was initally 7
in the ED. He was intubated initally for airway protection.
Past Medical History:
none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: temp 97.5, HR 84, BP 134/71, RR18 100% Room air
Gen: NAD, AOX3
HEENT: Missing right anterior maxillary incisor, small
ecchymosis over nasal bridge
CV: RRR, no chest wall tenderness
Resp: CTAB
Abd: soft NTND, pelvis stable
Ext: Atraumatic, spontaneous movement in all extremities. ___
strength.
Pertinent Results:
CT face: Non-displaced fracture of the right nasal bone. Absent
right
maxillary incisor tooth.
CT head: No acute intracranial process.
Ct c-spine: No acute fracture or traumatic malalignment.
Trauma CXR and pelvis: 1. Standard positions of the endotracheal
and orogastric tubes.2. No acute traumatic injury within the
chest or pelvis.
Brief Hospital Course:
Mr. ___ was admitted to the trauma ICU for management of his
injuries. He was initially intubated in the ED for airway
protection. He was subsequently extubated on ___ after
imaging showed only a displaced front tooth and non-displaced
facial fracture. He was cognitive wise, back at his baseline. He
had no respiratory, cardiovascular, GI, GU, or ID issues.
He was discharged home from the trauma ICU after voiding,
tolerating a regular diet, and being able to ambulate.
Medications on Admission:
none
Discharge Medications:
none.
Over the counter pain medication recommended.
Discharge Disposition:
Home
Discharge Diagnosis:
Nondisplaced nasal fracture, Right maxillary incisior injury and
displacement.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
You were admitted to the ___ Deaconess ___ Service
for management of your fall. Your workup was significant for a
non-displaced nasal fracture and injury to your front tooth.
These can be managed non-operatively. You should follow up
outpatient with orthodontics (for your tooth) and plastic
surgery (for your nose) if you are worried about cosmesis.
You should manage your pain with over the counter pain
medication. Tylenol and motrin are recommended.
It was a pleasure taking care of you. We wish you well with your
recovery.
Followup Instructions:
___
|
10553084-DS-11 | 10,553,084 | 25,379,329 | DS | 11 | 2199-11-18 00:00:00 | 2199-11-19 20:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
___: Transesophageal Echocardiogram
___: ___ placement
History of Present Illness:
___ w/ CKD IV, membranous glomerulonephritis, afib, mitral
stenosis, HTN, former tobacco abuse, and new diagnosis of small
cell lung ca on C1D9 etoposide, carboplatin, foaprepitant, and
neulasta on C1D4, who presents w/ loose stools associated with
low-grade fevers as high as 100 home. No abdominal pain. Denies
any chest pain, shortness of breath. Has a baseline dry cough.
No
new rashes. She is unable to provide me much more history
stating, "I just am tired of the diarrhea." Records from the
chart indicate that her diarrhea started the day of or after her
first cycle of chemotherapy.
In the ED, VS 98.8 89 118/48 18 100% RA and was found to have a
low grade fever of 100.1F and received:
-- 18:05 IV CefePIME 2 g
-- 18:14 IVF 1000 mL NS 1000 mL
-- 18:36 IV Vancomycin 1000 mg
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
Hypertension, essential, benign
Hypothyroidism
OSTEOARTHRITIS - MULT JOINTS
Palpitations
COLORECTAL POLYPS
LEIOMYOMA - UTERUS
DRUSEN - DEGENERATION OF MACULA / POST POLE
CATARACT - NUCLEAR SCLEROTIC SENILE
HYPERCHOLESTEROLEMIA
HYPERCOAGULABLE STATE - SECONDARY
Nephrotic syndrome with lesion of membranous glomerulonephritis
Anemia associated with chronic renal failure
Chronic kidney disease, stage IV (severe)
Anticoagulant long-term use
Hyperparathyroidism due to renal insufficiency
Hyperkalemia
Atrial fibrillation
Mitral stenosis
Basal cell carcinoma of skin, L chest
Dry ARMD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
General: NAD
VITAL SIGNS: ___, 131/38, 93, 18, 98%RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy
CV: RR, NL S1S2 no S3S4 MRG, JVP 5 cm H2O
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Oriented to person, place, and ___ and then
after prompting several times, ___ and told me this was a
"tricky question."
DISCHARGE PHYSICAL EXAM:
=====================
VS: 98.6-99, 136-158/50-62, rr20, 95% on RA
GEN: AOx3, NAD
HEENT: MMM with oral ulcers on left inner cheek, no thrush.
Cards: Regular rate and rhythm, with S1/S2 normal. ___ systolic
murmur present loudest at apex.
Pulm: Diminished breath sounds in bilateral bases, no crackles
or wheezes.
Abd: BS+, soft, NT, no rebound/guarding
Extremities: No lower extremity edema.
Skin: left picc site C/D/I
Pertinent Results:
ADMISSION LABS:
============
___ 05:19PM BLOOD WBC-0.3*# RBC-2.41* Hgb-7.1* Hct-22.6*
MCV-94 MCH-29.3 MCHC-31.4 RDW-16.0* Plt Ct-83*#
___ 05:19PM BLOOD Neuts-16.5* Lymphs-72.3* Monos-5.8
Eos-2.7 Baso-2.7*
___ 05:19PM BLOOD ___ PTT-63.1* ___
___ 05:19PM BLOOD Glucose-127* UreaN-47* Creat-3.3* Na-132*
K-3.4 Cl-99 HCO3-20* AnGap-16
___ 05:19PM BLOOD ALT-21 AST-18 AlkPhos-59 TotBili-0.4
___ 05:19PM BLOOD Albumin-2.8*
___ 05:33PM BLOOD Lactate-1.2
OTHER PERTINENT LABS:
===============
___ 08:15AM BLOOD WBC-12.6* RBC-3.16* Hgb-9.3* Hct-29.3*
MCV-93 MCH-29.4 MCHC-31.7 RDW-16.9* Plt ___
___ 06:18AM BLOOD WBC-13.5* RBC-2.95* Hgb-8.8* Hct-27.2*
MCV-92 MCH-29.9 MCHC-32.5 RDW-17.1* Plt ___
___ 05:28AM BLOOD WBC-13.7* RBC-2.99* Hgb-8.7* Hct-27.4*
MCV-92 MCH-29.1 MCHC-31.7 RDW-17.2* Plt ___
___ 02:57PM BLOOD ___ PTT-42.3* ___
___ 05:28AM BLOOD ___ PTT-42.8* ___
___ 05:28AM BLOOD Plt ___
___ 06:18AM BLOOD Glucose-84 UreaN-34* Creat-2.8* Na-140
K-2.8* Cl-109* HCO3-20* AnGap-14
___ 02:55PM BLOOD Glucose-134* UreaN-35* Creat-2.9* Na-139
K-3.4 Cl-107 HCO3-21* AnGap-14
___ 05:28AM BLOOD Glucose-93 UreaN-36* Creat-2.7* Na-138
K-3.2* Cl-105 HCO3-23 AnGap-13
___ 06:40PM BLOOD LD(___)-166 TotBili-0.4 DirBili-0.3
IndBili-0.1
___ 07:15AM BLOOD ALT-21 AST-16 LD(LDH)-156 AlkPhos-47
TotBili-0.4
___ 07:24AM BLOOD ALT-14 AST-15 LD(LDH)-158 AlkPhos-79
TotBili-0.3
___ 06:18AM BLOOD Phos-3.0 Mg-1.4*
___ 02:55PM BLOOD Calcium-7.9* Phos-2.1* Mg-3.1*
___ 05:28AM BLOOD Calcium-7.6* Phos-2.3* Mg-2.4
___ 06:18AM BLOOD CRP-81.1*
___ 10:30PM BLOOD freeCa-1.07*
___ 05:33PM BLOOD Lactate-1.2
MICROBIOLOGY:
===========
___. difficile DNA amplification assay - NEGATIVE
___ CULTURE-FINALINPATIENT - NEGATIVE
___ CULTUREBlood Culture, Routine-PENDING - NGTD
___ CULTUREBlood Culture, Routine-PENDING - NGTD
___ CULTUREBlood Culture, Routine-NEGATIVE
___ CULTURE ( MYCO/F LYTIC BOTTLE)BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARYINPATIENT
___ CULTUREBlood Culture, Routine-FINAL- NEGATIVE
___ CULTUREBlood Culture, Routine-FINAL- NEGATIVE
___ CULTUREBlood Culture, Routine-FINAL- NEGATIVE
___ CULTURE ( MYCO/F LYTIC BOTTLE)BLOOD/FUNGAL
CULTURE-PENDING; BLOOD/AFB CULTURE-PENDINGINPATIENT
___ CULTUREBlood Culture, Routine-- NEGATIVE
___ CULTUREBlood Culture, Routine-FINAL ___
(TORULOPSIS) GLABRATA}; Anaerobic Bottle Gram
Stain-FINALINPATIENT
___ CULTURE ( MYCO/F LYTIC BOTTLE)BLOOD/FUNGAL
CULTURE-FINAL ___ (TORULOPSIS) GLABRATA}; BLOOD/AFB
CULTURE-FINAL; Myco-F Bottle Gram Stain-FINALINPATIENT
___ CULTURE-- NEGATIVE
___ + PARASITES-- NEGATIVE
___ + PARASITES-- NEGATIVE
___. difficile DNA amplification assay-FINAL;
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA +
PARASITES-FINALINPATIENT
___ CULTUREBlood Culture, Routine-FINAL ___
(TORULOPSIS) GLABRATA}; Aerobic Bottle Gram Stain-- NEGATIVE
___ CULTUREBlood Culture, Routine-- NEGATIVE
___ CULTUREBlood Culture, Routine-- NEGATIVE
IMAGING:
=======
___: TTE
Severe eccentric mitral regurgitation. Normal global and
regional biventricular systolic function. Very small pericardial
effusion.
___: TEE
Preserved biventricular systolic function. Amorphous mildly
mobile mass adherant/adjacent to the supporting structures of
the posterior mitral valve leaflet. Perforation of the posterior
mitral leaflet with at least moderate to severe mitral
regurgitation. Findings could be consistent with fungal
endocarditis (atypical for bacterial endocarditis).
Brief Hospital Course:
___ w/ CKD IV, membranous glomerulonephritis, atrial
fibrillation, severe MR, HTN, former tobacco abuse, and new
diagnosis of small cell lung ca on C1D11 etoposide, carboplatin,
fosaprepitant, and neulasta on C1D6, who presents with low grade
fevers and diarrhea/soft stools after receiving chemotherapy,
found to be severely neutropenic with now recovering counts but
with budding yeast in two blood cultures and recent worsening of
MR. ___ ___, s/p PICC placement for blood draws and
administration of IV antifungals.
# Fungemia/Fungal Endocarditis:
Budding yeast on BCx on ___ and ___ positive for budding
yeast, and concerning for fungemia. ID consulted, felt most
likely species was ___, started Micafungin (___).
Source unclear, given pt has no port and is not on TPN; however,
in neutropenic patient, likely represents true infection. Pt
with thrush on exam previously, raised concern for invasive
fungal infection ___ thrush.
Antifungal plan is for continuation via PICC (placed ___
of micafungin (___) for total of 6 week course. Patient
was provided with ___ services to provide these antibiotics at
home. At the time of discharge patient will be discharged with a
total of 6 week course of medication - 39 total doses starting
on ___ (via home ___ and to be completed on ___. This
regimen may be adjusted by the infectious disease service as an
outpatient in ___ clinic. Optho consult ordered on ___ to r/o
endopthalmitis as per ID team, will need repeat eye exam as
outpatient.
Given the echocardiogram results showing worsening of MR over ___
span of ~1 month, cardiology recommended a TEE to assess for
potential valvular fungal infection. TEE was performed on ___
and indicative of possible fungal endocarditis requiring
extended course of antibiotics. Cardiac surgery team consulted
as an inpatient, no surgery to be performed during this
admission. Patient was also seen by Cardiology service and they
recommended she re-start her home Torsemide given her worsening
of MR and increased risk for CHF.
# CKD stage IV/V ___ MPGN
Stable during hospitalization. Patient was seen in the hospital
by her outpatient nephrologist, Dr. ___. During
hospitalization avoided nephrotoxins, renally dosed medications,
continued home sodium bicarbonate, and did not use lovenox or
electrolyte scales given the CKD.
# Hypoxia:
S/p blood transfusion the patient had a 6L NC O2 oxygen
requirement. She improved with lasix, weaning to room air. A
chest XR was obtained on ___ due to patient having continuing
saturation in low ___ on room air. The xray showed no worsening
versus prior, no indication of infectious source, but did show
compressive atelectasis. The Echocardiogram results showing
severe MR along with the hypoxic episode arising in the context
of a blood transfusion pointed toward volume overload as the
source/CHF. The case was discussed with the transfusion medicine
team, and they believe TRALI to be an unlikely cause of the
patient's hypoxia, and rather TACO (overload) being the most
likely. This goes along with echo results as noted above. Given
the likely fungal endocarditis and damage to the mitral valve,
patient is likely prone to volume overload and CHF and may
require redosing of her lasix in the future.
# Anemia:
Patient required multiple blood transfusions this admission. No
clear evidence of bleeding, and the likely source of the anemia
was found to be chemo and ESRD. She received Epogen 10,000 subQ
x 1 on ___, and received a total of 2 units pRBCs. The first
of which she likely experienced TACO with and the second which
she tolerated. Given improving counts, will continue to trend
patient's H/H but can do so daily at this time and discontinue
type and screen in coming days.
# Diarrhea in s/o neutropenic fever: Diarrhea may have been
related to chemotherapy given it followed receiving chemo,
however pt had recent hospitalization and received abx therapy,
and is neutropenic, raising her risk of infection of stool. She
was started on Vanc on ___ given pressure ulcers, and on ___
was started on Cefepime/Flagyl initially due to unclear source
of both fever and her diarrhea. Her stool cultures and C. dif
were all negative. She was transitioned to Levofloxacin
monotherapy on ___. Given resolution of fevers, and more
likely a fungal source of infection with other blood cultures
negative - her Levofloxacin was planned to be continued through
___ to provide for a full 8 days of coverage for empiric HCAP
tx. This was discontinued on ___.
# Neutropenia: Pt received neulasta with last chemo. Counts
continued to improve. Neutropenic precautions were provided
until ___ >1000, and were then discontinued due to improved
blood counts
# Concern for aspiration: RN observed pt coughing after eating,
concerned for aspiration. S&S consult eval. was initially
ordered to assess patient, but as she was tolerating her diet
well a full evaluation was not completed.
# SCLC Lung Ca: C2D1 ___
Encouraged patient to follow up with her outpatient oncologist
for further management of her malignancy. Otherwise stable.
# Afib: Valvular afib due to mitral stenosis, high risk for
thromboembolism. Remained in sinus rhythm w/rate in ___.
Given good rate control, patient continued after discharge on
her home medications. Home Warfarin held due to supratherapeutic
INR, with INR slow to fall. At time of discharge Warfarin was
restarted.
Transitional Issues:
=============
1. Follow up with oncologist
2. Follow up with infectious disease team ___ clinic)
3. Follow up with cardiologist
4. Follow up with nephrologist
5. Follow up with ___
**Please check INR, CBC, Chem 10 on follow up visit on ___.
**Patient discharged to complete 6 weeks of IV micafungin. Has
___ clinic follow up on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Sodium Bicarbonate 650 mg PO BID
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Amiodarone 200 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Diltiazem Extended-Release 120 mg PO DAILY
9. PreserVision (vit C-vit E-copper-ZnOx-lutein;<br>vitamins
A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral qd
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Warfarin 2 mg PO 3X/WEEK (___)
12. Warfarin 1 mg PO 4X/WEEK (___)
Discharge Medications:
1. Micafungin 100 mg IV Q24H
RX *micafungin [Mycamine] 100 mg 1 vial IV once a day Disp #*39
Vial Refills:*0
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Sodium Bicarbonate 650 mg PO BID
9. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. PreserVision (vit C-vit E-copper-ZnOx-lutein;<br>vitamins
A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral qd
11. Warfarin 1 mg PO DAILY16
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Diltiazem Extended-Release 120 mg PO DAILY
14. Heparin Flush (10 units/ml) 3 mL IV DAILY and PRN, line
flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
3 mL IV once a day Disp #*30 Syringe Refills:*0
15. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 mL IV once a day Disp #*30
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
___ (TORULOPSIS) GLABRATA Endocarditis and Fungemia
Neutropenic Fever
Chronic Kidney Disease Stage ___
Membranous Glomerulonephritis
Small Cell Lung Cancer
Atrial Fibrillation on Coumadin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You came to ___ with a fever,
and a very low white blood cell count. You were found to have a
fungal infection, and it is thought that this fungal infection
has caused "fungal endocarditis" where your heart valve was
damaged by the fungus. You received a PICC line so that as an
outpatient you can continue to receive antifungal agents. It
will be very important to take your medication daily, and to
follow up with your oncologist, infectious disease doctors and
with ___ to ensure no fungal infection of your eyes.
It has been a pleasure caring for you here at ___, and we wish
you all the best.
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10553084-DS-12 | 10,553,084 | 22,235,988 | DS | 12 | 2200-06-18 00:00:00 | 2200-06-18 22:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ with history of progressive small cell
lung cancer (Dx ___ s/p chemotherapy and course of
radiation therapy (14 sessions completed the day PTA), atrial
fibrillation on warfarin, CKD (baseline Cr ~3; secondary to
membranous glomerulonephritis), history of fungal endocarditis
on lifelong IV Micafungin (not a surgical candidate) who was
sent from ___ clinic for management of weakness and
hypokalemia. Patient reports one week of loose diarrhea with 5
BMs per day along with feeling fatigued for the past 3 days. She
attributes the diarrhea to her radiation therapy. She also
reports episode of nausea and vomiting few ___ ago. She has
been having trouble with swallowing her pills therefore she has
not taken any medications for the past 3 days. She continues to
have good po intake. She denies any fevers, chills, night
sweats, abdominal pain. No abdominal pain. Denies any chest
pain, shortness of breath, orthopnea, PND or lower extremity
edema.
She was seen in radiation clinic today where her BP was 90/50's
standing to 110/60's sitting. Patient was sent to ___ where she
was seen by her oncologist. Labs showed K 2.0, Cr 4. Patient was
given 1L ___ NS along with potassium repletion and sent to ___
ED.
In the ED intial vitals were: 98.6 85 116/60 16 97%. Labs
notable for WBC 16.4. INR 4, Na 125, K 2.6, Cr 3.5. Patient was
given 2L D5NS along with 120mEq of K. Patient also received her
regular dose of Micafungin and admitted for further care.
Past Medical History:
Hypertension, essential, benign
Hypothyroidism
OSTEOARTHRITIS - MULT JOINTS
Palpitations
COLORECTAL POLYPS
LEIOMYOMA - UTERUS
DRUSEN - DEGENERATION OF MACULA / POST POLE
CATARACT - NUCLEAR SCLEROTIC SENILE
HYPERCHOLESTEROLEMIA
HYPERCOAGULABLE STATE - SECONDARY
Nephrotic syndrome with lesion of membranous glomerulonephritis
Anemia associated with chronic renal failure
Chronic kidney disease, stage IV (severe)
Anticoagulant long-term use
Hyperparathyroidism due to renal insufficiency
Hyperkalemia
Atrial fibrillation
Mitral stenosis
Basal cell carcinoma of skin, L chest
Dry ARMD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.5 119/45 90 100%RA
GENERAL: chronically ill appearing, although in no acute
distress, conversant
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple, no JVD, no LAD
CARDIAC: RRR, normal S1, S2. III/VI holosystolic murmur best at
___.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds in the bases
ABDOMEN: Obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM:
===============
Vitals: Tm 98.0 BP 125/53-174/76 HR 77-105 RR26 100%RA
BMx1
General- Chronically ill appearing but alert and oriented x3,
NAD
HEENT- MMM, oropharynx clear
Neck- JVP not elevated
Lungs- CTAB no wheezes, rhonchi, or crackles
CV- RRR, II/VI systolic murmur best heard at ___
Abdomen- nontender, nondistended, no organomegaly
GU- no foley
Ext- Left forearm edematous but nonerythematous/nontender, no
palpable cord. warm, well perfused, 2+ pulses, no clubbing,
cyanosis.
Neuro- moving all extremities, walking with walker
Pertinent Results:
ADMISSION LABS:
===============
___ 08:24PM ___ PTT-55.1* ___
___ 05:11PM LACTATE-2.1*
___ 04:40PM GLUCOSE-106* UREA N-58* CREAT-3.5*
SODIUM-125* POTASSIUM-2.6* CHLORIDE-97 TOTAL CO2-17* ANION
GAP-14
___ 04:40PM estGFR-Using this
___ 04:40PM ALT(SGPT)-32 AST(SGOT)-25 ALK PHOS-87 TOT
BILI-0.4
___ 04:40PM LIPASE-21
___ 04:40PM ALBUMIN-2.8* CALCIUM-8.7 PHOSPHATE-3.7
MAGNESIUM-1.6
___ 04:40PM WBC-16.9*# RBC-2.79*# HGB-9.0* HCT-27.5*#
MCV-99* MCH-32.1* MCHC-32.6 RDW-19.8*
___ 04:40PM NEUTS-88.3* LYMPHS-5.4* MONOS-5.7 EOS-0.4
BASOS-0.2
___ 04:40PM PLT COUNT-194
DISCHARGE LABS:
===============
___ 06:23AM BLOOD WBC-9.7 RBC-3.04* Hgb-9.6* Hct-29.4*
MCV-97 MCH-31.7 MCHC-32.8 RDW-21.4* Plt ___
___ 06:23AM BLOOD ___ PTT-64.8* ___
___ 06:23AM BLOOD Glucose-98 UreaN-40* Creat-2.9* Na-139
K-3.4 Cl-111* HCO3-17* AnGap-14
___ 06:23AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9
PERTINENT MICRO:
================
___ 1:11 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ @1336.
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.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
IMAGING:
========
CHEST X-RAY (___)
IMPRESSION:
Interval progression of elevation of the left hemidiaphragm
reflects
progressive atelectasis in the left lower lobe. Cardiac
silhouette is
partially obscured but appears larger. Moderate bilateral
pleural effusionspersist. Mild pulmonary edema is new. Left
PICC line ends in the upper SVC.
LEFT UPPER EXTREMITY ULTRASOUND (___)
FINDINGS:
There is normal flow with respiratory variation in the bilateral
subclavian veins. An intravascular line is incidentally noted
within a left brachial,axillary and subclavian veins. No
thrombus is visualized adjacent to the line.
The left internal jugular, axillary and brachial veins are
patent and
compressible. The left basilic and cephalic veins are patent.
Incidentally noted there are innumerable abnormal enlarged lymph
nodes seen in the left supraclavicular region.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Incidentally noted, innumerable enlarged lymph nodes are
present in the left supraclavicular region.
CARDIOLOGY:
===========
TRANSTHORACIC ECHOCARDIOGRAPHY (___)
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
The aortic valve leaflets are mildly thickened (?#). No masses
or vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the degree of mitral and tricuspid regurgitation are less in the
current study.
ECG (___)
Sinus tachycardia. Left bundle-branch block. No major change
from the
previous tracing.
ECG (___)
Sinus tachycardia. Left bundle-branch block. Compared to the
previous tracing the rate has increased.
ECG (___)
Sinus rhythm. Left bundle-branch block. Diffuse ST-T wave
changes. Compared to the previous tracing left bundle-branch
block and ST-T wave changes are now seen.
ECG (___)
Sinus rhythm. Intraventricular conduction delay. Compared to the
previous
tracing QRS complex is narrower.
ECG (___)
Sinus rhythm. Intraventricular conduction delay. No major change
from the
previous tracing.
Brief Hospital Course:
Mrs. ___ is a ___ year-old woman with progressive small
cell cancer status post chemo rads (last radiation ___, fungal
endocarditis (___) on life-long micafungin, chronic kidney
disease due to membranous glomerulonephritis, atrial
fibrillation on coumadin who presented with weakness, diarrhea,
and hypokalemia and was found to have clostridium dificile
infection. She was treated with PO vancomycin and IV flagyl with
subsequent resolution of her diarrhea. She also developed a
rate-related left bundle branch block that resolved
spontaneously with no chest pain or evidence of ischemia.
ACTIVE ISSUES:
==============
# Severe Clostridium dificile infection: Mrs. ___
presented to her outpatient oncologist with 1 week of profuse
watery diarrhea (~5BM's) per day. She had developed weakness
that was due to a low potassium of 2.0. She went to ___ ED and
was admitted to medicine, where she received IV fluids,
potassium, IV metronidazole and PO vancomycin. Her stool assay
was positive for C diff, and she had a profound leukocytosis of
26,000. Throughout her hospital course, her episodes of
diarrhea slowly diminished to 1 mostly formed bowel movement per
day and resolved leukocytosis. She had minimal abdominal pain
throughout her hospital course.
# Rate-related Left Bundle Branch Block: Developed during her
first night in the hospital with an unclear precipitant. Mitral
valve abscess given her prior history was considered, but her
trans-thoracic echocardiogram showed no evidence of an abscess.
# Elevated INR: INR on admission was 4.0 on admission and
climbed to 7.9. Supratherapeutic INR was thought to be due to
malnutrition, diarrhea and subsequently low absorption of
vitamin K, and drug interactions with metronidazole. Her
warfarin was held throughout her admission. Her INR on discharge
was 4.0.
# Hypokalemia: Potassium on admission was 2.0, depleted due to
profuse diarrhea and taking her home torsemide. Was complicated
by elevated QTc interval. Her potassium was repleted throughout
her admission, and there were no further episodes of
hypokalemia.
# Acute on Chronic Kidney Disease: Creatinine was elevated at
4.0 on admission from a baseline of 3.0. Was likely pre-renal
from hypovolemia due to profuse diarrhea. She was given IV fluid
resuscitation, and her Cr quickly returned to her baseline of
2.9.
# Acute on Chronic Anemia: Her Hgb fell to 7.1 (baseline 9.0),
likely due to not receiving EPO injections and hemodilution. She
complained of shortness of breath on her ___ night, and she was
given 1 unit of blood for symptomatic anemia. Her symptoms of
fatigue and low energy improved. Hgb on discharge was 9.6.
CHRONIC ISSUES:
===============
# Atrial fibrillation: Takes warfarin at home, was controlled on
metoprolol, diltiazem, and amiodarone. Her warfarin was held
throughout her admission due to her supratherapeutic INR, and
her metoprolol and diltiazem were held due to dehydration. The
metoprolol and diltiazem were resumed prior to discharge.
# Fungal Mitral Valve Endocarditis: Was diagnosed in ___ and
is on life-long suppressive micafungin (given that she is not a
candidate for surgery). This was stable throughout this
admission; there was no evidence of decompensated heart failure.
# Progressive Small cell Lung cancer: Is status post
chemotherapy and radiation (last dose of radiation on ___. Was
stable throughout this admission. Incidentally, a left upper
extremity ultrasound found supraclavicular lymphadenopathy that
may warrant further follow-up.
# Hypothyroidism: Stable, continued home levothyroxine.
# Gout: stable, continued home allopurinol
# Hyperlipidemia: stable, continued home atorvastatin
TRANSITIONAL ISSUES:
====================
- Patient started on PO Vancomycin for a total 14 day course
(last day of antibiotics: ___
- The patient had evidence of a new rate-related LBBB on
telemetry during this admission; this may be related to her
underlying fungal endocarditis. There was no evidence of
decompensated heart failure.
- LUE ultrasound incidentally noted L supraclavicular LAD - this
may warrant further workup as an outpatient.
- The patient's INR was supratherapeutic during this
hospitalization to 7.1 without evidence of bleeding, so her
warfarin was held and will need to be re-started at discharge.
====================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Micafungin 100 mg IV Q24H
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Amiodarone 200 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Torsemide 20 mg PO DAILY
7. PreserVision (vit C-vit E-copper-ZnOx-lutein;<br>vitamins
A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral qd
8. Warfarin 1 mg PO DAILY16
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Diltiazem Extended-Release 120 mg PO DAILY
11. Heparin Flush (10 units/ml) 3 mL IV DAILY and PRN, line
flush
12. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Medications:
1. Micafungin 100 mg IV Q24H
RX *micafungin [Mycamine] 100 mg 100 mg IV once a day Disp #*60
Vial Refills:*3
2. Vancomycin Oral Liquid ___ mg PO/NG Q6H ?c. diff
last day of antibiotics: ___
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. Amiodarone 200 mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Heparin Flush (10 units/ml) 3 mL IV DAILY and PRN, line flush
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
11. Torsemide 20 mg PO DAILY
12. PreserVision (vit C-vit E-copper-ZnOx-lutein;<br>vitamins
A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral qd
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Clostridium difficile infection
hypokalemia
dehydration
Rate-related Left bundle branch block
SECONDARY DIAGNOSES:
====================
-atrial fibrillation
-anemia
-Chronic kidney disease
-Small cell lung cancer
-fungal endocarditis
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 ___,
___ were hospitalized for infectious diarrhea, dehydration, and
very low potassium levels. ___ were given intravenous fluids for
dehydration and potassium supplements. We found that your
diarrhea was caused by an infection called Clostridium difficile
(C. diff). We started ___ on an antibiotic, which ___ will
continue taking until ___.
Also during this hospitalization, ___ also had some
irregularities on your electrocardiogram (ECG), which may be due
to your fungal heart valve infection; however, there was no
evidence of a heart attack. ___ also had incidentally detected
enlarged lymph nodes above your left shoulder, which your
oncologist will follow-up on. Finally, we gave ___ a blood
transfusion because your blood counts were a bit low, and ___
felt that your symptoms of fatigue and low energy improved.
Thank ___ for allowing us to participate in your care.
Followup Instructions:
___
|
10553084-DS-13 | 10,553,084 | 24,259,555 | DS | 13 | 2200-08-26 00:00:00 | 2200-08-27 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
weakness, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with PMHx small cell lung
cancer s/p radiation (completed ___ and chemotherapy (two
rounds, failed, last ___, C. glabrata MV endocarditis on
lifelong micafungin (not a surgical candidate), recurrent C.diff
(3 episodes) recently started on fidaximicin, AF on coumadin,
CKD (baseline Cr 3.0, d/t membranous glomerulonephritis) who
presents with few-day history of fever, anorexia, and weakness.
Patient states that she has been undergoing chemotherapy for her
progression of her small cell lung cancer despite one round of
chemotherapy initiated in ___ and radiation. She was
supposed to get chemo on ___, but was unable to due to
neutropenia (WBC 0.9 with 2% PMN). Since the day, she had been
feeling weak and tired. She had no localizing symptoms, but did
have a temperature to 100.3. She denies shortness of breath,
chest pain, abdominal pain, dysuria, ___ edema, abdominal pain,
nasal congestion, mouth sores, pain wiht swallowing, rash. Did
cut her right lower extremity while shaving recently. No sick
contacts, no recent travel. Recently told that stool was c diff
positive on surveillance screening and was started on fidaxamin.
No diarrhea.
Patient presented to the ED on T 100.7, 106 166/62 18 100% RA.
Labs significant for wbc 0.5, N 7%, ANC 35; H/H 7.9/23.3 (b/l
Hgb ~9); trop 0.07, BNP 11359; Na 131, K 2.5, Cl 99, Bicarb 14,
BUN 45, Cr 3.4 (b/l 2.9-3.5). AST/ALT 158/267, alk phos 149. INR
4.8. She spiked a fever to 102.1. Started on Vanc/Cefepime for
neutropenic fever. Given 1L NS for tachycardia. REpeat BNP 27505
and H/H 6.8/20.7 and was given 1 U rbc (leukoreduced). Repeat
trop 0.07. Blood cultures grew GNR in ___ bottles. She was
evaluated by ID, who suggested keeping her on cefepime for GNR
bacteremia in a neutropenic patient and stopping vancomycin. CXR
showed mild pulmonary edema, given 20mg IV lasix. Recieved
micafungin for known C. glabrata MV endocarditis and po vanc for
c diff. Spent 24 hours in the ED before being transferred to the
floor.
Upon arrival to the floor, 97.9, 159/56, 85, 18, 98RA. She feels
well, despite how sick she knows she is. No diarrhea currently.
No shortness of breath, chest pain. Has pain in back of right
thigh where she fell recently. She feels strongly about being
full code.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Hypertension, essential, benign
Hypothyroidism
OSTEOARTHRITIS - MULT JOINTS
Palpitations
COLORECTAL POLYPS
LEIOMYOMA - UTERUS
DRUSEN - DEGENERATION OF MACULA / POST POLE
CATARACT - NUCLEAR SCLEROTIC SENILE
HYPERCHOLESTEROLEMIA
HYPERCOAGULABLE STATE - SECONDARY
Nephrotic syndrome with lesion of membranous glomerulonephritis
Anemia associated with chronic renal failure
Chronic kidney disease, stage IV (severe)
Anticoagulant long-term use
Hyperparathyroidism due to renal insufficiency
Hyperkalemia
Atrial fibrillation
Mitral stenosis
Basal cell carcinoma of skin, L chest
Dry ARMD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals: 97.9, 159/56, 85, 18, 98RA
General: elderly woman, lying comfortably in bed, alert,
oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, multiple fixed, lymph nodes in left
supraclavicular region
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse breath sounds diffusely, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; large bruise on posterior of right thigh
Neuro: CNII-XII intact, ___ strength upper extremities and left
leg. strength of right leg limited by pain of bruise, gait
deferred.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T 98.4F BP 129/48 mmHg P 88 O2 100% RA
General: Elderly woman, pleasant, wearing cap, NAD.
HEENT: Anicteric, MMM, OP clear, EOMs intact.
Neck: Supple; Firm, fixed LAD in left supraclavicular region.
CV: RRR, Normal S1/S2. Soft systolic murmur best appreciable in
LLSB. No rubs or gallops.
Pulm: CTA b/l; no wheezes or rales.
Abd: Soft, non-tender, non-distended. NABS. No organomegaly.
GU: No Foley in place.
Ext: Warm, well-perfused. 2+ pulses, no clubbing, cyanosis, or
edema. Right thigh erythema considerably improved. Multiple
ecchymoses on arms.
Neuro: A&Ox3.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 07:03PM BLOOD WBC-0.5*# RBC-2.36* Hgb-7.9* Hct-23.3*
MCV-99* MCH-33.5* MCHC-33.9 RDW-16.6* RDWSD-59.6* Plt Ct-38*#
___ 07:03PM BLOOD Neuts-7* Bands-0 Lymphs-89* Monos-4*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.04*
AbsLymp-0.45* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 07:50PM BLOOD ___
___ 07:03PM BLOOD Glucose-144* UreaN-45* Creat-3.4* Na-131*
K-2.5* Cl-99 HCO3-14* AnGap-21*
___ 07:03PM BLOOD ALT-267* AST-158* LD(LDH)-209 CK(CPK)-20*
AlkPhos-149* TotBili-0.4
___ 07:03PM BLOOD Lipase-26
___ 07:03PM BLOOD CK-MB-1 ___
___ 07:03PM BLOOD Albumin-3.4* Calcium-9.1 Phos-1.5*
Mg-1.5*
___ 07:03PM BLOOD Hapto-332*
============
INTERIM LABS
============
___ 05:40AM BLOOD WBC-1.3*# RBC-2.06* Hgb-6.8* Hct-20.7*
MCV-101* MCH-33.0* MCHC-32.9 RDW-16.8* RDWSD-62.1* Plt Ct-40*
___ 01:36AM BLOOD WBC-2.2*# RBC-2.58*# Hgb-8.4* Hct-25.0*
MCV-97 MCH-32.6* MCHC-33.6 RDW-17.6* RDWSD-63.6* Plt Ct-54*
___ 05:40AM BLOOD Neuts-16* Bands-5 Lymphs-54* Monos-22*
Eos-0 Baso-0 Atyps-3* ___ Myelos-0 NRBC-1* AbsNeut-0.27*
AbsLymp-0.74* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00*
___ 01:36AM BLOOD Neuts-46 Bands-4 ___ Monos-11 Eos-1
Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-1.10*
AbsLymp-0.84* AbsMono-0.24 AbsEos-0.02* AbsBaso-0.00*
___ 10:12AM BLOOD Neuts-51 Bands-4 ___ Monos-15*
Eos-2 Baso-0 ___ Myelos-0 AbsNeut-1.71 AbsLymp-0.87*
AbsMono-0.47 AbsEos-0.06 AbsBaso-0.00*
___ 01:36AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL Burr-2+ Tear Dr-1+
___ 06:36AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+
Burr-2+ Bite-OCCASIONAL
___ 07:50PM BLOOD ___ PTT-51.7* ___
___ 05:40AM BLOOD ___ PTT-57.4* ___
___ 05:40AM BLOOD Plt Smr-VERY LOW Plt Ct-40*
___ 01:36AM BLOOD ___ PTT-92.6* ___
___ 05:53AM BLOOD ___ PTT-150* ___
___ 12:23PM BLOOD ___ PTT-98.5* ___
___ 01:36AM BLOOD Glucose-92 UreaN-53* Creat-3.5* Na-129*
K-3.2* Cl-103 HCO3-14* AnGap-15
___ 12:23PM BLOOD Glucose-76 UreaN-54* Creat-3.4* Na-133
K-5.2* Cl-108 HCO3-11* AnGap-19
___ 06:36AM BLOOD Glucose-165* UreaN-54* Creat-3.3* Na-133
K-3.3 Cl-98 HCO3-21* AnGap-17
___ 04:10AM BLOOD CK(CPK)-14*
___ 12:23PM BLOOD ALT-131* AST-30 LD(LDH)-142 AlkPhos-97
TotBili-0.7
___ 03:09AM BLOOD cTropnT-0.07___ 01:36AM BLOOD CK-MB-2 cTropnT-0.05*
___ 10:12AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9
___ 06:36AM BLOOD Albumin-2.5* Calcium-9.1 Phos-1.6* Mg-1.7
___ 01:03PM BLOOD Type-ART pO2-116* pCO2-17* pH-7.31*
calTCO2-9* Base XS--15 Intubat-NOT INTUBA
___ 04:46PM BLOOD ___ pO2-83* pCO2-25* pH-7.32*
calTCO2-13* Base XS--11 Comment-GREEN TOP
___ 12:06AM BLOOD ___ pO2-200* pCO2-23* pH-7.42
calTCO2-15* Base XS--6 Comment-GREEN TOP
___ 07:14AM BLOOD ___ pO2-57* pCO2-28* pH-7.47*
calTCO2-21 Base XS--1 Comment-GREEN TOP
___ 04:09PM BLOOD ___ pO2-92 pCO2-31* pH-7.41
calTCO2-20* Base XS--3
==============
DISCHARGE LABS
==============
___ 06:38AM BLOOD WBC-10.5* RBC-2.58* Hgb-8.2* Hct-25.9*
MCV-100* MCH-31.8 MCHC-31.7* RDW-17.9* RDWSD-65.5* Plt ___
___ 06:38AM BLOOD Neuts-68 Bands-0 Lymphs-16* Monos-12
Eos-3 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-7.14*
AbsLymp-1.68 AbsMono-1.26* AbsEos-0.32 AbsBaso-0.00*
___ 06:38AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-NORMAL
___ 06:38AM BLOOD ___ PTT-47.5* ___
___ 06:38AM BLOOD Glucose-121* UreaN-40* Creat-3.3* Na-137
K-3.7 Cl-105 HCO3-19* AnGap-17
___ 06:38AM BLOOD ALT-74* AST-40 LD(LDH)-249 AlkPhos-160*
TotBili-0.2
___ 06:38AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.7
===============
IMAGING/STUDIES
===============
CHEST (PA & LAT) (___)
IMPRESSION:
Hilar congestion, small left pleural effusion new from prior.
PICC line
unchanged.
ABDOMEN US (___): LIVER: The hepatic parenchyma appears within
normal limits. The contour of the liver is smooth. There is no
focal liver mass. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: There is a 2.2 x 2.8 x 2.7 cm hypoechoic mass in the
region of the tail of the pancreas.
SPLEEN: Normal echogenicity, measuring 7.3 cm.
KIDNEYS: The right kidney measures 8.5 cm. The left kidney
measures 9 cm.
Normal cortical echogenicity and corticomedullary
differentiation is seen
bilaterally. There is no evidence of masses, stones, or
hydronephrosis in the kidneys.
RETROPERITONEUM: Atherosclerotic disease is seen in the aorta.
No evidence of aneurysm. Visualized portions of the IVC are
within normal limits.
IMPRESSION:
1. There is a hypoechoic region in the region of the tail of
the pancreas which is incompletely evaluated on this study and
was not visualized on the PET scan from ___, concerning
for metastatic disease. A MRI of the abdomen or alternatively a
repeat PET-CT is recommended for further evaluation.
2. No focal liver lesion.
RECOMMENDATION(S): MRI of the abdomen or repeat PET/CT for
further
characterization of possible mass in the tail of the pancreas.
CHEST PORT. LINE PLACEMENT (___)
IMPRESSION:
___ on with the study ___, the new left subclavian PICC
line extends tothe distal SVC just above the cavoatrial
junction. Again there is elevationof the left hemidiaphragm
with blunting of the costophrenic angle consistentwith small
pleural effusion and compressive atelectasis. The pulmonary
vascularity is essentially within normal limits.
============
MICROBIOLOGY
============
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___
___.
WOUND CULTURE (Final ___: No significant growth.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with extensive stage SCLC
on topotecan (last ___ second line therapy s/p radiation
(completed ___ and previous tx with carboplatin/etoposide
(7 cycles), C. glabrata MV endocarditis on lifelong micafungin
(not a surgical candidate), recurrent C.diff (3 episodes)
recently started on fidaximicin, AF on coumadin, CKD (baseline
Cr 3.0, d/t membranous glomerulonephritis) who presented with
several days of fever, anorexia, and weakness. Found to have
neutropenic fever, GNR bacteremia, metabolic acidosis, and
supratheraputic INR.
.
>>> ACTIVE ISSUES:
.
# Neutropenic fever with Klebsiella bacteremia. Ms. ___
was found to have neutropenia on admission with an ANC of 35.
Her blood cultures grew Klebsiella pneumoniae in two of two
bottles. She was initially treated with cefepime, but this was
narrowed to ceftriaxone 2g daily for a total 14-day course to be
completed ___. Her neutropenia was thought to be secondary
to her chemotherapy for the treatment of her SCLC. She has a
history of recurrent Clostridium difficile infection. She denied
any shortness of breath, mucosal pain, or abdominal pain. On
admission she was also found to have a right thigh cellulitis,
for which she was treated with two doses of vancomycin, with
appropriate response. Her PICC line was removed until her blood
cultures were sterilized, at which point a new PICC line was
inserted. The infectious disease team was consulted in her care,
recommendations were followed.
.
# Pancytopenia. Related to above, the patient had a hemoglobin
drop to 6.8, for which she was transfused one unit of packed red
blood cells. She recovered to her baseline of ~8 on the day of
discharge. This was thought to be related to her chemotherapy
with known pancytopenia. However, in the setting of an elevated
INR of 9.2 on admission (as discussed below), there had been
concern for DIC but fibrinogen was elevated. A peripheral blood
smear indicated occasional schistocytes. However, her
coagulation panel began to recover, with an INR of 2.9 on
discharge (on warfarin). She had no active signs of bleeding
during her hospitalization.
.
# Atrial fibrillation on warfarin/supratheraputic INR: The
patient had a history of atrial fibrillation diagnosed in
___, treated with warfarin. As above, the INR on admission
was 9.2, for which she received vitamin K. Warfarin was
restarted at 0.5 mg of her home dose on discharge, and her INR
was 2.9 on ___. The patient had been holding her metoprolol at
home for well controlled BP. She was continued on her amiodarone
and discharged on her metoprolol and diltiazem at ___ her home
dose.
.
# Transaminitis: Ms. ___ was admitted with elevated liver
enzymes and coagulation panel, which were thought to be
attributable to her chemotherapy. A RUQ ultrasound was performed
which did not show any acute process, specifically possible
abscess as a source of infection, however, it did indicate a new
pancreatic mass, which was discussed with the patient and with
the oncology team. It was felt that this did not change her
overall prognosis, given her extensive disease and will be
further discussed in the outpatient setting regarding her
overall oncology care as outpatient.
.
#C. glabrata MV endocarditis: The patient has been on micafungin
since her diagnosis in ___. She demonstrated new EKG
changes with new LBBB and borderline PR prolongation. These
corrected on a repeat EKG and were thought to represent
rate-related changes or electrolyte changes (initially with
severe hypokalemia). TTE showed possibly worsened mitral
regurgitation from prior study in ___. She was continued on
her micafungin 100 mg q daily.
.
#C.difficile infection: Ms. ___ has a history of
recurrent C. difficile infection, and was most recently positive
on a stool sample one week prior to admission for which she was
treated with fidaxomicin. Her diarrhea had resolved and she had
no abdominal pain. She was treated with vancomycyin 125 mg q6h
in concurrence with her ceftriaxone (to be completed on ___, after which she would complete a 10 day course of
fidaxomicin.
.
# Metabolic acidosis. Ms. ___ also had a compensated
metabolic acidosis with pH of 7.31 and HCO3 of 9 on ___. This
was thought to be related to her infection, and it recovered
with the administration of bicarbonate. Her final venous blood
gas demonstrated a HCO3 of 19 and pH of 7.44 as per her
baseline.
.
# Volume overload, elevated BNP, troponemia, new LBBB: The
patient presented with elevated BNP of 11359, troponin of 0.07.
She was given 1L NS for tachycardia and had crackles at the
bases and repeat BNP of 27505 with repeat troponin 0.07. She
improved with 20mg IV Lasix. EKG demonstrated new LBBB and
borderline PR prolongation. As above, these corrected on a
repeat EKG and were thought to represent rate-related changes.
She was continued on her home torsemide 20 mg PO daily.
.
# Small cell lung cancer: Her disease is extensive stage, for
which she is was treated with topotecan (last ___ as second
line therapy s/p radiation (completed ___ and previous
treatment with carboplatin/etoposide (7 cycles) She had
progressed on this therapy, with new firm lymph nodes in her
left supraclavicular neck. She was continued on her allopurinol
___ mg every other day. The oncology team was involved in her
care, with outpatient follow up scheduled after discharge.
.
#Chronic kidney disease. The patient's creatinine was 3.3 on
admission, which is her baseline, and remained in that range.
This was followed throughout her hospitalization without any
acute worsening.
.
#Hyperlipidemia. Home atorvastatin 20 mg daily was continued.
.
# Hyperthyroidism. Home levothyroxine odium 100 mcg was
continued.
.
===================
TRANSITIONAL ISSUES
===================
#Anticoagulation. Patient is managed by the ___
clinic at ___, with ___ checking INR every ___ and results
sent to Dr. ___. She is scheduled for her next INR check on
___. Please also check PTT as this was
elevated during the course of her hospitalization. She has been
discharged on half of her home dose of warfarin (0.5 mg), with
an INR of 2.9 on the day of discharge.
.
# Klebsiella bacteremia. Ms. ___ will be continuing her
course of IV ceftriaxone 2g daily at home, for a ___ompleted on ___.
.
# Clostridium difficile. Ms. ___ will be continuing PO
vancomycin 125 mg q6h at the same time as her ceftriaxone,
completed on ___. At that time, she will need to
initiated on a 10 day course of fidaxomicin, as she was taking
prior to this hospitalization.
.
# Atrial fibrillation. Ms. ___ metoprolol and diltiazem
were held during her hospitalization in the setting of HRs in
the ___ and normal BPs. These were restarted at half of her home
dose upon discharge. Please evaluate increasing this dose as
needed.
.
# ___ line. Patient is being discharged on a ___ line for IV
ceftriaxone and micafungin. She will continue to receive the
micafungin on an ongoing basis.Please continue routine PICC line
and care.
.
# Goals of care. Please continue to discuss goals of care with
Ms. ___ as you have been doing, given the stage of her
SCLC.
.
# Transaminitis: Improving throughout hospital stay, please
trend to normal.
.
# CODE STATUS: Full code (confirmed)
# CONTACT: ___ (HCP, husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Amiodarone 200 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
7. Epoetin Alfa ___ U SC WEEKLY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Lorazepam 0.5 mg PO Q8H:PRN anxiety
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Micafungin 100 mg IV Q24H
13. Prochlorperazine 10 mg PO Q8H:PRN nausea
14. Torsemide 20 mg PO DAILY
15. Warfarin 1 mg PO DAILY16
16. B Complex Plus Vitamin C (vitamin B comp and C no.3)
___ mg oral DAILY
17. Vitamin D ___ UNIT PO DAILY
18. Ferrous Sulfate 325 mg PO DAILY
19. vitamin A-vit C-vit E-zinc-Cu 2 capsules oral DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H Duration: 11 Days
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 50 cc IV daily
Disp #*11 Intravenous Bag Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. Amiodarone 200 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Micafungin 100 mg IV Q24H
RX *micafungin [Mycamine] 100 mg 100 mg IV daily Disp #*30 Vial
Refills:*0
9. Torsemide 20 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Warfarin 0.5 mg PO DAILY16 atrial fibrillation
12. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*36 Capsule Refills:*0
13. Atorvastatin 20 mg PO QPM
14. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
15. B Complex Plus Vitamin C (vitamin B comp and C no.3)
___ mg oral DAILY
16. Epoetin Alfa ___ U SC WEEKLY
17. Lorazepam 0.5 mg PO Q8H:PRN anxiety
18. Prochlorperazine 10 mg PO Q8H:PRN nausea
19. vitamin A-vit C-vit E-zinc-Cu 2 capsules oral DAILY
20. Diltiazem Extended-Release 60 mg PO DAILY
21. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- Neutropenic fever with Klebsiella bacteremia
- Supratherapeutic INR
- Endocarditis of the mitral valve (C. glabrata)
- Clostridium difficile infection
- R thigh cellulitis
===================
SECONDARY DIAGNOSES
===================
- Atrial fibrillation
- Small cell lung cancer, extensive stage
- Chronic kidney 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 ___,
___ was a pleasure caring for you at ___
___. You were admitted for an infection in your
bloodstream because your white blood cell count was low
("neutropenic fever with bacteremia"). You were treated with
antibiotics for this through intravenous, and you improved. You
will be sent home with these antibiotics until ___. You
continued to receive the antibiotics for your heart (micafungin)
throughout your stay with us. You will continue to take the
antibiotics for your abdominal infection (Clostridium difficile)
by mouth until ___, and then you will switch back to your
original medication (fidaxomicin) for 10 days (until ___.
You were also found to have a very high INR, which is the blood
level that we monitor with your Coumadin. Your Coumadin was
held, and it was restarted at one-half of your usual dose (0.5
mg). You are schedule to have your INR re-checked on ___,
___, and the results will be sent to your PCP, ___.
You are scheduled to see your PCP, ___, nephrologist, and
infectious disease specialists, as listed below. Please take
your discharge medications as directed.
We wish you the very best and hope you enjoy your time in
___!
Warmly,
Your ___ Team
Followup Instructions:
___
|
10553635-DS-11 | 10,553,635 | 21,843,080 | DS | 11 | 2151-04-16 00:00:00 | 2151-04-16 10:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Headache x 7days
Major Surgical or Invasive Procedure:
___ Cerebral angiogram for coiling of L PCOMM aneurysm
History of Present Illness:
Ms ___ had a syncopal episode in the bathroom on ___ at
2pm,she woke up on the floor, possibly hitting her head on the
bath tub. Her daugther was in another room and heard the fall,
no
seizure activity. Her daugther helped her lay down and found her
to be confused and incontient a few hours later complaining of a
headache,she drove her to ___. He daughter than called EMS and
she was transported to ___. Ms ___ states she has had
intermittent headaches over the last few days along with
bronchitis. She had a headache prior to her vasovagal episode. A
CT at ___ showed a left frontal SAH. The
patient also had a BP of 220/114 at ___. She received Dilantin
and Vitamin K for an INR of 1.2. She was med flighted here for a
neurosurgery evaluation
Past Medical History:
PMHx:None
PSHX: C-Section
All:PCN
Social History:
___
Family History:
Family Hx:Denies any family hx of subarachnoid hemorrhage
Physical Exam:
___ and ___: 2 (for moderate headache) Fisher: 4
GCS: 15
O: T:98.9 BP:131/76 HR:69 R 18 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
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,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
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
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger,
Handedness Right
On Discharge:
A&ox3
PERRL
EOMs intact
Face symmetrical
No pronator drift
Motor: full
Pertinent Results:
CTA Brain ___:
Upon review of this study with Dr. ___, endovascular
neuroradiologist, seen on images 55-57, series 3, and on coronal
reconstructed image 17, series 401b, is a probable aneurysm,
arising from the lateral aspect of the supraclinoid portion of
the left internal carotid artery, and directed in an unusual
anterolateral long axis.
The aneurysm appears to measure 1.5mm in maximal width, by
3.75mm in axial
length. Particularly in view of this revised finding, Dr. ___
has informed me that the patient will undergo catheter
angiography today, with potential endovascular coiling as well.
CXR ___:
Relatively diminished lung volumes with crowding of the
pulmonary vasculature but no evidence of focal airspace
consolidation, pleural effusions, pulmonary edema, or
pneumothorax. Overall, cardiac and mediastinal contours are
upper limits of normal in size given portable technique. No
acute bony abnormality.
NCHCT ___:
IMPRESSION:
1. Stable moderate ventriculomegaly.
2. Stable, evolving distribution of subarachnoid and
intraventricular
hemorrhage.
3. Stable mild paranasal sinus disease.
ECHO ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric LVH with normal global biventricular
systolic function. Mild pulmonary hypertension.
CTA ___:
IMPRESSION:
No significant change in the size of the intracranial arteries
allowing for the artifact from the coils. Diminutive basilar
artery and P1 segments along with fetal PCA pattern and
prominent posterior communicating arteries withs lightly more
narrow size of the Basilar artery. Assessment for any residual
flow in the coiled aneurysm is limited on the present study.
Followup as clinically indicated. If there is concern for
parenchymal changes, MR can be considered if not CI.
___ CXR
IMPRESSION: AP chest compared to ___:
Although mediastinal vascular distention is no longer present,
pulmonary
circulation is engorged, and there is mild edema at the lung
bases. Elevation of the left lung base could be due to left
lower lobe atelectasis or upward displacement by abdominal
abnormality such as gastric distention. Right PIC line ends in
the region of the superior cavoatrial junction. No pneumothorax.
___ LENIES: No evidence of deep vein thrombosis in either
leg
Brief Hospital Course:
Ms. ___ was evaluated in the Emergency room, sent for a CTA of
the brain which was suspicious for an underlying aneurysm as the
cause of her intracranial hemorrhage. She was taken to the
angio suite emergently where under general anesthesia she has a
cerebral angiogram with coiling of a right PCOM aneurysm.
She was extubated immediately after the procedure and
transferred to the ICU on a heparin drip.
ICU Course:
On ___ Heparin drip was discontinued. Patient underwent
TCDs that showed no vasospasm. She was febrile and was cultured.
Her HR went up to the 150's and responded to Lopressor.
On ___, She developed some delerium over night with the
development of fevers and was given a dose of Haldol.
Priliminarly her UA revealed a UTI, she was started on
Ciprofloxicin . She remained stable. Overnight she was found to
be in afib with RVR, treated with lopressor, checked cardiac
enzymes which appeared negative.
On ___, She remained stable. TCDs showed mildly elevated
velocities but no vasospasm.
On ___, cardiology was consulted for the arrythmia's that
developed in the ICU, they believe that the underlying Afib was
not new, patient was taken off of the Amiodrone drip and started
on Sotalol. She underwent a CTA to rule out vasospasm after she
was found to have a new right pronator drift. The CTA was
negative.
on ___, Patient was found to be somewhat confused and
periodically halucinating. A CTA that was done on ___ was
reported as questionable for left A1 spasm. She remains in the
ICU with IV fluids and spasm watch.
Her anti-epileptics were discontinued and she was transferred to
the floor after stable TCD's. Screening lower extremity
dopplers were performed and were negative for DVT.
On ___ the foley catheter and IVF were discontinued. A ___
consult was obtained for elevated blood sugars and the patient
was subsequently started on Amaryl per ___ recommendations.
Nursing iniated diabetic teaching.
On ___ the patient experienced tachy-brady arrhythmias and
cardiology came to evaluate the patient. She was continued on
sotalol, and verapamil 40mg TID was added for rhythm
stabilization. No further medication titrations were required.
On ___, patient remained intact on examination, cardiology
recommended outpatient follow up and patient was decleared safe
from ___ to be discharged home.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. metformin 500 mg Tablet Sig: One (1) Tablet PO WITH DINNER
().
6. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 10 days.
Disp:*120 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Left PCOMM aneurysm
UTI
ATRIAL FIBRILLATION
ACUTE DELERIUM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
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 activities you can and cannot do:
When you go home, you may walk and go up and down 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 that is draining, as needed
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
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
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 our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
Followup Instructions:
___
|
10553803-DS-18 | 10,553,803 | 21,309,325 | DS | 18 | 2181-11-27 00:00:00 | 2181-11-27 16:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cauda Equina Syndrome
Major Surgical or Invasive Procedure:
___ emergent L4-5 laminectomy and discectomy
History of Present Illness:
Pt is a ___ yo F hx chiari malformation and decompression
___ and Pituitary adenoma on cabergoline who has been managing
back pain since ___. She developed bilat buttock pain,
went
to ___ but it didn't help. ___ weeks ago the back pain and bilat
buttock pain got worse, radiating largely to right leg and she
would have periodic numbness in the right leg. She describes
that the entire leg would go numb. She also had pain into the
left leg. This past week pain and numbness significantly
worsened, she was in and out of ED and PCP's office. Yesterday
(___) pain suddenly worsened in the left foot and mother
brought her again to OSH ED where they admitted her for pain
control. Around 11pm she noted the numbness extending to her
buttocks and thighs, at 1:30 AM ___ her nurse had to assist
her to the bathroom bc her legs and feet were numb and she notes
she had no sensation when wiping. Sometime during the day she
worked with ___ at OSH and they alerted the MDs that she had
bilateral foot drop and couldn't walk at approximately 1:30PM.
She was transferred to ___ ED for higher level of care and
MRI.
Here in the ED she was noted to have bilateral foot drop and
diminished rectal tone. She was sent for STAT MRI that revealed
L4-5 disc causing severe canal stenosis.
Past Medical History:
hx pituitary adenoma on cabergoline, chiari malformation
s/p decompression ___ (age ___
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
Gen: obese, NAD. flat in bed
HEENT: normocephalic, atraumatic,
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, flat
affect
Orientation: Oriented to person, place, and date.
Motor:
D B T Gr IP Q H AT ___ G
R 5 5 5 5 4 4 3+ 0 0 0
L 5 5 5 5 4 4 4 0 0 1
Sensation: decreased to light touch in the legs anteriorly
bilaterally. Loss of light touch sensation in bilat buttocks
and
posterior thighs as well as bilat plantar feet.
Propioception appears to be intact at the great toe bilat.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 1+ 0
Left 2+ 2+ 2+ 1+ 0
Toes mute bilaterally
Rectal tone absent
General: awake, alert, oriented, no acute distress, pleasant to
conversation
Pulm: no increased work of breathing, able to participate with
interview without difficulty
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___+01
Left5 5 5 4+ 1 1
Sensation intact in L2-4 bilaterally. There is diminished
sensation in the L5 dermatomes. Sensation is absent in
the S1-S5 distribution bilaterally.
Incision: is well approximated with staples. The area is without
erythema or induration. There is minimal serosanguinous spotting
on the linen but no active drainage.
Pertinent Results:
please see OMR
Brief Hospital Course:
Pt found in the ED to have ___ weakness, saddle anesthesia,
urinary retention and absent rectal tone. MRI showed large
herniated disc at L4-5 and compression of the cauda equina. She
was taken emergently to the OR for decompression with
laminectomy and discectomy at L4-5. Postoperatively she was
extubated and transferred to the PACU. She regained some
strength in the ___ compared to preop and minimal return of
sensation in the feet with tingling. Urinary retention,
numbness in S1-5 distribution bilaterally and absent rectal tone
persisted. She failed a voiding trial and foley was replaced.
She was seen and evaluated by physical therapy who recommended
acute rehab. The remainder of her hospital course was
uneventful.
At the time of discharge she was tolerating a regular diet,
ambulating short distances with a walker and assistance,
afebrile with stable vital signs.
Medications on Admission:
Cabergoline 0.5mg weekly
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
4. Senna 17.2 mg PO QHS
5. cabergoline 0.5 mg oral 1X/WEEK (SA)
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
cauda equina syndrome
L4-L5 disc herniation
urinary retention
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:
Discharge Instructions
Spine Surgery without Fusion
Surgery
· Your dressing may come off on the second day after
surgery.
· Your incision is closed with staples. You will need staple
removal in ___ days from your surgery. Please keep your
incision dry until staple removal.
· Do not apply anylotions or creams to the site.
· Please avoid swimming and submersion 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 leisurelywalks 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.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You may take Ibuprofen/ Motrin for pain after 1 week.
· 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:
___
|
10554112-DS-12 | 10,554,112 | 24,773,199 | DS | 12 | 2154-02-05 00:00:00 | 2154-02-05 11:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ambien / Percocet / Cephalosporins
Attending: ___.
Chief Complaint:
GNR Bacteremia Referral; Fevers, Hip Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ F w/ relevant hx of Hep C cirrhosis who
presents with 4 days of fevers, chills, diaphoresis and hip
pain.
VS in her PCP's office were 100.4 105/71 113. Labs revealed WBC
of 19.6, her chemistry panel had an anion gap of 20. Urinalysis
with suggestion of possible UTI. Patient was started on cipro
(PO 250mg). ___ on-call physician was called by the lab on ___
at 0550, notified that ___ bottles of blood cultures was growing
gram negative rods. Referred for initiation of IV antibiotics
and concern for developing GNR sepsis, as well as hip
involvement per PCP, ___, R hip pain, and no other focal
infx sxs.
In the ED, initial vitals: P 9 T 97.0 HR 93 BP 119/79 RR 17 O2S
100% RA
Labs were significant for GNR sepsis with leukocytosis
Imaging showed adductor sprain (hip MRI), cirrhotic liver
without e/o cholecystitis or other acute concern (liver US),
clear CXR
Currently, feels overall well/asymptomatic except for R hip
pain, which hurts more with motion than at rest particularly
abduction and external rotation of her hip. Denies urinary
urgency, pain / burning on urination, increased frequency, or
bloody urine. No longer feels feverish/rigors/diaphoretic.
ROS:
No unintended weight changes. No changes in vision or hearing,
no changes in balance. No cough, no shortness of breath, no
dyspnea on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea or constipation. No dysuria or hematuria.
No hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
# Hepatitis C genotype 1B, failed multiple curative treatments,
due to undergo new therapy this year. Contracted from blood
transfusion as a child (during treatment of CML)
# Hypothyroidism. ___ XRT.
# s/p Supracervical Hysterectomy @ ___ for uterine rupture at 17
weeks, thought due to weakened uterine wall from whole-body
radiation. (___)
--- Complicated by cardiac arrest in operating room, requiring
15 minutes of compressions and six attempts at cardioversion.
Complicated by suspected DIC. Required massive resuscitation.
--- [Patient does have a cervix and should follow appropriate
cervical cancer screening guidelines.]
--- Operative report not ___ clear on whether atrophic ovaries
were removed.
# Cardiac:
--- Partial anomalous pulmonary venous return with right upper
lobe pulmonary vein draining into the azygos.
--- Mixed pulmonary hypertension secondary to cirrhosis and
right-sided volume overload from PAPVR.
--- Cardiomyopathy from cardiac arrest secondary to intrapartum
ruptured uterus.
--- Mild radiation to ?his valvulopathy.
# CML diagnosed at age ___ status post whole body XRT and
BMT.
# Clear cell renal carcinoma status post partial nephrectomy
complicated by postoperative ARDS, diaphragmatic perforation and
chest tube.
# History of active tobacco use; quit one week ago.
# "Stress induced" type 2 diabetes, now off medications, last
A1c ___ 5.9
# Sciatic neuropathy with foot drop.
Social History:
___
Family History:
Father diabetes, mother arthritis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
VS: 97.9, 76, 110/56, 16, 100%RA
GEN: Alert, lying in bed, no acute distress
HEENT: Dry MM, anicteric sclerae, no conjunctival pallor
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2, systolic early crescendo-decrescendo murmur
best heard at the LUSB, no r/g
ABD: Soft, non-tender, non-distended
GU: no CVA tenderness
EXTREM: Warm, well-perfused, no edema, right hip with excellent
range of motion with flexion/extension. Pain with external
rotation and abduction. No warmth to the touch or effusion
detected.
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.3, BP 129/76, HR 83, RR 18, 99% RA
GEN: Alert, lying in bed, no acute distress
HEENT: anicteric sclerae, no conjunctival pallor
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2, systolic early crescendo-decrescendo murmur
best heard at the LUSB, no r/g
ABD: Soft, non-tender, non-distended
GU: no CVA tenderness
EXTREM: Warm, well-perfused, no edema, right hip with excellent
range of motion with flexion/extension. Pain with external
rotation and abduction. No warmth to the touch or effusion
detected.
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
LABS ON ADMISSION:
=====================
___ 11:00AM BLOOD WBC-19.6*# RBC-4.15 Hgb-13.2 Hct-41.3
MCV-100* MCH-31.8 MCHC-32.0 RDW-14.6 RDWSD-54.1* Plt ___
___ 11:00AM BLOOD Neuts-83.6* Lymphs-5.5* Monos-9.1
Eos-0.1* Baso-0.7 Im ___ AbsNeut-16.36* AbsLymp-1.08*
AbsMono-1.77* AbsEos-0.02* AbsBaso-0.13*
___ 11:00AM BLOOD UreaN-21* Creat-0.9 Na-135 K-4.3 Cl-95*
HCO3-20* AnGap-24*
___ 11:00AM BLOOD ALT-54* AST-74* TotBili-1.8*
___ 08:30AM BLOOD Lipase-80*
___ 08:30AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.7 Mg-2.4
___ 08:39AM BLOOD Lactate-1.9 K-4.0
LABS ON DISCHARGE:
====================
___ 05:35AM BLOOD WBC-10.7* RBC-3.49* Hgb-10.8* Hct-32.9*
MCV-94 MCH-30.9 MCHC-32.8 RDW-15.0 RDWSD-52.2* Plt ___
___ 08:30AM BLOOD Neuts-78.4* Lymphs-6.1* Monos-13.5*
Eos-0.2* Baso-0.9 Im ___ AbsNeut-16.16* AbsLymp-1.25
AbsMono-2.78* AbsEos-0.05 AbsBaso-0.18*
___ 05:35AM BLOOD Glucose-75 UreaN-12 Creat-0.7 Na-137
K-4.1 Cl-101 HCO3-25 AnGap-15
___ 09:47AM BLOOD ALT-39 AST-62* LD(___)-248 AlkPhos-85
TotBili-0.8
MICRO:
==========
Urinary culture:
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 11:00 am BLOOD CULTURE
2 OF 2 AND THE TIME ON BLOOD CULTERS IS 11:15 .
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0550.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
IMAGING:
===========
MR HIP ___:
Wet Read Audit # 1 by ___. on SAT ___
2:10 ___
No osteomyeltis of the right hip. No occult fracture. No joint
effusion.
Slight asymmetric high signal in R adductor group very mild can
be sprain. No collections or abscess in soft tissue.
RUQ US ___:
IMPRESSION:
Hepatic cirrhosis. Unremarkable gallbladder without evidence of
gallstones or cholecystitis.
Renal US ___:
IMPRESSION:
Tiny 5 mm simple appearing right renal cyst. Otherwise,
unremarkable renal ultrasound. No hydronephrosis.
Brief Hospital Course:
# E. Coli bacteremia
___ y/o female with history of hep C cirrhosis who presented for
fever, R hip pain, and outpatient cultures growing GNR's of
unknown etiology. Ultimately patient was found to have E. coli
both in blood cultures and in urine although she did not report
symptoms of a urinary tract infection; this was this presumed
source. The patient also noted right hip for which MRI
evaluation had been done prior showing no signs of infection,
abscess, or osteomyelitis though did show right sided adductor
sprain.
The bacteremia was treated with Piperacillin/Tazobactam
monotherapy and she was transitioned to PO ciprofloxacin to
complete full 14 day course to be completed on ___.
# Right adductor muscle sparin
Patient presented with right hip pain with MRI that ruled out
abscess or osteomyelitis though did show evidence of adductor
sprain on MR imaging was controlled with acetaminophen and PRN
oxycodone.
# Hypotension:
Patient had several bouts of asymptomatic hypotension while
sleeping that were responsive to fluids. Nadolol held
transiently during this time but restarted prior to discharge.
She was normotensive on disharge.
# Asthma: Continued Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
# Hypothyroid: Continued Levothyroxine Sodium 50 mcg PO DAILY
# Cirrhosis: Nadolol 10 mg daily held transiently in setting of
hypotension though restarted prior to discharge.
TRANSITIONAL ISSUES:
====================
- Ciprofloxacin antibiotic therapy started this hospitalization
to continue until ___ (14 day course)
- please follow up patient's right MSK hip pain and adductor
sprain. Consider referral to physical therapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5-1 mg PO QHS:PRN insomnia
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Acetaminophen 1000 mg PO Q12H:PRN fever/pain/ha
4. Ciprofloxacin HCl 250 mg PO Q12H
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Nadolol 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q12H:PRN fever/pain/ha
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Lorazepam 0.5-1 mg PO QHS:PRN insomnia
4. Nadolol 10 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
E. Coli Bacteremia
Complicated Urinary tract Infection
Adductor Muscle Sprain
Secondary:
Cirrhosis - Hepatitis C, Compensated
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to bacteria found in your blood.
While here, you received antibiotics, as well as fluids for
intermittent, low blood pressure. By discharge, you had a
stable, normal blood pressure, your pain was controlled, and you
were transitioned to a medication called ciprofloxacin to take
for a total 14 days for treatment of your blood stream and
urinary infection. Please make sure you complete all of your
medications.
You were also found to have sprain of one of the muscle groups
in your hip causing pain that we treated with tylenol.
Reassuringly your hip was not a source of infection.
Please follow-up with your primary care doctor and complete all
of your antibiotics.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
10554112-DS-16 | 10,554,112 | 27,074,470 | DS | 16 | 2155-04-15 00:00:00 | 2155-04-15 19:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ambien / Percocet / Cephalosporins / oxycodone
Attending: ___.
Chief Complaint:
Leg and arm pain
Major Surgical or Invasive Procedure:
Muscle biopsy
History of Present Illness:
___ w/PMHx pyomyositis in the setting of E. coli bacteremia, HCV
cirrhosis (non-responder to curative therapy) s/p TIPS in
___, ___ s/p partial nephrectomy, s/p hysterectomy for
uterine rupture d/t radiation c/b cardiac arrest and subsequent
CMP, PH (d/t cirrhosis & anomalous pulmonary venous return),
severe TR, prior allo-SCT for Leukemia at ___ who presents with
leg and arm pain. Pt was in her USOH until yesterday evening
when she developed acute-onset bilateral leg and arm pain L>>R.
She reports pain distal to her Left shoulder, Right elbow, Left
hip and Right knee. Pain is severe and worsened with any
movement or even light touch. She notes that she may have had a
rash on her right arm. She notes some difficulty extending the
fingers on her Left hand. She denies any fevers, chest pain,
light-headedness/dizziness. She has SOB at baseline, but this is
chronic and unchanged. She denies any GI or urinary sx. She also
denies IVDU.
Of note, pt was found to have pyomyositis in ___,
presumable from hematogenous spread of E. coli from a UTI. She
was treated with ertapenem and followed by ID OPAT for a total
for 4 weeks. Given her history of varicies, a TEE was deferred
at that time. Pt was also notably admitted to ___ on ___
for a GIB, during which time she had a TIPS placed. Finally, pt
also recently completed outpatient treatment with
Harvoni/ribavirin with good response.
In the ED, initial vitals:
97.7; 113; 99/79; 18; 100% RA
- Exam notable for: Left arm erythema.
- Labs notable for:
Cr: 0.6
Glucose: 123
P: 2.1
CK: 564
CRP: 208.3
30.0>12.0/35.6<281
UA unremarkable
2x bcx were sent
- Imaging notable for:
LLE LENIS
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. No fluid collection seen.
Left knee AP/lateral/oblique X-ray:
Bones are diffusely demineralized. There is no focal lytic or
blastic lesion. No significant degenerative changes. There is no
suprapatellar effusion or soft tissue abnormality.
Right knee AP/oblique X-ray:
No fracture. Partially visualized apparent cortical thickening
of the
posterior right femoral cortex which is only partially
visualized. Consider dedicated femoral films for
characterization
Forearm AP/lateral X-ray:
There is no fracture or focal osseous abnormality. Ulnar minus
variant is noted. Soft tissues are unremarkable.
- Patient given:
1g IV vancomycin
4mg IV morphine
2L NS
- Vitals prior to transfer:
98.2; 110; 122/61; 15; 99% RA
On arrival to the floor, pt reports continued pain in her Left
arm and Left leg which were unchanged from prior. She denies any
new neurologic symptoms or coldness in her hands/feet.
REVIEW OF SYSTEMS: Per HPI.
Past Medical History:
#Renal cell CA ___ clear cell type, 1.5 cm, ___ Grade
___ s/p partial left nephrectomy
#Leukemia: treated at age ___ DFCI, CH, with chemotherapy,
radiation as child s/p MRD from brother
#E.coli UTI, blood stream infection, and left calf pyomyositis
___
#Hepatitis C genotype 1B
#Cirrhosis due to HCV: failed multiple curative treatments,
due to undergo new therapy this year. Contracted from blood
transfusion as a child. Stage 4 fibrosis, IL 28b
CC genotype. She is a non-responder to interferon and ribavirin
treatment on two occasions as well as a non-responder to a ___
clinical trial with 2 directly acting antivirals: Asunaprevir
and
Daclatasvir. She has cords of grade II-III varices and is on
nadolol. Not otherwise decompensated.
#Hypothyroidism: ___ XRT
#s/p Supracervical Hysterectomy @ ___ for uterine rupture at 17
weeks, thought due to weakened uterine wall from whole-body
radiation. (___)
-Complicated by cardiac arrest in operating room, requiring
15 minutes of compressions and six attempts at cardioversion.
Complicated by suspected DIC. Required massive resuscitation.
#Partial anomalous pulmonary venous return with right upper
lobe pulmonary vein draining into the azygos.
#Mixed pulmonary hypertension secondary to cirrhosis and
right-sided volume overload from PAPVR.
#Cardiomyopathy from cardiac arrest secondary to intrapartum
ruptured uterus > ___ had normal biventricular fxn
#Moderate-severe TR
#Mild PH
#Tobacco abuse
Social History:
___
Family History:
No family history of recurrent skin infections, renal cancer,
leukemias, immune deficiency.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals: 97.9; 120 / 63; 112; 18; 95 RA
General: Alert, oriented, pt appears very uncomfortable.
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, II/VI holosystolic murmur at ___.
Normal S1 + S2, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Left arm diffusely tender even to light touch. No crepitus
appreciated. Erythematous patch on medial/dorsal aspect of
forearm ~2cm x 6cm. Right arm mildly TTP from elbow to wrist.
Left leg diffusely tender even to light tough. 2x ~1.5cm patches
just superior to Left knee. Right leg TTP from mid thigh to
ankles. No c/c/e. Normal capillary refill. Normal sensation. 2+
DP/radial pulses, equal bilaterally.
MSK: Pt unable to fully extend fingers on Left arm. ROM on
Right hand WNL.
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAM:
======================
Vitals: 97.9 100-116/63-66 94-102 18 96%RA
General: Alert, oriented, pt appears very uncomfortable.
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, II/VI holosystolic murmur at LLSB.
Normal S1 + S2, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Left arm without tenderness. No crepitus. Erythematous
patch on medial/dorsal aspect of forearm resolving. Left leg
tenderness to palpation is largely improved. improving 2x ~1.5cm
patches just superior to Left knee. Right leg minimal TTP from
mid thigh to ankles. No c/c/e. Normal sensation. 2+ DP/radial
pulses, equal bilaterally.
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
==============
Admission Results
==============
___ 05:50PM BLOOD WBC-30.0*# RBC-3.81* Hgb-12.0 Hct-35.6
MCV-93# MCH-31.5 MCHC-33.7 RDW-15.2 RDWSD-52.0* Plt ___
___ 05:50PM BLOOD Neuts-83.2* Lymphs-5.7* Monos-6.8 Eos-2.9
Baso-0.5 Im ___ AbsNeut-24.88*# AbsLymp-1.72 AbsMono-2.04*
AbsEos-0.88* AbsBaso-0.16*
___ 07:30AM BLOOD ___ PTT-32.2 ___
___ 05:50PM BLOOD Glucose-123* UreaN-15 Creat-0.6 Na-135
K-4.7 Cl-101 HCO3-23 AnGap-16
___ 07:30AM BLOOD ALT-36 AST-77* AlkPhos-107* TotBili-0.9
___ 05:50PM BLOOD CK(CPK)-564*
___ 05:50PM BLOOD Calcium-9.0 Phos-2.1* Mg-2.0
___ 07:30AM BLOOD calTIBC-218* Ferritn-223* TRF-168*
___ 05:50PM BLOOD CRP-208.3*
============
Imaging results
============
CT UP and LOWER EXT W/O C LEFT
No evidence of subcutaneous gas, as clinically questioned. No
fractures or
dislocations.
___ THIGH W&W/O CONTRAST
Multifocal muscle abnormality in both thighs. Findings would be
compatible
with history of pyomyositis. Alternative considerations, which
are less
likely include sarcoidosis, or metastasis in a patient with
known underlying
neoplasm.
=============
Discharge Results
=============
___ 05:58AM BLOOD WBC-8.9 RBC-3.59* Hgb-10.7* Hct-32.8*
MCV-91 MCH-29.8 MCHC-32.6 RDW-14.2 RDWSD-48.0* Plt ___
___ 05:58AM BLOOD ___ PTT-38.1* ___
___ 05:58AM BLOOD Glucose-93 UreaN-11 Creat-0.5 Na-140
K-4.5 Cl-106 HCO3-24 AnGap-15
___ 05:35AM BLOOD ALT-27 AST-55* AlkPhos-82 TotBili-0.9
___ 06:10AM BLOOD ALT-33 AST-62* CK(CPK)-240* AlkPhos-94
TotBili-1.1
___ 12:48PM BLOOD Cryoglb-NO CRYOGLO
___ 06:10AM BLOOD CRP-82.6*
Brief Hospital Course:
___ w/PMHx pyomyositis in the setting of E. coli bacteremia, HCV
cirrhosis (s/p harvoni and ribavirin) s/p TIPS in ___, PH
(d/t cirrhosis & anomalous pulmonary venous return), RCC s/p
partial nephrectomy, s/p hysterectomy for uterine rupture d/t
radiation, severe TR, prior allo-SCT for Leukemia at ___ who
presented to ___ with severe bilateral UE and ___ pain and
tenderness.
Patient presented on ___ after acute onset of bilateral
leg and arm pain and tenderness L>>R. She was noted to have a CK
of 564, a CRP of 208, and a WBC 30.0. She was empirically
started on vancomycin and meropenem, although she was notably
afebrile throughout hospitalization. Initial imaging with Xrays
and CT showed no signs of necrotizing fasciitis or trauma. The
patient's pain and erythema improved significantly. Her WBC, CK,
and CRP trended down throughout her stay.
The workup for the etiology included infectious and
rheumatological workups. Infectious disease and rheumatology
were consulted and recommended MRI to evaluate for myositis. The
MRI thigh showed multifocal muscle abnormalities in both thighs
but were non-specific so a muscle biopsy was performed on ___.
The results of the muscle biopsy were pending at time of
discharge. Rheumatologic data including MI2 autoantibodies and
SRP autoantibodies were pending at time of discharge. Anti-JO1
was negative. Other infectious data including blood cultures x4,
cryoglobulins, and cryptococcal serologies were negative at time
of discharge. Of note, vancomycin and meropenem were d/c'd on
___. She continued to improve off of antibiotics and was
discharged home.
# Myositis, bilateral UEs and LEs. Patient initially presented
after 1.5 days of BLE and RUE pain, with extreme tenderness to
light touch. On arrival, LRINEC score = 7, leukocytosis at 30.0
(now down to 20.3), CK of 564, CRP of 208, so she was started on
empiric vancomycin and meropenem. However, she was afebrile
during her stay. CT w/o contrast did not demonstrate evidence of
subcutaneous gas or definite fluid collections (to the extent
that can be appreciated w/o contrast), together suggesting that
bacterial etiology (necrotizing fasciitis or pyomyositis) was
unlikely. Viral or inflammatory causes were also considered. The
workup for the etiology included infectious and rheumatological
workups. Infectious disease and rheumatology were consulted and
recommended MRI to evaluate for myositis. The MRI thigh showed
multifocal muscle abnormalities in both thighs but were
non-specific so a muscle biopsy was performed on ___. The
results of the muscle biopsy were pending at time of discharge.
Rheumatologic data including MI2 autoantibodies and SRP
autoantibodies were pending at time of discharge. Anti-JO1 was
negative. Other infectious data including blood cultures x4,
cryoglobulins, and cryptococcal serologies were negative at time
of discharge. Of note, vancomycin and meropenem were d/c'd on
___. She continued to improve off of antibiotics and was
discharged home.
#Hypothyroid: ___ XRT. Patient was found to have a TSH of 15
(previous 0.33 on ___. She reported that she had been
taking her medications as directed. Her levothyroxine was
increased to 75mcg from 55mcg. She will follow-up as an
outpatient for a re-draw of her TSH in 6 weeks.
#Anemia: iron studies were consistent with anemia of
inflammation/chronic disease. Hgb remained stable throughout her
stay.
#Hepatitis C genotype 1B
#Cirrhosis due to HCV: c/b varicies, s/p TIPS. Pt is also s/p
Harvoni with good response. Continued home lactulose
#Tobacco abuse: Continued nicotine patch
*****TRANSITIONAL ISSUES*****
#NEW OR CHANGED MEDICATIONS:
- Levothyroxine 75mcg QDAY (up from 55mcg)
- Vicodin ___ Q4H PRN:PAIN
#Follow up labs:
- MI2 autoantibodies
- Anti-Jo1 autoantibodies
#Follow up muscle biopsy, pending
#Follow up TSH in 6 weeks. TSH was 15 on ___.
- Dose increased to 75mcg from 55mcg.
#CODE: FULL
#HCP/CONTACT:
Next of Kin: ___
Relationship: OTHER
Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5-1 mg PO QHS:PRN Insomnia
2. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
4. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN
Pain - Moderate
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Every 6 hours Disp #*16 Tablet Refills:*0
2. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*1
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
4. LORazepam 0.5-1 mg PO QHS:PRN Insomnia
5. HELD- Acetaminophen 1000 mg PO BID:PRN Pain - Mild This
medication was held. Do not restart Acetaminophen until you stop
taking vicoden (Hydrocodone-Acetaminophen).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Myositis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
the hospital because you were in severe pain all over your body.
We were concerned that you may have an infection so you were
given antibiotics. The infection doctors and ___
saw you and were not sure what was causing your pain so we took
a sample of your muscle to try and find out more. We are still
waiting for the results of the muscle sample. Your pain improved
and you did well after we stopped antibiotics so you were able
to go home.
It is important that you follow up with your primary doctor, ___.
___, on ___. You also have an appointment with Dr.
___ on ___ and Dr. ___
(Infectious Disease). Please see below for all of your
appointments.
Please stop taking Tylenol while your are taking vicoden
(hydrocodone/acetaminophen- has the same active ingredient as
Tylenol and too much can be bad for your liver). Once your pain
has improved and you do not need to vicoden any more you can
restart the Tylenol.
It was a pleasure caring for you at ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10554112-DS-17 | 10,554,112 | 26,641,002 | DS | 17 | 2155-09-17 00:00:00 | 2155-10-08 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ambien / Percocet / Cephalosporins / oxycodone
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this is a ___ woman with complex PMH including
childhood CML s/p HSCT, RCC s/p nephrectomy, HCV cirrhosis s/p
TIPS and Harvoni, uterine rupture c/b cardiac arrest (EF
recovered >55% in ___, moderate-severe pulmonary HTN, multiple
prior admissions for myositis (believed to be infectious), now
presenting with severe bilateral leg pain x 3 days consistent
with her prior episodes of myositis.
In the ED:
- She had a low-grade fever to 99.6, tachycardia to 100s
- Legs were severely tender to palpation with linear
erythematous patches
- Labs notable for WBC 30.6, CK 1062, CRP 282
- UA had 32 WBC, many bacteria (only 1 epi)
- CT bilateral ___ was c/w deep cellulitis and possible myositis
but could not entirely rule out soft tissue gas.
- ACS was consulted and did not think nec fasc likely,
recommended admission to Medicine for IV abx.
- Derm was consulted and felt her superficial lesions were
consistent with non-specific capillaritis and deferred further
workup and management of possible deeper infection to primary
teams.
- She was started on vanc/meropenem (allergic to cephalosporins)
and given 1.5L IVF.
This morning, patient continues to endorse severe leg pain,
worst in left calf, also present in left thigh and right calf.
Pain is worse with palpation and any movement. She denies
fevers/chills, cough/SOB, N/V/D/abd pain, dysuria.
Past Medical History:
#Renal cell CA ___ clear cell type, 1.5 cm, ___ Grade ___
s/p partial left nephrectomy
#Leukemia: treated at age ___ DFCI, CH, with chemotherapy,
radiation as child s/p MRD from brother
#E.coli UTI, blood stream infection, and left calf pyomyositis
___
#Hepatitis C genotype 1B
#Cirrhosis due to HCV: failed multiple curative treatments,
due to undergo new therapy this year. Contracted from blood
transfusion as a child. Stage 4 fibrosis, IL 28b
CC genotype. She is a non-responder to interferon and ribavirin
treatment on two occasions as well as a non-responder to a ___
clinical trial with 2 directly acting antivirals: Asunaprevir
and
Daclatasvir. She has cords of grade II-III varices and is on
nadolol. Not otherwise decompensated.
#Hypothyroidism: ___ XRT
#s/p Supracervical Hysterectomy @ ___ for uterine rupture at 17
weeks, thought due to weakened uterine wall from whole-body
radiation. (___)
-Complicated by cardiac arrest in operating room, requiring
15 minutes of compressions and six attempts at cardioversion.
Complicated by suspected DIC. Required massive resuscitation.
#Partial anomalous pulmonary venous return with right upper
lobe pulmonary vein draining into the azygos.
#Mixed pulmonary hypertension secondary to cirrhosis and
right-sided volume overload from PAPVR.
#Cardiomyopathy from cardiac arrest secondary to intrapartum
ruptured uterus > ___ had normal biventricular fxn
#Moderate-severe TR
#Mild PH
#Tobacco abuse
Social History:
___
Family History:
No family history of recurrent skin infections, renal cancer,
leukemia, immune deficiency.
Physical Exam:
ADMISSION EXAM
===========================
Vitals- 99.1 PO 115 / 59 107 18 97
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. ___ clear bilaterally with normal light reflex. Dry
MM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Tachycardic with ___ systolic murmur LUSB
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: Marked areas of tender erythematous skin on Body, mainly
LLE, clearly marked borders, some areas petechial
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait is
normal.
DISCHARGE EXAM
=======================
GEN: Very thin middle-aged woman.
CV: RRR, ___ crescendo-decrescendo systolic murmur heard
throughout.
RESP: Non-labored, CTAB.
ABD: Soft, NDNT, +BS. Tattoo on LLQ.
EXT: Areas of prior erythema marked with pen, minimally
erythematous at this point (left leg, left thigh, right leg).
Very tender to light touch, could not tolerate palpation. Tender
with plantarflexion.
NEURO: Alert and oriented, normal speech and memory. CN intact.
PSYCH: Hostile and uncooperative. Poor insight and judgment.
Pertinent Results:
ADMISSION LABS
===========================
___ 01:00PM BLOOD WBC-30.6*# RBC-4.46 Hgb-14.2 Hct-42.8
MCV-96 MCH-31.8 MCHC-33.2 RDW-14.2 RDWSD-50.3* Plt ___
___ 01:00PM BLOOD Neuts-87.3* Lymphs-3.9* Monos-6.8
Eos-0.4* Baso-0.6 Im ___ AbsNeut-26.64*# AbsLymp-1.18*
AbsMono-2.06* AbsEos-0.11 AbsBaso-0.17*
___ 01:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL
___ 01:00PM BLOOD ___ PTT-23.7* ___
___ 01:00PM BLOOD Glucose-75 UreaN-22* Creat-0.8 Na-135
K-4.6 Cl-100 HCO3-19* AnGap-21*
___ 01:00PM BLOOD CK(CPK)-1062*
___ 02:00AM BLOOD ALT-28 AST-85* LD(LDH)-283* CK(CPK)-768*
AlkPhos-111* TotBili-1.5
___ 06:40AM BLOOD ALT-29 AST-82* LD(___)-324* CK(CPK)-583*
AlkPhos-123* TotBili-1.8*
___ 01:00PM BLOOD CK-MB-9 cTropnT-<0.01
___ 01:00PM BLOOD Calcium-9.1 Phos-2.4* Mg-2.3
___ 01:00PM BLOOD CRP-282.3*
___ 01:14PM BLOOD Lactate-3.5*
___ 09:57PM BLOOD Lactate-2.9*
___ 02:11AM BLOOD Lactate-2.4*
___ 02:40PM BLOOD Lactate-2.9*
___ 02:12PM URINE barbitr-NEG opiates-NEG cocaine-POS*
amphetm-NEG oxycodn-NEG mthdone-NEG
___ 02:12PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:12PM URINE Blood-TR Nitrite-POS Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 02:12PM URINE RBC-1 WBC-32* Bacteri-MANY Yeast-NONE
Epi-1
___ 02:12PM URINE UCG-NEGATIVE
IMPORTANT INTERVAL LABS
======================================
___ 06:30AM BLOOD Cryoglb-NO CRYOGLO
___ 02:00AM BLOOD TSH-7.6*
___ 06:30AM BLOOD HBsAg-Negative HBsAb-Borderline
HBcAb-Negative
___ 02:00AM BLOOD CRP-201.3*
___ 01:00PM BLOOD C3-123 C4-7*
___ 06:40AM BLOOD C3-88* C4-5*
___ 06:30AM BLOOD HIV Ab-Negative
___ 01:00PM BLOOD Barbitr-NEG
___ 06:30AM BLOOD HCV VL-5.8*
___ 06:40AM BLOOD MYOSITIS ANTIBODY PROFILE-PND
DISCHARGE LABS
=======================================
___ 06:40AM BLOOD WBC-29.9*# RBC-3.97 Hgb-12.7 Hct-38.0
MCV-96 MCH-32.0 MCHC-33.4 RDW-14.2 RDWSD-50.1* Plt ___
___ 06:40AM BLOOD Neuts-84.2* Lymphs-5.6* Monos-7.3
Eos-0.9* Baso-0.7 Im ___ AbsNeut-25.19* AbsLymp-1.69
AbsMono-2.18* AbsEos-0.27 AbsBaso-0.21*
___ 06:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:40AM BLOOD ___ PTT-31.6 ___
___ 06:40AM BLOOD Glucose-75 UreaN-10 Creat-0.6 Na-136
K-4.3 Cl-101 HCO3-25 AnGap-14
___ 06:40AM BLOOD ALT-29 AST-82* LD(LDH)-324* CK(CPK)-583*
AlkPhos-123* TotBili-1.8*
___ 06:40AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.5*
MICRO
=========================================
___ CULTURE-FINAL {ESCHERICHIA COLI}EMERGENCY WARD
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------------ <=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
ALL NEGATIVE:
___ IgG ANTIBODY-FINAL; TOXOPLASMA IgM
ANTIBODY-FINALINPATIENT
___ Culture, Routine-FINALINPATIENT
___ Culture, Routine-FINALINPATIENT
___ Culture, Routine-FINALINPATIENT
___ Culture, Routine-FINALEMERGENCY WARD
___ Culture, Routine-FINALEMERGENCY WARD
___ Culture, Routine-FINALEMERGENCY WARD
STUDIES
==================================
+ ___ CT BILAT LOWER EXTREMITY W&W/O CONTRAST
IMPRESSION:
1. Soft tissue edema tracking into the deep, medial portion of
the left lower extremity suggestive of deep cellulitis and
possible myositis. No evidence of drainable fluid collection.
There are a few small hypodense foci in the deep soft tissues of
the medial calf, which may represent insinuating fat, but
difficult to entirely exclude soft tissue gas.
2. No acute fracture seen.
+ ___ LOWER EXT VEINS
No evidence of deep venous thrombosis in the left lower
extremity veins within the limitations of this exam (see
findings).
+ ___ CXR
AP portable upright view of the chest. Lower lung opacity
partially due to bilateral breast implants. A TIPS shunt
projects over the right upper abdomen. An embolic coil is noted
in the left upper quadrant. The lungs appear clear without
focal consolidation, large effusion or pneumothorax. The
cardiomediastinal silhouette is unchanged. No signs of edema or
congestion. Bony structures are intact.
Brief Hospital Course:
___ with complex PMH including childhood CML s/p HSCT, RCC s/p
nephrectomy, HCV cirrhosis s/p TIPS and Harvoni, uterine rupture
c/b cardiac arrest (EF recovered >55% in ___, moderate-severe
pulmonary HTN, multiple prior admissions for myositis (believed
to be infectious), admitted for recurrent severe bilateral leg
pain x 3 days consistent with her prior episodes of myositis.
She presented with leukocytosis to 30 and elevated lactate to
3.5, but with stable hemodynamics. Although she had been treated
with antibiotics on previous presentations, infection may be
less likely as pt has never had a positive blood culture. She
did have a positive urinalysis with GNRs in culture, although
she was not having urinary symptoms. Rheumatology was consulted
and did not feel that her presentation was an
inflammatory/autoimmune phenomenon and did not recommend
steroids. A tox screen was added on during admission, which
noted a positive cocaine level in urine from admission,
concerning for a possible cocaine-induced myopathy. A routine
bed search was performed after this was explained to the
patient. She insisted on being discharged AGAINST MEDICAL
ADVICE. She was not discharged on any new medications.
An MRI of the thigh and calf was ordered for further evaluation
of myositis but not completed prior to discharge. Multiple labs
tests were also pending upon discharge (see Results section).
TRANSITIONAL ISSUES:
[] Consider outpatient MRI of LLE to further evaluate myositis
[] Urine culture during hospitalization positive for E coli.
Patient denied urinary symptoms. Consider treating for UTI if
symptomatic.
[] Myositis antibody panel pending
[] HCV viral load positive this admission
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. LORazepam 0.5 mg PO QHS
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
4. Sumatriptan Succinate 50 mg PO ONCE
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. LORazepam 0.5 mg PO QHS
6. Sumatriptan Succinate 50 mg PO ONCE
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Myositis of unclear etiology
+cocaine in urine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because of leg pain, similar to a
presentation that you've had in the past. You were initially
started on antibiotics but these were stopped because you were
stable and we weren't convinced that you had an infection. We
had consulted our infectious disease and rheumatology doctors to
___ to help figure out your lab abnormalities and muscle pain.
As part of our workup, we checked a toxicology screen, which was
positive for cocaine. Cocaine can sometimes lead to problems
with muscles. As a result, we felt obligated to perform a room
search to protect your safety and for the safety of other
patients. You chose to leave the hospital against medical
advice. You were informed of the gravity of this situation and
understood.
If at any time you start feeling worse and choose to come back
to care, please do not hesitate to come to the ED.
- Your ___ Team
Followup Instructions:
___
|
10554304-DS-14 | 10,554,304 | 29,511,973 | DS | 14 | 2194-12-18 00:00:00 | 2194-12-19 07:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ILD, DMII, HTN, hypothyroidism, OA here with sore
throat, SOB x 6 days, sent in from PCP after finding crackles on
lung exam and pt found to be hypoxic. Pt is completely
disoriented, which is her current baseline per family. Pt states
that she has a chronic cough and recently is getting worse. She
also has a rhinorrhea. She denies F/C, N/V/D, no chest pain or
leg swelling. She denies orthopnea or PND. She has limited
ambulatory capacity to several steps and relies on wheel chair
most of the time. It is unclear whether this is secondary to
diabetic neuropathy or cardiopulmonary cause.
In the ED, initial vitals were 97.0 61 171/86 18 91% RA. EKG
showed sinus bradycardia with LAx deviation, L anterior
fascicular block, LVH and diffuse TWI in III, aVF, V1-5. Pt was
given aspirin 325 and lasix 40 mg iv X1.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Diastolic Congestive Heart failure: LVEF 60% ___
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Dementia
Anemia
Hypothyroidism
Urinary incontinence
Spinal stenosis
Chronic leukocytosis
s/p Hip placement
Social History:
___
Family History:
Denies history of cardiopulmonary disease
Physical Exam:
ADMISSION EXAM
VS: T=97.4, HR 71, BP 162/92, RR 16, O2 sat 96% on 2L
GENERAL: ___ in NAD. Oriented x1. Pleasant and appropriate
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. Bilateral
rales upto ___ lower lung fields, no wheeze or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: no pitting edema, No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
ADMISSION LABS
==============
___ 01:40PM BLOOD WBC-11.8* RBC-3.71* Hgb-10.9* Hct-34.1*
MCV-92 MCH-29.3 MCHC-31.9 RDW-14.5 Plt ___
___ 01:40PM BLOOD Neuts-69.1 ___ Monos-4.1 Eos-5.7*
Baso-0.5
___ 01:40PM BLOOD Glucose-100 UreaN-19 Creat-0.7 Na-140
K-5.0 Cl-103 HCO3-23 AnGap-19
___ 01:40PM BLOOD ALT-19 AST-48* CK(CPK)-129 AlkPhos-60
TotBili-0.3
___ 06:00AM BLOOD Calcium-9.0 Phos-4.8* Mg-1.7
___ 01:59PM BLOOD ___ pO2-117* pCO2-34* pH-7.44
calTCO2-24 Base XS-0
CARDIAC ENZYMES
==============
___ 01:40PM BLOOD CK-MB-6 proBNP-3493*
___ 01:40PM BLOOD cTropnT-0.03*
___ 06:00AM BLOOD CK-MB-5 cTropnT-0.02*
DISCHARGE LABS
==============
___ 07:05AM BLOOD WBC-15.0* RBC-3.83* Hgb-11.3* Hct-34.2*
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.8 Plt ___
___ 07:05AM BLOOD Neuts-72.2* Lymphs-17.6* Monos-4.7
Eos-4.8* Baso-0.6
___ 07:05AM BLOOD Glucose-153* UreaN-25* Creat-0.9 Na-137
K-3.8 Cl-100 HCO3-23 AnGap-18
___ 07:05AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8
CXR ___
==========
Severe interstitial pulmonary edema.
ECHO ___
===========
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 60%). The right ventricular
free wall thickness is normal. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
root is mildly dilated at the sinus level. The aortic arch is
mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets are mildly thickened (?#). There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are grossly similar, but the
technically suboptimal nature of both studies precludes
definitive comparison.
MICRO
==========
___ 1:24 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ Blood culture pending (NGTD x 96 hours)
Brief Hospital Course:
A ___ year old female with PMH dCHF (LVEF 55%), Interstitial lung
disease, DMII, HTN, hypothyroidism, OA admitted with new
pulmonary edema and CHF exacerbation.
# Congestive heart failure with Diastolic dysfunction: pulmonary
edema and worsened hypoxemia is consistent with acute
exacerbation of dCHF. ECHO in ___ shows E/e' >15 suggesting
diastolic dysfunction. Etiology of acute exacerbation was
attributed to recent viral URI. She was ruled out for myocardial
infarction. ECHO was repeated which appeared unchanged from
___. She was diuresed with furosemide 80mg (she did not
repond to furosemide 40mg). Though weight remained stable at
88kg, symptoms improved. She was discharged on furosemide 40mg
daily and a plan for continued weights and PCP follow up. ___ is
possible that she will not need furosemide longterm however in
the setting of acute exacerbation, it is reasonable to continue
unless she develops hypovolemia. She should continue 2g Na diet
and 1500 cc fluid restriction. Electrolytes should be checked
___ given newly started diuretic regimen. Betablocker was
changed from metoprolol to carvedilol for improved blood
pressure control. Valsartan was changed to losartan for improved
afterload reduction given longer duration of action with
losartan.
# Dyspnea: multifactorial and ralted to recent viral URI,
intersitial lung disease and CHF exacerbation. No evidence of
pneumonia given absence of infiltrate on CXR. Dyspnea improved
with diuresis.
# Viral upper respiratory infection: patient with cough and
sinus pressure, no fever though she had leukocytosis which
appears to be chronic. She was ruled out for influenza and
treated with cough suppressants and nasal saline.
# Hypertension: Poorly controlled on admission. She as observed
to have nocturnal hypertension. Valsartan has a short duration
of BP effect and was changed to losartan 100mg, this may be
uptitrated as an outpatient. Metoprolol was changed to
carvedilol for improved blood pressure control.
# Leukocytosis: patient has had elevated WBC since ___,
interestingly neutrophilic predominance has resolved at the time
of admission. She had absolute eosinophilia with eos >500 which
waxed and wained in her admission. Blood cultures were negative
x 4 days, urine culture negative, and CXR showed no sign of
infection. She had no gastrointestinal symptoms.
# Diabetes: Insulin sliding scale while in hospital, reseumed
metformin on discharge.Discontinue pioglitazone on discharge
given diagnosis of heart failure which is a contraindication to
thiazolidinediones. Glipizide is an option however this can also
cause fluid retention and should be used with caution.
# Delirium: patinet has baseline dementia and short term memory
loss. While in the hospital, she had delirium, particularly at
night. As above, infectious work up negative. She is on a lot of
medications which can potentially cause delrium. Vicoden was
discontinued, could consider stopping oxybutinin if tolerated by
patient. At the time of discharge she was oriented to
place:hospital, month ___.
# Interstitial lung disease/bronchectasis: In discussion with
Dr. ___ pulmonologist at ___ is unlikely to
explain pulmonary edema. She remained with rales to the mid lung
field at discharge which is likely related to ILD.
# Hypothyroidism: TSH 1.3 in ___. Continued Levothyroxine
Sodium 75 mcg daily.
# Urinary incontinance: Continued Oxybutynin 5 mg PO DAILY
# Dementia: Continued Donepezil 5 mg daily, Memantine 10 mg BID
# GERD: Continued Omeprazole 20 mg BID
# Hyperlipidemia: Continued Rosuvastatin Calcium 10 mg PO DAILY
# Primary prevention: patient without history of coronary artery
disease or Atrial fibrillation. She was admitted on aspirin 325
which was lowered to aspirin 81mg to decrease risk of bleeding.
TRANSITIONAL ISSUES
Check Daily weight: discharge weight 88kg. If appearing
dehydrated, decrease furosemide to 20mg or consider stopping
entirely. If weight goes up by 3lbs in one day or 5lbs in 1
week. Call PCP ___ and discuss increasing furosemide
Monitor glucose as pioglitasone was stopped in this hospital
stay given diagnosis of CHF. Consider starting glipizide, or
glargine + humalog.
- Blood cultures from ___ were pending final read and showed
NGTD x 96 h at the time of discharge
CODE: DNR/DNI
CONTACT: ___, ___ (HCP)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. olopatadine *NF* 0.6 % NU bid
3. Metoprolol Succinate XL 75 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Senna 1 TAB PO BID:PRN constipation
6. Memantine 10 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. celecoxib *NF* 100 mg Oral bid
9. Guaifenesin ER 1200 mg PO Q12H
10. Oxybutynin 5 mg PO DAILY
11. Rosuvastatin Calcium 10 mg PO DAILY
12. Donepezil 5 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Aspirin 325 mg PO DAILY
15. Loratadine *NF* 10 mg Oral qd
16. Pioglitazone 45 mg PO DAILY
17. Levothyroxine Sodium 75 mcg PO DAILY
18. PNV w/o calcium-iron fum-FA *NF* ___ mg Oral Daily
19. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q8H:PRN
pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Donepezil 5 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Memantine 10 mg PO BID
6. Omeprazole 20 mg PO BID
7. Oxybutynin 5 mg PO DAILY
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Senna 1 TAB PO BID:PRN constipation
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Carvedilol 25 mg PO BID
12. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
13. Furosemide 40 mg PO DAILY
14. Losartan Potassium 100 mg PO DAILY
15. Sodium Chloride Nasal ___ SPRY NU BID
16. Celecoxib *NF* 100 mg ORAL BID
17. Loratadine *NF* 10 mg Oral qd
18. MetFORMIN (Glucophage) 1000 mg PO BID
19. olopatadine *NF* 0.6 % NU bid
20. PNV w/o calcium-iron fum-FA *NF* ___ mg Oral Daily
21. Outpatient Lab Work
Lab work: ___
___ Phone: ___ Fax: ___.
ICD9 code heart failure 428.0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute congestive heart failure diastolic dysfunction
Viral syndrome
Hypertension
Diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mrs ___,
___ was a pleasure taking care of you in your hospital stay at
___. As you know, you were admitted to the hospital with
shortness of breath. We performed a chest xray which showed
fluid in the lungs. We performed an EKG and blood tests which
confirmed that you did not have a heart attack. We performed an
ultrasound of the heart which showed that your heart does not
fill with blood as well as it should (congestive heart failure).
You were started on a water pill to help manage your fluid
balance.
Given your diagnosis of heart failure, you should stop taking
Pioglitazone.
Please adhere to a 2 gram sodium diet. Please check your weight
daily on a scale and notify your PCP if your weight goes up by
3lbs in 1 day or 5 lbs in 1 week. Your weight at discharge is
88kg (193 lbs)
please note the following changes to your medications
CHANGE Aspirin to Aspirin 81mg
START Furosemide for fluid
START Losartan for blood pressure
START Carvedilol for blood pressure
START Acetaminophen for Pain
START Dextromethorphan-Guaifenesin for cough
START Sodium Chloride Nasal for nasal congestion
STOP Valsartan [replaced by losartan]
STOP Metoprolol [replaced by carvedilol]
STOP Pioglitazone this is not a medication that you should take
with your heart condition.
STOP Vicoden (Hydrocodone) this can cause delirium
Followup Instructions:
___
|
10554449-DS-7 | 10,554,449 | 29,236,524 | DS | 7 | 2171-09-12 00:00:00 | 2171-09-14 17:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
iodine / Wellbutrin / gabapentin
Attending: ___.
Chief Complaint:
Nausea and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of GERD s/p Nissen
fundiplication and vagotomy complicated by gastroparesis
requiring subtotal gastrectomy with (duodenal switch) who
presents with nausea and abdominal distention. Patient reports
that she was in her USOH until 5 days ago when developed
intermittent abdominal pain and distention. Episodes were
short-lived however increased in frequency while over the next 3
days. The day of admission, she awoke with severe abdominal pain
and distention with inability to pass gas.
Given her symptoms she presented to the ___ for
evaluation where she underwent a CT which initially was
concerning for SBO. Given her extensive surgical history, she
was sent to ___ for further evaluation, where she was
ultimately admitted to the surgery team for further management.
Past Medical History:
Severe GERD s/p multiple surgeries complicated by dumping
syndrome, Barretts eesophagus, constipation, Thyroid cancer s/p
thyroidectomy, progressive disorder of lumbosacral and
thoracolumbar spinal deformity, Anemia, Insomnia, Osteoporosis
Social History:
___
Family History:
NC
Physical Exam:
Vitals: T: 98.4 HR: 59 BP: 109/53 RR: 18 SaO2: 98%RA
NAD
RRR
CTAB
Abd: Soft, mildly distended, minimally tender
Pertinent Results:
CXR ___: No convincing signs of bowel obstruction or free
air
CXR ___: Non-obstructive bowel gas pattern
___ 01:30PM BLOOD TSH-___*
___ 06:25AM BLOOD WBC-7.5 RBC-3.41* Hgb-11.4* Hct-35.0*
MCV-103* MCH-33.5* MCHC-32.6 RDW-11.2 Plt ___
___ 11:35PM BLOOD Neuts-92* Bands-0 Lymphs-1* Monos-7 Eos-0
Baso-0 ___ Myelos-0
___ 06:25AM BLOOD ___ PTT-28.5 ___
___ 07:00AM BLOOD Glucose-96 UreaN-9 Creat-0.5 Na-133 K-4.1
Cl-100 HCO3-27 AnGap-10
___ 07:00AM BLOOD Calcium-8.0* Phos-1.6*# Mg-2.2
___ 11:49PM BLOOD Lactate-1.1
Brief Hospital Course:
On ___, Ms. ___ was transferred to ___ from ___
___ with nausea, abdominal pain and concern for possible
small bowel obstruction on CT scan. IV fluids were given and NG
tube was placed in the ___ ___, which had moderate output.
Admission CXR showed non-obstructive bowel gas pattern.
On HD1, her NG tube output was very minimal, her abdomen was
soft and she was passing flatus. The NG tube was therefore
removed and her diet was advanced to clear liquid then regular
diet which she tolerated.
She continued to complain of abdominal pain on HD2 and HD3,
however, and had moderate abdominal distension. On HD3, she was
transferred to Dr. ___ surgery service for
further management. Gastroenterology was also consulted.
Repeat KUB on HD3 again revealed non-obstructive bowel gas
pattern. TSH was 11. Given the lack of radiolographic evidence
of SBO, her presentation was felt to be more consistent with
paralytic ileus, the etiology of which was unclear
(possibilities included infectious v. toxic/metabolic v.
idiopathic v. medication induced). Additionally, we learned that
she typically takes 5 doses of bisacodyl and 5 doses of senna
each night, which she had abruptly stopped. Given the presence
of stools in her colon, she was given an aggressive bowel
regimen including senna, bisacodyl, and several enemas.
On HD4, she began to have bowel movements and her pain was much
improved. She began tolerating a regular diet again on HD5.
On HD5, ___, she was discharged to home. She was
tolerating a regular diet, passing flatus, having bowel
movements, and her pain was minimal. She will follow up with Dr.
___ gastroenterologist at ___,
for continuation of her care. Her Endocrinologist, Dr. ___
___ also be informed about her TSH of 11, to see if
any change in management of her Hashimoto's disease is required.
Medications on Admission:
Bisacodyl 10 mg PO/PR HS (taking 5 doses per night)
Senna (taking 5 doses per night)
Aprepitant 125 mg PO BID PRN nausea
Diazepam 5 mg PO TID:PRN Anxiety
Hydrochlorothiazide 25 mg PO DAILY
Levothyroxine Sodium 112 mcg PO DAILY
Lisinopril 5 mg PO DAILY
Lorazepam 0.5 mg PO BID PRN anxiety, insomnia
Methocarbamol 500 mg PO BID
Ranitidine 150 mg PO DAILY
Zolpidem Tartrate
Discharge Medications:
Bisacodyl 10 mg PO/PR HS (5x per night pre-admission, wean as
tolerated)
Senna (5x per night pre-admission, wean as tolerated)
Aprepitant 125 mg PO BID PRN nausea
Diazepam 5 mg PO TID:PRN Anxiety
Hydrochlorothiazide 25 mg PO DAILY
Levothyroxine Sodium 112 mcg PO DAILY
Lisinopril 5 mg PO DAILY
Lorazepam 0.5 mg PO BID PRN anxiety, insomnia
Methocarbamol 500 mg PO BID
Ranitidine 150 mg PO DAILY
Zolpidem Tartrate
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and abdominal pain (most likely due to paralytic ileus)
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 nausea and abdominal pain.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your symptoms have subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and are having bowel movements. You may return home
to finish your recovery.
Please monitor your bowel function closely. It is important that
you have a bowel movement in the next ___ days.
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:
___
|
10554657-DS-20 | 10,554,657 | 22,923,535 | DS | 20 | 2174-06-19 00:00:00 | 2174-06-20 13:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine / Vicodin / Seroquel
/ Lamictal
Attending: ___.
Chief Complaint:
Falling episodes, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/hx of depression, anxiety presents after multiple
falling episodes over the last week. Patient states the first
episode started three days prior to admission. Patient states
that per her husband and uncle she got up from bed walked to the
hall and then fell. At this time, per her uncle she seemed to be
shaking throughout. She was unresponsive at this time, for
unknown time frame. She states she was told she hit her head.
She then got up and her husband asked her if she was ok, she
said she didn't think so and then fell again this time in her
husband's arms. Per the husband patient felt lifeless. She was
unresponsive for 45sec. When she came to she had no recolleciton
of the events preceeding her falling. By the time EMS arrived
though, patient had clear sensorium. She denies loss of bowel or
bladder or any tongue biting. She came to our ED for workup that
evening with normal EKG, electrolytes and negative troponin.
Patient states she felt better after IVF. Patient then had
another syncopal episode unwitnessed on ___ consisting of
taking a nap and the next thing she remembers she woke up in the
hallway. She does not know how she got there or how long she was
down for. Patient states she did not go to an ED at that time
for evaluation. Patient came in today for concern of headache
that has since diminished with tylenol administration.
She denies blurry vision, numbness, tingling or weakness of her
extremities. She states she had a 10lb weight gain in the last
few weeks. She states her last time purging was one month ago.
She recently started prazosin for her PTSD/nightmares which has
been helping to control her symptoms.
Of note patient recently admitted at ___ for workup
of shortness of breath which per patient she had pulse ox in the
___ and tachycardia. Patient does not know what workup was done
at that time including radiographs.
.
In the ED, initial VS were 98 70 105/55 20 100%. CT head without
showed no acute process. CXR was normal. Electrolytes showed no
abnormalities. EKG was baseline with NSR in the ___. Nonfocal
neurologic examination. Discussed with patient's PCP and PCP
requested admission for further workup including echocardiogram.
.
Upon transfer to the floor, patient c/o mild headache, frontal,
nonradiating. No blurry vision. No numbness, tingling or
weakness.
.
ROS: per HPI, denies fever, chills, night sweats, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
Past Medical History:
PSYCHIATRIC HISTORY:
-anorexia -- began at age ___, tx with many inpatient and
outpatient programs, lowest weight was 85 lbs (pt 5'4"), stable
for several years
-depression -- started as a teenager, c/b two suicide attempts
in
her teens by overdose on prescription meds, also one SA in ___
with potassium for which she got IV fluids and was discharged
-dx of anxiety, first panic attack age ___, very few until last
two weeks
-recent hospitalizations:
-___ at ___ for 3.5 weeks on trauma/dissociative
program, pt states not helpful due to overly focused on trauma
and denies dissociative sx
-___ ___ for medication
management
and therapy after discharge from program in ___ with
incomplete med titration, felt that this was a helpful stay
-___ hospitalized in ___ for SI
-___ hospitalized at ___ for SI
-treaters: psychopharm Dr. ___, ___ on
vacation this week, has been seeing him every 2 weeks; therapy
with ___, cell ___ seeing 2x per week lately
.
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
-no h/o head trauma
-one unprovoked seizure, age ___, not started on AEDs, no cause
identified, no recurrence
-reactive hypoglycemia
-s/p ___ fundoplication for GERD in ___ purging as teen
Social History:
___
Family History:
-dad - EtOH, marijuana, other hx unknown
-mom's family - OCD, depression, BPAD, EtOH, drug abuse
Physical Exam:
Admission Exam:
VS - Temp ___, BP 108/62, HR 72, R 18, O2-sat 99% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, normal cup to
disc ratio on fundocscopic examination. MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
Discharge Exam:
VS - Temp 98.2F, Tmax 98.2F BP 92/54, HR 55, R 16, O2-sat 98% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no LAD
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, 2+ peripheral pulses (radials, DPs, PTs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout.
Pertinent Results:
___ 12:20PM GLUCOSE-83 UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 12:20PM URINE HOURS-RANDOM
___ 12:20PM URINE UCG-NEGATIVE
___ 12:20PM WBC-4.4 RBC-4.05* HGB-11.4* HCT-34.9* MCV-86
MCH-28.1 MCHC-32.5 RDW-12.6
___ 12:20PM NEUTS-54.2 ___ MONOS-5.6 EOS-3.4
BASOS-1.8
___ 12:20PM PLT COUNT-346
___ 12:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Brief Hospital Course:
ASSESSMENT & PLAN: ___ F w/hx of depression, anxiety presents
with three episodes of falling in the last three days and mild
headache.
.
#Syncope: Ddx includes sleepwalking, vasovagal, psychiatric,
orthostatic, cardiogenic or neurologic etiology. Patient seen in
ED after first two episodes of syncope with nml EKG and negative
trended troponins. Patient had CAT scan that showed no evidence
of mass or bleed causing symptoms. Patient has no prodromal
symptoms of ligthheadedness, blurry vision, warmth, nausea prior
to falling making vasovagal less likely. Patient does not get
lightheaded or syncopize from sitting to standing and
orthostatics negative in ED on presentation making orthostatic
causes less likely. Patient has no CP, palpitations prior to
syncopizing. When she does fall it is quick and takes time to
recover which could indicate some cardiac origin. Patient has no
abn on EKG of hypertrophic cardiomyopathy, brugada, WPW,
prolonged intervals to explain her syncopal episodes. Patient
had TTE which showed trivial tricuspid regurgitation but was
otherwise normal. Patient will be d/c with ___ monitor. Given
that patient had some "shaking" and a short "postictal" phase
during the second episode of syncope this could be due to
seizure activity esp with hx of seizure when ___. This will need
further workup as an outpatient. Given that these symptoms
happen at night could be due to sleepwalking, though not waking
up right away makes this unlikely. Patient also mentions feeling
thirsty after the falls and so orthostatic hypotension secondary
to dehydration is a possibility. Addditionally, we considered a
med effect of the prazosin which can cause hypotension,
orthostasis and syncope. We have discontinued the prazosin, and
patient will follow up for possible alternative treatment as
outpatient.The patient takes this medication at night.
.
#Headache: Patient c/o headache. No blurry vision, nausea, or
neurologic deficits. Most likely tension. Given tylenol, toradol
and reglan. Continue on tylenol regimen with toradol for
breakthrough. Pain had resolved in morning of HD2. continue to
monitor as outpatient.
.
#Depression/Anxiety/PTSD:
-- hold prazosin for now
.
#GERD: Continued home medication of omeprazole
Medications on Admission:
omeprazole 20mg BID
prazosin 3mg qHS
iron 325mg daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
3. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for headache.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary: falling episodes, headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen for several falling episodes in the past week, as
well as a headache that developed around the time of your first
fall. You underwent evaluation in the emergency room, where a
chest x-ray, a CT scan and an electrocardiogram were performed.
These tests were negative for any acute process in your heart,
lungs, or brain that would be consistent with your symptoms.
Upon transfer to the floor, we held Prazosin as it can cause
fainting episodes. We performed a repeat electrocardiogram and
an echocardiogram which showed no processes concerning for heart
disease or a heart cause of falling episodes.
.
We recommend continuing home medications with the exception of
Prazosin, as it may be contributing to the episodes of falls.
Additionally, we recommend follow-up with your PCP, and an
appointment has been scheduled and is listed below.
Followup Instructions:
___
|
10554684-DS-5 | 10,554,684 | 28,586,974 | DS | 5 | 2127-05-26 00:00:00 | 2127-05-26 14:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Aphasia.
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram.
History of Present Illness:
Mr. ___ is a ___ yo RHM with h/o HTN who presents with
aphasia, sent from OSH after CT showed multiple areas of L
hemispheric infarct. The patient ate a tuna and jalepeno
sandwich from Subway at noon yesterday. By 3pm, he had GI upset
and called friend. By evening, he had vomiting and diarrhea, so
the friend came to stay with him (he lives alone). Overnight, he
was up most of the night, with
N/V/D. He c/o dizziness with standing. He got up around ___
and fell (friend thought he may have tripped over sweatpants if
he was groggy). His friend heard and came over to him, he was
lying on the floor, eyes open, staring ahead, but did not
respond to him for about 30 seconds, after which he replied
"what?" After this, he was able to speak normally, and was able
to get up and ambulate. At 6am, he was washing dishes and
stretching his legs, and was speaking normally. This friend did
call him around 10am, and thought he was speaking normally.
Specifically he asked the patient if a friend of theirs was
usually early or late, the patient replied "he's usually on
time." The patient's daughter called him at 9:30am. He was
having word finding difficulty and said "easel" instead of
answering her question, mostly saying yes or no. At 12:30,
another daughter called, and he was the same. When asked what he
was doing, he replied "potato." His daughter was concerned, so
she went to his
house. He was still having difficulty getting words out, but
face looked symmetric, he could move all extremities and
ambulate, good grip strengths bilaterally. Patient was brought
to ___. Significant
findings included elevated WBC 20.9, Na 131, Cr 3.2, neg EtOH
level. NCHCT showed multiple areas of L MCA territory infarct.
No vessel imaging was done. Patient was transferred to ___ ED
for further evaluation.
.
In ___ ED, patient's exam remained stable from arrival until
transfer to floor. He was slightly improving in his ability to
comprehend and was using more words, but nonfluent, and what few
words he used were paraphasias or repeated connector words ie
"like". No dysarthria.
.
ROS: obtained from family -> no headache, vision change,
dysarthria, CP, SOB
Past Medical History:
-HTN
-multiple R knee surgeries, last > ___ years ago, no metal
-s/p DVT and bacteremia
Social History:
___
Family History:
Father died of MI at young age.
No strokes in anyone.
Physical Exam:
ON ADMISSION:
-------------
Physical Exam:
Vitals: T: 99.3 P: 115 R: 16 BP:125/86 SaO2:99/2L
___: 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 however difficult with
tachycardia
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted, no signs of endocarditis
.
Neurologic:
-Mental Status: Alert, awake, attentive but exam limited due to
language deficits, tries to cooperate. Unable to say his name,
unable to name any objects. He nods and says "yes" to indicate
he knows what the object is, but cannot come up with any words.
No paraphasias but difficult to tell because speech too limited.
He is saying automatic phrases like "that's alright" ___
words). Comprehension intact for simple commands, with complex
commands he partially complies (opens mouth for stick out
tongue, shows hand for 2 fingers).
Perseveration limits ability to judge comprehension with yes/no
questions. No neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, no APD. VFF to confrontation. Blinks to
threat bilaterally.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: cannot perform
VII: intermittent L ptosis, R nasolab flattening at rest, but
good elevation on volitional expression.
VIII: Hearing intact grossly to voice bilaterally.
IX, X: cannot perform
XI: cannot perform
XII: cannot perform
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 5 - ___ 5 - 5 5 5 5
R 5 5 5 - ___ 5 - 5 5 5 5
.
-Sensory: No deficits to pinch in all extremities.
.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2+ 1
R 3 3 3 0 1
+ Hoffmans bilaterally, no clonus
Plantar response was equivocal as patient withdrew.
.
-Coordination: Difficulty performing tasks, finger to nose
without dysmetria.
.
-Gait: deferred.
.
EXAM ON DISCHARGE:
------------------
-able to say words on command, answers simple questions
-extreme TTP right ___ (chronic)
-comprehension intact, follows simple commands
-anomia improving, A&O X 3
-can write name and one word phrases on command
-can sum and count people in room
-can read to follow commands
-R > L pupil, but ERRLA
-LEFT ptosis waxes and wanes
-full strength throughout
-brisk reflexes throughout w/ toes downgoing bilaterally
-slower RAMs on LUE > RUE
Pertinent Results:
ON ADMISSION:
------------
___ 04:00PM BLOOD WBC-18.4* RBC-5.45 Hgb-16.2 Hct-50.5
MCV-93 MCH-29.6 MCHC-32.0 RDW-13.7 Plt ___
___ 04:00PM BLOOD Neuts-90.8* Lymphs-5.0* Monos-3.3 Eos-0.7
Baso-0.3
___ 04:00PM BLOOD ___ PTT-29.9 ___
___ 04:00PM BLOOD Glucose-102* UreaN-40* Creat-3.2* Na-133
K-4.5 Cl-101 HCO3-17* AnGap-20
___ 04:00PM BLOOD ALT-56* AST-58* LD(LDH)-415* AlkPhos-69
TotBili-0.4
___ 04:00PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD Albumin-4.6 Calcium-9.7 Phos-3.8 Mg-2.2
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:54AM BLOOD ESR-30*
___ 05:05AM BLOOD %HbA1c-5.3 eAG-105
___ 05:05AM BLOOD Triglyc-163* HDL-49 CHOL/HD-4.0
LDLcalc-112
___ 05:05AM BLOOD CRP-93.4*
___ 05:00AM BLOOD D-Dimer-749*
.
ON DISCHARGE:
-------------
___ 05:15AM BLOOD WBC-10.0 RBC-4.31* Hgb-12.9* Hct-39.5*
MCV-92 MCH-29.8 MCHC-32.5 RDW-13.2 Plt ___
___ 10:35AM BLOOD ___ PTT-51.6* ___
___ 05:15AM BLOOD Glucose-108* UreaN-19 Creat-1.2 Na-137
K-4.2 Cl-107 HCO3-22 AnGap-12
___ 05:15AM BLOOD ALT-54* AST-40 AlkPhos-55 TotBili-0.4
___ 05:15AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
.
IMAGING & STUDIES:
------------------
EKG ___:
Sinus tachycardia. Otherwise, within normal limits. No previous
tracing
available for comparison.
Rate PR QRS QT/QTc P QRS T
108 136 82 316/400 72 4 45
.
MRA BRAIN/NECK & MRI HEAD ___:
IMPRESSION:
1. Subacute infarctions involving the left inferior frontal
gyrus as well as the left parietal lobe with petechial
transformation, likely embolic in
nature.
2. MRA of the head demonstrates decrease flow-related signal in
left M2, M3, and M4 branches.
3. Limited MRA of the neck demonstrates no evidence of
significant stenosis or dissection.
.
TTE ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. Agitated saline contrast study revealed
borderline evidence of a patent foramen ovale. No cardiac source
of embolus identified.
.
BILATERAL LOWER EXT U/S ___:
IMPRESSION: No evidence of deep vein thrombosis in either leg.
.
TEE ___:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right and left atrial appendage
ejection velocities are good (>20 cm/s). A small interatrial
septal defect is present with left-to-right shunting across the
interatrial septum at rest. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular systolic
function is normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. There are diffuse complex
atheroma with extensive, large superimposed mobile
atherothrombotic components in the aortic arch and descending
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and trace aortic regurgitation. No
masses or vegetations are seen on the aortic valve. No mass or
vegetation is seen on the mitral valve. No vegetation/mass is
seen on the tricuspid valve. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: Diffuse complex atheroma with extensive, large
superimposed atherothrombotic components in the aortic arch and
descending aorta. Small atrial septal defect with left-to-right
shunt at rest. No thrombus or vegetations seen. Normal
biventricular systolic function.
.
BLOOD CX FROM ___ and ___: pending at time of discharge,
NGTD.
Brief Hospital Course:
This is the brief hospital course for a ___ year old male with a
past medical history significant for hypertension, DVT, and
bactermia who presented to an outside hospital on ___ with
new onset aphasia. He received a head CT at the OSH which showed
anterior and posterior LEFT MCA infarcts. He was then
transferred to ___ Service
for further management.
.
At ___, the patient was found to have a WBC of 20 with a Cr of
3.2. These values both improved with rehydration so it was
likely that his preceding diarrheal illness contributed to these
lab abnormalities.
.
An MRI HEAD as well as MRA BRAIN AND NECK were performed at
___ and confirmed the infarcts which were seen on the OSH CT
and did not demonstrate any dissections, masses, or bleeds.
Surface echocardiogram was performed to look for a stroke
source. TTE did not provide adequate information for
confirmation. A PFO was believed to be present. Bilateral lower
extremity U/S were performed and (-) for DVTs. Given the lack of
a clear source, an esophageal echocardiogram was attained. This
study demonstrated MANY COMPLEX, MOBILE atheromatous thrombi in
the patient's aorta as well as a PFO. The infarcts were likely
due to embolus of one of these deposits.
.
The patient was started on a statin as well as a heparin gtt and
oral coumadin. The heparin gtt can be stopped when INR levels
are within 2.0-3.0 range. His PCP ___ follow his INRs as an
outpatient after he is released from rehab.
.
%HbA1c-5.3
Triglyc-163* HDL-49 LDLcalc-112
.
Blood pressure was well-controlled over the entire hospital stay
without meds.
.
He was also advised to change his eating habits, stop smoking,
and to control his blood pressure tightly in order to prevent
further strokes.
Medications on Admission:
One anti-HTN medication, name unknown.
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
6. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: continuous @ 1220 units/hour Intravenous ASDIR (AS
DIRECTED): Discontinue heparin gtt when INR therapeutic.
(2.0-3.0).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Large anterior and posterior LEFT middle cerebral artery
atheromatous embolic stroke. Origin atheromas/thrombi within
aorta seen on TEE.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
.
NEURO EXAM PERTINENTS ON DISCHARGE:
-able to say words on command, answers simple questions
-extreme TTP right ___ (chronic)
-comprehension intact, follows simple commands
-anomia improving, A&O X 3
-can write name and one word phrases on command
-can sum and count people in room
-can read to follow commands
-R > L pupil, but ERRLA
-LEFT ptosis waxes and wanes
-full strength throughout
-brisk reflexes throughout w/ toes downgoing bilaterally
-slower RAMs on LUE > RUE
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after
you showed signs of neurological impairment including trouble
speaking.
.
Imaging of your head revealed that you had suffered a large
stroke on the left side of your brain in several areas. There
are many things which can cause a stroke like this. Your stroke
was likely caused by a atheromatous thrombus which broke loose
from your aorta. Atheromatous thrombi are made of cholesterol
deposits. Your history of smoking, high blood pressure, and an
unhealthy diet put you at risk for this embolic event.
.
Your blood pressure should be tightly controlled with
medications as well as a low salt diet. It is an absolute
necessity that you stop smoking as soon as possible or else you
run an extremely high risk of having another, more devastating,
stroke. Additionally, your diet must be low in foods with
saturated fats, but high in fruits and vegetables. To help to
keep your cholesterol under good control, we have started a
medication called Simvastatin for you to take daily. If your
cholesterol improves with time, you may not need this medication
forever. Your primary care doctor ___ monitor this.
.
Patients who suffer an embolic stroke like you did must be
treated with a blood thinner. The thinner of choice for
outpatients like yourself is coumadin or warfarin. This
medication does not start to work until ___ days after its
initiation. For this reason, we have started you on heparin in
addition to the warfarin until your blood levels are safe for
warfarin alone.
.
Patients on warfarin must have frequent blood draws to help map
and titrate the medication levels in your blood. Many foods
affect the metabolism of warfarin, and you will be given
materials to read on this topic by our nurses before you leave
the hospital today.
.
After a stroke like this, patient's require extensive
rehabilitation for physical, occupational, and speech tasks. The
more active patients are in their rehab, especially in the time
immediately following the stroke, the better their long term
prognosis in regards to regaining functionality. From the
hospital, it is recommended by our therapists and doctors that
___ have a short stay in rehab prior to returning home. This
rehab stay will allow you to become stronger and more
independent with your everyday tasks.
.
Thank you for allowing us to provide your healthcare. We wish
you the very best with your recovery and health.
Followup Instructions:
___
|
10554761-DS-19 | 10,554,761 | 20,409,234 | DS | 19 | 2125-08-16 00:00:00 | 2125-08-16 21:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Cholestyramine / Ciprofloxacin / Hyoscyamine /
Sulfa (Sulfonamide Antibiotics) / Flagyl / Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Endoscopic Ultrasound and Fine Needle Biopsy ___
History of Present Illness:
Pt is an ___ yo female with six months of abdominal pain of
unlcear etiology, two weeks of night sweats and a thirty pound
weight loss over the last six months, who was transferred from
___ after a new diagnosis of iliac thrombosis. Of
note, pt had an ERCP in ___ for suspected pancreastitis
thought to be ___ choledocholithiasis that revealed a 2 cm area
of narrowing in the lower CBD, as well as a 6 mm stone that was
removed. Brushings were negative for malignant cells. Pt then
had an EUS-FNA in ___ that showed atypical cells. Follow
up CT scan in ___ showed three cytic lesions in the head
of pancreas (pseudocyts vs. IPMN) and 0.9 cm mass in the lower
pole of the left kidney. Pt notes that her abdominal pain has
been getting progressively worse over the last six months. She
notes that her appetite has been severely decreased and has
nausea and abdominal cramping shortly after eating meals. Pt
also says that she has been extremely fatigued and has not been
able to walk her dog for the last month.
Pt received zofran, IV morphine and was started on a
heparin gtt and transfered to ___ for further work up of her
abdominal pain.
Pt was seen by vascular surgery in the ED who recommended
heparin gtt with PTT goal of 60-80, on intervention and
admission to medicine
In the ED, initial VS: Pulse: 73, RR: 14, BP: 149/60, O2Sat:
100
Currently, pt is thirsty and complains of diffuse abdominal
discomfort.
Past Medical History:
- Newly identified pancreatic mass ___, likely malignant in
etiology, biopsy pending
- HTN
- GERD
- Sigmoid Diverticulitis
- Diabetes Mellitus
- h/o Bell's Palsy
- h/o colon resection at OSH for tumor, per patient
non-malignant, no chemo or radation
- Laparoscopic cholecystectomy ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam on admission:
VS - Temp 98.7 F , bp 139/76 HR 75, R 20 , O2-sat 97% RA
GENERAL - ill- appearing female, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, dry mucous membranes, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, minimal diffuse tenderness, no rebound or
guarding, no masses or organomegaly appreciated
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no inguinal LAD
NEURO - awake, A&Ox3, pt with left-sided facial droop consistent
with known Bell's Palsy
Physical Exam on admission:
VS - Tmax 98.4 F , bp 100/54(100-153/54-90) HR 70, R 18 , O2-sat
96% RA
GENERAL - ill- appearing female, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, dry mucous membranes, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, minimal diffuse tenderness, no rebound or
guarding, no masses or organomegaly appreciated
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no inguinal LAD
NEURO - awake, A&Ox3, pt with left-sided facial droop consistent
with known Bell's Palsy
Pertinent Results:
Labs on admission:
___ 11:41AM BLOOD WBC-10.0 RBC-4.69 Hgb-14.1 Hct-41.5
MCV-88 MCH-30.0 MCHC-33.9 RDW-12.4 Plt ___
___ 11:41AM BLOOD ___ PTT-80.2* ___
___ 07:00AM BLOOD Glucose-135* UreaN-13 Creat-0.6 Na-139
K-4.2 Cl-102 HCO3-21* AnGap-20
___ 11:41AM BLOOD ALT-17 AST-45* LD(LDH)-770* AlkPhos-103
TotBili-0.6
___ 07:00AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
___ 06:03AM BLOOD CEA-3.3
___ 11:57AM BLOOD Glucose-161* Na-137 K-5.4* Cl-99
calHCO3-26
Labs on discharge:
___ 06:03AM BLOOD WBC-7.7 RBC-4.62 Hgb-13.8 Hct-40.4 MCV-87
MCH-29.9 MCHC-34.2 RDW-12.6 Plt ___
___ 06:03AM BLOOD ___ PTT-87.4* ___
___ 06:03AM BLOOD Glucose-128* UreaN-13 Creat-0.6 Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
Imaging:
CT Abdomen without contrast ___:
IMPRESSION:
1. DVT involving the left common iliac vein extending into the
IVC to right below the level of the right renal vein.
2. Short non-occlusive thrombus in the SMV below the level of
the confluence with the splenic vein. There is no evidence for
bowel wall edema.
3. New dilatation of the pancreatic duct in the body and tail of
the pancreas with new atrophy of the body and tail of the
pancreas. While no definite mass is seen at the abrupt
transition of the duct to normal caliber, there is now a
hypo-enhancing mass in the uncinate process that is extending to
and encasing the SMA for about 180 degrees, this finding is
concerning for adenocarcinoma. This is a new finding compared
to the prior examination where the SMA had a surrounding fat
plane and there was only mild heterogeneity in the uncinate
process.
EUS ___:
EUS; A 3 cm ill-defined malignant appearing mass was noted at
the head / uncinate pancreas. FNA was performed. The mass
encased the porto-splenic confluence. PD was diffusely dilated
in the body and tail of pancreas.
Brief Hospital Course:
HOSPITAL COURSE
Pt is an ___ yo female with six months of abdominal pain, two
weeks of night sweats and a thirty pound weight loss over the
last six months, who was transferred from ___ after
a new diagnosis of iliac thrombosis, disovered on CT scan and
EUS to have a 3 cm uncinate process mass with invasion into
local vasculature.
ACTIVE
# Pancreatic mass / Abdominal Pain: Given previous bile duct
stricture in conjunction with new iliac vein clot, night sweats,
weight loss and CT scan showing uncinate process lesion we were
extremely concerned for pancreatic malignancy, which was
confirmed on EUS. Surgery was consulted, however they did not
feel that she is a surgical candidate given that the mass
encases the SMA. Pt was converted from IV morphine to MS ___
15mg twice a day with morphine ___ 15 mg every six hours for
breakthrough pain. If does not tolerate morphine ___ side
effects, could change to trial of oxycodone/oxycontin.
Initiated prn simethicone, senna, colace, polyethylene glycol.
# Iliac vein thrombus: Identified on OSH CTA, confirmed by our
radiologists as involving nonocclusive left common iliac vein
extending into the IVC to right below the level of the right
renal vein, also short non-occlusive thrombus in the SMV below
the level of the confluence with the splenic vein. Patient was
anticoagulated w heparin dripp then converted to lovenox 60mg
twice a day for DVT treatment.
# Depression: Patient endorsed several months of feeling
depressed without SI/HI; also with concurrent weight loss and
difficulty sleeping; likely all secondary to ongoing malignancy;
patient evaluated by social work and started mirtazapine 15mg;
patient will likely benefit from further talk-therapy regarding
diagnosis and coping.
INACTIVE
# Hypertension: Normotensive on admission, continued felodipine
and nadaolol
# GERD - Continued pantoprazole
# h/o pancreatitis - cont zenepep
Transitional Issues:
- Dr ___ will follow up pathology results and call Ms. ___
at rehab
- Given known abdominal mass, can uptitrate pain regimen as
needed
- If does not tolerate morphine ___ side effects, could change
to trial of oxycodone/oxycontin.
Medications on Admission:
Felodipine 5 mg daily
nadolol 20 mg daily
Protonix 40 mg bid
Zenepep ___
Discharge Medications:
1. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. zenepep Sig: ___ once a day.
5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release(s)* Refills:*0*
11. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Pancreatic mass
Secondary:
Iliac vein thrombosis
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:
Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were transferred
from ___ after a CT scanound several blood clots and
an abnormality in your pancreas.
You had an endoscopic ultrasound performed of your pancreas,
which showed a large mass, which is most likely cancer. You
were evaluated by surgeons who did not think that surgery was a
good option for you. You had a biopsy performed--once the
results are back Dr. ___ will call you to set up follow-up
appointments.
You were treated with a blood thinner to prevent the clots from
getting any larger. You will need to stay on herapin shots for
an extended period of time.
You are now ready for discharge to a rehab facility.
PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
- STARTED Simethicone 80 mg Tablet four times a day as needed
for gas
- STARTED Senna 8.6 mg Tablet twice a day as needed for
constipation
- STARTED docusate sodium 100 mg twice a day as needed for
constipation
- STARTED mirtazapine 15 mg Tablet at bedtime for sleep
- STARTED polyethylene glycol 3350 17 gram/dose Powder daily
for consipation
- STARTED morphine 15 mg Tablet Extended Release twice a day for
pain
- STARTED enoxaparin 60 mg twice a day for blood clots
- STARTED morphine 15 mg Tablet ___ every six hours as needed for
pain
Followup Instructions:
___
|
10554952-DS-18 | 10,554,952 | 27,914,062 | DS | 18 | 2177-01-09 00:00:00 | 2177-01-12 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, chills, body aches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F previously healthy with recent travel to ___ and
___ presents with fevers, body aches and chills since the
evening prior to admission.
Of note, patient was a nurse at ___ ___ in
___ from ___ through ___. She took
doxycycline malaria prophylaxis for the first year, and used
mosquito nets consistently. She denies ever feeling ill during
those ___ years. Since returning to ___, she has worked as an
___ at ___ and has generally been healthy.
About 3 weeks ago, she suddenly developed fever, chills, and
myalgias. Subsequently, she had daily cyclical fevers. She was
afebrile during the day, with fevers beginning at 4 pm daily and
defervescing overnight on Tylenol/Ibuprofen. Five days after the
fevers began, she went to her PCP. Mono and flu tests were
negative, her PCP suggested likely viral syndrome and
recommended supportive care. However, she continued to have
these daily cyclical fevers and on ___ presented to ___ ED
with fever to 104 and headache. Per patient report, at that time
she was acutely ill, with BP ___, HR 130s, WBC 1.7, and
hemolytic anemia. Her blood smear was sent to CDC for diagnostic
confirmation given atypical presentation and concern for P.
falciparum. CDC labs confirmed P. ovale parasitemia. From ___
records, she had paresitemia of 0.9-1.2% seen on several blood
smears, with ring forms seen in RBCs. She subsequently completed
a 3-day course of Coartem from ___, and was afebrile
following the first day of treatment. The decision was made to
hold off on starting primaquine given patient's pancytopenic
state at that time. Patient had an appointment with ___ ID on
___ to start primaquine, but she developed recurrence of
fevers/chills/body aches yesterday (___) and presented to ___
ED today.
Of note, during prior ___ admission malaria antigen, influenza,
RSV, parainfluenza, mycoplasma, bordatella, babesia, ehrlichia,
and coronavirus were all negative.
Past Medical History:
None
Social History:
___
Family History:
Father - MI, otherwise negative
Physical Exam:
Exam on admission:
VS - AF, 102/60, 66, 16, 100% on RA
General: well appearing, NAD
HEENT: White exudative plaques on tonsils bilaterally, tonsils
not enlarged, no oropharyngeal erythema, MMM, EOMI
Neck: no JVD, tender anterior cervical lymphadenopathy
CV: rrr, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nontender, nondistended, no HSM appreciated,
normoactive bowel sounds
GU: deferred
Ext: warm and well perfused, pulses, no edema
Neuro: grossly normal
Exam on discharge:
General: well appearing, NAD
HEENT: White exudative plaques on tonsils bilaterally, tonsils
not enlarged, no oropharyngeal erythema, MMM, EOMI
Neck: no JVD, tender anterior cervical lymphadenopathy
CV: rrr, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nontender, nondistended, no HSM appreciated,
normoactive bowel sounds
GU: deferred
Ext: warm and well perfused, pulses, no edema
Neuro: grossly normal
Pertinent Results:
LABS UPON ADMISSION:
___ 03:40PM BLOOD WBC-6.9 RBC-3.62* Hgb-9.6* Hct-29.4*
MCV-81* MCH-26.5 MCHC-32.7 RDW-19.1* RDWSD-55.9* Plt ___
___ 03:40PM BLOOD Plt ___
___ 03:40PM BLOOD Glucose-98 UreaN-9 Creat-0.8 Na-133 K-3.8
Cl-98 HCO3-23 AnGap-16
___ 03:40PM BLOOD ALT-16 AST-24 LD(___)-193 AlkPhos-43
TotBili-0.5
LABS UPON DISCHARGE:
___ 07:42AM BLOOD WBC-4.4 RBC-3.73* Hgb-9.6* Hct-31.0*
MCV-83 MCH-25.7* MCHC-31.0* RDW-18.7* RDWSD-56.4* Plt ___
___ 07:42AM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-138 K-3.8
Cl-103 HCO3-24 AnGap-15
___ 07:42AM BLOOD ALT-12 AST-21 LD(___)-146 AlkPhos-37
TotBili-0.3
___ 07:42AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9
OTHER LABS:
___ 07:42AM BLOOD QG6PD-11.3
___ 12:27AM BLOOD Parst S-NEGATIVE
___ 03:10PM BLOOD Parst S-NEGATIVE
___ 03:40PM BLOOD Parst S-NEG
___ 03:40PM BLOOD Albumin-4.3 Iron-10*
___ 03:40PM BLOOD calTIBC-462 ___ Ferritn-57 TRF-355
___ 07:42AM BLOOD SCHISTOSOMA ANTIBODIES-PND
___ 07:42AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
IMAGING:
CXR ___
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear.
There is no
pneumothorax or pleural effusion. There is pectus excavatum
IMPRESSION:
No acute cardiopulmonary abnormalities
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood (Malaria) TAKEN SPECIMEN 1629H @ 1802.
**FINAL REPORT ___
Malaria Antigen Test (Final ___:
Negative for Plasmodium antigen.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
Note, Malaria antigen may be below the detection limit of
this test
in a small percentage of patients. Therefore, malaria
infection can
not be ruled out. Negative results should be confirmed by
thin/thick
smear with testing recommended approximately every ___
hours for 3
consecutive days for optimal sensitivity.
___ 10:32 am THROAT FOR STREP
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
Brief Hospital Course:
___ y/o F previously healthy with travel history to ___ and
___ and recent diagnosis of P. ovale s/p 3-day course of
Coartem presents with fevers, body aches and chills for one day/
# P. ovale malaria:
Patient's presentation of fevers, chills, aches and abdominal
pain in the setting of recent travel to ___ is most
concerning for malaria. Patient presented on ___ to ___ ED
with one week of cyclical fevers, aches and chills and diagnosis
confirmed by CDC with positive P. ovale parasites on blood
smear. She completed a 3-day course of Coartem from ___
and had plans to start Primaquine on ___. However, she
re-presented on ___ with recurrence of fevers/chills/aches.
During this hospitalization, patient appeared to have
uncomplicated malaria, as she does not have symptoms of
hemodynamic instability, severe anemia, coagulopathy,
hypoglycemia, renal failure, hepatic dysfunction, or cerebral
involvement. Infectious Disease was consulted. Parasite smears
were negativex3. Patient was initiated on primaquine (15 mg
daily) for two weeks starting ___, confirmed normal G6PD
activity. Patient was also initiated on a 3-day course of
atovaquone/proguanil(1000 mg - 400 mg) daily to be completed
___. This was initiated given concern for co-infection with
second strain of malaria not responsive to Coartem. Given
potential exposure to other infections, we also tested patient
for Strongyloides and Schistosoma (results still pending). EBV,
CMV, throat swab negative.
# Tonsillar exudates:
Patient developed new tonsillar exudates and tender anterior
cervical lymphadenopathy on the second day of admission. Most
likely etiology is infectious. We tested patient for common
infectious causes including EBV/Monospot, CMV, and Group A
Strep. Patient had evidence of past EBV infection, though
Monospot and all other labs were negative. Managed expectantly
with supportive care.
# T-wave inversions on previous EKG:
Patient had new-onset T-wave inversions seen on EKG during ___
hospitalization. Repeat EKG during this hospitalization showed
no T-wave inversions, normal sinus rhythm.
# Anemia:
Hb 9.6, MCV 81
No evidence of hemolysis
Iron of 11, ferritin 57. Likely ___ iron deficiency
-Consider oral iron replacement as outpatient
TRANSITIONAL ISSUES
===================
--F/u with ID as outpatient
--Consider quant gold as outpatient given possible TB exposure
--Continue primaquine for 14 day course (end date ___
--Continue malarone for 3 day course (end date ___
--F/u pending tests (strongyloidies and schistosomiasis)
--Consider iron for iron deficiency anemia
Medications on Admission:
None
Discharge Medications:
1. Malarone (atovaquone-proguanil) 1000 mg-400 mg oral DAILY
Duration: 3 Days
RX *atovaquone-proguanil 250 mg-100 mg 4 tablet(s) by mouth
daily Disp #*8 Tablet Refills:*0
2. Primaquine Phosphate 15 mg PO DAILY Duration: 14 Days
RX *primaquine 26.3 mg 1 tablet(s) by mouth daily Disp #*12
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Malaria (p ovale)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was I admitted to the hospital?
-You came into the hospital with fevers and chills
-We think that this is likely from your malaria
What happened while I was in the hospital?
-We tested your blood looking for other viruses (CMV, EBV)
-We also looked at your blood and found (no parasites)
-Because of concern for co infection with another type of
malaria, we started you on malarone. You should complete a three
day course of this medication (last day on ___. We also
started you on primaquine, which you will take for 14 days (end
date ___.
What should I do when I leave the hospital?
-You should continue taking your medication (Primaquine and
Malarone)
-You should also follow up with infectious disease
-We have confirmed the following pharmacies have the
medications:
Primaquine - Rite Aide on ___ in S ___
Malarone - ___ on ___
Thank you,
-Your ___ team
Followup Instructions:
___
|
10555659-DS-17 | 10,555,659 | 26,405,103 | DS | 17 | 2187-07-06 00:00:00 | 2187-07-12 09:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
complete heart block
Major Surgical or Invasive Procedure:
Dual chamber pacemaker placement (___)
History of Present Illness:
___ y.o male with pmhx of stage III CKD, HTN and HLD who
experienced several days of lightheadedness, nausea when
standing, went to ED for the same, ___, EKG found to be
complete heart block, negative enzymes. He states that last
___ he had a severe episode of dizziness and he briefly
passed out after quickly standing up. He states that since
___ he has experienced more dizziness on standing. He has
associated left upper abdominal pain on standing. He has had a
similar abdominal discomfort over the past year when walking up
inclines. He is asymptomatic at rest. He typically is very
active walking 3 miles per day during nice weather.
The patient experienced syncope in the ED and went straight to
cath lab from ED for pacemaker placement.
Transfer vitals from the cath lab were 98.9, 124/47, 66, 18, 96%
RA.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Patient currently denies any CP, dyspnea, PND, orthopnea,
dizziness/lightheadedness.
Past Medical History:
hypertension
hyperlipidemia
chronic kidney stage III ___ HTN
LBBB
prostatectomy in ___
bladder cancer and cystectomy in ___
appendectomy in ___.
history of small bowel obstructions
esophageal narrowing status post dilation
cystectomy in ___
prostatectomy in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 98.9, 124/47, 66, 18, 96% RA
GENERAL: WDWNM in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. Urostomy bag with
straw colored clear urine.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Axillary site- no swelling, bruising, hematoma
VS: 98.4, 124-141/52-90, 59-6666, 18, 100% RA
GENERAL:NAD
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. Urostomy bag with
straw colored clear urine.
EXTREMITIES: No c/c/e. No femoral bruits.
Axillary site- no swelling, bruising, hematoma
Pertinent Results:
Labs:
___ 07:17AM BLOOD Glucose-97 UreaN-38* Creat-2.0* Na-139
K-4.8 Cl-107 HCO3-20* AnGap-17
___ 03:30PM BLOOD ___ PTT-31.8 ___
Imaging:
___ Radiology CHEST (PA & LAT)
FINDINGS:
A left-sided pacemaker is new with leads in the expected
position of the right atrium and right ventricle. No focal
consolidation, pleural effusion or pneumothorax is present.
Normal heart size, mediastinal and hilar contours. No evidence
of pulmonary vascular congestion.
IMPRESSION:
New left-sided pacemaker with leads in the expected location of
the right
atrium and right ventricle.
ECG Study Date of ___ 3:24:24 ___ Complete heart block with
junctional rhythm in the thirties with right
bundle-branch block configuration. The atrial rate is 70.
Clinical
correlation is suggested. No previous tracing available for
comparison.
TRACING #1
ECG Study Date of ___ 7:43:02 AM A-V sequentially paced
rhythm with capture, new as compared with previous
tracing of ___ and the rate is now 60.
Brief Hospital Course:
___ y.o male with pmhx of stage III CKD, HTN and HLD who
experienced several days of lightheadedness, nausea when
standing, went to ED and found to be complete heart block, now
s/p PPM.
#Complete heart blcok- Patient presented to OSH with complaint
of lightheadedness and syncope found to be in heart block. EKG
on arrival showed multilevel block with AVNWB with Mobitz II
intra/infra HIS block with RBBB and LPFB pattern junctional
escape rhythm at rate of 25. Patient transferred for emergent
permanent pacemaker placement. EKG on arrival complete heart
block with junctional escape with rate in 30___. SJM Zyper ___
___ successfully implanted on ___. Patient
tolerated procedure well. CXR s/p PPM with leads in RA and RV
and no pneumothorax. EKG ___ AV sequentially paced with
rate of 60. He received ___ procedural cefazolin for
prophylaxis and will complete three days of Kelfex after
discharge.
#HLD- continue simvastatin and fenofibric acid
#HTN- continue losartan, hold atenolol for now, consider
starting amlodipine
Transitional Issues:
- Patient to follow up at device clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Psyllium Wafer Dose is Unknown PO Frequency is Unknown
3. Aspirin EC 325 mg PO DAILY
4. Atenolol 50 mg PO BID
5. Meclizine 25 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Trilipix *NF* (fenofibric acid (choline)) 45 mg Oral daily
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Atenolol 50 mg PO BID
3. Losartan Potassium 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Meclizine 25 mg PO QHS
8. Trilipix *NF* (fenofibric acid (choline)) 45 mg Oral daily
9. Psyllium Wafer 1 WAF PO DAILY
10. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*9 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Complete heart block
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 dizziness and fatigue and
were noted to have complete heart block. A permanent pacemaker
was placed without any complications.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR REGIMEN
START Keflex ___ mg every eight hours for 3 days
Followup Instructions:
___
|
10555770-DS-4 | 10,555,770 | 24,921,021 | DS | 4 | 2168-04-10 00:00:00 | 2168-04-13 22:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, bilateral pulmonary emboli and right heart strain
discovered at ___
___ Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with no significant past
medical history who presents with three days of dyspnea.
The patient reports that she has not been in touch with medical
care on a regular basis since her children were born (about
___ years ago). She noticed some discomfort in the left thigh
since the end of ___ but did not think much of it because she
has a history of back pain radiating into the left leg.
Otherwise she was in her usual state of health. She plays golf
frequently and tries to walk about 2 miles per day. On ___ she
played in a golf tournament and was able to walk around without
symptoms. Three days prior to presentation, she had increasing
shortness of breath. Since that time she has progressed to the
point where she cannot walk more than 20 feet without feeling
shortness of breath. She had no cough, no chest pain, no change
in lower extremity swelling. She has no recent travel with the
exception of travelling to ___ two weeks ago. She did
travel to ___ in ___. She flew to ___ (3.5 hours) then
drove up the ___, playing golf along the way. Some car
rides up to 5 hours at a time. This travel preceded the change
in LLE symptoms as above.
She has no known family history of PE/DVT. Her brother is on
anticoagulation for atrial fibrillation. She has no personal
history of cancer or DVT. She has not had a pap since her last
pregnancy ___ years ago. She reports a mammogram in the
distant past. She has never had a colonoscopy.
She presented to the ___ where she was normotensive
but found to have SaO2 83% on room air. She was placed on 5L NC.
She had an unremarkable EKG. CTA performed that showed a large
bilateral clot burden with evidence of RV strain. She was
transferred to ___ for evaluation for ingervention. She was
started on a heparin gtt 5000 unit bolus at 14:24 on ___.
Labs at ___ pertinent for troponin of 0.07, proBNP of
1844. INR 1.09. Hemoglobin 11.3
In the ED initial vitals were:
T 96.7 HR 80 BP 132/88 RR 20 SaO2 97% 6L NC
Labs/studies notable for:
PTT 131.6
INR 1.2
proBNP ___
Cr 0.7
Trop 0.07
Patient was given:
___ 16:05 IV Heparin ___ Started 1600 units/hr
___ 16:56 IV Heparin ___ Stopped As Dire
The vascular medicine consult team was consulted and
recommended heparin gtt, ___, non-urgent TTE.
Vitals on transfer:
T 98.1 HR 82 BP 126/105 RR 17 SaO2 92% 3L NC
On the floor the patient confirms the history above. She denies
chest pain, fever, cough, chills, syncope, palpitations. She has
ongoing dyspnea with exertion but not at rest.
Past Medical History:
-G3P2 (2 NSVD, 1 SAB)
-Obesity
-Knee pain
Social History:
___
Family History:
No family history of DVT/PE
Mother - colon cancer in her ___, died age ___
Father - ___/CHF, died age ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:
24 HR Data (last updated ___ @ ___
Temp: 98.8 (Tm 98.8), BP: 140/93 (140-148/89-93), HR: 78
(78-82), RR: 18, O2 sat: 95% (94-95), O2 delivery: 3L NC, Wt:
310
lb/140.62 kg
GEN: Nontoxic appearing and appears stated age.
HEENT: PERRL, EOMI, Oropharynx clear with moist mucous
membranes.
NECK: Supple, nontender. No lymphadenopathy.
PULM: Lungs clear to auscultation bilaterally. No wheezes,
rales,
or rhonchi.
CV: RRR normal S1 S2. No murmurs rubs or gallops. Radial pulses
2+ symmetric.
ABD: Obese, soft, nontender, nondistended. Bowel sounds present.
EXTR: Warm, well perfused. No cyanosis, clubbing. Trace
symmetric
edema. Significant subcutaneous tissue in ___.
NEURO: Alert and oriented. Strength ___ in upper and lower
extremities. Sensation to light touch intact and symmetric.
SKIN: No visible ecchymoses or rash.
ADDITIONAL EXAMS PERFORMED ___
PELVIS: bimanual exam with firm, small, regular uterus. No
adnexal masses palpated though exam limited by habitus.
RECTAL: nl tone, fleshy outpouchings of tissue around rectum w/o
obvious vascularity, no blood, guaiac negative. No masses.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1040)
Temp: 98.1 (Tm 99.0), BP: 137/88 (121-167/79-93), HR: 69
(67-79), RR: 20 (___), O2 sat: 88-100% (88-100), O2 delivery:
RA, ambulating
GEN: woman with large body habitus in NAD
HEENT: PERRL, EOMI, Oropharynx clear with moist mucous
membranes.
PULM: Lungs clear to auscultation bilaterally. No wheezes,
rales,
or rhonchi.
CV: RRR normal S1 S2. No murmurs rubs or gallops. Radial pulses
2+ symmetric.
ABD: Obese, soft, nontender, nondistended. Bowel sounds present.
EXTR: Warm, well perfused. No cyanosis, clubbing. Trace
symmetric
edema, no erythema. L leg with varicosity.
NEURO: Alert and oriented. face symmetric. moves all 4 w
purpose.
SKIN: No visible ecchymoses or rash.
Pertinent Results:
ADMISSION LABS
==============
___ 04:05PM BLOOD WBC-7.8 RBC-4.39 Hgb-10.5* Hct-34.3
MCV-78* MCH-23.9* MCHC-30.6* RDW-15.8* RDWSD-44.1 Plt ___
___ 04:05PM BLOOD Neuts-69.5 ___ Monos-5.4 Eos-1.5
Baso-0.4 Im ___ AbsNeut-5.45 AbsLymp-1.79 AbsMono-0.42
AbsEos-0.12 AbsBaso-0.03
___ 04:05PM BLOOD ___ PTT-131.6* ___
___ 04:05PM BLOOD Glucose-106* UreaN-17 Creat-0.7 Na-145
K-4.3 Cl-107 HCO3-25 AnGap-13
___ 04:05PM BLOOD ___ 04:05PM BLOOD cTropnT-0.07*
___ 11:55PM BLOOD CK-MB-5 cTropnT-0.07*
___ 07:15AM BLOOD CK-MB-4 cTropnT-0.07*
PERTINENT LABS
==============
___ 12:51PM BLOOD LMWH-0.90
___ 07:21AM BLOOD calTIBC-412 Ferritn-11* TRF-317
___ 07:21AM BLOOD Iron-29*
___ 07:15AM BLOOD %HbA1c-5.5 eAG-111
___ 07:15AM BLOOD Triglyc-107 HDL-42 CHOL/HD-3.6 LDLcalc-88
___ 07:15AM BLOOD IgA-340
___ 07:15AM BLOOD tTG-IgA-3
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-5.6 RBC-4.11 Hgb-9.8* Hct-32.1*
MCV-78* MCH-23.8* MCHC-30.5* RDW-15.4 RDWSD-42.8 Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-145
K-3.9 Cl-107 HCO3-25 AnGap-13
IMAGING
=======
___ venous duplex ultrasound
IMPRESSION:
No evidence of acutedeep venous thrombosis in the right or left
lower
extremity veins.
___ Transvaginal U/S
IMPRESSION:
1. Limited visualization of the uterus however the endometrium
is normal
measuring 4 mm.
2. Despite effort the ovaries are not visualized.
___ Transthroracic echo
CONCLUSION:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 61 %.
There is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Mildly dilated right
ventricular cavity with low normal free wall motion. Tricuspid
annular plane systolic excursion (TAPSE) is normal. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. There
is no evidence for an aortic arch coarctation. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is mild [1+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mildly dilated right ventricular size with
low-normal function. Moderate pulmonary hypertension. Normal
left ventricular regional and global systolic function.
___ COLONOSCOPY: high residue material noted throughout.
Multiple attempts made to irrigate colon but mucosa could not be
visualized adequately. Right colon evulated in retroflexion and
forward view. Internal hemorrhoids. Polyp (2cm) in proximal
ascending colon (bx performed). Polyp not removed. Repeat
colonscopy for screening as polyps may have been missed, or wait
until anticoagulation can be discontinued and perform at time of
EMR.
path: sessile, serrate adenoma
___ ENDOSCOPY: nl mucosa in esophagus and duodenum. Patchy
erythema and erosions in antrum, compatible with gastritis.
Brief Hospital Course:
SUMMARY
========
Ms. ___ is a ___ year-old woman with no significant past
medical history who presented with three days of dyspnea and was
found to have bilateral submassive pulmonary embolism. She has
been hemodynamically stable with no DVTs, started on heparin and
transitioned to Lovenox. Anti-Xa levels checked and appropriate.
She was also found to have iron deficiency anemia, and underwent
EGD/Colonoscopy which were negative for malignancy. Etiology of
thrombophilia remains unknown.
ACTIVE ISSUES:
===============
# Unprovoked bilateral submassive pulmonary emboli
The patient presented with dyspnea for four days with CTA
demonstrating bilateral submassive PEs with mild troponin
elevation, EKG c/w RH strain; bilateral dopplers negative.
Transthoracic echocardiography with increased RA pressure and RV
dilation. Vascular was consulted and recommended heparin, no
role for thrombolysis. She received heparin and was transitioned
to Lovenox, given DOACs not thoroughly studied for her BMI.
Etiology of thrombophilia unclear although some concern for
malignancy raised given no cancer screening in ___ years. No
other evidence of provocation. No PMH or FMH of clots. Did not
pursue thrombophilia workup as patient age> ___, no family hx
VTE, no recurrent VTE, and no splanchnic or cerebral VTE, no
arterial VTE (___, ___. Scheduled for f/u with
vascular medicine and hematology. Symptomatically improved with
anticoagulatoin, and weaned off oxygen. Satting 94% on RA on
discharge, high ___ with ambulation.
# Malignancy screen
No cancer screening in ___ years. No abdominal, gastrointestinal
symptoms, vaginal bleeding, or weight loss; in fact, reporting
100lb weight gain in past ___ years. However, mild bloating over
the ___. Underwent menopause at age ___, LMP ___. Reports
hx intermittent small volume BRBPR, family hx polyps in middle
age and colon cancer in ___, though ___ here with only a small
non-bleeding polyp (unable to completely visualize d/t
incomplete prep) and EGD with mild gastritis. She will schedule
a follow-up colonscopy in 2 months for possible polyp removal
and better visualization. Started pantoprazole 40mg PO daily for
14 day course. On bimanual exam, she had a small and firm
uterus, no adnexal masses were felt but exam limited by body
habitus. TVUS demonstrated 4mm uterus, however not completely
visualized and ovaries not visualized. Further cancer screening
deferred to outpatient primary care team: mammography, cervical
cancer screening, consider CT abdomen for ovarian, pancreatic,
intestinal malignancy. However, she does not have elevated
calcium which may be a sign o malignancy, and, she has had no
weight loss, but rather a 100 lb weight gain in the past few
years.
# Iron Deficiency Anemia
Hb low, with microcytic but normal RDW. Low ferritin at 11 with
normal transferrin. Suspected chronic low level GI bleed,
however EGD and ___ reassuring against this. Possible
intermittent gastritis with bleeding, although reportedly quite
mild; no blood at present. Also possibly intermittent polyp
bleeding, as pt mentioned intermittent small volume BRBPR. Had
menses until ___ yr ago, but this would not evidence in iron
deficiency anemia one year after menopause.No absorptive
deficiency clinically, and celiac negative. Daily CBC monitored
without drop. Pt received IV iron 125mg x 3d.
CHRONIC ISSUES:
================
# Healthcare maintenance
Has not seen physician in decades, was feeling well. Patient is
obese with family history of coronary artery disease. Patient
advised to have age-appropriate cancer screening as above. A1C
5.5. Lipids wnl.
TRANSITIONAL ISSUES
===================
[ ] Started on Lovenox for minimum of ___ months, likely
indefinite i/s/o unprovoked PE. Scheduled with vascular medicine
to determine length of treatment.
[ ] Needs cancer screening: minimum of normal screening
(mammography, pap smear). Consider more thorough imaging if
screening otherwise unrevealing such as CT Abdomen to assess for
ovarian, pancreatic or intestinal malignancy I/s/o bloating and
unclear etiology of thrombophilia in otherwise active patient.
[ ] Recheck CBC in 1 month. Gastritis treated with PPI and
treated with IV iron so would expect significant improvement in
Hb. If not improved, would consider push enteroscopy.
[ ] On labs drawn here, lipids noted to be wnl and A1c 5.5%
Greater than ___ hour spent on care on day of discharge.
# CODE STATUS: Full
# CONTACT: ___ ___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Enoxaparin Sodium 150 mg SC Q12H
2. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral submassive pulmonary emboli
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having trouble breathing, and felt dizzy
- You were found to have blood clots in your lungs causing
strain on your heart, and transferred here
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received blood thinning medication (heparin) through the
IV
- Your breathing improved and you were transitioned to blood
thinner injections (Lovenox)
- You also were found to have anemia, low red blood cell counts,
and low iron. This is often caused by chronic low level blood
loss.
- Causes of these blood clots were investigated
- You had colonscopy that showed a polyp.
- You had endoscopy that showed stomach irritation (gastritis)
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Give yourself Lovenox injections twice a day, rotating
injection sites.
- There were parts of the colon not entirely visualized on
colonscopy, so you should schedule a repeat colonscopy in 2
months to take a better look, and possibly remove the polyp
- You should have cancer screening for breast and cervical
cancer, and possibly endometrial, ovarian, and other cancers
based on the discretion of your primary care doctor.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10555781-DS-6 | 10,555,781 | 24,518,674 | DS | 6 | 2130-11-24 00:00:00 | 2130-11-24 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
___ biopsy of mass in the mesentary
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of DM2, GERD, Hyperlipidemia, obesity, chronic back
pain,
who presents to the ER with abdominal pain. He noted that this
started 3 days prior to presentation and was provoked by eating
dinner, dull ___, no radiation, not associated with N/V and
went away on its own. This recurred 2 days prior to admission,
but on one day prior to admission, it was ___ would not
remit, and prompted him to come to the ER. There, CT scan showed
mesenteric mass, and he was transferred to ___ for further
evaluation.
He was stable in the ER and seen by ACS who recommended
admission
to medicine. Currently, he feels very mild pain in his mid-lower
abdomen. He states that he can sometimes take food, but it can
provoke pain, and can usually but not always, take liquids
without problems.
ROS is negative for headache, vision changes, N/V, weight loss,
swelling, diarrhea, constipation, dysphagia, fatigue. Complete
ROS is otherwise negative.
Past Medical History:
DM2 - Dx for ___ years, recently started on Glipizide for
slightly elevated A1C
GERD
HTN
Hyperlipidemia
Obesity
chronic back pain
s/p laparoscopic cholecystectomy around ___
s/p cervical spine surgery around ___
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM:
VITALS: (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 rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, obese, non-distended, mild tenderness to deep
palpation in mid abdomen, no hepatosplenomegaly appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle bulk and tone
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: normal thought content, logical thought process,
appropriate affect
DISCHARGE EXAM
T 98.2 BP 155/93 HR ___ RR 20 O2: 96%
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
CV: RRR, no mrg
RESP: CTAB
GI: Abdomen soft, non-distended, slight discomfort/ttp in
epigastric and mid abdomen right under biopsy site. Bowel
sounds
present. No HSM
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 04:30AM GLUCOSE-140* UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
___ 04:30AM ALT(SGPT)-21 AST(SGOT)-25 LD(LDH)-165 ALK
PHOS-74 TOT BILI-0.8
___ 04:30AM LIPASE-24
___ 04:30AM ALBUMIN-4.1 URIC ACID-4.8
___ 04:30AM WBC-8.2 RBC-4.86 HGB-14.8 HCT-43.7 MCV-90
MCH-30.5 MCHC-33.9 RDW-12.3 RDWSD-40.7
___ 04:30AM NEUTS-64.2 ___ MONOS-10.8 EOS-1.6
BASOS-0.5 IM ___ AbsNeut-5.29 AbsLymp-1.85 AbsMono-0.89*
AbsEos-0.13 AbsBaso-0.04
___ 04:30AM PLT COUNT-235
___ 04:30AM ___ PTT-28.1 ___
EKG: pending
WBC 5.0/HB 14.3/Plt 196
Na 141/K 4.2/Cl 101/HCO3 30/BUN 11/Cr 0.8<Glu 142
LFTs (___): wnl
CEA 1.4
CA ___ negative
___ CT Abdomen/Pelvis from outside hospital: no read in our
system, but per surgery note, "There appears to be a roughly
3x3.5cm mass near the root of the mesentery which is adjacent to
multiple small bowel venous and arterial tributaries. there is a
significant inflammatory response in the adjacent mesentery with
multiple small foci of what may be metastatic spread. the small
bowel is closely approximated to this mass and does appear
narrowed in this segment but is not obstructed. there is no
evidence of spread elsewhere. there is no free fluid or free
air."
___: CT orbits: no metal objects in orbits
___: CT Chest: 3 mm solid nodule in R lung apex, mediastinal
lymph nodes measure up to 8mm in the short axis in the R
paratracheal station (5:116). Mild bibasilar atelectasis. No
intrathoracic malignancy.
Brief Hospital Course:
SUMMARY/ASSESSMENT: Mr. ___ is a ___ male with
the
past medical history of HCV s/p anti-viral treatment, DM2, GERD,
Hyperlipidemia, obesity,chronic back pain, who presents to the
ER with abdominal pain and
was found to have mesenteric mass suspicious consistent with a
follicular lymphoma
#Abdominal mass with radiographic concern for local metastasis
causing abdominal pain and partial small bowel obstruction:
Patient's initial CT scan and presentation was concerning for
small bowel obstruction but was still producing gas and having
bowel movements and when re-evaluated showed a narrowing of the
small bowel but no obstruction. Through the hospitalization
patient with early satiety and mild discomfort in the epigastric
area with better meals. Patient's preliminary biopsy done by ___
on ___ showed follicular lymphoma, molecular studies pending.
Patient was seen on discharge by oncology to discuss his
upcoming plan for chemotherapy.
-#DM2: Patient's home metformin and glipizide were held, insulin
sliding scale in the hospital with plan to restart home
medications as an outpatient.
#GERD - continue omeprazole 20 mg daily
#HTN
#Hyperlipidemia: continued home medications
- atorvastatin 20 mg daily
- lisinopril 10 mg daily
#Insomnia
-continue temazepam ___ mg qhs PRN
TRANSITIONAL ISSUES
Labs to follow up on:
Hepatitis Bs antigen/antibody pending
Hepatitis C antibody/viral load pending
Immunoelectrophoresis: pending
HIV: pending
Will follow up with oncology on ___
More than 30 minutes were spent on the patient's discharge
planning
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
2. GlipiZIDE XL 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Lisinopril 10 mg PO DAILY
5. Temazepam ___ mg PO QHS:PRN insomnia
6. Omeprazole 20 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 500 mg 2 capsule(s) by mouth every 8 hours
Disp #*30 Capsule Refills:*0
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Atorvastatin 20 mg PO QPM
4. GlipiZIDE XL 5 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Temazepam ___ mg PO QHS:PRN insomnia
9. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
New mesenteric mass
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 ___ for further workup of a mass near the
root of the mesentery that was seen at an outside hospital. We
were initially concerned about a bowel obstruction but were
reassured by your able to tolerate a regular diet. You received
a biopsy on ___ and you will follow up with oncology an general
surgery regarding a plan moving forward once the biopsy results
come back. The preliminary biopsy showed a low grade follicular
lymphoma. Oncology will be calling you by the end of the week to
schedule an appointment. If you do not hear from them by
tomorrow, please call ___.
It was a pleasure taking part in your care,
Your ___ Team
Followup Instructions:
___
|
10555781-DS-7 | 10,555,781 | 24,504,512 | DS | 7 | 2132-07-18 00:00:00 | 2132-07-18 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Single balloon enteroscopy
History of Present Illness:
Mr. ___ is a ___ year old man with h/o of diabetes mellitus
type 2, HCV infection ___ IFN, with symptomatic stage IIE
follicular lymphoma in remission; ___ 6 cycles of BR regimen
(end ___, who arrives from OSH with c/o abdominal pain with
concern for possible lymphoma recurrence on OSH CT.
Two days prior to admission, he notes developing notable early
satiety with poor PO intake. Then yesterday developed acute
onset worsening abdominal pain. He describes this as ___
"rolling" pain bilateral mid abdominal pain, similar but less
persistent than the pain he had when initially diagnosed with
lymphoma in the setting of an SBO. No nausea/vomiting,
tolerating PO though with decreased intake. His last BM was
yesterday and since was unable to pas gas/stool until this
afternoon. No fevers/chills/night sweats, weight loss, dysuria,
SOB. He describes occasional chest discomfort with exertion
which he thinks is muscle pain.
At OSH, CT scan showed misting of mesentery with prominent lymph
nodes concerning for return of lymphoma. Could not exclude
partial SBO given collection of contrast, though felt to be more
likely related to bolus effect of the contrast.
Abdominal pain has much improved on arrival, ___ from ___
yesterday. He reports feeling less distended now, as his abdomen
was "like a rock" previously.
In the ED,
- Vitals were unremarkable: T 98.5 HR 75 BP 124/71 RR 18 SpO2
96% RA - Exam notable for tenderness to palpation diffusely in
the abdomen. - Labs normal except mildly elevated K as below:
136 | 102 | 12 ---------------- 148 AGap=10 5.3 | 24 | 0.9
WBC 4.7 HGB 13.6 PLT 210
Lactate:1.4 UA neg
Interventions: Given ondansetron and IV dilaudid for a total of
3mg
Consults: Surgery consulted with no acute surgical intervention
indicated. Recs for KUB which showed mild dilated loop of bowel
which is nonspecific.
Review of Systems: (+) Per HPI. Denies fever, chills, night
sweats, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
PAST ONCOLOGIC HISTORY:
ONCOLOGIC HISTORY:
- ___: 3 episodes of abdominal pain -> presented to ED
- ___: CT at ___ showed a 3 X 3.5 cm mass near the
root of mesentery. There was significant inflammatory response
in
the adjacent mesentery with multiple small foci. There was
concern for small bowel thickening as well.
- ___: Hospitalized at ___
- ___: CT chest was negative for any evidence of
intrathoracic malignancy.
- ___: ___ guided core biopsy of mediastinal mass
Final pathology showed follicular lymphoma, grade ___ of 3.
Ki-67
immunostain revealed low proliferation index of ___.
Cytogenetics showed evidence of IGH/BCL-2 gene rearrangement and
gain of MYC. Overall his findings were consistent with low-grade
follicular lymphoma, with No evidence of concurrent involvement
by diffuse large B-cell lymphoma.
LDH at diagnosis was 165. Normal CBC at diagnosis
- ___: Did not meet ___ criteria. However, he was
started
on treatment as he had symptomatic disease (partial SBO).
Recommended BR regimen based on StiL and BRIGHT trials
- ___: C1 D1 & D2 Bendamustine/Rituximab
- ___: C2 D1 & D2 Bendamustine/Rituximab
- ___: C3 D1 & D2 Bendamustine/Rituximab
- Mid-treatment re-staging scans showed persistent haziness
along
the root of mesentery with interval resolution of previously
biopsied mass.
- ___: C4D1 & D2 Bendamustine/Rituximab
- ___: C5D1 & D2 Bendamustine/Rituximab
- ___: C6D1 & D2 Bendamustine/Rituximab
- ___: CT scans showed stable 1.4 cm treated mesenteric mass
and multiple small adjacent mesenteric lymph nodes; with no
bowel
obstruction.
-___: CT scans show improvement in nodular thickening of the
small bowel mesentery and mesenteric fat stranding. No new LAD.
-___: CT torso shows thyroid nodule, stable nodular
thickening of small bowel mesentery and mesenteric fat
stranding,
but no evidence of recurrent disease.
-___: CT A/P no significant interval change in the
mesentery
increased density or
adenopathy. No new adenopathy in the abdomen or pelvis.
Past Medical History:
FOLLICULAR LYMPHOMA
DIABETES MELLITUS
HYPERTENSION
GASTROESOPHAGEAL REFLUX
SACROILIITIS
Surgical History Last Updated: ___
CHOLECYSTECTOMY ___
CERVICAL SPINE SURGERY ___
Social History:
___
Family History:
- Father: ___ cancer
- ___ grandfather: ___ cancer, colon cancer at age of
___ years, smoker
- Maternal grandmother: Lung cancer, smoker
Physical Exam:
ADMISSION EXAM
==============
Vitals: ___ 1722 Temp: 98.7 PO BP: 136/84 HR: 79 RR: 18 O2
sat: 96% O2 delivery: RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM.
NECK: JVP not elevated
LYMPH: no apparent cervical or axillary LAD but notably firm L
SCM muscle
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi.
ABD: NABS. Soft, moderately distended but soft. Diffusely tender
to palpation slightly worse near RUQ. no rebound or guarding
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: R antecubital PIV
DISCHARGE EXAM
===============
24 HR Data (last updated ___ @ 351)
Temp: 97.6 (Tm 98.3), BP: 124/73 (124-137/73-81), HR: 61
(61-72), RR: 18 (___), O2 sat: 98% (95-98), O2 delivery: Ra
Gen: NAD
HEENT: MMM.
LYMPH: no apparent cervical or axillary LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi.
ABD: Moderately distended but soft. Mild periumbilical TTP, no
guarding.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: R antecubital PIV
Pertinent Results:
ADMISSION LABS
==============
___ 06:17AM BLOOD WBC-4.7 RBC-4.39* Hgb-13.6* Hct-40.8
MCV-93 MCH-31.0 MCHC-33.3 RDW-12.8 RDWSD-43.8 Plt ___
___ 06:17AM BLOOD Neuts-59.6 ___ Monos-13.8*
Eos-3.6 Baso-0.6 Im ___ AbsNeut-2.81 AbsLymp-1.04*
AbsMono-0.65 AbsEos-0.17 AbsBaso-0.03
___ 05:22AM BLOOD ___ PTT-29.7 ___
___ 06:17AM BLOOD Glucose-148* UreaN-12 Creat-0.9 Na-136
K-5.3 Cl-102 HCO3-24 AnGap-10
DISCHARGE LABS
===============
___ 03:20PM BLOOD ALT-21 AST-19 LD(LDH)-195 AlkPhos-91
TotBili-1.2
___ 06:17AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
___ 06:39AM BLOOD Lactate-1.4
___ 05:30AM BLOOD WBC-5.7 RBC-4.63 Hgb-14.1 Hct-42.3 MCV-91
MCH-30.5 MCHC-33.3 RDW-12.4 RDWSD-40.6 Plt ___
___ 05:30AM BLOOD Neuts-55.1 ___ Monos-13.0 Eos-5.2
Baso-0.9 Im ___ AbsNeut-1.82 AbsLymp-0.83* AbsMono-0.43
AbsEos-0.17 AbsBaso-0.03
___ 05:30AM
IMAGING
=======
CT neck W/contrast (___)
1. No evidence of malignancy within the neck.
2. 1.6 cm left thyroid nodule, unchanged compared to the thyroid
ultrasound
dated ___.
CT chest W/contrast disease (___)
1. No evidence of metastatic disease within the chest.
2. Please refer to the CT neck with the same date for evaluation
of the left
thyroid nodule.
3. Hepatic steatosis.
MR enterography (___)
1. Technical limitation due to artifact from endoclips.
2. Decreased caliber of the proximal small bowel with no
evidence of
obstruction. Mild localized jejunal mesenteric stranding may
correspond with the previously identified abnormal jejunal
segment, but the bowel does not demonstrate thickening on this
study. This could represent a resolving
inflammatory process. There is no evidence of focal mass.
STUDIES/PROCEDURES
====================
Single balloon enteroscopy (___)
Normal mucosa in the whole esophagus, stomach, duodenum,
examined jejunum.
PATHOLOGY
=============
___
Small intestine, random, biopsy:
Small intestinal mucosa, no diagnostic abnormalities recognized.
BLOOD Glucose-150* UreaN-7 Creat-1.0 Na-145 K-4.2 Cl-106
HCO3-27 AnGap-12
___ 05:30AM BLOOD ALT-18 AST-17 LD(LDH)-164 AlkPhos-74
TotBili-0.9
___ 05:30AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ year old man with h/o of diabetes mellitus
type 2, HCV infection ___ IFN, with symptomatic stage IIE
follicular lymphoma in remission; ___ 6 cycles of BR regimen
(end ___, who arrived from OSH with c/o abdominal pain.
Symptoms included early satiety, poor p.o. intake, decreased
flatus, and ___ abdominal pain worse with eating. CT scan at
the outside hospital showed misting of mesentery with prominent
lymph nodes concerning for return of lymphoma. After transfer to
___ chest and neck were obtained that did not show any
metastatic disease. Single balloon enteroscopy was completed by
the advanced endoscopy team which did not demonstrate any
narrowing, obstruction, or bowel wall thickening. Random jejunal
biopsies were obtained which showed normal mucosa. MRE showed no
evidence of obstruction, mild localized jejunal mesenteric fat
stranding, and no evidence of focal mass. Colorectal surgery
team was consulted and overall impression was of mesenteric
panniculitis and partial small bowel obstruction. There was no
evidence of recurrence of lymphoma on any of the above studies;
however, PET CT was scheduled as an outpatient to further
evaluate for any evidence of lymphoma recurrence. Prior to
discharge patient was tolerating diet with minimal abdominal
pain and was passing gas and having normal bowel movements.
TRANSITIONAL ISSUES
====================
[] Follow-up PET CT scan to comprehensively evaluate for
recurrence of lymphoma
[] Colorectal surgery recommended repeat CT abdomen in 3 to 4
weeks to evaluate for resolution of mesenteric panniculitis
[] Follow-up appointments: Dr. ___ oncologist), Dr.
___ surgery)
CHRONIC ISSUES
==============
# History of follicular lymphoma
Follows w Dr. ___ 6 cycles of bendamustine and rituximab
(BR) for symptomatic follicular lymphoma, since in remission
after last cycle in ___. Scheduled for outpatient follow-up
with Dr. ___ PET-CT scan as above.
# DM2: Held home MetFORMIN XR (Glucophage XR) 1000 mg PO BID,
GlipiZIDE XL 10 mg PO DAILY while inpatient. Continued home
Atorvastatin 40 mg PO QPM given ___ yo with DM2
# GERD: Omeprazole 40 mg PO DAILY
# Hypertension: home Lisinopril 10 mg PO DAILY
# Anxiety: Zolpidem Tartrate 10 mg PO QHS
CORE MEASURES
==============
# CODE: Presumed Full
# EMERGENCY CONTACT: ___ (HCP, wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. GlipiZIDE XL 10 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
6. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. GlipiZIDE XL 10 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Abdominal pain
Partial small bowel obstruction
SECONDARY DIAGNOSES:
====================
Type 2 diabetes mellitus
Hypertension
GERD
History of follicular lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had several imaging studies including a single balloon
enteroscopy, magnetic resonance enterography, and CT scan of the
chest and neck. You were also seen by the colorectal surgery
team. No definitive diagnosis was made for the cause of your
abdominal pain, but the overall impression is that you had a
partial small bowel obstruction and a condition known as a
mesenteric folliculitis.
- There was no evidence of recurrence of your lymphoma. You
are scheduled for an outpatient PET scan to comprehensively
evaluate for any recurrence. You are also scheduled for
follow-up with your primary oncologist Dr. ___.
- You are scheduled for follow-up with Dr. ___ with
colorectal surgery to monitor resolution of the mesenteric
panniculitis.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You should continue to eat small portions and stick with low
fiber foods.
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Seek medical attention if you have new or concerning symptoms
such as inability to eat or drink, inability to have a bowel
movement, or vomiting.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10556108-DS-11 | 10,556,108 | 21,699,228 | DS | 11 | 2176-04-27 00:00:00 | 2176-04-28 21:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal distension, scrotal edema, and dizziness
Major Surgical or Invasive Procedure:
intubation ___
MAC line placement ___
A-line placement ___
diagnostic paracentesis ___
diagnostic and therapeutic paracentesis ___
therapeutic paracentesis ___
History of Present Illness:
___ w/ PMH of alcoholic cirrhosis (Child Class C) c/b recurrent
ascites, hepatic encephalopathy and varices who presents with
diffuse abdominal distension, scrotal edema, and dizziness.
The patient has had multiple prior admissions, for complications
from his liver cirrhosis. Briefly, he was admitted in ___
HRS, requiring midodrine and ocrtreotide. He was enrolled in
the
trial of Terlipressin trial without good effect. His hospital
course was complicated by enterococcus UTI (resistant) requiring
IV vancomycin. After discharge he had a large volume
paracentesis and was restarted on his home diuretics.
He was admitted once again in ___ for ___ ___ HRS. His
creatinine was stabilized on midodrine and octreotide and he was
discharged
with midodrine. His course was again complicated by a UTI
requiring IV ceftriaxone. His furosemide 20mg daily and
spironolactone 50mg daily were stopped due to HRS. Multiple
family meetings were held emphasizing the importance of sobriety
moving forward.
Since discharge, the patient was well until 3 days prior to
admission. He states he had a fall, striking his head. Since
then, he has had intermittent lightheadedness and dizziness. He
states that he has also had progression of his ascites and
significant scrotal edema. Otherwise, he denied any double
vision
but he does endorse a dull aching headache.
He denied any fevers, chills, nausea, vomiting, dysuria or
hematuria. He was scheduled to get a therapeutic paracentesis on
the day of admission. However, he states that the dizziness and
scrotal edema were so much worse that he presented to ___ ED
for evaluation.
In the ED, the patient had an episode of large volume
hematemesis. He started to become more hypotensive, and was
intubated for airway protection.
Initial Vitals:
T 96.4 HR 114 BP 95/42 RR 18 SPO2 100% RA
Exam:
Gen: Appears uncomfortable, not acute distress
HEENT: NC/AT. EOMI.
Neck: No swelling. Trachea is midline. No JVD
Cor: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Profound distention and extreme scrotal edema
Ext: No edema, cyanosis, or clubbing.
Skin: No rashes. No skin breakdown
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechia. No ecchymosis.
Labs:
CBC: WBC 15.8 Hgb 8.0
INR: 1.9
BMP: Na 126 BUN/Cr 42/4.0
Lactate: 17.0 -> 16.0 -> 13.3
Diagnostic Paracentesis: Protein 1.5 WBC 105 PMN 8
UA: pnd
Utox: pnd
Imaging:
+CT Abd/Pelvis:
1. Large amount of intra-abdominal ascites tracking through left
inguinal hernia into the scrotum with large resultant hydrocele.
No subcutaneous gas identified.
2. Cirrhotic morphology of the liver which is diffusely
heterogeneous with low attenuating areas. This could be due to
geographic fat given lack of focal abnormality identified on
prior ultrasound. However, follow-up, nonurgent MRI is suggested
when patient is amenable to exclude mass.
3. Cholelithiasis.
4. Apparent wall thickening of the distal esophagus could be in
part to adjacent varices and possible esophagitis.
5. Left-sided rib deformities compatible with fractures though
the acuity of which should be correlated clinically.
+CT Head W/O Contrast
No acute intracranial abnormality.
+CXR
In comparison with the study of ___, there is an placement
of an endotracheal tube with its tip approximately 2.5 cm above
the carina. Nasogastric tube tip is in the upper stomach, with
the side port above the esophagogastric junction. The tube
should
be pushed forward at least 5-8 cm for more optimal positioning.
There are very low lung volumes. The cardiac silhouette is at
the
upper limits of normal and there is no evidence acute pneumonia.
Some indistinctness of engorged pulmonary vessels on the left
could represent asymmetric edema.
+RUQUS:
1. Cirrhotic liver, without evidence of focal lesion.
2. The portal vein and its right and left branches demonstrates
hepatofugal flow.
3. Borderline splenomegaly.
4. Nondistended gallbladder with wall thickening likely
secondary
to chronic
liver disease.
Consults: GI, ACS
Interventions:
IVF LR ( 500 mL ordered)
IV DRIP Octreotide Acetate (50 mcg/hr ordered)
IV Albumin 5% (12.5g / 250mL) 25 g
IV Vancomycin (1000 mg ordered)
IV Clindamycin (600 mg ordered)
IV MetroNIDAZOLE (500 mg ordered)
+IV CefTRIAXone 2g
IV Etomidate 20 mg
IV Rocuronium 100 mg
IV DRIP Fentanyl Citrate ___ mcg/hr ordered)
IV DRIP Midazolam ___ mg/hr ordered)
VS Prior to Transfer:
T 97.2 HR 135 BP 100/49 RR 20 SPO2 100% intubated
On arrival to the MICU, the patient is intubated and sedated.
Past Medical History:
- EtOH Use Disorder
- cirrhosis w/o h/o GIB, ascites, HE
- GERD
Social History:
___
Family History:
Mother - CAD,
Father - HTN, ___ Abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in metavision
GENERAL: intubated and sedated
HEENT: PERLLA. mild scleral icterus. dry mucous membranes. ETT
in
place. crusted blood around mouth.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: absent bowel sounds. distended with fluid wave. No
organomegaly.
EXTREMITIES: No peripheral or dependent edema. Pulses DP/Radial
2+ bilaterally.
SKIN: diffuse spider angiomata and palmar erythema.
NEUROLOGIC: CN2-12 grossly intact. no asterixis.
Discharge Exam
-----------------
Deferred due to patient comfort.
Patient noted to be resting comfortably in his bed, denying any
pain or discomfort. Breathing was noted to be unlabored.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:55AM BLOOD WBC-15.8* RBC-2.48* Hgb-8.0* Hct-24.3*
MCV-98 MCH-32.3* MCHC-32.9 RDW-16.4* RDWSD-57.8* Plt ___
___ 06:55AM BLOOD Neuts-86.7* Lymphs-5.7* Monos-6.6
Eos-0.1* Baso-0.1 Im ___ AbsNeut-13.74* AbsLymp-0.90*
AbsMono-1.04* AbsEos-0.01* AbsBaso-0.02
___ 06:55AM BLOOD ___ PTT-35.7 ___
___ 04:57PM BLOOD ___
___ 06:55AM BLOOD Glucose-90 UreaN-42* Creat-4.0*# Na-126*
K-6.8* Cl-74* HCO3-16* AnGap-36*
___ 06:55AM BLOOD ALT-47* AST-200* AlkPhos-82 TotBili-4.3*
___ 06:55AM BLOOD Lipase-29
___ 06:55AM BLOOD Albumin-2.8* Calcium-9.0 Phos-7.6*
Mg-1.4*
___ 03:59PM BLOOD Type-ART pO2-96 pCO2-42 pH-7.41
calTCO2-28 Base XS-1
___ 07:00AM BLOOD Lactate-17.0*
___ 09:04AM BLOOD Lactate-16.0* Creat-4.1* K-4.9
___ 10:25AM BLOOD Lactate-13.3*
___ 03:59PM BLOOD Lactate-7.4*
___ 11:45AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 11:45AM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 11:45AM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-0
___ 11:45AM URINE CastHy-28*
___ 11:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 07:05AM ASCITES TNC-105* RBC-357* Polys-8* Lymphs-12*
Monos-3* Mesothe-3* Macroph-74* Other-0
___ 07:05AM ASCITES TotPro-1.5 Glucose-130
INTERIM LABS:
==============
___ 11:35AM ASCITES TNC-57* RBC-1030* Polys-50* Lymphs-31*
Monos-9* Macroph-10*
___ 11:35AM ASCITES TotPro-1.6 LD(LDH)-67 TotBili-0.7
Albumin-0.7
___ 05:24AM URINE Hours-RANDOM Creat-186 Na-<20
___ 05:24AM URINE Osmolal-322
___ 05:25AM BLOOD Cortsol-9.3
___ 05:25AM BLOOD Osmolal-289
___ 11:27PM BLOOD Lactate-1.2
___ 10:49AM BLOOD O2 Sat-80
DISCHARGE LABS:
================
MICROBIOLOGY:
==============
___ 11:35 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending): No growth to date.
___ 11:35 am PERITONEAL FLUID PERITONEAL FLUID.
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 (Preliminary): NO GROWTH.
___ Blood Culture, Routine-PENDING INPATIENT
___ 2:34 pm SWAB Source: Stool. R/O VANCOMYCIN
RESISTANT ENTEROCOCCUS (Final ___: No VRE isolated.
___ Blood Culture, Routine-PENDING INPATIENT
___ MRSA SCREEN-FINAL No MRSA isolated.
___ URINE CULTURE (Final ___:
< 10,000 CFU/mL.
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Blood Culture, Routine-FINAL NO GROWTH.
___ 7:05 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
3+ ___ 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 (Preliminary): NO GROWTH.
IMAGING:
==========
RUQUS ___
1. Cirrhotic liver, without evidence of focal lesion.
2. The portal vein and its right and left branches demonstrates
hepatofugal flow.
3. Borderline splenomegaly.
4. Nondistended gallbladder with wall thickening likely
secondary to chronic liver disease.
CXR ___
In comparison with the study of ___, there is an placement
of an
endotracheal tube with its tip approximately 2.5 cm above the
carina.
Nasogastric tube tip is in the upper stomach, with the side port
above the
esophagogastric junction. The tube should be pushed forward at
least 5-8 cm for more optimal positioning.
There are very low lung volumes. The cardiac silhouette is at
the upper
limits of normal and there is no evidence acute pneumonia. Some
indistinctness of engorged pulmonary vessels on the left could
represent
asymmetric edema.
CT ABD & PELVIS W/O CONTRAST ___
1. Large amount of intra-abdominal ascites tracking through left
inguinal
hernia into the scrotum with large resultant left hydrocele. No
subcutaneous gas identified.
2. Cirrhotic morphology of the liver which is diffusely
heterogeneous with low attenuating areas. This could be due to
geographic fat given lack of focal abnormality identified on
prior ultrasound. However, follow-up, nonurgent MRI is suggested
when patient is amenable to exclude mass.
3. Cholelithiasis.
4. Apparent wall thickening of the distal esophagus could be in
part to
adjacent varices and possible esophagitis.
5. Left-sided rib deformities compatible with fractures though
the acuity of which should be correlated clinically.
CT HEAD W/O CONTRAST ___
No acute intracranial abnormality.
CHEST PORT. LINE PLACEMENT ___
1. Right IJ catheter projects over the right lung apex.
2. Enteric tube terminates at the GE junction, with the side
port projecting over the mid to distal esophagus. Consider
advancement for optimal positioning.
RENAL U/S ___
No hydronephrosis. Massive ascites..a
CXR ___
New mild pulmonary edema and increased left basilar atelectasis.
TTE ___
Vigorous biventricular systolic function. No clinically
significant valvular disease. Normal pulmonary pressure.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
CXR ___
In the final image, the Dobhoff tip projects over the stomach.
Discharge Labs
=-=============
Deferred as patient transitioned to CMO
Brief Hospital Course:
Mr. ___ is a ___ w/ PMH of alcoholic cirrhosis (Child
Class C) c/b recurrent ascites, hepatic encephalopathy and
varices, not a transplant candidate as he is actively drinking,
who presented in the setting of an acute GI bleed, shock, and
___ on CKD, intubated iso hematemesis and admitted to the MICU.
He became anuric without evidence of renal recovery and was not
started on dialysis given his ultimate prognosis and likely
inability to tolerate HD from a hemodynamic standpoint. After
some days of goals of care discussions, the decision was made
for ___ to be transferred home with hospice.
Transitional Issues
===================
**Patient is CMO**
[] Drain pleurX catheter regularly and ensure patient and family
understands how to use it.
[] Patient discharged on short course of oxycodone until IV
morphine is delivered
[] MOLST filled out DNR/DNI/Do no transfer to hospital
ACUTE ISSUES
===============
#Goals of care discussions
The patient and family have had multiple conversations regarding
his goals of care with his primary hepatologist. With ___
liver failure and subsequent renal failure without hope of
curative intervention, ___ prognosis is poor. Ultimately,
palliative care was consulted and after some days of thinking
and in-depth discussion with family, patient was transitioned to
___ focused care, though with continued lab draws and
midodrine. He is being transferred home with hospice.
# Hematemesis:
# c/f UGIB
# Esophagitis
# Acute on chronic normocytic anemia:
Hb 9 at baseline. On admission ___ s/p 1 episode of hematemesis.
EGD notable for grade D esophagitis, likely ___ tear
at GEJ, with large grade ___ varices. Mild Hb drop ___ requiring
1U PRBC without HD instability or active extravasation, possibly
___ mild oozing from severe esophagitis. Started sucralfate
x14d, ___, octreotide drip, IV PPI which was transitioned to
PO.
# Shock:
Initially hypotensive required pressors. Weaned off quickly.
Differential included distributive ___ sepsis but infectious
workup was unrevealing. Ceftazidime was continued empirically
for possible pulmonary or intra-andominal source. Home midodrine
was continued.
# Respiratory Failure:
The patient was intubated in the setting of airway protection
after an episode of hematemesis. There was no evidence of
hypoxemia that was contributing prior to intubation.
Successfully extubated ___.
# ___ on CKD
# Hepatorenal syndrome:
Baseline Cr ~2.2 elevated to 4.0 on admission. The patient has a
history of hepatorenal syndrome. He was recently managed with
diuretics in ___, though currently off diuretics given HRS. Has
had recurrent ascites, requiring multiple therapeutic
paracenteses. In the past, has had unsuccessful responses to
challenge or terlipressin, though has responded to octreotide
and midodrine. Other contributions include intravascular volume
depletion. Renal consulted and determined he was not ___ candidate
for RRT given his liver transplant candidacy. He received
albumin challenge, then continue midodrine/octreotide. He
remained anuric without any evidence of renal recovery.
# Decompensated alcohol cirrhosis (MELD 32, CHILDS C):
Patient with h/o alcohol cirrhosis complicated by refractory
ascites. He is not a transplant candidate as he is actively
drinking. Last EGD in ___ showed 3 cords of grade 2 varices.
Also complicated by HE and HRS, with multiple recent admissions
for renal failure. He had multiple paras and ultimately had a
pleurX placed for management of his ascites.
- HE prophylaxis: no evidence of HE, remained on lactulose PRN.
- Varices: Severe esophagitis and large grade ___ varices
- SBP: s/p diagnostic para ___ negative for SBP. On ceftazidime
given concern for sepsis for 7 day course to finish ___, then
switch to SBP ppx with ciprofloxacin
- Nutrition: tube feeds and regular/thin diet
# Hydrocele
# c/f cellulitis:
The patient has had baseline scrotal edema, with an acute
worsening. CT A/P on admission with large resultant hydrocele.
No subcutaneous gas identified. Per ACS, consulted in ED, low
c/f ___ so recommended d/c'ing clinda which he received
briefly on admission.
# Traumatic fall
# Left Sided Rib Fractures:
Patient stated he had a mechanical fall 3 days prior to
presentation. CT head neg for any acute intracranial process. CT
Abd/Pelvis reporting multiple rib fractures. Encouraged
incentive spirometer.
# Thrombocytopenia
# Coagulopathy:
Likely in the setting of his underlying liver dysfunction. Of
note, his platelet count acutely worsened from baseline,
possible reactive ___ acute infection resulting in marrow
suppression. Ongoing bleed likely exacerbated by his elevated
INR. Trended fibrinogen, CBC, platelets. Had oozing from his
neck after discontinuing the MAC line, improved with FFP.
# Portal Vein thrombus:
Documented on prior CT during last hospitalization.
# AGMA
# Lactic Acidosis:
Lactate elevated to 17 initially on admission, improved
substantially with blood resuscitation and pressure support.
# Hyponatremia:
Presented with Na 125-126. Likely hypervolemic hyponatremia in
the setting of liver cirrhosis. Clinically volume overloaded
with significant ascites. Na improved to 130s.
CHRONIC ISSUES
==============
# Alcohol use disorder:
Current ETOH use with longstanding etoh use disorder.
# GERD
- discharged on omeprazole 20mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Midodrine 15 mg PO TID
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Lactulose 30 mL PO DAILY
6. Sarna Lotion 1 Appl TP DAILY:PRN itching
7. Magnesium Oxide 400 mg PO BID
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) ___ mg PO Q2H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every two to three
hours as needed Disp #*60 Tablet Refills:*0
2. Midodrine 20 mg PO TID
3. Lactulose 30 mL PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Sarna Lotion 1 Appl TP DAILY:PRN itching
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
--------
EtOH cirrhosis
Hemorrhagic shock
Upper Gastrointestinal bleed
Acute tubular necrosis
acute hypoxemic respiratory failure
decompensated cirrhosis
portal hypertension
hepatorenal syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for gastrointestinal bleeding.
What was done for me while I was in the hospital?
- Your liver failure led to worsening kidney failure and your
kidneys stopped working.
- You, with your family, came to accept that ultimately you did
not have much time left to live.
- We transitioned our focus from extending your life, to
optimizing the time you have left
- We placed a catheter in your belly to help remove the excess
fluid
What should I do when I leave the hospital?
- Enjoy the time you have left with your loved ones
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10556676-DS-4 | 10,556,676 | 25,577,156 | DS | 4 | 2163-12-19 00:00:00 | 2163-12-19 21:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
transaminitis
Major Surgical or Invasive Procedure:
EGD ___
Diagnostic/therapeutic paracentesis ___
Central line placement
___ placement with esophageal perforation
TIPS
Multiple intubations
Tracheostomy placement
History of Present Illness:
___ F hx of EtOh abuse, presents to the ED after falling down
stairs and admitted to medicine for abnormal LFTs.
___ the ED, initial VS were: 98.6 72 ___ 100/RA. Labs
notable for EtOH level 136, AST 371, ALT 81, tbili 8.8, Na 122,
lactate 4.7, albumin 2.3, INR 1.5, lipase 116, WBC 12 (N88), MCV
110. Pt had normal platelets and renal function. Serum tox
screen negative. Multiple radiology studies obtained as part of
trauma workup including: CT head, CT c-spine, wrist, chest and
pelvic plain films. Pt had R comminuted wrist fracture. RUQ u/s
obtained and showed cirrhosis w ascites, unable to r/o PVT.
Orthopedics consulted and recommended surgical reduction
tomorrow as add on case. She was given fentanyl 50mcg, and
tetanus vaccine. Also received 2L NS.
On arrival to the floor, pt reports that she's been drinking at
least 1 regular sized bottle of wine daily since losing her job
___ years ago. She had elevated LFTs ___ years ago at her PCP but no
other known liver issue. No f/u with PCP ___. She denies hx
of jaundice, ascites, ___, encephalopathy or hemoptysis. Denies
hx of withdrawal, seizure, or ICU stay ___ EtOH use. Has been to
rehab before. She endorses anorexia, weight loss (used to wear a
size 8, doesn't recall weight prior), abdominal distension that
started 1 week ago. Says she didn't realize her eyes were
yellow. Husband drinks beers regularly and children are
chronically ill -she cites these issues as current stressors.
Had a blood transfusion as a newborn due to prematurity.
Otherwise, denies recent fever, n/v, BRBPR, confusion, rash, or
abd pain.
Past Medical History:
EtOH use
HTN
ulcerative colitis: self dc'd asachol, last GI seen ___ yrs ago
by Dr. ___. last colonoscopy ___ yrs ago, no EGD.
Social History:
___
Family History:
Mother deceased with COPD, father alive without medical issues,
brother DM
Physical ___:
ADMISSION PHYSICAL EXAM:
VS - 984 91/56 81 19 98/RA wt 52KG
GENERAL - ill appearing cachectic female anxious lying ___ bed,
cooperative, appropriate
HEENT - scalp laceration, PERRL, EOMI, sclerae icteric, mucus
membranes pink/dry, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, poor air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - distended, firm, nontender, liver border palpated and
nontender, fluid wave present with shifting dullness, caput
medusae
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - small scattered spider angiomata over chest, very dry and
peeling diffusely
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, no
asterixis
DISCHARGE PHYSICAL EXAM:
VS: 99.1, Tc 98.8, 105/67 (94-120/52-87), 81 (80-87), 20, 98% on
35% FIO2 trach mask, I/O: TF: 1000, flush: 1560 + 50/1300,
1400cc stools and guaic negative stools. Since midnight: TF 200
+ flush 300/550
GENERAL: Chronically ill appearing thin woman with trach and
trach mask ___ place. Comfortable, sleepy this morning, but
responding to questions and following commands
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with JVP at clavicle
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles,
fewer rhonchi and upper respiratory sounds. No wheezes
ABDOMEN: Distended but Soft, non-tender to palpation. +fluid
wave. Nontender to palpation.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
pitting ___ bilaterally to knees. 2+ edema of upper b/l
extremities. R wrist stabilized with cast. Able to wiggle toes
and squeeze fingers, but unable to lift any extremities.
Strength ___
NEURO: A&Ox3, unable to assess asterixis due to weakness
Pertinent Results:
___ 06:45PM BLOOD WBC-12.5*# RBC-3.19* Hgb-11.7* Hct-35.2*
MCV-110*# MCH-36.6*# MCHC-33.2 RDW-15.8* Plt ___
___ 05:25AM BLOOD WBC-9.5 RBC-2.72* Hgb-10.1* Hct-29.7*
MCV-110* MCH-37.0* MCHC-33.8 RDW-15.4 Plt ___
___ 05:40AM BLOOD WBC-9.3 RBC-2.71* Hgb-10.1* Hct-30.5*
MCV-113* MCH-37.4* MCHC-33.2 RDW-16.2* Plt ___
___ 06:10AM BLOOD WBC-8.9 RBC-2.77* Hgb-10.3* Hct-31.4*
MCV-113* MCH-37.0* MCHC-32.7 RDW-15.6* Plt ___
___ 06:20AM BLOOD WBC-8.3 RBC-2.01*# Hgb-7.6*# Hct-23.1*#
MCV-115* MCH-37.9* MCHC-33.0 RDW-16.5* Plt ___
___ 08:55AM BLOOD Hgb-7.8* Hct-24.0*
___ 03:08PM BLOOD WBC-12.3* RBC-1.68* Hgb-6.3* Hct-19.9*
MCV-119* MCH-37.7* MCHC-31.8 RDW-17.2* Plt ___
___ 08:27PM BLOOD Hct-20.6*
___ 10:10PM BLOOD Hct-22.6*
___ 11:45PM BLOOD Hct-32.0*# Plt ___
___ 03:40AM BLOOD WBC-12.0* RBC-3.04*# Hgb-10.1*# Hct-28.9*
MCV-95# MCH-33.1*# MCHC-34.9 RDW-20.0* Plt ___
___ 12:05PM BLOOD WBC-9.1 RBC-2.86* Hgb-9.6* Hct-26.2*
MCV-91 MCH-33.4* MCHC-36.5* RDW-20.3* Plt ___
___ 04:00PM BLOOD WBC-10.9 RBC-2.71* Hgb-9.2* Hct-24.9*
MCV-92 MCH-34.2* MCHC-37.1* RDW-20.9* Plt ___
___ 05:00PM BLOOD Hct-25.3*
___ 08:00PM BLOOD Hct-32.1*#
___ 03:30PM BLOOD Hct-32.6*
___ 06:48PM BLOOD Hct-30.8*
___ 04:02AM BLOOD WBC-15.9* RBC-3.28* Hgb-10.8* Hct-32.5*
MCV-99* MCH-33.0* MCHC-33.3 RDW-22.9* Plt ___
___ 05:52PM BLOOD WBC-18.0* RBC-3.32* Hgb-11.4* Hct-34.0*
MCV-103* MCH-34.4* MCHC-33.5 RDW-23.2* Plt ___
___ 02:51AM BLOOD WBC-16.8* RBC-3.30* Hgb-10.9* Hct-33.8*
MCV-102* MCH-33.2* MCHC-32.4 RDW-22.3* Plt ___
___ 09:45PM BLOOD Hgb-10.4* Hct-32.0*
___ 03:36PM BLOOD WBC-7.6 RBC-2.65* Hgb-9.1* Hct-28.4*
MCV-107* MCH-34.4* MCHC-32.1 RDW-22.4* Plt ___
___ 05:00AM BLOOD WBC-7.1 RBC-2.80* Hgb-9.7* Hct-29.7*
MCV-106* MCH-34.6* MCHC-32.6 RDW-22.1* Plt ___
___ 05:15AM BLOOD WBC-6.9 RBC-3.14* Hgb-10.6* Hct-33.1*
MCV-105* MCH-33.9* MCHC-32.2 RDW-22.0* Plt ___
___ 05:52AM BLOOD WBC-8.9 RBC-2.77* Hgb-9.4* Hct-29.7*
MCV-107* MCH-33.9* MCHC-31.6 RDW-21.8* Plt ___
___ 06:27PM BLOOD WBC-9.9 RBC-2.36* Hgb-8.2* Hct-26.0*
MCV-110* MCH-34.6* MCHC-31.4 RDW-21.9* Plt ___
___ 07:35AM BLOOD WBC-5.5 RBC-2.77* Hgb-9.3* Hct-29.7*
MCV-108* MCH-33.6* MCHC-31.3 RDW-20.9* Plt ___
___ 06:40AM BLOOD WBC-13.8*# RBC-3.06* Hgb-10.2* Hct-31.9*
MCV-104* MCH-33.3* MCHC-32.0 RDW-20.5* Plt ___
___ 03:01PM BLOOD WBC-20.0* RBC-2.53* Hgb-8.4* Hct-26.0*
MCV-103* MCH-33.1* MCHC-32.2 RDW-20.1* Plt ___
___ 06:15AM BLOOD WBC-16.3* RBC-2.40* Hgb-8.1* Hct-24.9*
MCV-104* MCH-33.8* MCHC-32.5 RDW-19.7* Plt ___
___ 04:25AM BLOOD WBC-9.4 RBC-2.51* Hgb-8.3* Hct-25.0*
MCV-100* MCH-33.0* MCHC-33.1 RDW-20.8* Plt ___
___ 02:33AM BLOOD WBC-9.8 RBC-2.56* Hgb-8.4* Hct-25.9*
MCV-101* MCH-32.8* MCHC-32.4 RDW-20.7* Plt ___
___:26AM BLOOD WBC-9.1 RBC-2.66* Hgb-8.7* Hct-26.9*
MCV-101* MCH-32.9* MCHC-32.5 RDW-20.8* Plt ___
___ 01:40AM BLOOD WBC-7.3 RBC-2.66* Hgb-8.6* Hct-27.1*
MCV-102* MCH-32.2* MCHC-31.6 RDW-20.8* Plt ___
___ 04:29AM BLOOD WBC-6.4 RBC-2.46* Hgb-8.1* Hct-25.3*
MCV-103* MCH-32.8* MCHC-31.9 RDW-21.0* Plt ___
___ 06:45PM BLOOD ___ PTT-42.4* ___
___ 05:25AM BLOOD ___ PTT-46.1* ___
___ 06:20AM BLOOD ___ PTT-91.7* ___
___ 06:00AM BLOOD ___ PTT-34.3 ___
___ 04:02AM BLOOD ___ PTT-44.1* ___
___ 02:51AM BLOOD ___ PTT-43.5* ___
___ 05:45AM BLOOD ___ PTT-45.0* ___
___ 05:13AM BLOOD ___ PTT-52.0* ___
___ 02:33AM BLOOD ___ PTT-58.7* ___
___ 03:26AM BLOOD ___ PTT-45.2* ___
___ 01:40AM BLOOD ___ PTT-44.9* ___
___ 04:29AM BLOOD ___ PTT-40.0* ___
___ 04:25AM BLOOD Glucose-88 UreaN-26* Creat-0.7 Na-138
K-3.2* Cl-104 HCO3-26 AnGap-11
___ 08:30PM BLOOD Glucose-82 UreaN-24* Creat-0.7 Na-146*
K-3.4 Cl-112* HCO3-25 AnGap-12
___ 02:33AM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-143
K-4.3 Cl-110* HCO3-24 AnGap-13
___ 03:26AM BLOOD Glucose-155* UreaN-26* Creat-0.8 Na-142
K-3.0* Cl-109* HCO3-24 AnGap-12
___ 05:00PM BLOOD Glucose-118* UreaN-26* Creat-0.7 Na-146*
K-8.0* Cl-112* HCO3-24 AnGap-18
___ 06:43PM BLOOD Glucose-110* UreaN-28* Creat-0.8 Na-143
K-6.6* Cl-110* HCO3-27 AnGap-13
___ 01:40AM BLOOD Glucose-96 UreaN-28* Creat-0.7 Na-147*
K-3.7 Cl-114* HCO3-26 AnGap-11
___ 08:35PM BLOOD Glucose-113* UreaN-28* Creat-0.6 Na-148*
K-4.5 Cl-111* HCO3-29 AnGap-13
___ 04:29AM BLOOD Glucose-127* UreaN-27* Creat-0.6 Na-147*
K-3.8 Cl-111* HCO3-27 AnGap-13
___ 06:45PM BLOOD ALT-81* AST-371* AlkPhos-321*
TotBili-8.8*
___ 05:25AM BLOOD ALT-71* AST-330* AlkPhos-276*
TotBili-8.4*
___ 05:40AM BLOOD ALT-73* AST-323* AlkPhos-257*
TotBili-9.6*
___ 06:10AM BLOOD ALT-75* AST-297* AlkPhos-245*
TotBili-10.0*
___ 06:20AM BLOOD ALT-55* AST-216* AlkPhos-172*
TotBili-7.4*
___ 03:40AM BLOOD ALT-48* AST-164* LD(___)-437*
AlkPhos-111* TotBili-11.9*
___ 04:26AM BLOOD ALT-81* AST-270* AlkPhos-79 TotBili-12.9*
___ 02:51AM BLOOD ALT-122* AST-390* LD(___)-320* AlkPhos-81
TotBili-8.5*
___ 02:51AM BLOOD ALT-96* AST-288* LD(___)-591*
AlkPhos-148* TotBili-7.7*
___ 03:53AM BLOOD ALT-105* AST-304* AlkPhos-156*
TotBili-10.0*
___ 04:02AM BLOOD ALT-126* AST-313* LD(___)-464*
AlkPhos-169* TotBili-10.6*
___ 06:15AM BLOOD ALT-102* AST-305* AlkPhos-152*
TotBili-5.3*
___ 05:26AM BLOOD ALT-123* AST-341* AlkPhos-175*
TotBili-6.3*
___ 05:31AM BLOOD ALT-135* AST-344* AlkPhos-204*
TotBili-6.2*
___ 05:15AM BLOOD ALT-104* AST-241* AlkPhos-244*
TotBili-5.1*
___ 03:26AM BLOOD ALT-80* AST-184* AlkPhos-184*
TotBili-5.8*
___ 05:20AM BLOOD ALT-93* AST-207* AlkPhos-261*
TotBili-4.9*
___ 06:40AM BLOOD ALT-111* AST-255* AlkPhos-363*
TotBili-3.9*
___ 02:45AM BLOOD ALT-109* AST-247* AlkPhos-400*
TotBili-3.0*
___ 03:01AM BLOOD ALT-60* AST-125* AlkPhos-248*
TotBili-3.0*
___ 04:25AM BLOOD ALT-53* AST-123* AlkPhos-270*
TotBili-2.7*
___ 02:33AM BLOOD ALT-50* AST-122* AlkPhos-298*
TotBili-2.6*
___ 03:26AM BLOOD ALT-46* AST-108* AlkPhos-326*
TotBili-2.3*
___ 01:40AM BLOOD ALT-42* AST-101* AlkPhos-302*
TotBili-3.3*
___ 04:29AM BLOOD ALT-38 AST-91* AlkPhos-272* TotBili-2.1*
RELEVANT LABS
___ 05:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 05:25AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *, TITER
1:20
___ 05:40AM BLOOD AFP-3.7
___ 05:25AM BLOOD ___
___ 06:19AM BLOOD Vanco-24.4*
___ 06:45PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:25AM BLOOD HCV Ab-NEGATIVE
___ 04:51PM BLOOD Hapto-48
___ 05:25AM BLOOD calTIBC-95* VitB12-GREATER TH Folate-9.2
Ferritn-880* TRF-73*
___ 04:00PM BLOOD Triglyc-75
___ 05:25AM BLOOD Osmolal-281
___ 04:20AM BLOOD ___ Temp-37.4 ___ Tidal
V-350 PEEP-5 FiO2-60 pO2-70* pCO2-49* pH-7.39 calTCO2-31* Base
XS-3 Intubat-INTUBATED
___ 04:13AM BLOOD Lactate-1.6
DISCHARGE LABS
___ 04:59AM BLOOD WBC-8.5 RBC-3.05* Hgb-9.8* Hct-30.2*
MCV-99* MCH-32.2* MCHC-32.6 RDW-17.5* Plt ___
___ 04:59AM BLOOD ___ PTT-37.7* ___
___ 04:22AM BLOOD Glucose-113* UreaN-11 Creat-0.3* Na-138
K-4.5 Cl-101 HCO3-32 AnGap-10
___ 04:59AM BLOOD ALT-39 AST-96* LD(LDH)-337* AlkPhos-263*
TotBili-1.3
___ 04:22AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.7
URINE
___ 11:40AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD
___ 11:40AM URINE RBC-<1 WBC-27* Bacteri-FEW Yeast-NONE
Epi-31 TransE-1
___ 10:15AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:15AM URINE RBC-7* WBC-4 Bacteri-FEW Yeast-OCC Epi-0
___ 02:22AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:22AM URINE RBC-15* WBC-1 Bacteri-MANY Yeast-NONE
Epi-2
___ 01:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 11:40AM URINE Hours-RANDOM UreaN-846 Creat-198 Na-<10
K-39 Cl-<10 HCO3-<5
___ 11:40AM URINE Osmolal-530
ASCITES FLUID
___ 10:23AM ASCITES WBC-58* RBC-2325* Polys-35* Lymphs-0
___ Mesothe-22* Macroph-43*
___ 01:44PM ASCITES WBC-6* RBC-900* Polys-0 Lymphs-0
___ 12:51PM ASCITES WBC-40* RBC-905* Polys-54* Lymphs-3*
Monos-5* NRBC-1* Mesothe-15* Macroph-23*
___ 10:40AM ASCITES WBC-18* RBC-106* Polys-56* Lymphs-14*
Monos-17* Mesothe-6* Macroph-4* Other-3*
___ 03:34PM ASCITES WBC-8* RBC-2260* Polys-90* Lymphs-5*
Monos-3* Eos-1* Other-1*
MICRO
___ 1:27 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 1:26 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
BORDETELLA BRONCHISEPTICA. PRESUMPTIVE IDENTIFICATION.
RARE GROWTH. sensitivity testing performed by
Microscan.
RESISTANT TO TOBRAMYCIN AT >=16 MCG/ML.
INTERMEDIATE TO AMPICILLIN/SULBACTAM AT ___ MCG/ML.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
BORDETELLA BRONCHISEPTICA
|
AMIKACIN-------------- 8 S
AMPICILLIN/SULBACTAM-- I
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 8 S
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- 4 S
TOBRAMYCIN------------ R
___ BLOOD CULTURE Blood Culture, Routine- NO
GROWTH
___ URINE URINE CULTURE- NO GROWTH
___ MRSA SCREEN MRSA SCREEN- No MRSA isolated.
___ FLUID RECEIVED ___ BLOOD CULTURE BOTTLES
Fluid Culture ___ Bottles- NO GROWTH
___ 3:34 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture, Routine- NO
GROWTH
___ BLOOD CULTURE Blood Culture, Routine- NO
GROWTH
___ STOOL C. difficile DNA amplification assay-
NO C.diff
___ BLOOD CULTURE Blood Culture, Routine- NO
GROWTH
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-NO GROWTH
___ URINE URINE CULTURE-NO GROWTH
___ BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
___ 10:02 pm SWAB
Source: ___ site REFER TO PREVIOUS PROBLEM ___ ___.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ CATHETER TIP- No significant growth.
___ BLOOD CULTURE Blood Culture, Routine-NO
GROWTH.
___ 10:40 am PERITONEAL FLUID PERITONEAL FLUID.
**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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture, Routine- NO
GROWTH
___ STOOL C. difficile DNA amplification assay-
NO C.DIFF
___ 12:51 pm PERITONEAL FLUID PERITONEAL FLUID.
**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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 4:53 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
BORDETELLA BRONCHISEPTICA. SPARSE GROWTH.
sensitivity testing performed by Microscan.
RESISTANT TO SULFA X TRIMETH (MIC: > 2 MCG/ML ).
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
BORDETELLA BRONCHISEPTICA
|
AMIKACIN-------------- 8 S
CEFTRIAXONE----------- 8 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=1 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- R
___ BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
___ URINE URINE CULTURE-NO GROWTH
___ 1:44 pm PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by ___ (___)
___ @1725.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
___ BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
___ URINE URINE CULTURE-NO GROWTH
___ 5:35 am Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
___ Commensal Respiratory Flora.
___ MRSA SCREEN MRSA SCREEN-No MRSA isolated.
___ SWAB R/O VANCOMYCIN RESISTANT
ENTEROCOCCUS-No VRE isolated.
___ 10:23 am PERITONEAL FLUID PERITONEAL FLUID.
**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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
___ 5:25 am Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
74 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
IMAGING
___ CXR (PORTABLE)
CONCLUSION:
1. Improvement of right lower lung consolidation/atelectasis.
2. Unchanged small left lower lung consolidation. There is no
new opacity.
___ CXR (PORTABLE)
FINDINGS: The atelectasis at the right lung base has slightly
increased ___ extent. The tracheostomy tube is unchanged. The
Dobbhoff catheter has been pulled back. The tip now becomes
visible slightly proximal of the duodenojejunal plica. There is
no evidence of complications, notably no pneumothorax.
___ CXR (PORTABLE)
FINDINGS: ___ comparison with study of ___, there is now a
tracheostomy tube ___ place. There is no evidence of
pneumothorax or pneumomediastinum.
There is some increasing opacification at the right base. This
most likely reflects a combination of layering effusion and
atelectasis. However, ___ the appropriate clinical setting,
supervening pneumonia would have to be considered. Less
prominent opacification at the left base most likely represents
atelectasis, though again infection would have to be considered.
There is some increased indistinctness of engorged pulmonary
vessels,
consistent with some increasing pulmonary venous pressure.
___ PORTABLE ABDOMEN
FINDINGS:
Supine portable radiograph of the abdomen was acquired. The
___ tube is seen with the tip ___ the pylorus. Air is seen
distending the small bowel with changes suggestive of bowel wall
edema. The TIPS shunt is seen ___ the right upper quadrant.
IMPRESSION: ___ tube with tip at pylorus.
___ LIVER ULTRASOUND
IMPRESSION:
1. Cirrhotic liver. Patent TIPS with appropriate velocities.
2. Possible isolated dilated intrahepatic duct with dilatation
of the common duct to 7 mm. Of note, the common duct previously
measured 4 mm on ultrasound from ___. Further
evaluation could be performed with repeat ultrasound, with a
radiologist present.
3. Gallbladder debris. Otherwise, normal-appearing
gallbladder.
4. Left pleural effusion, as seen on prior CT.
___ CT HEAD
IMPRESSION:
1. No evidence of hemorrhage or infarction
2. Atrophy.
___ CHEST (PORTABLE)
IMPRESSION: AP chest compared to ___:
Aeration at the right lung base which worsened from ___
through
___, has returned to baseline. There is still reason
for concern
about cause of a persistent right basal atelectasis,
specifically aspiration and retained secretions.
Small-to-moderate right pleural effusion is present, not
surprising for this longstanding atelectasis. ___ the left lung
peribronchial opacification ___ the lower lobes has improved,
quite likely another finding due to aspiration. Heart size is
normal. ET tube and left subclavian line are ___ standard
placements and a feeding tube passes into the stomach and out of
view. No pneumothorax.
___ R WRIST
RIGHT WRIST, FOUR VIEWS: Cast material limits evaluation of
bony detail. There is re-demonstration of a comminuted distal
radial fracture, with intra-articular extension. As before,
there is slight dorsal displacement of the dominant distal
fracture fragment, although the distal radius articulates
appropriately with the carpal bones. The fracture lines are
less conspicuous on today's study compared to the prior study
from ___. There is no acute fracture or
dislocation.
IMPRESSION: Healing distal right radial fracture, with
unchanged alignment.
___ ESOPHAGUS
IMPRESSION:
1. Severe gastroesophageal reflux.
2. No extraluminal leakage of contrast was noted.
ESOPHAGUS
___ CT ABD AND PELVIS
IMPRESSION:
1. Extensive pneumoperitoneum and retroperitoneal free air with
a small
amount of free air seen ___ the mediastinum. Findings are
concerning for
perforation at the level of the gastroesophageal junction given
the pattern of free air distribution. Exact site of perforation
cannot be identified.
2. Extensive air within the subcutaneous tissues of the lower
chest and
abdominal wall bilaterally, likely direct extension from the
intraperitoneal process.
3. Moderate bilateral pleural effusions with associated
compressive
atelectasis 4. Moderate nonhemorrhagic ascites
5. Patent TIPS
___ EGD:
Findings: Esophagus:
Protruding Lesions 2 cords of grade II varices were seen with
active bleeding sites at 30cm and 35cm. Upon entering the
esophagus, no bands from prior endoscopy this AM were present.
Attempts were made at band ligation (5 successful bands were
deployed at first attempt, 3 additional bands were placed at
second attempt), but hemostasis could not be achieved with
banding. Therefore, a Minnesota tube was placed at 29cm from the
lip.
Stomach:
Contents: Clotted and old blood was seen ___ the stomach with no
evidence of active bleeding.
Duodenum: Normal duodenum.
Impression: Varices at the 30 and 35cm
Blood ___ the stomach
Otherwise normal EGD to third part of the duodenum
___ EGD:
Findings: Esophagus:
Protruding Lesions 2 cords of grade II varices were seen ___ the
esophagus. One varix had ruptured with active bleeding. 2 bands
were placed for hemostasis successfully.
Other A medium hiatal hernia was seen.
Stomach:
Protruding Lesions A fundal varix was seen. There did not
appear to be active bleeding.
Duodenum: Normal duodenum.
Impression: Esophageal varices
Gastric varices
A medium hiatal hernia was seen.
Otherwise normal EGD to third part of the duodenum
___ EGD:
Findings: Esophagus:
Other There was active and fast bleeding ___ the esophagus.
There was also evidence of esophageal necrosis. Given that
banding has not worked multiple times ___ the past 24 hours, the
decision was made to use sclerosing agent (Tetradecaly sulfate
2cc was injected at the site of active bleed), but hemostasis
was not acheived. 2cc glue injection was then done. At this
time, it was noted that the patient's abdomen was firm and
distended, with swelling up to chest and neck ___ conjunction
with respiratory decompensation. The procedure was then aborted.
Stomach:
Contents: Fresh and old blood was seen ___ the stomach.
Duodenum: Not examined.
Impression: There was active and fast bleeding ___ the esophagus.
There was also evidence of esophageal necrosis. Given that
banding has not worked multiple times ___ the past 24 hours, the
decision was made to use sclerosing agent (Tetradecaly sulfate
2cc was injected at the site of active bleed), but hemostasis
was not acheived. 2cc glue injection was then done. At this
time, it was noted that the patient's abdomen was firm and
distended, with swelling up to chest and neck ___ conjunction
with respiratory decompensation. The procedure was then aborted.
Blood ___ the stomach
Otherwise normal EGD to stomach
___ KUB:
IMPRESSION: ___ tube with tip at pylorus.
___ Speech/language eval:
RECOMMENDATIONS:
1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!
2. Monitor O2 Sats / respiration while valve is ___ place.
3. Do not allow the patient to sleep with the valve ___ place.
4. PMV wear schedule is up to the discretion of the
nurse and/or respiratory therapist.
5. Remain NPO with continued alternate means of nutrition,
hydration and meds
6. Q4 oral care
7. Continued SLP f/u here and at rehab after d/c.
Brief Hospital Course:
___ F hx of EtOH abuse and hypertension, admitted with right
radial fracture and scalp laceration after mechanical fall and
found to have ETOH hepatitis and undiagnosed cirrhosis. She
subsequently developed a rapid variceal bleed requiring massive
transfusion protocol, banding, TIPS and ___ placement
complicated by esophageal perforation managed by
intra-esophageal glue. She became progressively deconditioned
and frequently aspirated requiring intubation 3 times over her
40 day hospital course for mixed hypoxic and hypercarbic
respiratory failure requiring tracheostomy placement.
# Massive variceal bleed: On the floor patient was noted to have
a nine-point Hct drop on ___. EGD showed active variceal bleed
which was banded. She was started on octeotride and pantoprazole
drips. Despite this, patient continued to have active,
hemodynamically significant bleed requiring intubation, massive
transfusion protocol and ___ placement. She required a
total of 11u prBCS, 9u FFP, 1u plt, and 2u cryo. She underwent
successful emergent TIPS on ___ but continued to have bleeding
immediately post-procedure. Susbequent imaging showed that TIPS
remained patent. Repeat endoscopy was performed at that time
which showed continued bleeding ___ the stomach and the esophagus
and prior bands were not visualized. Esophageal necrosis was
also noted at the time, thought to be related to recent
___ placement. Sclerosing agent was blindly injected but
hemostasis could not be achieved. The procedure had to be
aborted as patient began to show signs of respiratory
decompensation and subcutaneous air ___ the neck and free air ___
the abdomen. This was confirmed on post-procedure CXR. Despite
this, patient remained hemodynamically stable with no signs of
further bleed. Octeotride and pantoprazole drips were
discontinued. She was treated with ciprofloxacin for SBP
prophylaxis ___ the setting of her bleed. She spiked intermittent
fevers and had a persistent leukocytosis so her antibiotics were
broadened to linezolid after cultures from a groin bag returned
VRE, thought to be of a peritoneal source. However, these
cultures were not sterilely obtained so they could have been
contaminated. She was transferred to the medical floor on ___
and had no recurrence of hematemesis, but was noted to have a
slowly downtrending HCT and was transfused an additional unit of
PRBCs on ___. Pt was again transfused ___ and ___ for
gradually decreasing hematocrit. Patient's anemia is macrocytic
most likely secondary to liver disease; normal folate and vit
b12; LDH and hapto normal making hemolysis unlikely. Iron
studies shows anemia of chronic disease. Stools were guaic on
___ and ___ and were negative. Her hematocrit has then
remained stable for the rest of the hospitalization.
# Perforated viscus: Following repeat EGD, patient had evidence
of free air ___ the neck and under the diaphragm. CT Abdomen was
obtained which showed no obvious location of perforated viscus
but possible contained leak near the gastro-esophageal junction.
Surgery was consulted who felt there was no need for acute
intervention given patient's stability. Antibiotics were
broadened to flagyl, vancomycin, and fluconazole for a seven-day
course to cover any viscus rupture (see below for further
antibiotic course). She was kept NPO and TPN was initiated. She
underwent esophagram with gastrograffin which showed no
extraluminal leakage of contrast, but severe gastroesophageal
reflux. Dobhoff was placed with ___ guidance to minimize trauma
to the esophagus on ___ and tube feeding was initiated.
Bedside speech and swallow evaluation was requested but deferred
as negative gastrograffin swallow was felt to be sufficient for
such evaluation. She was again made strict NPO after aspiration
events requiring MICU transfer as described below. Her nutrition
was kept through dobhoff and tubefeedings.
# Persistent leukocytosis and fevers: After leaving the ICU,
patient was noted to have low grade fevers accompanied by
persistent leukocytosis. Infectious disease team was consulted,
and recommended changing patient to linezolid, aztreonam, and
flagyl for broad spectrum coverage of both pulmonary,
intraabdominal, and other causes (patient with VRE+ groin bag as
noted above). Patient's leukocytosis trended down and patient
remained afebrile on antibiotics. She completed antibiotics on
___. (metronidazole ___, aztreonam ___,
linezolid ___. WBC acutely rose 5.5->13.8 on ___,
attributed to possible aspiration given patient's persistent
difficulty ___ clearing secreations. Broad spectrum coverage with
cefepime, vancomycin and metronidazole was restarted on ___.
WBC continued to rise and a diagnostic paracentesis was
performed at the bedside on ___. Peritoneal fluid was negative
for SBP by cell count. Antibiotics were continued for a full 8
day course for HCAP (cefepime/flagyl till ___, linezolid till
___. Patient no longer febrile and without leukocytosis
starting ___.
# Aspiration: On the floor, pt was noted to have intermittently
labored breathing and significant difficulty clearing
respiratory secretions due to severe deconditioning and
waxing/waning mental status. On ___ she became acutely more
somnolent and hypoxic ___ the setting of aspiration that resolved
with deep suction. She was observed ___ the MICU overnight but
remained on nasal cannula and was transferred back to the floor.
Even with post-pyloric feedings she was felt to be at risk of
aspiration given her severe reflux, increased pressure due to
ascites, weakness and poor cough from prolonged hospitalization,
and fluctuating level of consciousness. Back on the floor, she
was kept strict NPO and was again noted to be diffusely
rhonchorous and unable to clear secretions effectively. A
scopolamine patch was considered but deferred due to concern for
further worsening her mental status. She required frequent oral
suctioning by nursing staff, deep suctioning by RT and chest ___.
She was noted to intermittently desaturate to ___ on telemetry.
Pt had second aspiration event and was transferred back to the
MICU on ___. Pt treated for aspiration pneumonitis and was not
given ABX course. She was observed ___ the ICU and transferred
back to the medicine floor. The evening of ___, pt was again
noted to have labored breathing and although O2 sats were
maintained on supplemental O2, repeat ABG showed worsening
acidemia with rising pCO2 to 68. Due to concern that she may be
tiring out with obtundation and inability to protect her
airwayd, she was again transferred to the MICU and was
intubated. Due to her multiple intubations secondary to poor
conditioning and inability to protect her airway, she went for
tracheostomy placement on ___. She did well after tracheostomy
placement and satting well with tracheostomy mask; this should
not be downsized until a minimum of 10 days post-op. Continues
to have productive secretions requiring constant suctioning,
however secretions and lung exam with significant improvement
from prior days. Most recent CXR on ___ without new acute
changes.
# Delirium/hepatic encephalopathy: During ICU stay as well as on
the floor, patient was noted to be hallucinating, with signs of
paranoia and inattention. Patient was, at times, interfering
with care. Psychiatry was consulted, who ascertained the patient
to be delirious, likely secondary to hepatic and other
toxic/metabolic ongoing insults. CT head without hemorrhage or
edema. A low dose antipsychotic was considered, but patient's
QTc was prolonged. Other alternatives were all oral, and while
patient was strictly NPO at that time, these were unable to be
used. The decision was made to pursue care plan as detailed
above with hope that patient would begin to clear as her
clinical picture improved. Pt's mental status improved to the
extent that she was no longer noted to have hallucinations or
inattention on the floor. However, mental status waxed and waned
and patient was intermittently less responsive to verbal
stimulation, but at other times was AAO to person and place and
able to answer questions appropriately. She was started on
lactulose and rifaximin. Her lactulose was uptitrated to achieve
1L of stools per day. Her mental status improved with the
lactulose. Her flexseal was discontinued on ___ and a fecal
incontinence pouch was placed.
# extremities edema: patient with 2++ pitting edema ___ all four
extremities. Weight is 59kg from admission 52kg. Also has been
net positive since MICU. As a result, diuretics were uptitrated
to 80mg daily and spironolactone to 200mg dialy. ___ addition,
her fluid flushes which was initially increased due to
hypernatremia was decreased to 100cc q4h as patient was no
longer hypernatremic.
# Deconditioning: Pt noted to be extremely weak on medical floor
with ___ strength ___ all four extremities, likely due to severe
illness and prolonged hospitalization with bedrest. Physical
therapy was consulted, noted limited ablility to
participate ___ therapy due to profound deconditioning and
recommended eventual discharge to rehab. Tube feeds were begun
with high caloric content to improve her nutrition ___ the hopes
of reversing her deconditioning. At discharge continued to be
very weak with ___ strength throughout. She is profoundly weak
and will require rather extensive rehabilitation and physical
therapy. Continued nutrition will be essential; albumin is 2.
# Goals of Care: Pt had strong family support with frequent
visitors. Multiple family meetings were held. Her HCP, ___
___ (___) continued to reaffirm her code status as
full code.
# Alcoholic hepatitis: Given clinical history ETOH hepatitis is
most likely explanation of elevated AST/ALT. Discriminant
function 42 on admission but patient was never started on
steroids due to her acute GI bleed.
# EtOH Cirrhosis: New diagnosis this admission, likely related
to alcohol. AFP negative. EGD showed 2 cords of grade II varices
on ___ with active bleeding, s/p TIPS. Her last TIPS
patency study was on ___ and was patent. She also had
complications of encephalopathy and ascites, requiring
paracenteses. She is not discharged on nadolol due to her TIPS.
She was initially receiving daily lasix 40mg IV for diuresis
and initiated on spironolactone and lasix when dobhoff was
placed. MELD score of 11 and ___ class B. No PVT per
ultrasound. Hepatitis panel negative, ___ negative. Anti
smooth muscle antibody positive, but titer not significant 1:20.
She was treated with rifaximin/lactulose as per above. Diuretics
were uptitrated as per above. Nadolol 20mg BID was started for
variceal bleed prevention; was not further uptitrated given that
BP at low 100s at times and ___ process of titrating diuretics.
Treated with lansoprazole, paracentesis for comfort, SBP ppx
with cipro 250mg daily. Patient will follow-up with her
hepatologist ___ ___ one month after discharge.
# Nutrition: patient on trach mask and enteric feeding via
dobhoff on ___. Can downsize trach after ___. Will need to
evaluate with speech and swallow to restart po intake.
# Wrist fracture: Right distal radius fracture was closed
reduced and splinted with hematoma block. Ortho recommended
follow-up ___ 4 weeks post-discharge ___ (the week
of ___
# TRANSITIONAL ISSUES
-patient with newly diagnosed alcoholic cirrhosis with various
complications: variceal bleed - 3 EGD, ___, esophageal
perforation, treated by blind glue injection; ascites - 5 liter
tap, s/p leak, peritoneal leak grew VRE that was treated with
antibiotics; Hepatic encephalopathy - rifaximin & lactulose;
respiratory - pna, pneumonitis, s/p three intubation, trach
placed ___
-please ensure patient follows up with Dr. ___,
scheduled for ___ and ortho (scheduled for ___
-patient requires Hep A and B vaccine
-please continue to uptitrate diuretics as appropriate
-tracheostomy may be downsized after ___. When able to
tolerate oral diet and maintain airway patency, tracheostomy may
be removed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze
2. Heparin 5000 UNIT SC BID
3. Lactulose 30 mL PO TID
4. Miconazole Powder 2% 1 Appl TP TID:PRN yeast infection
5. Rifaximin 550 mg PO BID
6. Ondansetron 4 mg IV Q8H:PRN n/v
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. Ciprofloxacin HCl 250 mg PO Q24H
9. Guaifenesin 10 mL PO Q6H:PRN cough
10. Nadolol 20 mg PO BID
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. Furosemide 80 mg PO DAILY
13. Spironolactone 200 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Variceal bleed s/p TIPS and ___ placement
Esophageal perforation
Hepatic encephalopathy
Delirium
Alcoholic hepatitis
Cirrhosis
Wrist fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for a wrist
fracture after a fall, and found to have cirrhosis of the liver
due to alcohol use. You had many complications from this
disease that kept you ___ the hospital for more than 40 days. You
are now stable to leave the hospital, but will need very close
medical care. It is very important that you STOP drinking
alcohol.
Followup Instructions:
___
|
10556676-DS-5 | 10,556,676 | 22,783,191 | DS | 5 | 2164-02-14 00:00:00 | 2164-02-14 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ former smoker w EtOH cirrhosis pw SOB. She is s/p recent
extended hospital stay ___ requiring EGD x 3, ___
for massive variceal bleed, s/p visceral perforation, and long
ICU stay. She returned home from a rehabilitation facility
___ and began experiencing progressive SOB, which prompted
her to seek an outpatient appointment with her PCP; she was sent
to the hospital after that appointment.
The clinical course of her liver disease has been excellent
since hospital discharge: ascites abated, nutritional status
improving, no further hepatic decompensation.
Per the patient, the SOB is worst when lying down. She does have
a h/o asthma, but did not require medications in the past
(occasional, moderate symptoms were relieved by albuterol). Has
a
dog, house was cleaned with noxious cleansers just prior to her
return from rehabilitation. Thinks that some foods worsen her
SOB (wheat/rye). Some cough, with clear phlegm, clear. Has a
Dubhoff tube, placement was seen on last CXR. Some wheezing,
notes some orthopnea, no PND, some swelling of legs. Previously
smoked 1ppd, quit ___ years ago.
She has been afebrile.
CT chest performed on admission ___ reveals background
emphysema with bronchial wall thickening, likely representing
chronic bronchitis/bronchiolitis; no focal opacification
concerning for pneumonia; 4 mm polypoid soft tissue density in
the anterior trachea at the level of clavicles.
Past Medical History:
PMH:
Cirrhosis (alcoholic)
Varices
Ulcerative colitis?
Right distal radius fracture
Variceal bleeds and placement ___ tube with visceral
perforation during prolonged inpatient/ICU course
___
PSH:
TIPS procedure
Social History:
___
Family History:
Mother deceased with COPD, father alive without medical issues,
brother DM
Physical ___:
Physical Examinaion on Admission:
VS: 97.8 AF 107/66 97 18 97% 3L
Gen: Sick appearing cachectic female, sitting up in bed. NAD.
Breathing unlabored, speaking in full sentences.
HEENT: NG tube in place. Sclerae anicteric.
Pulm: Some wheezes diffusely in R fields, absent on L. No rales
or ronchi.
Cor: RRR no MRG.
Abd: Enlarged, firm liver easily palpable ~4+ cm below costal
margin. Soft, nontender, distended abdomen.
Extr: No pedal edema.
Neuro: AOx3. Conversation on interview raised concern for
possible moderate encephalopathy (some impaired memory and
impaired thought processes) but no formal cognitive testing
performed. CNs: PER, ___, TM. FSAE. Asterixis (bimanual).
Patellar tendon reflexes 3+. Several beats of clonus on R.
Physical Examination at Discharge:
VS: 98.5 99/62 6 18 97%RA
Gen: Sitting up in bed. NAD. Breathing unlabored, speaking in
full sentences.
HEENT: NG tube in place. Sclerae anicteric.
Pulm: Bilateral wheezes diffusely. No rales or ronchi.
Cor: RRR no MRG.
Abd: Enlarged, firm liver easily palpable ~4+ cm below costal
margin. Soft, nontender, distended abdomen.
Extr: No pedal edema.
Neuro: AOx3, mentating normally. No asterixis. CNs: PER, ___, TM.
FSAE.
Pertinent Results:
___ 09:35PM BLOOD WBC-6.2 RBC-3.61* Hgb-12.3 Hct-37.8
MCV-105* MCH-34.2* MCHC-32.6 RDW-16.6* Plt ___
___ 04:25AM BLOOD WBC-6.9 RBC-3.23* Hgb-10.9* Hct-33.2*
MCV-103* MCH-33.7* MCHC-32.8 RDW-16.0* Plt ___
___ 09:35PM BLOOD Neuts-49.7* ___ Monos-7.8
Eos-10.1* Baso-0.9
___ 04:25AM BLOOD Neuts-57.9 ___ Monos-9.7 Eos-1.2
Baso-0.6
___ 09:35PM BLOOD ___ PTT-34.7 ___
___ 09:35PM BLOOD Glucose-145* UreaN-20 Creat-0.6 Na-141
K-3.7 Cl-100 HCO3-33* AnGap-12
___ 04:25AM BLOOD Glucose-132* UreaN-22* Creat-0.6 Na-140
K-3.5 Cl-100 HCO3-34* AnGap-10
___ 09:35PM BLOOD ALT-34 AST-54* AlkPhos-86 TotBili-0.6
___ 09:35PM BLOOD proBNP-382*
___ 09:35PM BLOOD D-Dimer-1263*
___ ___ F ___ ___
Radiology Report CHEST (PA & LAT) Study Date of ___ 8:43 ___
___ ___ 8:43 ___
CHEST (PA & LAT) Clip # ___
Reason: eval for volume overload
UNDERLYING MEDICAL CONDITION:
History: ___ with dyspnea and cirrhosis
REASON FOR THIS EXAMINATION:
eval for volume overload
Final Report
HISTORY: Dyspnea and cirrhosis.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___ at 11:58.
FINDINGS:
Enteric tube remains in unchanged position. Heart size is
normal.
Mediastinal and hilar contours are unremarkable. Lungs are
clear. No focal
consolidation, pleural effusion or pneumothorax is present.
There are no
acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
___ ___ ___ ___
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of ___ 12:12 AM
___ ___ 12:12 AM
CTA CHEST W&W/O C&RECONS, NON- Clip # ___
Reason: Eval for PE
Contrast: OMNIPAQUE Amt: 100
UNDERLYING MEDICAL CONDITION:
History: ___ with dyspnea after prolonged bedrest.
REASON FOR THIS EXAMINATION:
Eval for PE
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Dyspnea after prolonged bed rest, evaluate for
pulmonary
embolism.
COMPARISON: Comparison is made to chest radiograph from same
day as well as
CT torso performed ___.
TECHNIQUE: Intravenous contrast was administered and arterial
phase imaging
was acquired. Coronal, sagittal and oblique reformats were
provided.
FINDINGS:
CTA CHEST: The pulmonary vasculature is well opacified and
without filling
defect to suggest embolus. Minimal atherosclerotic change noted
in the aortic
arch. No aneurysm or dissection evident. Heart size is normal
without
pericardial effusion.
CT CHEST: Thyroid gland is unremarkable. No lymphadenopathy.
There is a 4 mm polypoid soft tissue density extending from the
anterior
aspect of the trachea at the level of the clavicles. This area
is not well
assessed on the prior study as patient was intubated at that
time. There is
bronchial wall thickening, most evident in the lower lobes.
Airways are not
well assessed on prior study due to collapsed pulmonary
parenchyma and large
effusion, but finding is likely chronic. Background moderate
emphysema is
again noted. No opacifications concerning for pneumonia
identified. No
pleural effusion or pneumothorax is evident.
Limited assessment of the upper abdomen demonstrates a TIPS.
There is a 1-cm hypodensity in the left hepatic lobe, unchanged
compared to
___ and most consistent with a simple cyst.
A 1.4 cm well-demarcated, rounded soft tissue density is noted
within the
medial aspect of the left breast.
No suspicious lytic or blastic lesions present.
IMPRESSION:
1. No pulmonary embolism or aortic pathology.
2. Background emphysema with bronchial wall thickening,
particularly evident
in the lower lobes likely represents a chronic
bronchitis/bronchiolitis
possibly due to smoking. No focal opacification concerning for
pneumonia.
3. A 4 mm polypoid soft tissue density in the anterior trachea
at the level
of clavicles. Recommend non-emergent evaluation with direct
visualization.
4. A 1.4 cm smoothly rounded soft tissue density in the medial
aspect of the
left breast, unchanged compared to ___. Recommend
correlation with
mammogram.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: WED ___ 9:32 AM
Brief Hospital Course:
SUMMARY:
Ms. ___ is a ___ former smoker (mother died of COPD) w EtOH
cirrhosis and recent extended hospitalization (___) for
massive variceal bleed & visceral perforation with placement of
___ tube. She presented with 2w of worsening SOB and was
admitted out of concern for COPD/asthma exacerbation vs CHF.
She was admitted on ___ with shortness of breath.
Evidently her symptoms began soon after returning home from a
rehabilitation facility, following her hospital stay here from
___ to ___ for a bleeding crisis due to
alcohol-induced liver disease. She experienced increasing
shortness of breath while at home, and saw her primary care
physician for that symptom on ___. She had a chest X-ray
performed, which showed some lung disease (emphysema and chronic
bronchitis, likely associated with past smoking (quit ___ years
ago), but no evidence of pneumonia. On admission, her CBC was
notable for WBC 6.2 with eosinophilia 10.1%; after
administration of prednisone her eosinophilia resolved to WBC
6.9 Eo 1.2. We believe her shortness of breath was due either to
an exacerbation of her asthma or to an exacerbation of COPD.
While in the hospital she initially required supplemental
oxygen. She was treated with a prednisone taper (started at 40
mg), and her symptoms improved quickly. She also received
albuterol nebulizer treatments, azithromycin (empiric pneumonia
coverage and anti-inflammatory) and fexofenadine to help
mitigate any allergic triggers of the asthma. Even as her
respiratory symptoms improved, her oxygen saturation continued
to drop to 85% when she walked short distances. We therefore
held her in the hospital for an extra day; on the evening of ___
___ she was able to maintain oxygen saturation of 92% while
walking. She was discharged the following day, ___.
ACTIVE ISSUES:
SOB: Eosinophilia and high bicarbonate with CT imaging
suggesting chronic bronchitis and no focal opacification
concerning for pneumonia raised concern for COPD flare (perhaps
also asthma flare). Possibly triggered by dust or dog at home.
She was treated with prednisone 40 mg PO on a 10-day taper,
albuterol nebulizers, azithromycin (5d course). Her peak flow
was measured to be 100 (down from baseline >400) on ___ ___. She
was also prescribed fexofenadine to mitigate any allergic
component of this flare and as prophylaxis as she returns home.
Consider long-term therapy with fluticasone as outpatient.
Cardiac Function: Little clinical concern for diastolic heart
failure or fluid overload. Her proBNP was high, but decreased
relative to ___ values:
___ 21:35 382
___ 05:52 606
TTE and further workup were not pursued after she improved with
steroid therapt.
CHRONIC ISSUES:
Liver Disease: Alcoholic cirrhosis sp massive variceal bleeds
(on nadolol, Lasix, spironolactone) and complicated by hepatic
encephalopathy (on Rifaximin) sp TIPS procedure. Her liver
disease was not addressed during this admission, and she was
maintained on her home regimen:
Nadolol 20 mg
Furosemide 20 mg
Spironolactone 50 mg
Lactulose: Concern for hepatic encephalopathy, no asterixis,
given once, resulted in diarrhea and poor continence,
subsequently held.
Rifaximin 550 mg
Active type & screen were maintained, IV access was maintained
until discharge as a precaution.
TRANSITIONAL ISSUES:
Incidentalomas:
# CT chest from ___ shows a 4mm lesion in the trachea at
level of the clavicles, non-urgent direct visualization
recommended. Should f/u with ENT.
# CT chest from ___ shows a 1.4 cm smoothly rounded soft
tissue density in the medial aspect of the left breast,
correlation with mammogram recommended in outpatient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID Duration: 7
Days
2. Nadolol 20 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID Duration: 7
Days
4. Nadolol 20 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth once daily Disp #*2
Tablet Refills:*0
10. Fexofenadine 60 mg PO BID
RX *fexofenadine 60 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
11. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 0. . . . Disp #*22 Tablet Refills:*0
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
Discharge Disposition:
Home With Service
Facility:
___
___:
COPD/asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege to participate in your care while you were a
patient on the Medicine Service at the ___
___.
Please find here a summary description of the care you received
while you were a patient here, together with instructions for
continuing your care after you leave the hospital.
Please accept my best wishes for your recovery.
Sincerely,
___ ___
You were admitted on ___ with shortness of breath.
Evidently your symptoms began soon after you returned home from
a rehabilitation facility, following your hospital stay here
from ___ to ___ for the bleeding crisis due to your
liver disease. You experienced increasing shortness of breath
while at home, and saw your primary care physician for that
symptom on ___. You had a chest X-ray performed, which
showed some lung disease (emphysema and chronic bronchitis,
likely associated with your past smoking), but no evidence of
pneumonia. We believe your shortness of breath is due either to
an exacerbation of your asthma, or to an exacerbation of the
chronic bronchitis seen on your chest X-ray. While in the
hospital, you initially required supplemental oxygen. You were
treated with prednisone, and your symptoms improved quickly. You
also received albuterol nebulizer treatments, and azithromycin,
an antibiotic that was given in case of pneumonia and that is
also used for its anti-inflammatory effects in the lungs. We
also prescribed fexofenadine, an antihistamine medication that
may help mitigate any allergic triggers of your asthma. Even as
your respiratory symptoms improved, your oxygen saturation
continued to drop to 85% when you walked short distances. We
therefore held you in the hospital for an extra day; on the
evening of ___ you were able to maintain oxygen
saturation of 91-92% while walking. You were discharged the
following day, ___.
The following are some important instructions for continuing
your care after you leave the hospital:
1. Please continue to take all of the medications prescribed for
your liver disease, and continue to follow up with your liver
doctors.
2. Please continue to take the prednisone until you complete the
10-day taper begun the day you were admitted.
3. Please follow up with your primary care physician.
Followup Instructions:
___
|
10557261-DS-14 | 10,557,261 | 25,532,125 | DS | 14 | 2179-07-10 00:00:00 | 2179-07-10 20:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH of COPD, WPW
s/p ablation (___), asthma, HTN, anxiety, and depression who
presents with approximately 5 days of worsening shortness of
breath, ___ cough, and wheezing.
The patient reports that his symptoms began approximately 5 days
ago when he noticed increasing exertional shortness of breath,
cough, and wheezing. Of note, the patient had taken a flight
from
___ to ___ only a few days prior to his symptom onset. He
presented to ___ for evaluation and reports that he was told he
had an asthma exacerbation, so he was discharged with albuterol
inhalers. Over the past three days since being discharged, the
patient reports he has been using the albuterol inhaler with
minimal benefit. Then, this morning, the patient began having
chest pain which he describes as ___, sharp, with
radiation to the neck and shoulder. Additionally, he
characterizes his chest pain as being pleuritic and
___. Due to concern for the chest pain, the patient
presented to ___ ER for further evaluation.
In the ED, initial vitals were T 97.7F, HR 116, BP 118/88, RR
16,
satting 100% RA. Exam was notable for "diffuse intermittent
wheezes with prolonged expiration. Uncomfortable appearing. No
pedal edema or lower ___ on exam. No appreciable JVD."
Labs were notable for normal CBC, ___ with Cr 0.8, proBNP 30,
troponin <0.01, normal coags, ___ 706, and normal UA. CTA
was
obtained and demonstrated emboli involving multiple segmental
and
subsegmental branches of the right pulmonary artery. He was
treated with albuterol and ipratropium nebs, methylprednisolone
125mg, magnesium, lrazepam 0.25mg, and enoxaparin 90mg. He was
admitted to Medicine for further evaluation and management.
On arrival to the floor, the patient confirmed the above
history.
Additionally, he reports he has a history of heavy alcohol use
(24 pack of beer, 3x/week for ___ years) and heavy cocaine use
(used ___ for ___ years). He subsequently stopped both
drinking and using cocaine several weeks prior to presentation.
Additionally, approximately one month prior to symptom onset, he
also noted leg heaviness and blurry vision. Otherwise, he denies
fevers/chills, sputum production, abdominal pain, or
nausea/vomiting. He reports having an episode of watery diarrhea
today.
Past Medical History:
-Asthma
-COPD
-Osteoarthritis
-Erectile dysfunction
-Depression
-Hypertension
-Coronary artery disease
-Low back pain with prior narcotics agreement
-Bilateral shoulder replacement in ___
-Bilateral hip replacement in ___
-Lumbar fusion (unknown levels) in ___
Social History:
___
Family History:
-Mother with ___ disease
-Father with lung cancer, CAD, and HTN
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.6 143/93 106 18 92 Ra
GENERAL: Pleasant, lying in bed comfortably
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, wheezes appreciated
diffusely in all lung fields, but difficult to distinguish from
upper respiratory noise.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: No peripheral edema appreciated
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN ___ intact, motor and sensory
function grossly intact
SKIN: 2cm black eschar on erythematous base appreciated on left
anterior thigh
DISCHARGE EXAM:
===============
T:98.3 BP:123/74 HR91 RR18 O296 Ra
GENERAL: Comfortable appearing man sitting up in bed speaking to
me in no distress
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: End expiratory wheezes in all lung fields; no use of
accessory muscles and no evidence of respiratory distress
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: No peripheral edema appreciated
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN ___ intact, motor and sensory
function grossly intact
SKIN: 2cm black eschar on erythematous base appreciated on left
anterior thigh; no purulence; minimal pain to palpation
Pertinent Results:
ADMISSION LABS:
===============
___ 08:33AM BLOOD ___
___ Plt ___
___ 08:33AM BLOOD ___
___ Im ___
___
___ 08:56AM BLOOD ___ ___
___ 08:33AM BLOOD ___
___
___ 06:00AM BLOOD ___ LD(LDH)-229 ___
___
___ 07:25PM BLOOD CK(CPK)-35*
___ 08:33AM BLOOD ___
___ 08:33AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD ___
___ 07:25PM BLOOD ___
___
___ 08:56AM BLOOD ___
CTA CHEST (___):
=================
FINDINGS:
Aorta and great vessels are unremarkable without dissection or
aneurysm. The pulmonary arteries are well opacified to the
subsegmental level. A filling defect is seen in a segmental
artery extending into a subsegmental branch in the right lower
lobe (3; 112). A second filling defect is seen a subsegmental
branch in the right upper lobe (3; 60). The pulmonary arteries
are normal in caliber. No evidence for right heart strain.
Heart size is mildly enlarged. There is no pericardial
effusion.
There is no consolidation, pleural effusion or pneumothorax.
There is
bilateral dependent atelectasis. The airways are patent to the
subsegmental level. There is mild bronchial wall thickening
diffusely.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. The included thyroid gland appears
unremarkable.
Limited images of the upper abdomen show a small subcentimeter
focus of hyper enhancement in the liver, likely representing
area of transient hepatic attenuation difference (3; 163). The
remaining images of the upper abdomen are unremarkable.
No suspicious osseous lesions identified. There is no acute
fracture.
Patient is status post bilateral shoulder arthroplasty.
IMPRESSION:
1. ___ pulmonary emboli involving segmental and
subsegmental branches of the lower lobe and a subsegmental
branch in the upper lobe. No evidence of right heart strain or
pulmonary infarct.
2. Mild diffuse airway wall thickening suggestive of chronic
bronchitis.
BILATERAL LOWER EXTREMITY DOPPLER U/S (___):
=============================================
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral common femoral, femoral, and popliteal veins. Normal
color flow and compressibility are demonstrated in the posterior
tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
DISCHARGE LABS
==============
___ 05:05AM BLOOD ___
___ Plt ___
___ 05:05AM BLOOD ___
___
___ 08:33AM BLOOD cTropnT-<0.01
___ 07:25PM BLOOD ___ cTropnT-<0.01
___ 05:05AM BLOOD ___
___ 08:56AM BLOOD ___
___ 06:11AM BLOOD ___
Brief Hospital Course:
Mr. ___ is a ___ gentleman with PMH of COPD, WPW
s/p ablation (___), asthma, HTN, anxiety, and depression who
presents with approximately 5 days of worsening shortness of
breath, ___ cough, and wheezing consistent with COPD
exacerbation, likely triggered by newly discovered PE.
ACUTE ISSUES:
=============
# Dyspnea:
# COPD exacerbation:
At presentation, the patient reported approximately five days of
worsening shortness of breath, along with wheezing and cough.
Peak flow was measured in the ER as ___. As a result, the
patient was admitted and treated for a presumed COPD
exacerbation, with the likely trigger being the patient's
pulmonary embolus. He was treated with prednisone 60mg QD and
azithromycin for five days, along with scheduled nebulizers. The
patient remained on room air during his hospitalization. With
this treatment, the patient gradually improved.
# Pulmonary embolus
Patient was found to have ___ pulmonary emboli involving
the segmental and subsegmental branches of the lower lobe and a
subsegmental branch in the upper lobe on CTA in ER. Notably,
there was no evidence of right heart strain or pulmonary
infarct. Based on the patient's history, he likely had a
provoked PE secondary to long flight from ___. LENIs were
without evidence of DVTs. He was treated with rivaroxaban 15mg
BID as an inpatient.
# Polysubstance abuse:
Patient endorses a history of cocaine, alcohol, and nicotine
abuse. He reportedly quit EtOH and cocaine one month prior to
presentation. Urine and serum tox screens were obtained and were
negative for substances. He was placed on CIWA after admission,
but did not score. He was supplemented with folate, thiamine,
and B12. Social work was consulted and the patient reported that
he was interested in ___ rehab for his substance abuse. He
said that he knew he would not be adherent to an outpatient
rehab. The patient was able to find an inpatient bed for rehab
starting ___ and preferred to go his girlfriend's apartment on
___ to get clothes and prepare for his rehab. We clarified that
he felt safe with this plan.
___, ___
ph: ___
fx: ___
___
# Depression/Anxiety:
Patient endorses a history of anxiety and depression. He reports
taking aripiprazole, lorazepam, and trazodone chronically,
although these medications could not be found in his medication
fill history. He denied suicidal ideation.
CHRONIC ISSUES:
===============
# HTN: patient was continued on home lisinopril
TRANSITIONAL ISSUES:
====================
NEW MEDS:
- Rivaroxaban 15mg BID through ___, then 20mg QD after that
[ ] Patient takes aripiprazole daily, but ran out of his
medication two weeks prior to presentation. He is unsure of the
dose and preferred to wait until his ___ rehab to start
taking the medication again.
[] Primary care physician - patient needs ___ for his
multiple medical conditions including COPD, pulmonary embolus,
and hypertension. Please ensure medication compliance.
[ ] Given no known precipitant for PE, would encourage patient
to have colonoscopy for routine cancer screen. Could also
consider HCV and HIV testing.
CODE: Full Code (confirmed)
CONTACT:
- ___ (girlfriend, ___
- ___ (sister, ___
Greater than ___ hour spent on care.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 400 mg PO TID
2. ___ Neb 1 NEB NEB Q6H
3. TraZODone 100 mg PO QHS:PRN sleep
4. Lisinopril 20 mg PO DAILY
5. Albuterol Inhaler 1 PUFF IH Q4H:PRN shortness of breath
6. ___ Diskus (100/50) 1 INH IH BID
7. ARIPiprazole Dose is Unknown PO DAILY
8. LORazepam 2 mg PO Q4H:PRN anxiety
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice Daily
Disp #*60 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX ___ 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 Patch Daily Disp #*14 Patch
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
7. PredniSONE 60 mg PO DAILY Duration: 5 Doses
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*3 Tablet
Refills:*0
8. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice daily
Disp #*35 Tablet Refills:*0
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*60 Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
11. ARIPiprazole unknown PO DAILY
12. Albuterol Inhaler 1 PUFF IH Q4H:PRN shortness of breath
RX *albuterol sulfate [Proventil HFA] 90 mcg 1 puff Every four
hours as needed Disp #*1 Inhaler Refills:*0
13. ___ Diskus (100/50) 1 INH IH BID
RX ___ [Advair Diskus] 100 ___ mcg/dose 1
inhalation Twice daily Disp #*2 Disk Refills:*0
14. Gabapentin 400 mg PO TID
15. ___ Neb 1 NEB NEB Q6H
16. Lisinopril 20 mg PO DAILY
17. LORazepam 2 mg PO Q4H:PRN anxiety
18. TraZODone 100 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Pulmonary embolism
SECONDARY DIAGNOSIS:
====================
Chronic obstructive pulmonary disease exacerbation
Polysubstance use disorder
Primary hypertension
Generalized anxiety disorder
Major depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
WHY WERE YOU ADMITTED:
- You were having shortness of breath which we thought was
caused by COPD
- We found a blood clot in your lungs
WHAT HAPPENED IN THE HOSPITAL:
- We gave you medications to treat your COPD
- We gave you a blood thinner to stop your blood clot from
growing
WHAT SHOULD YOU DO AFTER LEAVING:
- Please continue taking your medications as prescribed
- Please ___ with your doctors as ___
- ___ you notice worsening shortness of breath, cough up blood,
or develop severe chest pain, please return to the hospital
Thank you for allowing us to take part in your care!
Your ___ team
Followup Instructions:
___
|
10557261-DS-15 | 10,557,261 | 21,384,176 | DS | 15 | 2179-08-05 00:00:00 | 2179-08-05 14:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Dr. ___:
___ year old male with history of COPD, WPW s/p ablation (___),
asthma, HTN, anxiety, and depression, recently discharged from
hospital after being diagnosed with a pulmonary embolism,
currently on Xarelto, presenting at this time with one half
weeks
of worsening dyspnea and cough which is typical for him with an
asthma exacerbation. The patient says primary care provider were
initially started him on steroids with this is not helped his
symptoms.
In the ED, initial vitals were 97.6 ___ 20 97% RA. Labs
showed WBC 10.0K. He received albuterol and ipratropium
nebulizers x 10, prednisone 40 mg x 2, azithromycin 500 mg x 1,
2
grams magnesium sulfate, gabapentin 600 mg x 2, paroxetine 20 mg
x 1, aripiprazole 5 mg x 1. CTA and CXR were largely
unremarkable for any new findings, with essential resolution of
pulmonary embolism.
Currently, the patient reports feeling a bit better. He is
still
wheezy. There is no chest pain. He has a non-productive cough.
There is no abdominal pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
-Asthma
-COPD
-Osteoarthritis
-Erectile dysfunction
-Depression
-Hypertension
-Coronary artery disease
-Low back pain with prior narcotics agreement
-Bilateral shoulder replacement in ___
-Bilateral hip replacement in ___
-Lumbar fusion (unknown levels) in ___
Social History:
___
Family History:
-Mother with ___ disease
-Father with lung cancer, CAD, and HTN
Physical Exam:
98.2
PO ___ 18 94 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
___ 07:00AM BLOOD WBC-11.3* RBC-4.51* Hgb-13.8 Hct-41.4
MCV-92 MCH-30.6 MCHC-33.3 RDW-15.0 RDWSD-50.7* Plt ___
___ 07:00AM BLOOD Glucose-91 UreaN-19 Creat-0.9 Na-142
K-4.6 Cl-103 HCO3-24 AnGap-15
___ 07:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
___ Imaging CTA CHEST
INDICATION: History: ___ with hx of PE, presenting with
worsening WOB and
SOB// eval for PE extension
TECHNIQUE: Axial multidetector CT images were obtained through
the thorax
after the uneventful administration of intravenous contrast.
Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal
intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy
(Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 16.7 mGy
(Body) DLP = 526.5
mGy-cm.
Total DLP (Body) = 536 mGy-cm.
COMPARISON: CTA dated ___.
FINDINGS:
HEART AND VASCULATURE: There has been essential resolution of
the subsegmental
filling defects in the right lower lobe (3:119) and right upper
lobe (3:66).
There is an equivocal the small focus of hypodensity in the
right lower lobe
subsegmental branch which could represent a tiny focus of
residual clot.
However, no new pulmonary emboli are seen. The thoracic aorta
is normal in
caliber. As before, the heart is mildly enlarged. No
pericardial effusion is
seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of
parenchymal
opacification. Bilateral dependent atelectasis is again
present. The airways
are patent to the level of the segmental bronchi bilaterally.
Mild bronchial
wall thickening is again seen diffusely, similar to prior.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Subcentimeter hypodensity in the left lobe of the liver
is too small
to characterize, but unchanged. Otherwise, the included portion
of the upper
abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
As before, the patient is status post bilateral shoulder
arthroplasty.
IMPRESSION:
1. Essential resolution of right sided pulmonary emboli
involving the sub
segmental branches in the upper and lower lobes. There is an
equivocal, small
focus of hypodensity within the right lower lobe subsegmental
branch, which
could represent a tiny focus of residual clot. No new pulmonary
emboli are
seen.
2. Mild diffuse airway wall thickening suggestive of chronic
bronchitis,
unchanged.
Brief Hospital Course:
___ year old male with history of COPD, WPW s/p ablation (___),
asthma, HTN, anxiety, and depression, recently discharged from
hospital after being diagnosed with a pulmonary embolism,
currently on Xarelto, presenting at this time with one half
weeks
of worsening dyspnea and cough which is typical for him with an
asthma exacerbation.
# Asthma/COPD exacerbation: per patient, this feels similar to
previous exacerbations. He was reportedly on 20 mg of tapered
prednisone at the time of this flare. There is no fevers or
chills, no chest pain.
-CTA chest was done in ED showing no pneumonia or new PE.
-Patient improved with prednisone 40 mg once daily. He was given
a prolonged 11 day taper for this on discharge.
-Clear lung exam on discharge. He was on room air. He felt no
dyspnea.
-Continue home inhalers at home.
-Continue azithromycin for 4 more days for anti inflammatory
effects.
# Pulmonary embolism history: continue home rivaroxaban
# Hypertension: continue home lisinopril
# Depression: continue home paroxetine
Greater than 30 minutes was spent on discharge planning and
coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
2. Lisinopril 20 mg PO DAILY
3. TraZODone 100 mg PO QHS:PRN sleep
4. PredniSONE 20 mg PO DAILY
5. Rivaroxaban 20 mg PO DAILY
6. Gabapentin 400 mg PO TID
7. PARoxetine 20 mg PO DAILY
8. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #*4
Tablet Refills:*0
2. PredniSONE 40 mg PO SEE TAPER DIRECTION
This is a new medication to treat your asthma exacerbation. It
helps reduce inflammation in airways.
RX *prednisone 10 mg 1 tablet(s) by mouth DAILY Disp #*32 Tablet
Refills:*0
3. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
4. Gabapentin 400 mg PO TID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. Lisinopril 20 mg PO DAILY
7. PARoxetine 20 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
9. TraZODone 100 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Instructions: Dear Mr. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had shortness of breath.
====================================
What happened at the hospital?
====================================
-You were found to have an asthma exacerbation (flare up).
-It is not clear what triggered it this time, but fortunately
you had CT chest imaging that showed no evidence of a pneumonia
or infection causing this.
-You got better with higher dose prednisone (steroid medication)
that reduced the inflammation in your airways quickly.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Please take the new prescribed prednisone taper as directed.
You will need to take 40 mg once daily for 5 days, then 30 mg
once daily for 2 days, then 20 mg once daily for 2 days, then 10
mg once daily for 2 days, then STOP.
-Take azithromycin as prescribed for 4 days, then stop (this
drug helps reduce airway inflammation also).
-Use your short acting albuterol inhalers as needed.
-See your PCP as scheduled on ___ to ensure your flare is
still getting better.
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10557370-DS-19 | 10,557,370 | 20,986,567 | DS | 19 | 2181-08-21 00:00:00 | 2181-08-23 16:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
Left tibia intramedullary nail, rotational flap, split thickness
skin grafting
History of Present Illness:
___ ped struck while skateboarding w/L open tibia fx now s/p
I&D, tibial IMN and rotational flap (___).
Physical Exam:
LLE:
Dressing c/d/I
STSG healing nicely
SILT S/S/SP/DP/T
Firing ___
+2 pulses
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left open tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibia intramedullary nail,
rotational flap, and again on ___ for split thickness skin
grafting 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 left lower extremity, and will be
discharged on Aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth 1 tablet every 6 hours Disp #*60 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth ___ tablets
every 4 hours Disp #*84 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
left open tibia fracture
Discharge Condition:
AAOx3, mentating appropriately, NVI
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:
- touch-down weight bearing
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 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
Physical Therapy:
non weight bearing LLE
Followup Instructions:
___
|
10557653-DS-19 | 10,557,653 | 28,420,992 | DS | 19 | 2158-09-08 00:00:00 | 2158-09-08 10:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L unla and L fibula fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left ulna
History of Present Illness:
___ RHD woman rear helmeted passenger on a motorcycle hit
by a car at low speed. Brought into the ED complaining of
left-sided chest pain as well as left arm and leg pain. Patient
states the motorcycle fell on her left side. Denies any
numbness/paresthesias in any extremity. Found to have a single L
sided rib fracture, L ulna closed fracture, and a L distal
fibula
fracture.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, A&Ox3
LUE:
Splint in place
SILT m/r/u
+ EPL/EDC/FDS/FDP/DIP
WWP
LLE:
ACB in place
Skin c/d/i
SILT dp/sp/s/s
+ ___
2+ dp/pt
Pertinent Results:
___ 08:55PM BLOOD WBC-9.8 RBC-3.88* Hgb-12.4 Hct-37.5
MCV-97 MCH-32.1* MCHC-33.2 RDW-12.2 Plt ___
___ 08:55PM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-142
K-3.5 Cl-108 HCO3-24 AnGap-14
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
an operative left ulna fracture and non operative left fibula
fracture. The patient was taken to the OR and underwent an
uncomplicated ORIF Left ulna. The patient tolerated the
procedure without complications and was transferred to the PACU
in stable condition. Please see operative report for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status: NWB LUE, WBAT LLE in ACB
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis with Aspirin 325 for 4 weeks post-operatively.
She received an Air Cast Boot to LLE with Physical therapy
evaluation and treatment.
All questions were answered prior to discharge and the patient
expressed readiness for discharge on POD1.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
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. Multivitamins 1 CAP PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Hold for excess sedation, RR<10, O2sat<92%
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every four
(4) hours Disp #*90 Tablet Refills:*0
5. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L ulna fracture
L fibula fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Non-weight bearing left upper extremity
Weight bearing as tolerated left lower extremity in air cast
boot
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take apririn 325mg for DVT prophylaxis for 4 weeks
post-operatively.
******FOLLOW-UP**********
Please follow up with ___ in ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Followup Instructions:
___
|
10557857-DS-10 | 10,557,857 | 22,199,235 | DS | 10 | 2193-12-22 00:00:00 | 2193-12-22 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / latex / BiDil / cholestyramine / gemfibrozil /
lovastatin / Thiazides
Attending: ___
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
Upper endoscopy
Push enteroscopy
Placement of primary pacemaker
History of Present Illness:
Mr. ___ is an ___ w/ HF w/ borderline EF
EF40-50%, AFib on warfarin, CAD s/p POBAx1, HTN, HLD, and T2DM,
who presented with pre-syncopal episode, melena & anemia.
The patient described that for 3 days prior to admission he was
feeling generalized fatigue and weakness. On the day of
admission, per a family member, the patient was walking through
his house when he began to complain of dizziness, sat down, and
then became difficult to arouse for 10 seconds. The patient
denies losing consciousness but admits dizziness.
Of note, the patient admits 3 weeks of very dark stools.
He was brought to ___ by EMS for further evaluation.
Past Medical History:
CHF EF 45-50%, likely ETOH related
CAD, 3 vessel disease, being medically managed
T2DM on insulin
B iliac artery aneurysm s/p coiling ___ with continued
procedure planned
Atrial fibrillation CHADSVASC 6 on Coumadin
Benign Essential Hypertension
Social History:
___
Family History:
Denies FH cancer, MI, CVA. Sister with ESRD on HD at time of
death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, facial twitching
NECK: supple, no LAD, no JVD
HEART: Irregular irregular, bradycardic, loud ___ systolic
murmur
LUNGS: Decreased breath sounds at lung bases, otherwise CTAB
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISHCARGE PHYSICAL EXAM:
========================
General: Elderly male resting in bed, left arm in sling NAD,
A/Ox3, pleasant.
Head: NC/AT, conjunctiva w/ mild pallor, sclera anicteric, dry
MM.
Neck: Supple, no JVD, PPM site covered, c/d/i.
Cardiac: Irregularly irregular, S1, S2 w/ ___ systolic murmur.
Respiratory: CTAB w/o w/r/c.
Abdomen: Soft, NT, +bowel sounds.
Extremities: No edema, WWP.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:03PM BLOOD WBC-7.7 RBC-2.39* Hgb-6.3* Hct-21.3*
MCV-89 MCH-26.4 MCHC-29.6* RDW-18.3* RDWSD-59.2* Plt ___
___ 03:03PM BLOOD Neuts-74.1* Lymphs-14.9* Monos-8.2
Eos-1.4 Baso-0.5 NRBC-0.5* Im ___ AbsNeut-5.67#
AbsLymp-1.14* AbsMono-0.63 AbsEos-0.11 AbsBaso-0.04
___ 03:03PM BLOOD ___ PTT-34.5 ___
___ 03:03PM BLOOD Glucose-129* UreaN-56* Creat-1.4* Na-141
K-4.6 Cl-105 HCO3-19* AnGap-17*
___ 06:00AM BLOOD ALT-6 AST-10 AlkPhos-76 TotBili-1.1
___ 03:03PM BLOOD proBNP-1254*
___ 03:03PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
___ 02:56AM BLOOD calTIBC-367 Ferritn-102 TRF-282
DISCHARGE LABS:
===============
___ 03:03PM ___ PTT-34.5 ___
___ 05:55AM BLOOD WBC-11.7* RBC-2.96* Hgb-8.0* Hct-26.1*
MCV-88 MCH-27.0 MCHC-30.7* RDW-18.2* RDWSD-55.3* Plt ___
___ 05:55AM BLOOD Glucose-131* UreaN-47* Creat-1.5* Na-143
K-4.1 Cl-106 HCO3-24 AnGap-13
___ 05:55AM BLOOD ___
___ 02:56AM BLOOD calTIBC-367 Ferritn-102 TRF-282
MICROBIOLOGY:
=============
URINE CULTURE-NO GROWTH
IMAGING:
=========
CXR
1. No acute cardiopulmonary abnormality.
Brief Hospital Course:
Patient Summary:
================
Mr. ___ is an ___ w/ HF w/ borderline EF
EF40-50%, AFib on warfarin, CAD s/p POBAx1, HTN, HLD, and T2DM,
who presented with pre-syncopal episode, anemia, & 3 weeks of
melena.
On admission, he was HDS but labs were notable for acute anemia
(Hgb 6.3) and supratherapeutic INR (3.6). Over his first 24
hours, he received 3U pRBCs. He underwent upper endoscopy which
showed fresh blood in the duodenum past the scope, so he
subsequently underwent push enteroscopy which identified a
bleeding Dieulafoy's lesion which was successfully cauterized.
In addition to GI consultation, Cardiology was consulted for a
history of tachy-brady syndrome (previously had refused PPM). He
underwent PPM placement w/o complication ___.
See individual problems addressed below.
Acute Medical Issues Addressed:
===============================
# Melena:
# Anemia:
Pre-syncopal episode at home, Hgb 6.3 on admission w/ INR 3.6,
Guiac positive stools. Received 3U pRBCs. HDS after with stable
CBC. EGD performed initially ___ which saw bleeding Dieulafoy's
lesion in duodenum but could advance scope far enough. Small
bowel enteroscopy then performed ___, Dieulafoy's lesion
cauterized successfully.
-s/p 3U RBCs over course of admission
-IV --> PO PPI
-Had initially held warfarin, re-started once stable
# Pre-syncope, likely ___ anemia, bradycardia:
Witnessed episode of dizziness & questionable unresponsive, ___
GIB & bradycardia.
GIB handled as above, tach-brady syndrome handled as below.
# Supratherapeutic INR:
INR 3.7 on admission, held warfarin initially, INR 1.5 ___,
re-started ___ w/ goal INR ___. Was subtherapeutic on
discharge, uptrending, and did not feel indicated to bridge.
# Atrial fibrillation, tachy-brady syndrome:
-Rate: Held AV nodals initially, resumed prior to d/c at home
doses of carvedilol and diltiazem.
-Rhythm: No agents for now
-AC: CHA2DS2-VASc 6, HAS-BLED 7, held warfarin but re-started as
above
-As above, PPM ___
# HF w/ borderline EF (40-50%):
No s/s of overload on admission, BNP 1200 below previous values
of 2K.
-Preload: Continued furosemide 80mg
-Afterload: Held losartan & spironolactone ISO GIB, re-started
on d/c
-NHBK: Held carvedilol as above, re-started prior to d/c
-Inotropy: None
# Leukocytosis: Unclear etiology, no s/s of infection, likely
reactive.
Chronic Issues Pertinent to Admission:
=======================================
# CAD s/p POBAx1:
-Continued home ASA, statin, on BBs on d/c
# Essential HTN:
-Meds held initially as above, continued on d/c
# HLD
-Continued home statin
# CKD
-Creatinine 1.4 on admission, near baseline, monitored
# T2DM
-Continued glargine, HISS while inpatient
Transitional Issues:
====================
[ ] To complete 3 day course of PO Keflex, to complete on ___
[ ] Measure CBC at PCP ___. Hgb on d/c 8.0.
Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO QPM
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 20 mg PO BID
6. Senna 8.6 mg PO BID:PRN constiaption
7. Allopurinol ___ mg PO QPM
8. Losartan Potassium 25 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. Warfarin 1.5 mg PO 3X/WEEK (___)
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Furosemide 80 mg PO DAILY
13. Diltiazem Extended-Release 180 mg PO DAILY
14. Carvedilol 50 mg PO BID
15. Warfarin 2 mg PO 4X/WEEK (___)
16. Glargine 12 Units Dinner
Discharge Medications:
1. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*6 Capsule Refills:*0
2. Glargine 12 Units Dinner
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Allopurinol ___ mg PO QPM
5. Aspirin 81 mg PO QPM
6. Atorvastatin 80 mg PO QPM
7. Carvedilol 50 mg PO BID
8. Diltiazem Extended-Release 180 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Furosemide 80 mg PO DAILY
11. Losartan Potassium 25 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. Senna 8.6 mg PO BID:PRN constiaption
14. Spironolactone 25 mg PO DAILY
15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
16. Warfarin 1.5 mg PO 3X/WEEK (___)
17. Warfarin 2 mg PO 4X/WEEK (___)
18.Outpatient Lab Work
INR Check, please fax results to ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Syncope
Upper GI bleed
Secondary Diagnosis
Supratherapeutic INR
HFrEF
Atrial fibrillation
Tachy-brady syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing to receive your care at ___.
You were admitted because of dizziness. We found that you were
bleeding. When you are bleeding, sometimes not enough blood
goes to your brain and you feel like you can feel dizzy. The GI
tract doctors did ___ procedure where they were able to see the
blood vessel that was bleeding and stop the bleeding.
You also got a pacemaker placed. This is a device that controls
your heart rate so that it does not go too slow or too fast.
You should come back to the hospital if you feel dizzy. You
should also come back if you notice blood in your stool or dark
stool.
Please see a list of your medications and appointments below.
We wish you the best in your recovery.
Sincerely,
Your ___ Care team
Followup Instructions:
___
|
10557857-DS-12 | 10,557,857 | 27,615,566 | DS | 12 | 2196-03-05 00:00:00 | 2196-03-05 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / latex / BiDil / cholestyramine / gemfibrozil /
lovastatin / Thiazides
Attending: ___.
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
EGD with cautery
History of Present Illness:
___ male PMH A. fib on warfarin, HFrEF (LVEF 40-45%),
CAD
s/p POBA x1, HTN, HLD, and T2DM who presented with presyncope.
He
is being admitted for work-up of suspected UGIB given Hgb drop
and melenic stools.
His symptoms began last night with dizziness, weakness, and
significant fatigue. He was using the bathroom and felt like he
was going to pass out. Per EMS, his home health aid stated he
was
not acting like himself recently. He endorsed dark stools and
decreased PO intake. He denied hematochezia, hematemesis,
fevers,
chills, dyspnea, chest pain, or abdominal pain. He has some
sputum production but no significant cough.
Of note, he has history of UGIB with duodenal Dieulafoy lesion
in
___ which was identified with push enteroscopy. Hemostasis
was
achieved with epinephrine and cautery. His last colonoscopy in
___ showed diverticulum with adherent clot and underlying
visible vessel which was clipped.
Past Medical History:
CHF EF 45-50%, likely ETOH related
CAD, 3 vessel disease, being medically managed
T2DM on insulin
B iliac artery aneurysm s/p coiling ___ with continued
procedure planned
Atrial fibrillation CHADSVASC 6 on Coumadin
Benign Essential Hypertension
Social History:
___
Family History:
Denies FH cancer, MI, CVA. Sister with ESRD on HD at time of
death.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: T 98.3F, BP 158/81, HR 77, RR 18, SpO2 92% RA
GENERAL: alert, interactive, NAD
HEENT: NC/AT, EOMI, sclera anicteric, MMM
CARDIAC: RRR, no m/r/g
LUNG: Trace bibasilar inspiratory crackles, no wheezes,
unlabored
respirations
GI: abdomen soft, non-tender to palpation, non-distended, +BS
throughout, no rebound/guarding
EXT: Warm, no lower extremity edema
PULSES: 2+ DP pulses
NEURO: A/Ox3, moving all four extremities with purpose
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 833)
Temp: 97.5 (Tm 99.2), BP: 137/82 (114-137/63-82), HR: 84
(68-84),
RR: 18 (___), O2 sat: 98% (95-99), O2 delivery: RA, Wt: 155.5
lb/70.53 kg
GENERAL: Pleasant, lying in bed comfortably
HEENT: Normocephalic, atraumatic, sclerae anicteric, pale
conjunctiva, MMM
CARDIAC: Irregularly irregular rhythm, regular rate, ___
systolic
ejection murmur best heard at ___, no rubs or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, CN II-XII grossly intact, moving all 4
extremities with purpose
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
===============
___ 04:30PM BLOOD WBC-6.0 RBC-2.98* Hgb-6.7* Hct-24.7*
MCV-83 MCH-22.5* MCHC-27.1* RDW-22.7* RDWSD-68.8* Plt ___
___ 04:30PM BLOOD Neuts-79.2* Lymphs-11.1* Monos-6.7
Eos-1.7 Baso-0.8 Im ___ AbsNeut-4.71 AbsLymp-0.66*
AbsMono-0.40 AbsEos-0.10 AbsBaso-0.05
___ 04:30PM BLOOD ___ PTT-35.1 ___
___ 04:30PM BLOOD Plt ___
___ 04:30PM BLOOD Glucose-124* UreaN-49* Creat-1.5* Na-137
K-4.8 Cl-104 HCO3-20* AnGap-13
___ 04:30PM BLOOD CK-MB-2 cTropnT-0.01 proBNP-2185*
___ 04:30PM BLOOD ALT-7 AST-14 AlkPhos-85 TotBili-0.4
___ 04:30PM BLOOD Albumin-4.5
DISCHARGE LABS
===============
___ 05:45AM BLOOD WBC-8.5 RBC-3.21* Hgb-7.7* Hct-27.3*
MCV-85 MCH-24.0* MCHC-28.2* RDW-21.3* RDWSD-66.3* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-31.1 ___
___ 05:45AM BLOOD Glucose-72 UreaN-35* Creat-1.2 Na-143
K-4.5 Cl-106 HCO3-21* AnGap-16
___ 05:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0
PERTINENT IMAGING
==================
CXR
IMPRESSION:
1. Stable moderate to severe enlargement of the
cardiomediastinal silhouette.
2. No focal consolidation to suggest pneumonia or mass evident
by plain
radiography.
Brief Hospital Course:
Mr. ___ is an ___ gentleman with a significant past
medical history of Afib on warfarin with PPM, HFrEF (LVEF
40-45%), CAD s/p POBA, HTN, T2DM, and duodenal Dieulafoy lesion
in ___, who presented with fatigue and black stools with drop
in hgb to 6.7 from 10 in ___, found to have multiple AVMs on
EGD now cauterized.
During this admission, the patient's CBC was closely monitored.
His hgb and hct have remained stable at around 7.7 post 2 unit
pRBCs. He symptomatically improved with increased energy.
Patient also underwent an EGD and push enteroscopy to evaluate
for upper GI bleed. Multiple AVMs were found and cauterized
although they were not actively bleeding at the time of the
scope. There may have been other causes of bleed that were not
visualized. Patient was restarted on a regular diet and his home
warfarin and aspirin after the procedure and has tolerated diet
and medications well.
Patient also presented with an ___, likely prerenal in the
setting of active GI bleed, now resolved at discharge. His home
diuretics and blood pressure medications were held this
admission in the setting of possible active GI bleed. His home
diuretics and diltiazem were restarted at the time of discharge.
His carvedilol and losartan were held in the setting of normal
pressures while in the hospital. Given symptomatic improvement
and no sign of active bleeding, Mr. ___ was deemed ready to go
home.
TRANSITIONAL ISSUES:
[ ] f/u cbc within one week as there may be an additional source
of bleeding (AVMs were not bleeding at the time of EGD)
necessitating pill endoscopy or colonoscopy
[ ] Home carvedilol and losartan were held in the setting of
normal blood pressures while inpatient. Patient advised to check
blood pressures at home and restart losartan if SBP>140. Please
follow-up blood pressure and adjust medications as appropriate.
ACUTE ISSUES:
=============
# Acute blood loss anemia:
# Concern for UGIB:
Patient presented with dark stools and fatigue for 2 months
duration, seen in past for dark stools and fatigue outpatient.
Found to have drop of hemoglobin from 10 in ___ to
6.7 on admission. Transfused 2 units with appropriate response.
Home warfarin held until EGD then resumed without complication
post-procedure. Patient found to have multiple AVMs that were
not bleeding on EGD, which were cauterized. Given Pantoprazole
40mg PO BID to be continued outpatient.
# HFrEF: LVEF 40-45% (___). Arrival proBNP ~2200 (2700 ___.
Vitals stable, on room air. Denies any shortness of breath or
chest pain. Home diuretics and blood pressure medications were
held given concern for potential re-blead. Diuretics and
diltiazem were restarted on discharge. Continued to hold
carvedilol and losartan at discharge.
# ___ on CKD: Cr 1.5 on admission from baseline 1.1-1.2.
Possibly pre-renal in setting of blood loss anemia. Improved
following transfusion, back at 1.2 on discharge.
# A. fib:
# SSS s/p PPM in ___: CHADS-VASc 5.
Restarted home warfarin and aspirin following EGD. Patient
tolerated well.
CHRONIC ISSUES:
===============
# CAD s/p POBAx1: Patient was continued on home atorvastatin.
Aspirin was held until post procedure. Home carvedilol held as
per above.
#HTN: Home medications were held this admission in the setting
of GI bleed. Losartan and diltiazem were restarted at time of
discharge.
#HLD: Patient continued ___ Atorvastatin.
#T2DM: Patient continued on home glargine regime with
appropriate adjustments when NPO. Patient was also on sliding
scale insulin.
#Gout: Home allopurinol was decreased to 50mg PO daily given
___. Allopurinol dose was resumed to 100mg PO daily at discharge
given resolution of ___.
# CODE: full (presumed)
# CONTACT: ___, daughter, Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. CARVedilol 50 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Glargine 12 Units Bedtime
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Warfarin 1.5 mg PO DAILY16
13. Furosemide 80 mg PO DAILY
14. Losartan Potassium 25 mg PO DAILY
15. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
2. Glargine 12 Units Bedtime
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 80 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Polyethylene Glycol 17 g PO DAILY
12. Spironolactone 25 mg PO DAILY
13. Warfarin 1.5 mg PO DAILY16
14. HELD- CARVedilol 50 mg PO BID This medication was held. Do
not restart CARVedilol until you see your outpatient
cardiologist and your systolic blood pressure is >140
15. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you see your
outpatient cardiologist and your systolic blood pressure is >140
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
upper GI bleed
SECONDARY DIAGNOSIS
===================
HFrEF (40-45%)
Afib
CAD s/p POBAx1
HTN
HLD
T2DM
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You felt weak and dizzy and had black stools at home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Your blood counts were closely monitored while you were in the
hospital. You received 2 units of blood and tolerated the
transfusion well with good improvement in energy. Your blood
counts have remained stable since then, indicating that you have
not continued to bleed.
- You were found to have blood in your stool. We did a scope
study of the upper part of your GI tract, which found a
potential source of the bleed. Those vessels were cauterized,
which should keep them from bleeding again.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments. Please be
aware that you should NOT take your carvedilol and losartan at
home until you see your doctor at your follow up appointments OR
your blood pressure is too high.
- Please check your blood pressure at home. If the systolic
blood pressure (the number on top) is greater than 140, please
resume taking the losartan.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10558000-DS-12 | 10,558,000 | 27,045,306 | DS | 12 | 2151-07-07 00:00:00 | 2151-07-07 18:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / latex
Attending: ___.
Chief Complaint:
Acute cholecystitis
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement by interventional
radiology
History of Present Illness:
___ s/p SILS R colectomy ___ for polyps presents to ED
with 3 days of RUQ pain, chills, and inability to tolerate PO.
Pt
pain has been progressively worse and she presented to OSH.
At OSH, CT A/P obtained showing evidence of cholecystitis. She
was then transferred here for further care.
Past Medical History:
Heart Problems: yes, MI, CAD
High Blood Pressure: yes
Respiratory Problems: none
Liver Problems:
Kidney problems:
Ulcers:
Diabetes:
Cancer:
Arthritis:
HIV or AIDS:
Pregnant:
Psychiatric Problems: anxiety
Other: vascular: PAD, carotid stenoses, question of TIA
Social History:
___
Family History:
Inflammatory Disease: none
Colon Cancer: questionable colon cancer history in father
Physical ___:
DISCHARGE PHYSICAL EXAM:
99.6/99.6 84 168/64 20 98% on RA
N: Alert and oriented x3, no acute distress
CV: RRR
Pulm: unlabored
Abd: soft, non-tender, non-distended, perc chole tub in place in
RUQ with bilious output draining
Ext: warm and well perfused
Pertinent Results:
___ 07:10AM BLOOD WBC-9.7 RBC-3.62* Hgb-11.4* Hct-33.5*
MCV-93 MCH-31.4 MCHC-34.0 RDW-13.2 Plt ___
___ 05:50AM BLOOD WBC-13.8* RBC-3.80* Hgb-12.0 Hct-35.5*
MCV-94 MCH-31.7 MCHC-33.9 RDW-13.3 Plt ___
___ 05:30PM BLOOD WBC-20.1* RBC-3.93* Hgb-12.1 Hct-37.3
MCV-95 MCH-30.9 MCHC-32.5 RDW-13.5 Plt ___
___ 07:10AM BLOOD Glucose-66* UreaN-11 Creat-0.6 Na-141
K-2.8* Cl-100 HCO3-28 AnGap-16
___ 07:10AM BLOOD Calcium-8.9 Phos-2.3* Mg-1.9
Brief Hospital Course:
Ms. ___ was admitted to the Colorectal surgery service on
___ after being transferred from an OSH for acute
cholecystitis. Given her recent surgery as well as being on
plavix, she underwent placement of a percutaneous
cholecystostomy tube. She tolerated this procedure well. Her
white count subsequently trended down and was normalized at the
time of discharge. She was started on a regular diet which she
tolerated well. On HD3 her home medications were restarted. Her
potassium in the AM of discharge was 2.8. She was given 40mEq IV
and had her po dose of KCL restarted. At re-check in the aftern
it was normalized to 3.9 so she was discharged. She was afebrile
with stable vital signs.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Isosorbide Mononitrate 40 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN angina
8. Oxybutynin 5 mg PO DAILY
9. Potassium Chloride 20 mEq PO BID
10. Simvastatin 40 mg PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit oral
daily
14. melatonin 1 mg oral qhs
15. Multivitamins 1 TAB PO DAILY
16. Fish Oil (Omega 3) 1000 mg PO BID
17. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Potassium Chloride 20 mEq PO BID
7. Simvastatin 40 mg PO DAILY
8. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth q8hrs Disp #*30 Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Ascorbic Acid ___ mg PO DAILY
12. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit oral
daily
13. Fish Oil (Omega 3) 1000 mg PO BID
14. Isosorbide Mononitrate 40 mg PO BID
15. Lisinopril 5 mg PO DAILY
16. melatonin 1 mg oral qhs
17. Multivitamins 1 TAB PO DAILY
18. Nitroglycerin SL 0.4 mg SL PRN angina
19. Oxybutynin 5 mg PO DAILY
20. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after being found to have
acute cholecystitis, an infection in your gallbladder. A drain
was placed in your gallbladder in order to decompress it. You
will need to keep this drain in until the infection has been
appropriately treated with antibiotics. Your gallbladder may
need to be removed eventually, so you should follow up with a
general surgeon for discussion of this.
It will be important for you to follow up in clinic in ___ weeks
to determine when your gallbladder should occur. You should be
recording the drain output daily and keeping a log to bring with
you to clinic.
Please call the office or return to the ED if you develop nausea
or vomiting, fevers or chills, increased pain or redness around
the site of your drain, a change in the output of the drain, or
any other symptoms that may concern you.
Followup Instructions:
___
|
10558000-DS-13 | 10,558,000 | 25,690,009 | DS | 13 | 2153-04-20 00:00:00 | 2153-04-25 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / latex
Attending: ___
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of gastric ulcers, metastatic lung
adenocarcinoma presenting as transfer from ___ with
flank pain and CT concerning for gastric perforation. Per
patient
report, pain started 2 days prior in right flank, now migrating
towards midline. During this time, states that she has not been
eating, and has had nausea and non-bloody emesisx3. No fevers or
chills. Denies regular NSAID use. Patient had EGD on ___
which showed ___ ulcerations in body of stomach, biopsy showed
ulcerative gastritis with ___ species and no evidence of
malignancy. Of note, patient is receiving radiation for lung and
liver carcinoma, last treatment was approximately ___.
At ___ today patient was given protonix 40mg and
Zofran 8mg and meropenem 1gram. Transferred to ___.
At time of consultation, pt AFVSS however with low grade
temperature to 100.1, mild sinus tachycardia 93-100, WBC 7.1
without neutrophil predominance, lactate 1.1, normal CMP and
CTAP
with concern for potentially contained perforation along greater
curvature of stomach.
Past Medical History:
PMH: RLL metastatic adenocarcinoma (ongoing palliative XRT),
gastric ulcers, MI several years ago, coronary artery disease,
colonic polyps, hypertension, hyperlipidemia, aortic aneurysm,
peripheral vascular disease, ?TIA ___ years ago
PSH: Laparoscopic R Colectomy ___, abdominal
hysterectomy and bilateral salpingo-oophorectomy, laparoscopic
cholecystectomy ___ ___, bilateral iliac stents, carotid
artery endarterectomy
Social History:
___
Family History:
Positive for gallstones. Father deceased from metastatic
carcinoma, unknown primary.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.0 98 126/65 15 100% NC
GEN: A&O, NAD
HEENT: Scleral icterus bilaterally, arcus senilis, mucus
membranes moist
CV: RRR, S1/S2 heard, holosystolic murmur throughout
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mild diffuse tenderness to deep
palpation, no rebound or guarding, hyperactive bowel sounds, no
palpable masses, no upper midline or L subcostal incisional
scars
EXT: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
Vitals: 99.3 101-143/44-57 ___ 96-98%RA
General: Alert, noncooperative with orientation, agitated
HEENT: Sclerae anicteric, dry MM
Neck: Supple
Lungs: Breathing comfortably on RA, declines auscultation
CV: Declines
Abdomen: Declines
Ext: No cyanosis/clubbing/edema
Pertinent Results:
ADMISSION LABS:
___ 12:10AM BLOOD WBC-7.1 RBC-3.85* Hgb-11.0* Hct-34.5
MCV-90 MCH-28.6 MCHC-31.9* RDW-14.5 RDWSD-47.0* Plt ___
___ 09:10AM BLOOD WBC-5.5 RBC-3.38* Hgb-9.7* Hct-31.1*
MCV-92 MCH-28.7 MCHC-31.2* RDW-14.5 RDWSD-48.6* Plt ___
___ 09:10AM BLOOD ___ PTT-30.5 ___
___ 09:10AM BLOOD Glucose-86 UreaN-13 Creat-0.9 Na-146*
K-3.4 Cl-107 HCO3-26 AnGap-16
___ 09:10AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
___ 12:18AM BLOOD Lactate-1.1
PERTINENT LABS:
___ 04:45AM BLOOD Digoxin-1.2
___ 01:41AM BLOOD cTropnT-0.01
___ 09:30AM BLOOD cTropnT-<0.01
___ 05:40PM BLOOD cTropnT-0.01
___ 05:00AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 04:45AM BLOOD WBC-4.1 RBC-3.40* Hgb-9.7* Hct-30.9*
MCV-91 MCH-28.5 MCHC-31.4* RDW-14.6 RDWSD-48.1* Plt ___
___ 04:45AM BLOOD Glucose-91 UreaN-18 Creat-1.4* Na-142
K-3.6 Cl-106 HCO3-23 AnGap-17
___ 04:45AM BLOOD ALT-28 AST-48* LD(LDH)-260* AlkPhos-63
TotBili-0.3
___ 04:45AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.2 Mg-2.0
STUDIES:
___ CT abdomen/pelvis
1. Stable appearance of a 4.4 cm infrarenal abdominal aortic
aneurysm with
extensive intraluminal mural thrombus, larger since prior from
___ (at that time, 4.0 cm). No evidence of
retroperitoneal hematoma or aneurysm rupture. No evidence of
dissection.
2. Severe calcification of the abdominal aorta, with severe
narrowing of the origins of major branches including the celiac
axis, SMA and the right renal artery, as detailed above.
3. Highly stenosed versus occluded left SFA.
4. Diffuse heterogeneous liver enhancement may reflect
perfusional anomaly,
however correlation with LFTs is recommended to exclude liver
disease. If
further evaluation is required, consider MRI.
5. Mild prominence of the CBD and proximal intrahepatic biliary
tree measuring 8-9 mm is new since ___, possibly
related to interval
postcholecystectomy state.
6. Asymmetric mild left perinephric stranding with anterior and
posterior left pararenal fascial thickening is nonspecific. No
hydronephrosis.
7. A hypodense 2.3 x 2.1 cm segment VI/VII focus with adjacent
fiducials
likely represents treated metastasis.
8. Indeterminate right hepatic lobe 1.3 cm hypoenhancing focus,
possibly a
metastasis, larger since ___.
___ Arterial doppler
Moderate right lower extremity inflow arterial disease, likely
at the level of the right iliac artery.
Moderate left lower extremity outflow arterial disease at the
level of the
left superficial femoral artery.
MICROBIOLOGY
___ Urine culture negative
___ Serum H. pylori antibody negative
Brief Hospital Course:
SURGERY COURSE
Ms. ___ is a ___ with history of gastric ulcers, metastatic
lung adenocarcinoma presenting as transfer from ___
with concern for gastric perforation. Despite concerning
findings on CT, patient appeared clinically stable with only
mild abdominal tenderness to palpation, no peritoneal signs, and
no leukocytosis. Given the patient's chronically
immunosuppressed state in the setting of widely metastatic lung
cancer, she may not be able to mount an effective inflammatory
response, however her presentation despite this caveat is not
entirely consistent with ___ of gastric perforation given the
evident chronicity of the concerning radiographic findings and
presence of perigastric fat stranding. Chronic contained
perforation remains on the differential. Nevertheless, hospital
admission, serial exams, and close monitoring will be required
with low threshold for operative intervention.
On HD1 she was kept NPO with IV fluids, IV vancomycin and zosyn,
and a protonix drip. On HD2 she had 6 beats of ventricular
tachycardia and reported abdominal pain. Triponins were cycled
and negative. A CTA was obtained notable for a stable infrarenal
abdominal aortic aneurysom with extensive intraluminal mural
thrombus and a highly stenosed vs occluded SFA. See report for
more details. An EKG was obtained that showed sinus rhythm with
a new left axis deviation, and left bundle-branch block. On HD3
ABIs were obtained to evaluate the lower extremities. See report
for details. She had increasing delirium and paranoia that
improved with family presence. On HD4 she was tolerating a
regular diet, voiding without difficulty, denied abdominal pain
and had no bloody bowel movements or emesis. She continues to
have increasing paranoia and refusing medications and was
transferred to medicine.
============
MEDICINE COURSE
___ yo woman with h/o metastatic lung adenocarcinoma on XRT, CAD,
HTN, HLD, PAD, known PUD, transferred from ___ to ___
for gastric perforation, managed nonoperatively, and transferred
to medicine for further management. Patient was treated
conservatively with IVF. On ___ into ___, she was demanding to
leave the hospital and exhibited paranoid and claustrophobic
behavior; she did not cooperate with H+P. Her husband HCP noted
that she has had this kind of paranoid reaction to being in
hospitals in the past. Risks and benefits of leaving on ___
(and reasons for hospitalization including further w/u and ___
___ and AMS) were explained; they both desired to leave, with
close monitoring at home by her husband, and close followup with
PCP and specialist ___ and ___ (who comes daily). Pt took PO and
walked independently prior to leaving the hospital.
# Peptic ulcer disease c/b microperforation: Medically managed.
Abdominal exam remained benign. She was initially on
cipro/flagyl, and on ___ cipro was switched cefpodoxime in case
the fluoroquinolone was contributing to AMS. She should be
continued per surgery on flagyl/cefpodoxime x 2 weeks (last day
___. She was also discharged on Omeprazole 40 mg bid,
which should continue until her next GI followup.
# AMS: Has had waxing/waning mental status in house (see above).
# Acute kidney injury: Patient with increase in Cr from baseline
0.9 and clinically dry. Unable to obtain urine lytes, and pt had
refused IVF on ___ pm. She was likely dry and the ___ was
likely prerenal in etiology. Her BUN/Cr should be rechecked at
PCP or specialist ___.
# Metastatic lung adenocarcinoma (s/p palliative XRT): Patient
with metastasis to liver. Course of XRT completed ___ with
oncologist at ___. She was d/c'd with outpatient hem/onc
follow up.
# CAD with hx of MI: She was continued on digoxin, imdur,
simvastatin, amlodipine. She was discharged with instructions to
to hold chlorthalidone and lisinopril given ___ these should be
restarted once her kidney function improves.
# AAA with intramural thrombus: Stable 4.4 cm aneurysm on most
recent CT. We deferred restarting Plavix to outpatient, given
the concern for gastric microperforations.
TRANSITIONAL ISSUES:
-Patient's mental status should be assessed (see above); she
exhibited mild agitation and behavior of accusing staff of lying
and of refusing to answer any questions from the staff; her
husband reported seeing this similar behavior during past
hospitalizations with quick improvement upon being discharged in
the past, and expressed being comfortable with taking the
patient home with close followup.
-She was discharged with instructions to to hold chlorthalidone
and lisinopril given ___ these should be restarted once her
kidney function improves
-She should be continued per surgery on flagyl/cefpodoxime x 2
weeks (last day ___. She was also discharged on Omeprazole
40 mg bid, which should continue until her next GI followup.
-We deferred restarting Plavix to outpatient given the concern
for gastric microperforations; this should be restarted within
one week (by approximately ___ pending outpatient GI and
oncology followup.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Isosorbide Dinitrate 40 mg PO BID
2. Chlorthalidone 25 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Potassium Chloride 20 mEq PO BID
8. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Isosorbide Dinitrate 40 mg PO BID
3. Simvastatin 40 mg PO QPM
4. Amlodipine 10 mg PO DAILY
5. Potassium Chloride 20 mEq PO BID
Hold for K >
6. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth q12hr Disp #*44
Tablet Refills:*0
7. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*33 Tablet Refills:*0
8. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Peptic ulcer disease
Self contained gastric perforation
Altered mental status
Secondary
Acute kidney injury
Metastatic lung adenocarcinoma
CAD with h/o MI
AAA c/b intramural thrombus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with concern for a perforated gastric
ulcer. The CT scan showed a small leak but you did not have a
fever, your abdominal pain is controlled, and your blood tests
did not show evidence of infection. Your condition does not
warrant surgical intervention at this time. The CT scan also
showed a blockage in your legs. Ankle Brachial Indexes were
preformed on your legs and showed decreased blood flow. The CT
scan also showed a stable aneurysm. You should follow up with
your primary care provider for referral to an outpatient
vascular specialist.
Your condition improved, but you were likely dehydrated and
needed intravenous fluids and monitoring of your kidney
function, diet, and activity. You strongly desired to leave the
hospital, and after discussion with your husband, the decision
was made to let you leave. You should see Dr. ___ or his
team member on ___ at 9am. Please also keep your
appointments. You are being discharged with two antibiotics
(metronidazole and cefpodoxime) and a pill for stomach acid
(omeprazole); please take these as directed.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10558515-DS-15 | 10,558,515 | 25,531,621 | DS | 15 | 2203-10-24 00:00:00 | 2203-10-31 20:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Syncope/Flu
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a PMHx of NIDDM, HTN, and afib who
presents with syncope and head strike. Patient reports she
recently caught the flu 2 days ago, after being in contact with
a sick nurse while translating for a patient. She states since
then she has not been eating or drinking as much as she usually
does. She felt tired and fatigued all day long the day prior to
admission which was unusual for her. She endorses having fevers,
chills and sweats. Denies any nausea or vomiting at this time.
At 02:00 this morning she got up for a drink of water, she did
not feel like herself and then syncopized, hitting her head. She
does not remember the fall. Her husband heard a thud and found
her awake and alert, with no AMS. The patient states she was not
confused. She does not remember falling. The husband states the
patient was not unconscious for very long. After the fall the
patient notes trying to get back up and having an episode of
vomiting. Since the fall the patient has endorsed left sided
occipital pain from hitting her head, left shoulder, left hip
and coccyx pain from falling. Pt denies any palpitations, no
abdominal pain, no constipation or diarrhea, no BRBPR, no
melena, no chest pain, no SOB, no hx of syncope, no dizziness,
no incontinence, and no tongue-biting, no confusion. Of note the
patient had been started on chlorthalidone by her cardiologist
on ___ to help control her blood pressures.
In the ED, initial vital signs were: 99.8 79 136/66 12 96% RA.
Labs were notable for sodium of 125, potassium of 3.0, chloride
of 85, WBC count of 4.7 (70% neutrophils), UA concerning for
trace leuks, trace protein, 300 glucose, 10 ketones, 1 RBC, 3
WBC, Few bacteria and 1 epi. Flu PCR was positive. Patient was
given IV fluids, potassium and tylenol. On transfer vials were
85 139/76 22 96% RA.
On arrival to the floor the patient states she is feeling
better. Denies any SOB, chest pain, palpitations. No lightheaded
or dizziness. Denies any fevers, chills, nausea or vomiting.
States she is having left sided body pain from where she fell.
Review of Systems: As per HPI.
Past Medical History:
Diabetes type 2, non-insulin dependent on metformin
Paroxysmal atrial fibrillation on ASA
Irritable bowel syndrome
Proliferative retinopathy
Gastritis
Hepatitis C antibody positive
Chronic back pain
Hypertension
Social History:
___
Family History:
Mother with DM, CAD, and CVA and died of an MI at age ___. Her
father died of pancreatic cancer at ___. Her brother died of an
MI at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 130/70 92 18 97%RA
General: Ill appearing, no acute distress
HEENT: normocephalic, atraumatic, dry mucus membranes
CV: regular rate, normal S1,S2, no murmurs, rubs or gallops
Lungs: CTA-B, no wheezes, rhonchi, rales
Abdomen: +BS, soft, NTTP
Ext: No lower extermity edema. No tenderness to palpation over
left shoulder. No evidence of bruising. Patient unable to raise
left arm above 45 degress
Neuro: AOx3, CN2-12 intact, strength and sensation gross intact
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4 130/70 92 18 97%RA
General: Ill appearing, no acute distress
HEENT: EOMI, PERRLA, small bump with bruise over left occipit,
moist mucus membranes
CV: regular rate, normal S1,S2, no murmurs, rubs or gallops
Lungs: CTA-B, no wheezes, rhonchi, rales
Abdomen: +BS, soft, NTTP
Ext: No lower extermity edema. No tenderness to palpation over
left shoulder. No evidence of bruising. Patient has difficulty
raising left arm.
Neuro: AOx3, CN2-12 intact, strength and sensation gross intact
Pertinent Results:
LABS:
___ 04:34AM BLOOD WBC-4.7 RBC-4.32 Hgb-12.5 Hct-35.2*
MCV-81*# MCH-29.0 MCHC-35.6*# RDW-13.0 Plt ___
___ 07:20AM BLOOD WBC-3.0* RBC-4.37 Hgb-12.9 Hct-36.6
MCV-84 MCH-29.6 MCHC-35.3* RDW-13.2 Plt ___
___ 04:34AM BLOOD Neuts-70.3* ___ Monos-7.6 Eos-1.4
Baso-0.2
___ 04:34AM BLOOD ___ PTT-25.5 ___
___ 04:34AM BLOOD Glucose-211* UreaN-10 Creat-0.6 Na-123*
K-4.0 Cl-83* HCO3-26 AnGap-18
___ 06:02AM BLOOD Glucose-185* UreaN-9 Creat-0.6 Na-125*
K-3.0* Cl-85* HCO3-28 AnGap-15
___ 07:30PM BLOOD Glucose-179* UreaN-9 Creat-0.7 Na-135
K-3.5 Cl-94* HCO3-30 AnGap-15
___ 12:41AM BLOOD Glucose-161* UreaN-12 Creat-0.7 Na-136
K-3.1* Cl-98 HCO3-29 AnGap-12
___ 07:20AM BLOOD Glucose-209* UreaN-9 Creat-0.6 Na-134
K-3.5 Cl-95* HCO3-29 AnGap-14
___ 07:30PM BLOOD Calcium-9.7 Phos-2.8 Mg-1.9
___ 07:20AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.8
___ 06:02AM BLOOD cTropnT-<0.01
___ 05:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
___ 05:50AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
___ 05:50AM URINE Mucous-RARE
___ 07:40AM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
MICRO
___ 5:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 6:02 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
___ Imaging CT HEAD W/O CONTRAST
There is no evidence of hemorrhage, edema, mass effect, or large
territorial infarction. Mildly prominent ventricles and sulci
suggest age-related global atrophy.The basal cisterns appear
patent and there is preservation of gray-white matter
differentiation.
No fracture is identified. There is a small left parietoccipital
subgaleal hematoma. There is mucosal thickening involving the
left ethmoid air cells and sphenoid sinus. The remaining
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The globes are unremarkable.
IMPRESSION: No evidence of acute intracranial process. Small
left parieto-occipital subgaleal hematoma without underlying
calvarial fracture.
___-SPINE W/O CONTRAST
There is no fracture or traumatic malalignment. There is no
prevertebral soft tissue swelling. There is no significant
spinal canal stenosis or neural foraminal narrowing. There is no
cervical lymphadenopathy. The thyroid gland is unremarkable. The
lung apices are clear. IMPRESSION: No fracture or traumatic
malalignment.
___ Imaging CHEST (PA & LAT) No evidence of acute
cardiopulmonary process.
___ Imaging PELVIS (AP ONLY) No fracture or dislocation
of the left hip.
___ Imaging HIP UNILAT MIN 2 VIEWS No fracture or
dislocation of the left hip.
___ Imaging HUMERUS (AP & LAT) LEFT Normal radiographs of
the left humerus.
Brief Hospital Course:
___ year old female with a PMHx of diabetes, hypertension, and
atrial fibirllation who presents with syncope and head strike in
the setting of the flu, likely due to illness, poor PO intake
and recent initiation of treatment with chlorthalidone.
#Syncopal Episode: Patient had syncopal episode at home.
Patient was found to be hyponatermic and it is likely that her
electrolyte imbalance contributed to her syncope. The patient
had no chest pain or palpitations, she had a negative troponin
and normal EKG. She was monitored on tele and had no events. It
was thought less likely to be of cardiac etiology. The patient
did not have the typical prodromal symptoms associated with
vaso-vagal syncope. She also had no signs of seizure or
postictal confusion as per her husbands account. Orthostatics
were also negative during the hospital stay. It was noted that
the patient had been started on chlorthalidone one month prior
to admission. Given that the patient was ill with the flu,
dehydrated and had poor PO intake as she continued to take her
medications it was likely this combination that lead to her
syncopal episodes. The patients chlorthalidone was held during
her hospital stay and she was rehydrated. Since the patient had
fallen in the emergency department she underwent CT head which
was negative. Radiographic imaging of her arm, hip, pelvis and
C-spine were all negative for fracture.
The patient should follow up with her PCP to have her
electrolytes checked and medication restarted when deemed
appropriate.
#Hyponatremia: Initial sodium of 123 on presentation to
emergency department, baseline of 140. The patient appeared to
be intravascularly depleted on exam with evidence of dry mucous
membranes. Given that the patient was on a diuretic, urine
sodium and urine osmolarity would not be helpful and were not
obtained. The patient was fluid resuscitated with IV normal
saline and her sodium trended up to 125 and then 136. Given the
concern that she may be correcting too fast she was given approx
300cc of D5W and her sodium dropped to 134. The patient was
mentating well throughout the hospital stay and had no evidence
of neurlogic dysfunction. The patient will need to follow up
with her PCP for further labs.
#Hypokalemia- down to 3.0- patient was given IV potassium and
she improved to 3.5. Patient also was hypochloremic. This was
likely in the setting of her chlorthalidone and poor PO intake.
Her chlorthalidone and lisinopril were held.
#Influenza- Patient had typical symptoms as well as fluA PCR
swab positive. Given the onset of symptoms ___ days prior to
admission it was thought that the patient would not acutely
benefit from treatment with tamiflu. The decision was made to
provide the patient with supportive care. The patients symptoms
were improving on discharge.
#Hypertension: Blood pressures stable throughout hospital stay.
Chlorthalidone was held. Lisnopril was held during hospital stay
and restarted on discharge.
CHRONIC ISSUES
#Diabetes- currently on metformin, patient may have been
hypoglycemic during syncopal episode. Patients blood sugars were
normal during hospital stay. Her metformin was held temporarily
while in the hospital, she was switched to sliding scale
insulin. Her metformin was restarted on discharge.
#Atrial fibrillation- patient stable, in sinus rhythm during
hospital. Her home dose of flecanide was was continued. She was
switched temporarily to metoprolol tartrate while in the
hospital. She was not taking her apixiban and ASA because of
recent dental surgery. This should be restarted when deemed
appropriate by her dental team and PCP.
# Code: Full Code (confirmed)
# Emergency Contact: Name of health care proxy: ___
Relationship: daughter,Phone number: ___
TRANSITIONAL ISSUES:
========================
- Repeat Chem 7 next week
- Holding chlorthalidone given recent hyponatremia. Consider
restarting as an outpatient
- Consider restarting apixiban and aspirin once dental surgery
has healed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Flecainide Acetate 100 mg PO Q12H
4. Lorazepam 0.5 mg PO QHS
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
6. Metoprolol Succinate XL 25 mg PO QHS
Discharge Medications:
1. Flecainide Acetate 100 mg PO Q12H
2. Lisinopril 20 mg PO DAILY
3. Lorazepam 0.5 mg PO QHS
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. Metoprolol Succinate XL 25 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Influenza
Hyponatremia
Hypokalemia
Syncope
SECONDARY DIAGNOSIS
Atrial Fibrillation
Hypertension
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 hospitalized for the flu and
a fall and hitting your head. You likely fell due to imbalance
in your electrolytes and dehydration. You were diagnosed with
hyponatremia (low sodium) and hypokalemia (low potassium). Your
electrolyte levels were corrected and your symptoms improved.
This likely occured from poor oral intake secondary to the flu
and your blood pressure medication. You should stop taking your
chlorthalidone until you follow up with your docotor as below.
We wish you a quick recovery and a very happy birthday!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.