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10558630-DS-21 | 10,558,630 | 26,462,430 | DS | 21 | 2138-02-20 00:00:00 | 2138-02-27 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a past medical history of hypertension
and hypothyroidism presenting for evaluation after a syncopal
event. She was helping out at a funeral at her church when she
felt nauseated and lightheaded. She denies preceding
palpitations and diaphoresis. She decided she would walk to the
couch and fell down on the way. The thump was heard outside of
the room and her colleagues came to her aid. She was then helped
up and was reported by witnesses to have some mouth shaking and
urinary incontinence, but she does not recall this. She denied
any chest pain, headache, confusion, shortness of breath, or
trauma after the fall, feeling well enough to get up on her own
if she had to. After the event, she felt like her normal self.
She was recently restarted on amlodipine 2.5 mg daily by her
PCP's office last month, but did not begin taking the medication
until a few weeks ago. During this visit, she also noted that
for a year or longer, she occasionally experienced small volume,
fecal incontinence. She also reports a remote history of urinary
incontinence as well. Her last EKG was performed in ___
per Atrius records, showing NSR and no evidence of old or new
ishcemia. Per Atrius records she also had a negative
echocardiogram in ___.
Of note, she had a prior syncopal episode years ago after she
was running to her car. She passed out along the way without any
prodromal symptoms, resulting in some abrasions from hitting the
street. She got up on her own and felt well enough to drive
home. She does not report ever having any work-up for this.
In the ED, initial vitals were: 98.1 83 125/81 20 99%. Her exam
was notable for a grossly normal neurologic exam, but with
lateral nystagmus. CT head without any acute intracranial
process. EKG without apparent arrhythmia, NSR and normal
intervals, but poor R wave progression. She did not exhibit any
lab abnormalities. She was admitted for further syncopal
work-up, given these questionable EKG changes.
On arrival to the floor, she is feeling well without complaints.
No significant events have been recorded on telemetry. She
denies CP, SOB, recurrent syncope or presyncope. She notes that
her PO intake has been quite poor over the last few days.
Past Medical History:
- hypertension
- lactose intolerance
- cataracts
- hypothyroidism, s/p thyroid cancer and subtotal thyroidectomy
- history of colonic polyps
- s/p hysterectomy
Social History:
___
Family History:
Father - ___
Mother - ___ at ___ cancer, hypertension
Sister - Leg ulcers
Brother - ___ Cancer
Physical Exam:
ADMISSION/DISCHARGE PHYSICAL EXAM:
VS - Temp 97.9F, BP 130-140/70-84, HR 50-70, RR ___, O2-sat
98-100% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
but with extensive hypertrophy of the soft tissues of the hard
palate and underneath tongue
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTAB, no wheezes, rales, or rhonchi, good air movement,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, soft II/VI mid-systolic murmur,
no murmur increase from squatting to standing, nl S1/S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Labs:
___ 06:05PM BLOOD WBC-7.9 RBC-4.16* Hgb-13.0 Hct-40.4
MCV-97 MCH-31.1 MCHC-32.0 RDW-12.7 Plt ___
___ 05:50AM BLOOD WBC-5.8 RBC-3.98* Hgb-12.4 Hct-38.8
MCV-98 MCH-31.2 MCHC-31.9 RDW-12.8 Plt ___
___ 06:05PM BLOOD Neuts-74.3* ___ Monos-3.7 Eos-1.3
Baso-0.5
___ 06:05PM BLOOD ___ PTT-31.3 ___
___ 06:05PM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
___ 05:50AM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-30 AnGap-10
___ 06:05PM BLOOD CK(CPK)-68
___ 05:50AM BLOOD CK(CPK)-71
___ 06:05PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:05PM BLOOD Calcium-9.9 Mg-2.2
___ 05:50AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2
___ 06:05PM BLOOD TSH-0.51
___ 06:18PM BLOOD Lactate-1.1
CHEST XR
___
FINDINGS:
PA and lateral views of the chest. The lungs are clear.
Cardiomediastinal
silhouette is within normal limits. Note is made of pectus
excavatum.
Osseous and soft tissue structures are otherwise unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
CT HEAD
___
FINDINGS:
There is no hemorrhage, major vascular territory infarction,
edema, mass, or shift of midline structures. Mild prominence of
the ventricles and sulci is compatible with mild cortical
atrophy. The basal cisterns are patent. Gray-white
differentiation is normal. There is no osseous or soft tissue
abnormality. Partial opacification seen within the ethmoid air
cells and in the frontoethmoidal recesses. Other visualized
paranasal sinuses and mastoid air cells are clear. IMPRESSION:
No acute intracranial process.
ECG:
___
Sinus rhythm. Left axis deviation. Poor R wave progression,
likely a normal
variant. No previous tracing available for comparison.
___
Sinus rhythm, LAD, normal R wave progression, no TWI.
ECHOCARDIOGRAM:
___
The left atrium is normal in size. 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%). 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 a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
___ year old female with a history of hypertension and
hypothyroidism, now s/p syncopal episode with poor R wave
progression on ECG.
# Syncopal episode: Ms. ___ most recent syncopal episode
appears to be vasovagal with a classic prodrome. Her ECG on
admission demonstrated poor R-wave progression, not present on
prior ECGs. She ruled out for MI with negative troponins x2. Her
heart murmur was felt to be a benign SEM not characteristic of
HOCM. An echo was performed which showed a normal EF, no wall
motion abnormalities and no evidence of structural heart
disease. Orthostatics were performed and revealed no positional
change in BP but a ___ bpm increase in heart rate. Poor PO
intake and relative hypovolemia in the setting of a new
anti-hypertenisive most likely triggered her syncopal event. She
was given 1 liter of normal saline. She did not experience
recurrent syncope or pre-syncope during her admission. She
tolerated a regular diet well.
# Hypertension: Ms. ___ was borderline hypertensive during
her hospitalization. Amlodipine was held give the clinical
circumstances. She will follow up with her PCP regarding future
management of her hypertension.
# Hypothyroidism: No recent changes in her supplementation, but
she does mention that she has been having trouble gaining weight
recently, with a 7 lb weight loss over the past year. TSH
normal. Levothyroxine was continued at her home dose.
TRANSITIONAL ISSUES
*******************
-consider workup for weight loss given age
-consider Holter monitor if syncope is recurrent
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. ammonium lactate-emu oil *NF* 12 % Topical BID:PRN dry skin
3. Hydrocortisone Cream 1% 1 Appl TP BID:PRN rash
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
6. Multivitamins 1 TAB PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Hydrocortisone Cream 1% 1 Appl TP BID:PRN rash
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. ammonium lactate-emu oil *NF* 12 % Topical BID:PRN dry skin
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for syncope (fall). What you
experienced can occur in otherwise healthy people, but in your
case may have been brought on by poor fluid intake and your
blood pressure medication. We performed an echocardiogram
(ultrasound of yor heart) which was normal. We provided you IV
fluids and held your blood pressure medication. If you have any
further questions about your hospitalization feel free to
contact your ___ providers.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
STOPPED amlodipine
Followup Instructions:
___
|
10558865-DS-6 | 10,558,865 | 21,467,742 | DS | 6 | 2168-08-15 00:00:00 | 2168-08-15 12:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / latex / fluconazole / gabapentin / Topamax /
Cymbalta
Attending: ___.
Chief Complaint:
itching / burning
wrist pain
Major Surgical or Invasive Procedure:
___ - open reduction and internal fixation of R humerus for
___ with Dr. ___
___ of Present Illness:
See hospital course
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- Type 2 diabetes, uncontrolled
- Prior pulmonary embolism on lifelong AC
- Subacute distal radius fracture
- critical limb threatening ischemia of the right lower
extremity
s/p right common femoral to tibioperoneal trunk bypass with in
situ greater saphenous vein as well as her right second digit
amputation in ___.
--- s/p femoral to tibioperoneal trunk bypass with SVG on ___
--- then R ___ toe amputation
- Cluster A personality traits
- Chronic pain syndrome
- History of nonadherence
- History of PTSD
- ?COPD
- C. diff infection
Social History:
___
Family History:
FAMILY HISTORY:
- Father - DM2
- Mother - CAD/PVD
Physical Exam:
VITALS: Afebrile and vital signs within normal limits except
systolic BPs 140-150s
GENERAL: Alert, mildly anxious
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Splint on RUE and RLE; R ___ toe amputated. Extremities
warm to touch and well perfused today
SKIN: ulcer on RLE covered by bandages and boot
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout;
PSYCH: calm, pleasant
Pertinent Results:
NOTABLE LABS:
___ 07:24AM BLOOD WBC-6.4 RBC-3.49* Hgb-10.4* Hct-33.7*
MCV-97 MCH-29.8 MCHC-30.9* RDW-13.7 RDWSD-48.9* Plt ___
___ 07:24AM BLOOD Glucose-144* UreaN-18 Creat-0.6 Na-140
K-3.9 Cl-103 HCO3-24 ___ Cdiff PCR negative
___ CRP 4.0
___ Vit D 31
___: B12 565, Folate 13,
___ Ca 8.9, Phos 2.8, Mg 1.7
___ TSH 0.33, FT4 1.3
___
Hgb ___ stable (8.9 today)
INR 2.1
BMP Na 143, K 3.7, Cl 103, HCO3 25, UN 12, Cr 0.4
IMAGING:
Elbow XR
IMPRESSION:
Transversely oriented intercondylar fracture of the right distal
humerus with new displacement and angulation.
Wrist XR
IMPRESSION:
Continued interval healing of a impact and transversely oriented
fracture of the distal radius. Unchanged degree of displacement
and angulation.
Brief Hospital Course:
SUMMARY:
Ms. ___ is a ___ woman with history of IDDMII, PE on
lifelong warfarin, peripheral artery disease s/p bypass, left
distal radius and right distal humerus fractures with recent
admission for lower extremity abscess now presenting from rehab
due to discontent with her rehab. She was found to have
displacement of the fracture of her R humerus and underwent ORIF
on ___. Her course was complicated by hospital delirium that
improved with sleep and reduction in deleriogenic medications;
she was seen by psychiatry who felt that she is likely adjusting
to all her new medical issues on top of longstanding anxiety and
can benefit from extra social support. She is now working with
___ and OT towards improvement and mobility with the goal of
getting home.
___ HOSPITAL COURSE:
# Right distal humerus fracture:
# Left distal radius fracture:
Patient with left distal radius fracture being management
non-operatively. Patient also with right distal humerus fracture
for which she underwent ORIF on ___ with Orthopedic Surgery.
Pain was managed with tramadol and tylenol. She is NWB in the
LUE with removable wrist splint, okay for ROMAT at the wrist,
elbow and fingers for now. She is NWB in right arm until 2 week
post-op follow-up with orthopedics. She was started on vitamin
D for fragility fractures/presumed osteoporosis.
# History of pulmonary embolism:
She is on lifelong anticoagulation with coumadin. She has
history of one episode of DVT/PE in ___ and none since. No
known history of hypercoagulability. Her INR was reversed for
the orthopedic procedure but she was otherwise continued on
coumadin while in the hospital. INR on discharge 2.1.
# Right posterior calf abscess:
# R heel ulcer
# Severe PAD s/p bypass:
Continued aspirin and statin, as well as cipro/doxy for 4 week
course (last day ___ with po vanco for prophylaxis until
___. Of note, patient was only intermittently compliant with
her medications. Wound care instructions were followed: "Pack
wound with packing strips, dress with gauze, ABD, kerlix, and
ACE." Her weight-bearing status was updated to OK for forefoot
weight bearing, pivoting, but offload heel.
#Prutitus, burning skin
No visible rash or erythema. Patient feels it's related to
cleaning product used for linen. She was given sarna and prn
benadryl for her sx but had some confusion, so Benadryl was held
and then switched to hydroxyzine.
# History of C. diff:
# diarrhea
Patient on prophylactic vancomycin given ongoing antibiotics but
developed new diarrhea. C diff here was rechecked and negative.
She was continued on cdiff ppx and started on loperamide.
Diarrhea improved, now stable.
# IDMII: Continued Lantus plus hISS, metformin and glipizide;
she continuously refused short-acting insulin, but took lantus.
Resume lantus, metformin, glipizide on discharge
# HTN: Continued amlodipine, losartan
# Anxiety: Continued quetiapine, substituted hydroxyzine for
lorazepam. Ms ___ has been discouraged by all of her new
medical problems and can have panic attacks related to her
longstanding anxiety and family responsibilities.
She responds best to supportive language. Even if she is being
rude, please try to approach with a "we want to be supportive
and caring." She has a shifted sleep cycle, longstanding, where
she typically will go to sleep later and wake up later; this is
her normal, and she is much more approachable after ___ am. We
recommend that she see a psychiatrist at your facility or
outpatient for anxiety therapy and she has been receptive to
seeing a therapist to help her with all the stress she is now
under.
# Insomnia: Continued Ramelteon
# Chronic pain: Continued oxcarbazepine; continued tramadol as
needed, reduced frequency to BID PRN
TRANSITIONAL ISSUES:
[] Warfarin management through Atrius once discharge from rehab
[] Needs OPAT f/u (needs to have appointment scheduled, call
___
[] Ortho follow-up, call ___, opt 2 to schedule,
approximately ___
[ ] Needs podiatry f/u with Dr. ___
___ code
> 30 minutes spent in discharge planning and counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcium Carbonate 500 mg PO QID:PRN Reflux
6. Ciprofloxacin HCl 500 mg PO Q12H
7. Collagenase Ointment 1 Appl TP DAILY
8. Doxycycline Hyclate 100 mg PO BID
9. LORazepam 0.5 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. OXcarbazepine 150 mg PO BID
12. QUEtiapine Fumarate 25 mg PO QPM:PRN agitation/insomnia
13. Ramelteon 8 mg PO QHS:PRN Insomia
14. Sarna Lotion 1 Appl TP DAILY:PRN itching
15. Senna 17.2 mg PO BID
16. Vancomycin Oral Liquid ___ mg PO BID
17. ___ MD to order daily dose PO DAILY16
18. Warfarin 5 mg PO ONCE
19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
20. GlipiZIDE XL 5 mg PO DAILY
21. Losartan Potassium 50 mg PO DAILY
22. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. HydrOXYzine 25 mg PO BID:PRN skin pain / itching or anxiety
3. Magnesium Oxide 400 mg PO TID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Zinc Sulfate 220 mg PO DAILY Duration: 10 Doses
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
8. Glargine 20 Units Lunch
Insulin SC Sliding Scale using Novolog Insulin
9. QUEtiapine Fumarate 25 mg PO QHS insomnia
10. Ramelteon 8 mg PO QPM Insomia
11. Sarna Lotion 1 Appl TP BID itching
12. TraMADol 25 mg PO BID PRN Pain - Moderate
13. Warfarin 12 mg PO DAILY16
Discharged on 12 mg daily
14. amLODIPine 10 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 40 mg PO QPM
17. Calcium Carbonate 500 mg PO QID:PRN Reflux
18. Collagenase Ointment 1 Appl TP DAILY
19. GlipiZIDE XL 5 mg PO DAILY
20. Losartan Potassium 50 mg PO DAILY
21. MetFORMIN (Glucophage) 1000 mg PO BID
22. OXcarbazepine 150 mg PO BID
23. Senna 17.2 mg PO BID
24. Vancomycin Oral Liquid ___ mg PO BID Duration: 7 Days
to finish on the morning of ___
1. Ascorbic Acid ___ mg PO BID
2. HydrOXYzine 25 mg PO BID:PRN skin pain / itching or anxiety
3. Magnesium Oxide 400 mg PO TID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Zinc Sulfate 220 mg PO DAILY Duration: 10 Doses
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
8. Glargine 20 Units Lunch
Insulin SC Sliding Scale using Novolog Insulin
9. QUEtiapine Fumarate 25 mg PO QHS insomnia
10. Ramelteon 8 mg PO QPM Insomia
11. Sarna Lotion 1 Appl TP BID itching
12. TraMADol 25 mg PO BID PRN Pain - Moderate
13. Warfarin 12 mg PO DAILY16
Discharged on 12 mg daily
14. amLODIPine 10 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 40 mg PO QPM
17. Calcium Carbonate 500 mg PO QID:PRN Reflux
18. Collagenase Ointment 1 Appl TP DAILY
19. GlipiZIDE XL 5 mg PO DAILY
20. Losartan Potassium 50 mg PO DAILY
21. MetFORMIN (Glucophage) 1000 mg PO BID
22. OXcarbazepine 150 mg PO BID
23. Senna 17.2 mg PO BID
24. Vancomycin Oral Liquid ___ mg PO BID Duration: 7 Days
to finish on the morning of ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right displaced humerus fracture
Deconditioning
Adjustment with anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you during your hospitalization
at ___. We wish you all the best in your recovery!
Why did you come to the hospital?
- because you did not like your rehab placement
What happened while you were in the hospital?
- Our complex case manager worked with you to find an acceptable
solution
- We had the orthopedic, hand, vascular and podiatric surgeons
see you to re-evaluate your injuries and give recommendations on
next steps.
- You underwent a procedure to fix the right-sided elbow
fracture. The procedure went well.
What should you do after you leave the hospital?
- continue to work on regaining your mobility as you have been
- follow-up with the Orthopedic Surgeon Dr. ___ in 2 weeks
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10558983-DS-11 | 10,558,983 | 21,012,114 | DS | 11 | 2167-03-01 00:00:00 | 2167-03-01 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pedstrian Struck
Major Surgical or Invasive Procedure:
___ ORIF Left SI joint
History of Present Illness:
___ Creole speaking, who presented to the ED as pedestrian
struck by SUV. CT at admission demonstrated renal vascular
pedicle injury. Vascular and transplant surgery were consulted
and felt the kidney was not salvageable. His other injuries
include L2-4 transverse process fracture, left SI joint
separation, and posterior head laceration with hematoma, small
splenic laceration, and possible hepatic contusion.
Past Medical History:
PMH: hypercholesterolemia, HTN (PCP: ___,
Dr. ___, ___
PSH: denies
___: simvastatin 20 mg QPM, clorthaladone 25 mg daily, ASA 81 mg
daily, nifedipine 30 mg daily
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam upon admission:
HR: 110 BP: 120/90 Resp: 33 O(2)Sat: 100 Normal
Constitutional: He is awake and alert, and is uncomfortable.
HEENT: Complex laceration to the posterior scalp., Pupils
equal, round and reactive to light, Extraocular muscles
intact. Midface stable.
Oropharynx within normal limits. Tympanic membranes clear
bilaterally
Chest: Breath sounds equal bilaterally. Chest stable, nontender,
no crepitus
Cardiovascular: Tachycardic
Abdominal: Distended with an umbilical hernia, soft, nontender
Pelvic: Stable pelvis
Extr/Back: Extremities atraumatic, nontender, full range of
motion throughout. Pelvis stable, nontender.
Skin: Warm and dry. Intact except as noted above.
Neuro: Speech fluent, motor/sensory function intact throughout
Psych: Anxious, combatative
Physical Exam upon discharge:
VS: 98.6, 64, 132/71, 16, 98%/RA
Gen: NAD, resting in bed,
Heent: EOMI, MMM.
Cardiac: Normal S1, S2. RRR
Pulm: Lungs diminished at bases
Abdomen: Soft/nontender/mildly distended
Ext: + pedal pulses, No CCE Left hip steri strips C/D/I
Neuro: primarily Creole speaking, AAOx4, normal mentation
Pertinent Results:
___-SPINE W/O CONTRAST
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment of
the cervical spine.
2. Mild to moderate degenerative changes from C3-C6.
___ Radiology CT HEAD W/O CONTRAST
IMPRESSION:
1. Scalp hematoma at the posterior vertex without underlying
skull fracture.
2. No evidence of acute intracranial injury.
___BD & PELVIS WITH CO
1. Renal vascular pedicle injury involving the left kidney with
near complete disruption of the arterial supply with minimal
perfusion of the medial mid to lower pole. The left renal vein
is disrupted. Retroperitoneal hemorrhage
extends to the right and inferiorly into the pelvis.
2. Decompressed IVC suggests impending hemodynamic instability.
3. Areas of hypodensity in the right posterior liver (segment 7
and 6)
suggest hepatic contusion. Trace perihepatic fluid.
4. Small laceration of the inferior splenic tip with trace
surrounding fluid.
5. Fluid surrounding small bowel in the anterior abdomen (2: 69)
raise the possibility of mesenteric or bowel injury.
6. Streaky opacities in bilateral lung bases may represent
atelectasis but aspiration event cannot be excluded. Airways
appear patent to subsegmental levels.
6. Fractures of the left transverse processes of L2-L4 and
nondisplaced
fracture of the left inferior pubic ramus with widening of the
left sacroiliac joint and pubic symphysis.
___ Radiology CHEST (PORTABLE AP)
Low lung volumes are no worse, but mild pulmonary edema is new,
accompanied by mild mediastinal vascular engorgement. I see no
pneumothorax or large pleural effusion.
___ Radiology DUPLEX DOPP ABD/PEL
IMPRESSION:
1. Findings consistent with a nearly complete devascularized
left kidney. Preserved size compared to the contralateral side.
There is no perinephric collection. There are no cystic areas
with internal flow to suggest an AV fistula.
2. Minimal amount of vascularity noted in the upper pole of the
left kidney with no vascularity within the mid and lower pole.
Flow detected within the left main renal vein with no detection
of flow within the expected location of the left main renal
artery.
3. Normal size and vascularity with normal waveforms throughout
the right main renal artery and interpolar arteries.
___ Radiology CHEST (PA & LAT)
Bilateral low lung volumes are noted with mild crowding of
bronchovascular markings. Cardiac silhouette is accentuated by
low lung
volumes. No definite focal consolidation is noted in bilateral
lungs.
___ 11:45AM BLOOD WBC-16.2* RBC-3.43* Hgb-10.0* Hct-31.2*
MCV-91 MCH-29.1 MCHC-32.0 RDW-14.0 Plt ___
___ 06:27AM BLOOD WBC-15.6* RBC-3.36* Hgb-9.9* Hct-29.6*
MCV-88 MCH-29.3 MCHC-33.3 RDW-13.9 Plt ___
___ 06:35AM BLOOD WBC-18.4* RBC-3.29* Hgb-9.6* Hct-29.3*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.8 Plt ___
___ 12:15AM BLOOD WBC-15.2* RBC-3.06* Hgb-9.0* Hct-27.7*
MCV-91 MCH-29.4 MCHC-32.5 RDW-14.1 Plt ___
___ 05:30PM BLOOD WBC-11.7* RBC-2.89* Hgb-8.6* Hct-26.4*
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.0 Plt ___
___ 10:53PM BLOOD WBC-23.5* RBC-3.75* Hgb-11.2* Hct-34.1*
MCV-91 MCH-29.9 MCHC-32.8 RDW-13.6 Plt ___
___ 06:08AM BLOOD Glucose-113* UreaN-34* Creat-1.4* Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
___ 05:49AM BLOOD Glucose-107* UreaN-42* Creat-1.7* Na-141
K-4.1 Cl-109* HCO3-19* AnGap-17
___ 02:20AM BLOOD Glucose-128* UreaN-74* Creat-2.5* Na-145
K-4.1 Cl-107 HCO3-26 AnGap-16
___ 06:09AM BLOOD Glucose-195* UreaN-27* Creat-1.7* Na-139
K-4.2 Cl-104 HCO3-22 AnGap-17
___ 12:42AM BLOOD ALT-114* AST-73* AlkPhos-68 TotBili-0.5
___ 12:45AM BLOOD ALT-212* AST-276* AlkPhos-47
___ 05:30PM BLOOD ALT-211* AST-280* LD(LDH)-1594*
AlkPhos-46 TotBili-0.5
___ 06:09AM BLOOD ALT-162* AST-195* LD(LDH)-652* AlkPhos-47
TotBili-0.3
___ 06:08AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2
___ 02:48PM BLOOD Calcium-8.2* Phos-5.1* Mg-3.4*
___ 10:53PM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
___ 01:29AM BLOOD TSH-0.43
___ 01:29AM BLOOD T4-5.3
___ 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:33AM BLOOD Type-ART pO2-103 pCO2-40 pH-7.42
calTCO2-27 Base XS-0
Brief Hospital Course:
This patient is a ___ year old gentleman with no significant past
medical history who presents with head pain after being a
pedestrian struck by a motor vehicle. According to EMS, he was
struck by the front end of a car at low to moderate
speed. The front bumper of the car was damaged, but he did not
hit the windshield or get thrown over the top of the car.
Firefighters were the first on scene, and they reported a large
laceration to the posterior scalp. It is unclear if the patient
lost consciousness.
Here are the details of his ICU course:
On ___, the patient was admitted to ___, scalp laceration
sutured. C-spine cleared clinically.
___ - A Chest xray in the morning showed pulmonary edema, so
patient was given lasix 20 mg x 2, not responsive to 2nd dose.
Hct stable 30->32->31. Creatinine increasing from 1.7 to 2.3.
His Intravenous FLuids were stopped at this time. Started
Albuterol for wheezing. Changed metoprolol to labetalol for BP
contol. Hepatic enzymes rising, NTD per ACS.
___ - The patient experienced increased WOB and rising
Creatinine over the day. Bedside echo demonstrated engorged
LV/IVC. Mild increase in abdominal distention, bedside FAST
demonstrated no free fluid -> KUB (no obstructive pattern, mild
distention). Mild increase in oxygen requirement overnight,
bedside echo repeated, estimated PCWP 12mmHg. Transitioned to
CPAP + nebulizer tx, bedside u/s without significant increase in
PCWP, no significant lung water.
___ - Continued increased work of breathing and worsening
mental status. Intubated for worsening respiratory status and
airway protection. Sputum culture sent for increased thick,
purulent secretions; urine culture for cloudy urine in setting
of rising WBC.
___ - 1unit of packed RBC for Hct 21 in setting of persistent
tachycardia, rpt 25.4, Lasix 20 mg IV x1 for diuresis (-700cc),
started tube feeds, Urology consult for ballanitis with meatal
cultures & clotrimazole, bowel regimen, scalp sutures removed.
___ - Labetalol gtt for BP control intermittently, started
valsartan 40' for ?page syndrome, sent aldosterone level; Echo:
hyperdynamic state, TSH/T4 wnl (0.43/5.3), renal ultrasound to
look for AV fistula: not visible distally but cannot exclude
centrally near transection of main artery, no hematoma; given 1
PRBC to inc oxygen carrying capacity, rpt Hct: 23.9-> 24 -->1
PRBC-->25.9;; Bowel regimen. Famotidine was discontinued(TF to
goal), switched tube feeds to peptamen, Finger sticks were high
(160s-200s), SS increased; urology consult: continue
clotrimazole; CMV->CPAP tolerated all day
___ - started on labetalol 100mg TID Cr 2.4 (from 2.1),
changed sedation to fentanyl while titrating down propofol,
discontinued labetolol gtt. changed from peptamen 45 to
isosource 1.5 at 50 per nutrition now that off propofol, can't
remove mg/phos from tube feeds (cannot start PhosLo due to not
being able to crush)
___ - patient agitated on vent, required intermittent versed
for sedation, partially displaced tube; advanced tube with some
resistance, still slightly high on xray; started propofol gtt
given decreased renal function. Bronch done with + airway edema.
Kept intubated due to return to OR with ortho for SI joint
screws. Cr up to 3.0 post-op, decreasing Labetalol for possible
improved renal perfusion.
___ - Creatinine in am down to 2.8.
Bronched in AM: mild secretions bilateral.
Extubated without difficulty. Tolerated clear liquids/HLIV.
Echo: hyperdynamic (70%) persists. Arterial line dc'd overnight
due to near self-discontinuation, correlation with cuff
___- Increase labetalol and add home nifedipine for BP control.
___ today. Transfer out to surgical floor. Cr improving.
Aldosterone level still pending. Discuss w/radiology about
possibility of MRA to r/o AV fistula.
The patient was transferred to the surigcal floor in stable
condition. Ortho Spine felt that L2-4 Transverse fracture was
non-operative and did not require any bracing. The patient was
evaluated by physical therapy as well as occupational therapy
who recommended rehabilatation secondary to the patient's need
for increased mobilization. He was given a standing walker,
which he was able to use appropriately. Orthopedics recommended
non weight bearing status to the patient's Left lower extremity.
Due to a rising white blood cell count, a urinalysis was sent
and revealed a urinary tract infection. In addition, the
patient complained of burning upon urination. His chest xray did
not show any evidence of pneumonia. The patient was started on a
5 day course of Cipro, which he will continue in rehab.
The patient's pain was well controlled with oral pain
medications. He was tolerating a regular diet without any nausea
or vomiting. His vital signs were stable and he remained
afebrile. His WBC was still elevated at 16.2, however he just
started his antibiotic course and his symptoms improved. His
hematacrit was stable with no signs of bleeding.
Medications on Admission:
simvastatin 20 mg QPM
clorthaladone 25 mg daily
ASA 81 mg daily
nifedipine 30 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Heparin 5000 UNIT SC TID
5. Labetalol 200 mg PO TID
6. Valsartan 40 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Lanthanum 500 mg PO TID W/MEALS
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Senna 1 TAB PO BID:PRN constipation
12. Clotrimazole Cream 1 Appl TP BID balanitis
13. Albuterol Inhaler 6 PUFF IH Q4H:PRN shortness of breath,
wheezing
14. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
S/P pedestrian struck
Injuries:
Posterior head laceration
Left renal pedicle avulsion
L2-4 Transverse Process fracture
Left SI joint/symphisis widening
Left inferior pubic ramus
Small splenic laceration
Fluid surrounding small bowel
Hepatic contusion
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted after you were struck by a car and sustained
the following injuries: Posterior head laceration, Left renal
pedicle avulsion, L2-4 Transverse Process fracture, Left SI
joint/symphisis widening, Left inferior pubic ramus, Small
splenic laceration
Fluid surrounding small bowel, Hepatic contusion. On ___,
you underwent reapir of your Left Sacroileal joint. You were
evaluated by physical therapy and they recommended that you
receive rehabilitation to improve your mobility. You will have
followup appointments with Orthopedics as well as with ACS after
your discharge.
Followup Instructions:
___
|
10559046-DS-21 | 10,559,046 | 20,319,385 | DS | 21 | 2147-08-21 00:00:00 | 2147-08-21 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy, Thoracentesis, Bronchial stent placement
History of Present Illness:
Patient seen and examined...and I agree with resident's note
from
yest' evening.
Admitted last night with fever and leukocytosis; CXR showed
complete opacification of left hemithorax: consistent with
post-obstructive left lung atelectasis.
Started on antibiotics--now afebrile and breathing comfortably
on
room air.
Prelim' path c/w small cell carcinoma.
I have discussed ___ path' with patient and asked Rad' Onc',
Heme-Onc', and IP to weigh in. She may benefit from
bronchoscopi
tumor debulking but more definitive therapy will be
radiation-chemotherapy. Will go ahead and request brain MRI
byut
not sure if Onc' will start treating until PET scan has been
done.
R ___
Past Medical History:
Depression
Left Hilar Mass (bx c/w SCLC), c/b post-obstructive PNA (on
broad spectrum Abx s/p bronchial stenting), pleural effusion
(s/p thoracentesis)
Social History:
___
Family History:
No history of infection or immunocompromised state. Cancer -
Colon in her father; ___ in her father; ___ -
___ in her mother. Father had colon cancer age ___ -
alive in his ___ Mother alive late ___ No children
Physical Exam:
Discharge:
GEN: NAD, sitting in bed, pleasant, appears comfortable, dressed
EYES: PERRLA
HEENT: OP clear, MMM
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: Appears to be breathing comfortably. Lungs are clear
diffusely with the exception of left lower lobe where she has
inspiratory/expiratory wheeze, less than yesterday. She has a
normal respiratory rate and is without any increased work of
breathing. No oxygen use
Abd: BS+, soft, NT, no rebound/guarding
Extremities: warm and well perfused, no edema. no deformity
Skin: no rashes or bruising
Neuro: AOx3, fluent speech, gait normal
PSYCH: normal mood/affect/judgment/insight
Pertinent Results:
Admission:
___ 10:20PM BLOOD WBC-19.0* RBC-4.53 Hgb-13.3 Hct-40.4
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.4 RDWSD-43.7 Plt ___
___ 10:20PM BLOOD Glucose-105* UreaN-14 Creat-0.6 Na-138
K-4.4 Cl-99 HCO3-22 AnGap-17*
___ 05:00AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.5*
Discharge:
___ 06:25AM BLOOD WBC-14.8* RBC-3.63* Hgb-10.6* Hct-32.2*
MCV-89 MCH-29.2 MCHC-32.9 RDW-13.5 RDWSD-43.7 Plt ___
___ 06:25AM BLOOD Glucose-85 UreaN-16 Creat-0.7 Na-140
K-4.0 Cl-100 HCO3-25 AnGap-15
___ 06:25AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8
Micro:
___ 8:34 am BRONCHIAL WASHINGS LEFT UPPER LOBE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
___ 11:36 am PLEURAL FLUID PLEURAL FLUID.
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.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
___: Pleural fluid cytology: pending
___: Bronchial brushings: Atypical cells
___: Bronchial biopsy: SMALL CELL CARCINOMA.
___: Bronchial Biopsy: SMALL CELL CARCINOMA. positive for
TTF-1 and synaptophysin, and negative for chromogranin. More
than 90% of the cells are MIB-1 positive.
MRI Brain ___:
1. Moderately degraded exam due to motion artifact.
2. No evidence of acute infarct.
3. Within limits of study, no evidence of intracranial
hemorrhage, or intracranial metastasis.
4. Paranasal sinus disease, as described.
CT A/P ___:
1. New left lower lobe consolidation, likely postobstructive
pneumonia from the right hilar mass not seen on this study.
2. Left adrenal nodule, with imaging features in keeping with a
benign adenoma. Attention on follow-up is recommended however.
3. No CT evidence of metastatic disease within the abdomen or
pelvis.
Bone Scan ___:
IMPRESSION:
1. Focal area of radiotracer uptake in two adjacent left-sided
ribs, compatible with trauma.
2. No evidence of osseous metastasis.
Brief Hospital Course:
___ PMH of Depression, Left Hilar Mass (bx c/w SCLC), who
presented with fevers, was found to have post-obstructive PNA
(on broad spectrum Abx), whose hospital course was complicated
by lobar lung collapse (s/p rigid bronch, tumor destruction and
stent placement), who was then transferred to oncology service
thereafter given fragile respiratory status, s/p initiation of
cis/etoposide, whose respiratory status improved afterward so
was discharged with outpatient oncology/pulmonary followup
#Fever ___ Post Obstructive PNA ___ SCLC compression of bronchus
Patient was seen by ID on admission, who rec'd a regimen of CTX
and Flagyl initially as she was prior community dweller and non
diabetic so likely low risk for pseudomonas or MRSA infection to
require broad spectrum antibiotics. Later culture returned
negative from BAL so was switched to augmentin to complete 14
day course on ___. Patient is now s/p stenting which had not
improved mucus clearance but has responded well to nebulizers
and acapella/mucinex use. Patient is to ensure twice daily use
of acapella device and mucinex to ensure stents do not clog. She
will be called by Dr ___ regarding her next followup
appointment. They may want a CT scan prior to her visit, which
she should discuss with them when they call.
#Left Hilar Mass (Small Cell Lung Cancer)
Newly diagnosed. Path from bronchial biopsy on ___ and ___
revealed SCLC. Pt had MRI brain and CT A/P which did not
identify any metastatic lesions (adrenal lesion had benign
characteristics). Bone scan negative. As per operative note from
rigid bronch on ___, patient had tumor destruction with
cautery/forceps, had balloon dilitation and stent placement to
improve aeration. Thoracentesis on ___ with lymphocytic
predominant serosanguinous drainage (1L). Cis/Etoposide
___. Patient is to followup with Dr ___ on ___ for next
evaluation. Pending cytology from thoracentesis can be followed
up at that time. Port placement and future radiation to be
scheduled outpatient.
#Depression
Despite prognosis, patient remains in good spirits and is
supported by sister who had been visiting during stay. She
should be referred to outpatient therapist to continue
supportive care.
Transitional Issues:
1. Pt to continue augmentin to complete 14 day course on
___.
2. Patient is to ensure twice daily use of acapella device and
mucinex to ensure stents do not clog.
3. Pt will be called by Dr ___ regarding her next
followup appointment. They may want a CT scan prior to her
visit, which she should discuss with them when they call.
4. Patient is to followup with Dr ___ on ___ for next
evaluation. Pending cytology from thoracentesis can be followed
up at that time. Port placement and future radiation to be
scheduled outpatient.
5. She should be referred to outpatient therapist to continue
supportive care.
Significant time was spent in preparing this complex discharge
including coordination with outpatient providers. I personally
spent 49 minutes on this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 20 mg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
RX *albuterol sulfate [Ventolin HFA] 90 mcg 2 puff INH every
four (4) hours Disp #*1 Inhaler Refills:*1
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*16 Tablet Refills:*0
3. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*56 Tablet Refills:*2
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 mL by mouth every
six (6) hours Refills:*0
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 vial
INH every four (4) hours Disp #*30 Ampule Refills:*0
6. Ondansetron ODT 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
7. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. FLUoxetine 20 mg PO DAILY
10.Nebulizer
C34.90 Lung Cancer
Please provide nebulizer machine for use with
albuterol/ipratropium ampules, as well as appropriate
tubing/mask/mouthpiece. Qty: 1 each. Use: Ongoing
Discharge Disposition:
Home
Discharge Diagnosis:
Postobstructive PNA ___ SCLC mass compressing airway, s/p
stenting
Small cell lung cancer s/p chemotherapy
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___
It was a pleasure taking care of you at ___. As you know you
were admitted for pneumonia, which was caused by blockage of
your airway by your cancer. Accordingly, you received 2 stents,
drainage of the fluid around the lung, and antibiotics. To
prevent the stents from clogging you need to take mucinex twice
daily and use the acapella device twice daily. You were given
inhalers to use when wheezing and nebulizer treatments at home.
You will need to followup with the pulmonary doctors on
___.
For your cancer, you had scans which showed the disease is
limited to the chest. You started chemotherapy during your
admission and tolerated it well. You will followup with Dr ___
on ___ to be re-evaluated. Your next ___ appointment
will be on ___.
Followup Instructions:
___
|
10559141-DS-2 | 10,559,141 | 29,145,316 | DS | 2 | 2169-03-05 00:00:00 | 2169-03-07 19:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
egg, latec, PCN
Attending: ___.
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
Complete Heart block s/p Pacemaker placement
History of Present Illness:
Ms. ___ is a ___ year old woman with history of COPD who
presented to ___ with acute on chronic substernal chest
pain.
Patient reportedly has late stage COPD. Was recently treated
for exacerbation with levaquin and steroids. She reports she has
chronic shortness of breath, dyspnea on exertion. Takes
hydromorphone twice daily for shortness of breath. 2 days prior
to presentation she had worsening shortness of breath and
substernal chest pain, pressure. Did not take hydromorophone
more frequently. Noted chest pressure last night, left sided,
moderate, dull, initially constant and woke her from sleep. No
nausea, no diaphoresis. No orthopnea or PND. No new lower
extremity edema. No fever, chills or productive cough. Called
PCP who referred her to ___.
There she was found to have baseline LBBB. VSS. Trop 0.02.
DDimer 383. CXR without any acute cardiopulmonary process. CTA
performed given chest pain radiating to back, negative for PE,
dissection, showed moderate large hiatal hernia and subsegmental
pulmonary infection vs inflammation improved from prior in
___. While in ___ she developed sinus bradycardia with dropped
beads (7 p waves without QRS) that resolved without
intervention. She was subsequently transferred to ___ for
further evaluation.
In the ___, initial vitals were:
97.3 86 110/52 18 97% RA
Labs notable for: leukocytosis 13, normocytic anemia 9.___,
normal plts, mildly elevated PTT, bicarb 21, Cr 1.3, glucose 99,
trop <0.01
No further imaging performed.
Patient was given: no medications
Cardiology was consulted and recommended: admission to ___ for
further workup and monitoring
Vitals prior to transfer:
98.7 87 119/46 19 97% RA
On the floor, patient is sleeping comfortably. When awakened
she feels chest pressure is improved. Notes dyspnea with any
positional changes which is her baseline.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. 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:
COPD
HTN
HLD
depression
hypothyroidism
GERD
?malignancy
Social History:
___
Family History:
non contributory
Physical Exam:
Physical Exam on Admission:
===========================
99.9 142/63 89 18 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, right eye lid ptosis, oropharynx
clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD
CV: distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: poor air movement, Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Physical Exam on Discharge:
===========================
Vitals: Afebrile, HRs: 60s-80s, BPs 100s-120s/60s-80s RR 20 99RA
General: Alert, oriented, NAD, mood: slight anxiety
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: poor air movement. faint crackles b/l. no wheezes or
rhonchi. Unlabored breathing on RA.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses
Neuro: normal sensation throughout.
Pertinent Results:
Labs on Admission
=================
___ 07:43PM BLOOD WBC-13.6* RBC-3.85* Hgb-9.7* Hct-31.1*
MCV-81* MCH-25.2* MCHC-31.2* RDW-17.6* RDWSD-51.6* Plt ___
___ 07:43PM BLOOD Neuts-66.6 ___ Monos-8.7 Eos-2.6
Baso-0.3 Im ___ AbsNeut-9.05* AbsLymp-2.89 AbsMono-1.19*
AbsEos-0.36 AbsBaso-0.04
___ 07:43PM BLOOD ___ PTT-23.8* ___
___ 07:43PM BLOOD Glucose-99 UreaN-28* Creat-1.3* Na-141
K-3.5 Cl-108 HCO3-21* AnGap-16
___ 07:43PM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:50AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1
___ 05:50AM BLOOD TSH-1.9
Labs at discharge
=================
___ 06:10AM BLOOD WBC-10.3* RBC-3.70* Hgb-9.3* Hct-30.7*
MCV-83 MCH-25.1* MCHC-30.3* RDW-18.0* RDWSD-54.4* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-25.7 ___
___ 06:10AM BLOOD Glucose-77 UreaN-26* Creat-1.1 Na-142
K-4.9 Cl-105 HCO3-25 AnGap-17
___ 06:10AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.4
Other studies:
==============
ECHO ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate (___) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and ___ biventricular systolic
function. Mild to moderate mitral regurgitation.
CXR ___:
Comparison to ___. The patient has received a left
pectoral
pacemaker. The leads project over the right atrium and the
right ventricle, respectively. Stable moderate hiatal hernia.
No pneumothorax, no pulmonary edema. Stable borderline size of
the cardiac silhouette.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of HTN, HLD,
COPD who presented with worsening chest discomfort and shortness
of breath, and was found to have an episode of 3rd degree heart
block.
#Complete Heart Block:
She was found to have an episode of complete heart block noted
on telemetry at ___. She was noted to be symptomatic with
brief LOC; she noted that she had had several such instances at
home. The electrophysiologists were consulted. She underwent
pacemaker placement with no events. A CXR on ___ showed no
abnormalities. She was scheduled to follow-up with the device
clinic. She was discharged with Clindamycin with antibiotic
prophylaxis.
#Chest Pain:
She presented with acute worsening of chest pain, but the
quality remained unchanged. A CT was negative for PE and aortic
dissection. EKG and troponins were negative for ischemia. This
was thought to be due to anxiety vs. worsening of her pulmonary
process. Evaluation with a transthoracic echocardiogram showed
normal Left ventricular wall thickness, cavity size, and global
systolic function with (LVEF>55%). We continued her home Aspirin
and Dilaudid, which she has been taking for chronic chest pain.
She was discharged on Pantoprazole 40mg BID.
#Hypothyroid:
Her TSH was found to be 1.9; she was continued on her home dose
levothyroxine.
Transitional Issues:
====================
-New Medication: Clindamycin at 600 mg TID x 2 additional days
to complete 3 days of prophylactic antibiotics on ___.
-Patient received a pacemaker on ___, with follow up on
appointment at ___ Clinic on ___.
-Please follow up with her regarding atypical chest pain on
___
Please check vitals and site of placement to ensure she has no
infection.
-Please follow up with her regarding her anemia as this may be
contributing to her chronic shortness of breath.
-Please consider decrease of Aspirin 325mg as this may increase
her risk of bleeding.
Code: DNR/DNI (previously Full Code for procedure only)
HCP: son, ___, ___
___ on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. FLUoxetine 20 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN SOB
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Letrozole 2.5 mg PO DAILY
11. LORazepam 0.5 mg PO Q8H:PRN anxiety
12. Montelukast 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. PredniSONE 10 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Clindamycin 600 mg PO Q8H Duration: 6 Doses
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. FLUoxetine 20 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN SOB
9. Letrozole 2.5 mg PO DAILY
10. Levothyroxine Sodium 25 mcg PO DAILY
11. LORazepam 0.5 mg PO Q8H:PRN anxiety
12. Losartan Potassium 100 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Pantoprazole 40 mg PO Q12H
16. PredniSONE 10 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Complete Heart Block s/p Pacemaker placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___
because ___ had an irregular heart rhythm and increased chest
pain.
___ were found to have an irregular heart rhythm on the
telemetry monitor. The Electrophysiology Team (the heart rhythm
specialists), saw ___ and recommended the placement of a
pacemaker. ___ were started on antibiotics for prevention of an
infection, with a 2 additional days of clindamycin to be
completed on ___. Please start taking the antibiotics
tomorrow. A chest x-ray showed that the device was in the
correct place and that ___ did not have any damage to your lungs
from the device. ___ will follow up with the device clinic on
___ to ensure that the device is functioning normally. Your
appointment with Dr. ___ cardiologist, will be
scheduled at your device clinic appointment.
Your chest pain returned to it's baseline pressure and pain the
day following your admission. An echocardiogram (images of your
heart) showed normal function with an ejection fraction greater
than 55% (normal). ___ were discharged on your home medications
for your pain.
We have made changes to your medication list, so please make
sure to take your medications as directed. ___ will also need to
have close follow up with your heart doctor and your primary
care doctor.
It was a pleasure to take care of ___. We wish ___ the best with
your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
10559301-DS-12 | 10,559,301 | 29,383,747 | DS | 12 | 2174-11-04 00:00:00 | 2174-11-05 15:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is an ___ F with a h/o OA, morbid obesity,
lymphedema who presents to the ___ ED as a transfer from ___
___ where she was found to have a left basal ganglia
hemorrhage on NCHCT. Per her son the patient had been in her
usual state of health until yesterday evening when she began
having some slurred speech. She went to bed and awoke this
morning with continued slurred speech. Also noted by her family
was a facial droop and that the patient was acting "out of it,"
"like she was drunk." Her son also notes that her lower legs
have become more red than normal today. She was brought to ___
___ where a ___ demonstrated a 12mm left basal ganglia
hemorrhage. At ___ BP was documented at 168/77. Labs including
CBC, BMP and UA were unremarkable. She was transferred to ___
for further care.
Past Medical History:
OA
lymphedema
cholecystectomy
Social History:
___
Family History:
No family history of neurologic disease.
Physical Exam:
98.1 86 156/89 18 99% RA
GEN: Awake, obese, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
RESP: CTAB no w/r/r
CV: RRR, no m/r/g
ABD: soft, NT/ND
EXT/SKIN: Severe BLE edema with extensive stasis dermatitis and
erythemal of lower legs
NEURO EXAM:
MS:
Alert, oriented to self and hospital.
Speech is difficult to assess given patient is ___ speaking
only, she does sound fluent and mildly dysarthric
Able to relate history without difficulty.
Grossly attentive.
Speech was not dysarthric.
Able to follow both midline and appendicular commands.
No evidence of apraxia or neglect.
CN:
II:
PERRLA 3 to 2mm and brisk.
VFF to confrontation.
III, IV, VI: EOMI, no nystagmus. Normal saccades.
V: Sensation intact to LT.
VII: Facial musculature activates symmetrically.
VIII: Hearing intact to commands.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Delt Bic Tri WrE IP Quad Ham TA Gastroc
L ___ ___ 5 5 5
R ___ ___ 5 5 5
Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
Reflexes:
unable to obtain DTRs due to edema and body habitus
toes upgoing ___
Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on
FNF bilaterally.
Pertinent Results:
___ 06:50AM BLOOD WBC-10.0 RBC-4.27 Hgb-12.3 Hct-36.6
MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 Plt ___
___ 10:00PM BLOOD Neuts-57.8 ___ Monos-4.1
Eos-10.4* Baso-0.5
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-139* UreaN-11 Creat-0.6 Na-143
K-4.1 Cl-107 HCO3-25 AnGap-15
___ 06:50AM BLOOD ALT-18 AST-22 CK(CPK)-43 AlkPhos-58
TotBili-0.5
___ 10:00PM BLOOD Lipase-13
___ 06:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:50AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.2 Mg-2.1
Cholest-185
___ 06:50AM BLOOD %HbA1c-6.9* eAG-151*
___ 06:50AM BLOOD Triglyc-213* HDL-30 CHOL/HD-6.2
LDLcalc-112
___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MR ___ ___. Focal hemorrhage and mild surrounding edema within the left
thalamus,
unchanged from CT on ___. This is likely
hypertensive in etiology as there are no abnormal flow voids to
suggest an underlying vascular malformation and there is no
evidence of chronic blood product deposition throughout the
___ to suggest amyloid angiography. However, limited
assessment for slow flow vascular lesion such as cavernoma
within the focus of hemorrhage given the negative susceptibility
noted. Correlate clinically an followup. Intracranial
vasculature is better assessed on the recent CT angiogram study.
2. Multiple foci of FLAIR hyperintensity in the cerebral white
matter,
nonspecific but most likely due to chronic small vessel ischemic
disease.
Moderate generalized parenchymal volume loss.
Other details as above
Head CT ___. No significant interval change in left basal ganglia
hemorrhage.
2. Narrowing and irregularity of the right greater than left
posterior
cerebral arteries.
3. No evidence of aneurysm or vascular malformation.
4. No significant stenosis by NASCET criteria.
5. 3 mm pulmonary nodule in the right upper lobe of the lung.
ECG
Possible ectopic atrial rhythm with premature atrial complexes.
Non-specific ST-T wave abnormalities
Brief Hospital Course:
Ms ___ was transferred to ___ for an intraparenchymal
hemorrhage noted on a CT scan at the OSH. She was admitted to
the Neurology service for further workup. She had an MRI that
re-demonstrated the hemorrhage and no abnormal signal in the
surrounding parenchyma to suggest that a tumor or vascular
anomaly was the cause of the hemorrhage. Therefore, it was felt
that this was likely a hypertensive hemorrhage. She was started
on lisinopril for blood pressure control, and she was continued
on her home dose of lasix. She was noted to be in an irregular
rhythmn throughout her stay concerning for atrial fibrillation
or flutter, but her ECG only demonstrated PACs. She worked with
___ who felt that she could benefit from rehab, but the family
felt like she was not far from her baseline, and therefore, they
elected to have her come home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO BID
2. Potassium Chloride 20 mEq PO DAILY
3. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO QHS:PRN pain
Discharge Medications:
1. Furosemide 20 mg PO BID
2. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO QHS:PRN pain
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Potassium Chloride 20 mEq PO DAILY
Hold for K >
Discharge Disposition:
Home
Discharge Diagnosis:
Left basal ganglia bleed
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 with slurred speach and facial droop.
You were found to have a bleed on the left side of your ___
which caused these symptoms. This is likely due to elevated
blood pressure. We have started a new medication for blood
pressure control. Please have your doctor check your potassium
level in 1 week after being on this medication.
Followup Instructions:
___
|
10559301-DS-13 | 10,559,301 | 29,648,783 | DS | 13 | 2174-11-15 00:00:00 | 2174-11-20 17:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening right side weakness
Major Surgical or Invasive Procedure:
na
History of Present Illness:
Mrs ___ is an ___ yo ___ speaking woman with PMH significant
for recent hospitalization at ___ for left basal ganglia IPH
___ to ___ and now presents for new onset of right
sided
weakness
The patient was DCed home 4 days PTA. She was initially doing
well and getting around the house with her walker. The night PTA
she did not sleep well and was less active the following day.
starting around 3pm her family noticed that she was moving the
right side of her body less than before. They report that when
she left the hospital on the ___ she had no weakness on the
right. Her hand grip seemed weak to them and she was unable to
walk because her right leg "gave out on her". She was also
complaining of some LUQ pain. She was taken to ___ where a CT scan was reported as interval increase in
IPH
size and she was sent to ___.
When the patient initially presented on ___ her symptoms were
of
right facial droop and dysarthria. The etiology of the bleed was
thought to be hypertensive and she was started on lisinopril
with
good effect. The patient's son reports that she has been taking
all of her medications as prescribed. At the end of her prior
hospitalization ___ recommended rehab however the patient refused
and she was DCed home.
Past Medical History:
OA
lymphedema
cholecystectomy
left basal ganglia IPH (___)
Social History:
___
Family History:
No family history of neurologic disease.
Physical Exam:
MEDICAL EXAMINATION
HR: 96 BP: 136/82 RR: 14 Sat: 96% on 2L
GENERAL MEDICAL EXAMINATION:
General appearance: sleepy obese elderly woman
HEENT: Neck is supple. Mucous membranes are moist.
CV: Heart rate is irregular
Lungs: Clear to auscultation bilaterally without wheezing or
crackles.
Abdomen: active bowel sounds, soft, non-tender, no R/G
Extremities: chronic appearing edema in bl ___.
Skin: Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: sleepy but wakes to her name, quick to fall back
to sleep. not cooperative with the exam or history (turns away
from me, says no to motor commands) non-specific dysarthria
(equally lingual/guttural/labial). Language appears fluent. able
to follow basic commands.
Cranial Nerves:
I: not tested
II: unable to test visual fields
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: Face with right facial droop at rest and decreased speed
and
excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout.
Strength: Unable to test formally due to poor cooperation.
moving
the left more than the right. With noxious stim she is atleast
antigravity on the RUE. Only movement in the plane of the bed
for
bl ___ in the LUE.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Toes are up on the right; mute on the left.
Sensory: responds to noxious on all 4.
Coordination: unable to test.
Gait: unable to test
On discharge the patient's exam is notable for: improved
dysarthria, mildy improved right facial droop. Formal testing of
strength remains difficult due to poor effort. She is atleast
antigravity throughout on the right. She is ___ on the left with
the exception of 4+/5 in the left Delt and IP.
Pertinent Results:
___ 02:00AM BLOOD WBC-10.6 RBC-4.57 Hgb-13.0 Hct-38.9
MCV-85 MCH-28.5 MCHC-33.5 RDW-13.6 Plt ___
___ 07:20AM BLOOD Glucose-140* UreaN-13 Creat-0.6 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
___ 02:00AM BLOOD ALT-16 AST-23 AlkPhos-64 TotBili-0.9
___ 02:00AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.2 Mg-2.2
___ 06:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
NCHCT ___
1. Unchanged hemorrhage within the left basal ganglia with mild
surrounding edema.
2. Stable ventricular size.
3. No evidence of new intracranial hemorrhage or new mass
effect.
4. Brain parenchymal volume loss and presumed sequelae of
chronic small vessel ischemic disease
Brief Hospital Course:
Mrs ___ is an ___ yo ___ speaking woman with PMH significant
for recent hospitalization at ___ for left basal ganglia IPH
___ to ___ who presented for new onset of right sided
weakness and worsening dysarthria. The etiology of here weakness
is most likely due to slight enlargement of hemorrhage and
increased edema. The patient presented at day ___ s/p IPH which is
the start of peak edema. Her exam improved during her stay. She
was screened and DCed to rehab.
The patient has elevated blood pressures during her stay - her
lisinopril was increased to 10mg daily with improvement.
Medications on Admission:
1. Furosemide 20 mg PO BID
2. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO QHS:PRN pain
3. Lisinopril 5 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 100 mg PO TID
5. Furosemide 20 mg PO BID
6. Potassium Chloride 20 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal hemorrhage
OA
Chronic lymphedema
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 the Neurology service with difficulty
speaking, moving the right part of your face, and moving your
right arm. Your CT scan showed that the bleeding in your brain
had gotten slightly bigger, and that is the most likely reason
for the new weakness. We did not change any of your medications,
but it was noted that your blood sugars for the past several
months have been somewhat elevated. Therefore, we would
recommend decreasing the amount of carbohydrates in your diet
and following up with your primary care doctor.
Followup Instructions:
___
|
10559377-DS-5 | 10,559,377 | 28,348,476 | DS | 5 | 2158-03-26 00:00:00 | 2158-03-26 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down, septic shock
Major Surgical or Invasive Procedure:
TRACH AND PEG PLACEMENT ___
PICC PLACEMENT ___
History of Present Illness:
Mr. ___ is a ___ year-old male with a history of HIV on HAART
___ , CD4 ___, neurosyphilis and intravenous
crystal methamphetamine abuse being transferred from ___ for
septic shock and rhabdomyolisis.
He presented to ___ yesterday after being found down for an
unknown amount of time. Per report, over the last few weeks the
patient had been having abdominal distension with pain in the
right upper quadrant as well as back pain, dyspnea and edema in
the extremities, especially his righ upper one. He is also
reported non-quantified weight loss. It also reported that he
used crystal methamphetamine for the last time ___ days ago.
On arrival to ___, the patient was found to be hypotensive in
the ___ with an oxygenation in the ___ on room air. He had no
focal neurologic deficits per their report. He had a head CT
that was negative. His labs were remarkable for a platelet count
of 38, a white blood cell count of 4.3, lactate of 8, CK 6461,
INR 1.4, creatinine of 4.5, bicarbonate of 14, pH of 7.17, and
an elevated troponin of 0.6. Urine tox positive for amphetamines
and opiates. He was started on a bicarbonate drip and given
vancomycin and piperacillin-tazobactam. He remained hypotensive
despite aggressive IV fluid resuscitation. He was transferred
for the intensive care unit. There he received a total of 6 L of
IV fluids with persistent hypotension. We had a RIJ central line
placed. There was a concern for splinter hemorrhages but no
murmur. Right upper quadrant tender to palpation with no rebound
or guarding. Mild abdominal distention noted. Fast exam showed
no pericardial effusion or free fluid. No obvious vegetation was
noted on bedside echo. His cardiac contractility was largely
normal. His urine output was 10cc during his whole OSH course.
He was transferred to ___ due to concern for epidural abscess.
In the ED :
-His initial vitals were 117 82/47 28 99% NC (flow unknown)
-He was continued on NEpi at 0.18
-CHA called with GPCs in chains in ___ bottles
-CBC 3.4>12.2<27, N:70%, B:7%
-Lactate 3.2->3.5
-CK 8583
-Cr 3.8 (from 4.5)
-CT Abdomen and MRI Spine were done, after MRI he became
obtunded and there was concern that he could not protect his
airway so he was intubated.
-Vitals prior to transfer were: 129 114/60 27 99% ETT
On arrival to the MICU, 98.4 | 108 | 91/49 | 24 | 100%ETT
Past Medical History:
-HIV on HAART
acute retroviral sd ___ CD4 639 / VL>500K
Last VL <75 ___, Last CD4 594 ___
neg PPD ___, (-) anal pap ___
-INSOMNIA
-ANXIETY DISORDER, NOS
-CHOROIDAL NEVUS (left eye)
-LEFT HAND PARESTHESIA
-H/O NEUROSYPHYLIS
dx ___ (HA, alopecia, neck stiffness, hearing loss)
LP WBC 116, 55 protein, RPR 1:64
14d of IV PCN (finished ___
-BILATERAL EPIDYDIMAL CYSTS
-H/O VASECTOMY
Social History:
___
Family History:
-Father: Cancer of unknown origine, in remission
-Mother: ___ cancer, in remission, s/p bilateral mastectomy.
Thyroid cancer, status unknown.
-2 paternal cousins with breast cancer in ___
Physical Exam:
ADMISSIONE EXAM:
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, no pallor, dry MM
NECK: RIJ in place
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: REgular tachycardic heart sounds, normal S1 S2, no murmurs,
rubs, gallops
ABD: Distended, no collateral circulation, scant bowel sounds,
soft, no guarding, smooth liver palpable 3cm below right costal
border, no palpable spleen, tympanic ___: Edema in 4 extremities, distally cold and some cyanosis in
toes.
SKIN: No splinter hemorrhages
NEURO: Sedated.
DISCHARGE EXAM:
Vitals: HR in the 80___ to 110's. afebrile. BP 93/66 O2 sats on
RA______
GENERAL: alert and oriented x 3. Chronically ill-appearing and
cachetic
HEENT: Sclera anicteric, no pallor, MMM
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular tachycardic heart sounds, normal S1 S2, no murmurs,
rubs, gallops
ABD: soft and nontender. nondistended
___: no edema. no cyanosis.
Pertinent Results:
ADMISSION LABS:
___ 09:07PM BLOOD WBC-3.7* RBC-3.60* Hgb-12.2* Hct-35.1*
MCV-98 MCH-34.0* MCHC-34.8 RDW-13.7 Plt Ct-27*
___ 09:07PM BLOOD Neuts-70 Bands-7* Lymphs-11* Monos-8
Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-0
___ 09:07PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-1+
___ 05:43AM BLOOD ___
___ 09:07PM BLOOD Glucose-84 UreaN-55* Creat-3.8* Na-125*
K-4.6 Cl-92* HCO3-15* AnGap-23*
___ 09:07PM BLOOD ALT-80* AST-265* CK(CPK)-8583* AlkPhos-85
TotBili-2.3*
___ 05:43AM BLOOD Albumin-1.9* Calcium-6.3* Phos-6.4*
Mg-2.0
___ 09:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:35PM BLOOD Type-CENTRAL VE pO2-43* pCO2-34* pH-7.28*
calTCO2-17* Base XS--9
___ 09:09PM BLOOD Lactate-3.2*
PERTINENT LABS:
___ 09:07PM BLOOD cTropnT-0.11*
___ 09:54PM BLOOD CK-MB-468* MB Indx-12.3* cTropnT-5.36*
___ 01:32AM BLOOD CK-MB-GREATER TH cTropnT-10.34*
___ 09:30AM BLOOD CK-MB-GREATER TH cTropnT-9.69*
___ 03:38PM BLOOD CK-MB-GREATER TH cTropnT-6.54*
___ 10:01PM BLOOD CK-MB-466* MB Indx-28.7* cTropnT-4.71*
___ 10:00PM BLOOD CK-MB-3 cTropnT-13.78*
___ 03:58AM BLOOD CK-MB-3 cTropnT-11.89*
___ 04:04AM BLOOD CK-MB-3 cTropnT-9.07*
___ 05:59PM BLOOD ___
___ 10:00AM BLOOD ANCA-NEGATIVE B
___ 04:23AM BLOOD Vit___-___* Folate-17.1 Hapto-353*
___ 05:55AM BLOOD Ret Aut-2.7
DISCHARGE LABS:
MICRO:
Multiple negative blood, urine, and sputum cxs, c diff negative,
legionella negative.
___ sputum
GRAM STAIN (Final ___:
___ ALBICANS. MODERATE GROWTH. ID PER ___ ___ (___).
ASPERGILLUS FUMIGATUS. RARE GROWTH.
B-GLUCAN Test ___
Results Reference Ranges
------- ----------------
64 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
___ 18:55
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
INDEX VALUE 0.64 H <0.50
ASPERGILLUS AG,EIA,SERUM Detected A Not Detected
___
ASPERGILLUS GALACTOMANNAN ANTIGEN -PENDING
___ BAL postive for CMV
___ BAL pending
CXR ___
IMPRESSION:
Patchy bibasilar opacities could represent atelectasis,
aspiration or
infection. pulmonary vascular congestion with mild interstitial
edema.
ECHOCARDIOGRAM ___
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-50 %). 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 number of aortic valve leaflets cannot be
determined. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. No mitral regurgitation is seen. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No echocardiographic
evidence of endocarditis. Mildly depressed left ventricular
systolic function. At least moderate pulmonary artery systolic
hypertension.
CT A/P ___
IMPRESSION:
1. Moderate volume intra-abdominal free fluid as well as marked
periportal
edema seen within the liver. These findings can be seen in acute
hepatitis. No
evidence of cholecystitis. Though the pancreas appears normal,
recommend
correlation with serum lipase for evaluation of possible
pancreatitis.
2. Small bilateral pleural effusions with bilateral pulmonary
opacities which
are most consistent with atelectasis however could represent
areas of
infection in the appropriate clinical setting.
3. No free intra-abdominal air.
ECHOCARDIOGRAM ___
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. There is severe global left
ventricular hypokinesis (LVEF = ___ %). No masses or thrombi
are seen in the left ventricle. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate to severe (___)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
CT CHEST WITHOUT CONTRAST ___:
IMPRESSION:
Extensive bilateral ground-glass opacities involving each lobe
as well as
extensive consolidation of the bilateral lower lobes could
represent pulmonary
hemorrhage or multifocal infection.
Small to moderate nonhemorrhagic, bilateral pleural effusions
are seen.
MRI HEAD WITHOUT CONTRAST ___
IMPRESSION:
Partial mastoid air cell opacification. Otherwise normal study
RUQ US ___:
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. At least small right pleural effusion and trace ascites.
3. Echogenic right kidney, partially visualized, suggesting
parenchymal
disease. Per inpatient team, patient just recovered from acute
tubular
necrosis.
CT ABDOMEN/PELVIS ___:
IMPRESSION:
1. No acute intra-abdominal process to explain patient's
symptoms.
Specifically, there is no evidence of abscess formation adjacent
to the PEG tube.
2. Diffuse anasarca.
3. 9 x 7 mm calcific focus in the lateral aspect of the right
gluteal muscle at its insertion, likely calcific tendinitis.
4. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
CT CHEST ___:
IMPRESSION:
1. Extensive consolidation involving the bilateral upper lobes
and right
middle lobe is markedly increased from the prior examination and
suggests
pneumonia or ARDS. The bilateral lower lobes are collapsed and
there are
large bilateral pleural effusions, also significantly increased
from the prior study.
2. Main pulmonary artery is slightly enlarged suggesting
pulmonary arterial hypertension.
3. Linear hypodensity within the left internal jugular vein
likely represents a small nonocclusive thrombus.
4. Calcification of the left ventricular wall myocardium is most
likely
related to recent myocardial infarction.
ECHO ___:
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
and cavity size are normal. Overall left ventricular systolic
function is severely depressed (LVEF= 20 %) secondary to severe
global hypokinesis. No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is dilated with mild global free wall
hypokinesis. 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. The mitral valve leaflets do not fully coapt. Mild to
moderate (___) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension.
IMPRESSION: No evidence of valvular vegetations (better excluded
by TEE). Severely depressed global left ventricular systolic
function. Moderate pulmonary artery systolic hypertension.
Mild-moderate functional mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
there is less mitral, aortic, and tricuspid regurgitation. LV
cavity is less dilated. Other findings are similar.
PLEURAL FLUID CYTOLOGY ___:
Negative for malignant cells.
BILAT LOWER ___ VEINS U/S ___:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
BILAT UPPER ___ VEINS U/S ___:
IMPRESSION:
Nonocclusive DVT seen within the left subclavian vein, extending
to the left axillary and left basilic vein.
Noncompressibility of the left cephalic vein consistent with
thrombosis.
Noncompressibility of the right basilic and cephalic veins
consistent with thrombosis.
BILAT UPPER ___ VEINS U/S ___:
IMPRESSION:
1. On the left, there is occlusive thrombus within a left
brachial vein,
which was likely present in retrospect, with new but probably
redistribted nonocclusive thrombus now lying in the left
internal jugular vein, and also unchanged left basilic vein. On
the whole, clot burden has decreased among upper extremity
veins.
2. On the right, previously seen thrombus within the right
basilic and
cephalic veins is no longer identified; veins now clear on the
right side.
Brief Hospital Course:
Mr. ___ is a ___ year-old male with history of HIV and IVDU
who originally presented to CHA after being found down, and
found to have group C strep bacteremia, rhabdomyolysis, septic
shock and renal failure, course complicated by anterior STEMI.
# Group C strep bacteremia and septic shock: Patient initially
presented in septic shock and was broadly covered with
vancomycin, cefepime, then also given ampicillin, clindamycin
and single doses of linezolid and tobramycin pending culture
data. Pt received 6L of NS at ___, was started on NEpi and
recieved 3L on arrival to MICU. ___ bottles grew group C strep
at ___. Antibiotics narrowed to
ceftriaxone and clindamycin. Patient given dose of IVIG for
presumed toxic shock syndrome, which was not continued given
concern for thrombosis. No evidence of endocarditis on TTE or
TEE. No epidural abscess on MRI spine. Over the 3 initial days
of admission his septic shock picture worsened, requiring
addition of multiple pressors (vasopressin and phenylephrine) in
setting of worsening hemodynamics and perfusion (rising
lactate). As he was unstable to travel to radiology for
abdominal CT, RUQ-US and portable abdomen XR were done twice
without actionable findings. Acute care surgery was consulted
and they believed an intra-abdominal process would not explain
his clinical deterioration. His lactate peaked at 11.7, at which
point he received 1U PRBC and was broadened to meropenem,
vancomycin cefepime, clindamycin, micafungin. Over the next 2
days his lactate trended down and stabilized around ___, his
pressor requirement decreased. Given absence of other microbial
pathogens isolated as well as favorable clinical progress he was
narrowed back to ceftriaxone, clindamycin, micafungin on ___,
and clinda d/c'd on ___ and micafungin d/c'd on ___. He was
successfully off all pressors, requiring pressors transiently
___ trach and peg placement ___. Ultimately, plan was for
completing tx on ___ with Ceftx which was completed.
# Hypoxemic respiratory failure: Patient presented with
hypoxemic respiratory failure secondary to pneumonia and
pulmonary hemorrhage. He had bright red bloody secretions
through his ETT on ___. Over the next few days his bleed was
prominent requiring desmopressin, platelet and RBC
transfusions, as well as FFP. On ___ he desaturated and has
increased PIPs, CXR revealed RUL collapse. He underwent a
bronchoscopy requiring removal of large clot burden. He required
multiple bronchoscopies over the course of one week to alleviate
the clot burden. GBM and ANCA were negative. Serial lavage did
not clear but did not increase bloody return overall picture not
compatible with DAH. After discussion with family, he had a
trach and PEG placed on ___. On ___ patient continued to have
low grade fevers and increased work of breathing with CXR
showing new opacities concerning for evolving VAP. He was
broadened from ceftriaxone to vancomycin and cefepime on ___ and
placed back on ventilator from trach w/ sedation. Pt was
continued on vanco/cefepime for 10days, ___, which also
covered group strep C infection above. In addition, he was also
diuresed successfully for volume overload in the s/o
resuscitation from initial presentation. The patient continued
to have infiltrates on CXR and required going back on vent from
trach mask throughout his hospital course. On ___ he was
restarted on vanc/cefepime for respiratory distress, worsening
infiltrates for concern regarding VAP. Vanc discontinued after
one day but Cefepime continued for a complete 8day HCAP course.
On ___ he was again febrile with abdominal pain, was
tachycardic and hypotensive, requiring pressors and IVF. C. diff
was negative, CT torso showed increased consolidations of
bilateral upper lobes/RML from prior c/w PNA or ARDS, and large
increased bilateral pleural effusions, stranding around PEG site
wnl but no infection. He underwent a left thoracentesis on ___
with 1200cc of fluid removed and studies with negative culture.
On ___, he pulled out his trach which was replaced.
CXR on ___ showed worse infiltrates and sputum with yeast and
rare mold which eventually speciated for aspergillus.
Galactomanan was slightly positive, ID was consulted and did not
recommend treating for aspergillus lung infection as clinical
picture was not consistent. Galactomannan was repeated and
pending at discharge.
He underwent repeat bronchoscopy on ___ and studies showed
yeast on fungal culture and was positive for CMV. ID
recommendations were to resend CMV viral load and treat if
signifucantly higher than last one (1500copies). CMV viral load
resent on discharge and pending.
In setting of downtrending H/H requiring 1unit of PRBC's and
worsening bilateral infiltrates there was concern for DAH. He
underwent bronchoscopy again on ___ which was not quite
consistent with DAH but serial lavages on ___ showed increased
color, but not concerning enough to require steroid pulse. BAL
specimen sent for studies and pending at discharge. Holding off
further therapeutic anticoagulation for his UE DVT since it is
likely PICC related.
Overall pulmonary status stable at discharge and not requiring
intermittent vent anymore. On room air and sats 94-100%.
#Sinus tachycardia: HR in the 90's to 120's but otherwise
hemodynamically stable. Worked up extensively; echo with severe
cardiomyopathy. No concern for sepsis at discharge. likely
multifactorial; anxiety, severe deconditioning and severe
cardiomyopathy.
#Left upper Extremity DVT: Due to recurrent fevers and
tachycardia and negative infectious work up, he underwent
ultraso7und of extremities which showed Left upper extremity DVT
and bilateral superfical clots.. He was started on heparin gtt
with bridge to coumadin. In setting of downtrending H/H and
worsening bilateral infiltrates there was concern for DAH. His
warfarin was held and Upper extremity ___ repeated to
re-evaluate clot burden. A left IJ clot was demonstrated and the
right side with no more superfical clots. Heparin subsequently
discontinued as well.
Holding off further therapeutic anticoagulation for his UE DVT
since it is likely PICC related but ok to do prophylactic
antocoagulation.
# Anterior STEMI: Overnight on ___, telemetry alarmed for ST
elevations and 12 lead EKG showed anterior STEMI. Cardiology
consulted, and given patient's unstable clinical status, cath
was not pursued. Patient was loaded with aspirin and plavix and
started on a statin and a heparin drip. Echo showed moderately
depressed EF. Cardiology concerned for septic emboli,
recommended treating for endocarditis despite negative TEE. ___
and 3rd doses of IVIG held given concern re: pro-thrombotic
effect. He completed ___ on a heparin gtt. As he became
thrombocytopenic to the lower ___ while having a pulmonary
hemorrhage his aspirin was held on ___. His statin was held in
the setting of worsening transaminase elevation on ___. On ___
he alarmed again for ST elevations on telemetry and had
recurrence of his anterior STEs as his TnT was 13.78, cardiology
was consulted again, he was still deemed too unstable for cath
and the time frame for the event was not clear. He was reloaded
with ASA (and restarted with daily dosing) and statin was
restarted, TnT slowly decreased over the next couple of days.
Repeat Echocardiogram on ___ showed no evidence of valvular
vegetations. There was severely depressed global left
ventricular systolic function with moderate pulmonary artery
systolic hypertension, and mild-moderate functional mitral
regurgitation. Overall not much changed freom prior Echo.
# Acute renal failure: Patient presented anuric with creatinine
doubling from baseline as well as elevated CK with concern for
rhabdomyolisis. Urine sediment consistent with ATN. A temporary
dialysis line was placed and he was started on CRRT until it was
clogged on ___. However, his creatinine improved and he began
to produce urine output so CRRT was not resumed and his dialysis
line was pulled on ___. His creatinine normalized prior to d/c.
#Hypotension: Due to persistent hypotension in setting of
negative infectious workup, echocardiogram was repeated which
showed severely depressed EF but unchanged from before. TSH and
cortisol levels were wnl. Hypotension attributed to his severe
cardiomyopathy and lisinoptil and metoprolol currently on hold
due to his softer BP's
# Concern for fungal infection: On ___, given rising lactate
peaking at 11.7 and severe clinical deterioration, patient was
started on micafungin for empiric fungal coverage He had grown
yeast in BAL and urine. Serum beta-glucan was >500 although no
fungal culture came back positive. Fungal antigens were sent and
came back negative. BAL was sent and galactomanan which came
back positive but per ID was at a low level of positivity not
concerning for an Aspergillus infection. He did not receive any
fungal coverage with micafungin stopped ___ and respiratory
status continued to improved. Repeat beta glucan was
downtrending. See above
# Thrombocytopenia: Patient with thrombocytopenia on admission.
Previously normal platelets according to ___ Primary Care
Records. Unclear whether part of sepsis picture (although
fibrinogen was normal making DIC unlikely). ITP unlikely given
prolonged response to platelet transfusions. Clopidogrel was
held in setting of thrombocytopenia. Was transfused a total of
5U of platelets in setting of pulmonary hemorrhage. By ___ his
platelet counts started recovering without the need for further
transfusion. Most likely etiology was megakaryocyte progenitor
depletion in setting of prominent granulocytic response.
# Anemia: Initially attributed to DAH and critical illness and
required periodic transfusions. After stabilization fo his
infections and resolution of DAH, pt continued to have
downtrending H/H. Hemolysis labs negative but retic low
suggesting poor marrow response. B12 and folate wnl. As a
result, most likley due to critical illness and marrow
suppression, possibly also related to abx. WIll need to be
trended after d/c.
# Hepatitis: Transaminases and bilirubins were elevated on
arrival and rose during the admission. RUQ-US suggestive of
hepatitis. Likely hepatitis in context of bacteremia and/or
congestive hepatopathy. Slowly improved with treatment of
infections but never completely normalized, given persistent
mild transaminitis, repeat RUQ was obtained which did not show
cholecystitis. Downtrending on discharge.
# Rash: Developed a L sided trunk rash that did not cross
midline and maintained within a dermatomal distribution c/f
Zoster, started on Valacyclovir on ___ for planned 10d course.
#Anxiety: Significant issues with anxiety with associated
behavioral issues. Psychiatry was consulted and recommended
olanzapine BID and increase in Trazodone HS doing which improved
his symptoms. Continued Seroquel as well. Last QTc 422
Transitional issues:
[] Outpatient cardiology follow up, pending functional status at
the time, can consider stress test vs viability study and
revascularization if he has reversible ischemia
[] Lisinopril when BP can tolerate
[] Start metoprolol when BP can tolerate for his CAD
[] F/u IgE sent on ___
[] Needs outpt Pulm f/u with repeat chest CT 6 weeks from last
CT (on ___
[] Needs Weekly upper extremity ultrasound to evaluate clot
burden
[] Follow up BAL ___ studies
[] Follow up CMV viral load (___) and if significant increased
from prior then treat: CMV Viral Load (Final ___: 1,500
IU/mL.
[] Not treating his Left Upper extremity DVT due to some c/f DAH
and downtrending H/H, and relation to PICC line
[]Weekly ECG's to monitor QTc
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 400 mg PO QHS
2. Gabapentin 600 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Dolutegravir 50 mg PO DAILY
Discharge Medications:
1. Dolutegravir 50 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Gabapentin 600 mg PO DAILY
4. TraZODone 400 mg PO QHS
5. Acetaminophen 650 mg PO Q6H:PRN temp >100.4
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
7. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
8. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Famotidine 20 mg PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Heparin 5000 UNIT SC TID
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze, dyspnea
15. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
16. OLANZapine 2.5 mg PO BID:PRN anxiety
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
19. Sertraline 50 mg PO DAILY
anxiety
20. Simethicone 40-80 mg PO QID:PRN gas discomfort
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Refractory septic shock
2. Group C streptococcus bacteremia
3. ST elevation Myocardial Infarction
4. Acute Tubular Necrosis
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 caring for you at ___. You came to the
hospital because you were found down at home. We found that you
had a severe bloodstream infection, rhabdomyolysis, and
respiratory failure. Your hospital course was complicated by a
heart attack, blood clots in your left arm and pneumonias. You
required multiple treatments with antibiotics. You required
placement of a tracheostomy and feeding tube. You needed blood
thinners for your clots but then we were concerned for some mild
bleeding into your lungs, so we have stopped the blood thinners.
You are making progress on recovery but will need to continue
this at a long term acute rehab facility.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10559648-DS-3 | 10,559,648 | 29,543,158 | DS | 3 | 2185-02-17 00:00:00 | 2185-02-18 14:13:00 |
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:
None applicable
History of Present Illness:
Healthy ___ p/w two days of worsening abd pain. Pain sharp,
continuous, nonradiating, along lower abd. Associated nasuea but
no emesis. Endorses decreased appetite these past few days.
First episode of this pain. Last BM two days ago was formed,
nonbloody. CT scan in ED shows diverticulitis.
ROS:
(+) per HPI
(-) Denies fevers, chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, trouble with sleep, pruritis,
jaundice, rashes, bleeding, easy bruising, headache, dizziness,
vertigo, syncope, weakness, paresthesias, vomiting, hematemesis,
bloating, cramping, melena, BRBPR, dysphagia, chest pain,
shortness of breath, cough, edema, urinary frequency or urgency
Past Medical History:
GERD
Past Surgical History: None
Social History:
___
Family History:
No history of colon cancer
Physical Exam:
Vital Signs WNL
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR,
PULM: no respiratory distress
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP, no CCE, no tenderness
NEURO: A&Ox3, no focal neurologic deficits
Pertinent Results:
Laboratory Studies
___ 08:54AM BLOOD WBC-15.7*# RBC-5.49# Hgb-14.3# Hct-43.9#
MCV-80* MCH-26.0 MCHC-32.6 RDW-13.5 RDWSD-39.3 Plt ___
___ 07:00AM BLOOD WBC-17.2* RBC-4.96 Hgb-13.0* Hct-39.9*
MCV-80* MCH-26.2 MCHC-32.6 RDW-13.4 RDWSD-39.0 Plt ___
___ 06:40AM BLOOD WBC-12.1* RBC-4.76 Hgb-12.4* Hct-38.2*
MCV-80* MCH-26.1 MCHC-32.5 RDW-13.2 RDWSD-38.9 Plt ___
___ 08:54AM BLOOD Neuts-80.6* Lymphs-9.4* Monos-9.1
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.63* AbsLymp-1.47
AbsMono-1.43* AbsEos-0.01* AbsBaso-0.03
___ 08:54AM BLOOD Plt ___
___ 07:00AM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 08:54AM BLOOD Glucose-110* UreaN-14 Creat-0.9 Na-140
K-3.7 Cl-98 HCO3-26 AnGap-16
___ 07:00AM BLOOD Glucose-145* UreaN-11 Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-25 AnGap-14
___ 06:40AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-100 HCO3-26 AnGap-14
___ 08:54AM BLOOD ALT-24 AST-16 AlkPhos-104 TotBili-0.9
___ 08:54AM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.1 Mg-2.1
___ 07:00AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.___ and pelvis with contrast (___):
IMPRESSION: Acute diverticulitis of the sigmoid colon located
within the lower abdominal midline, with adjacent inflammatory
colitis. There is a focal area of adjacent extraluminal air
measuring 1.7 x 1.1 x 0.8 cm, concerning for microperforation.
There is no focal drainable fluid collection.
Brief Hospital Course:
The patient presented to Emergency Department on ___.
History, physical exam, laboratory studies and imaging indicated
that the patient had acute diverticulitis. He was admitted to
the acute care surgery unit for further management.
During the hospital course review of systems had as follow:
Neuro: The patient was alert and oriented throughout
hospitalization pain was well controlled. The patient only
needed minimal pain medication throughout the hospitalization.
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 then the diet
was advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. He was started on a course
of antibiotics. Originally the antibiotics were intravenous and
were then transitioned to oral once the patient's diet was
advanced to a regular diet.
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.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*12 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
do NOT drink alcohol while taking this medication
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*18 Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___-
___ were admitted to the Acute Care Surgery Unit for management
of an episode of acute diverticulitis. ___ were treated with
antibiotics. Please complete the course of antibiotics that ___
were put on. ___ are now ready for discharge.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ 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.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ 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.
___ 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
___.
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 ___ follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10559787-DS-13 | 10,559,787 | 26,344,174 | DS | 13 | 2175-06-07 00:00:00 | 2175-06-12 14:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / narcotics / Asacol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
___ with recurrent UC flairs transfered from ___ with
abdominal pain and blood clots per rectum.
Sudden onset of stabbing LLQ abdominal pain 1 day PTA,
waxing/waning. +anorexia, nausea and non-biliary emesis. Had
multiple blood clots per rectum overnight, and fever to 104.
Went to ___ this morning, given Unasyn, given demerol
for pian. Multiple BMs today which is watery vs pussy.
CT Abd/pelvis there showed wall thickening in hepatic flexure
and rectosigmoid region, UC in large bowel, acute on chronic
inflamm bowel disease is possible. Transfered to BI for further
management.
In the ED initial vitals were: 98.8 94 95/47 16 98%
- Labs were significant for WBC 6.3, Hct 28.7, Plt 448.
- Patient was given another dose of unasyn.
On the floor, patient dry heaving.
Past Medical History:
- Ulcerative colitis: diagnosed with sigmoidoscopy ___.
- Pancreatitis x2 - medication related?
Social History:
___
Family History:
Mother: ___
Maternal uncle: ___
Physical ___:
EXAM ON ADMISSION
Vitals - 98.1. 90/50, 97, 20, 96% RA
GENERAL: appears uncomfortable
HEENT: MMM, good dentition, OP clear
NECK: no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, diffuse TTP, worst in the LLQ, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM ON DISCHARGE
Vitals: 98.3 106/60-117/66 58-68 98% RA
General: Well-apperaing female laying in bed in NAD
HEENT: MMM
CV: Heart RRR, no murmurs/rubs/gallops
Lungs: CTAB, no tachypnea or increased WOB
Abdomen: Normoactive bowel sounds, soft, non-distended,
non-tender. No palpable masses or organomegaly
Extremities: Warm, well-perfused, no cyanosis/clubbing/edema. 2+
DP pulses.
Neuro: A&Ox3, fluent and logical speech
Pertinent Results:
LABS ON ADMISSION
___ 09:59PM BLOOD WBC-6.3# RBC-4.26 Hgb-8.0* Hct-28.7*
MCV-67*# MCH-18.7*# MCHC-27.8* RDW-17.4* Plt ___
___ 09:59PM BLOOD Neuts-66.4 ___ Monos-10.4 Eos-0.6
Baso-0.9
___ 09:59PM BLOOD ESR-38*
___ 09:59PM BLOOD Glucose-102* UreaN-7 Creat-0.8 Na-138
K-3.5 Cl-106 HCO3-22 AnGap-14
___ 06:40AM BLOOD ALT-22 AST-36 AlkPhos-55 TotBili-0.3
___ 06:40AM BLOOD Albumin-2.8* Calcium-7.5* Phos-2.9 Mg-2.0
Iron-8*
___ 09:59PM BLOOD CRP-167.5*
INTERVAL LABS, IMAGING
___ UPRIGHT ABDOMINAL XRAY
No free intra-abdominal air. No pathologic calcification. No
foreign bodies. No evidence of pathologic bowel distension or
bowel wall thickening. Minimal non characteristic air-fluid
levels but no evidence of pneumatosis.
___: Flexible Sigmoidoscopy
Impression: Ulceration, granularity, friability and erythema in
the rectum and sigmoid colon compatible with ulcerative colitis
(biopsy)
Otherwise normal sigmoidoscopy to sigmoid colon
LABS ON DISCHARGE
___ 06:40AM BLOOD WBC-14.5* RBC-4.35 Hgb-8.6* Hct-30.2*
MCV-70* MCH-19.9* MCHC-28.6* RDW-20.0* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-85 UreaN-18 Creat-0.7 Na-137
K-4.2 Cl-101 HCO3-20* AnGap-20
___ 06:40AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.3
___ 06:40AM BLOOD CRP-5.1*
Brief Hospital Course:
This is ___ year old woman with ulcerative colitis and a history
of pancreatitis who as transferred from ___ with
an ulcerative colitis flare. She was begun on
ampicillin/sulbactam and IV methylprednisolone with good
response.
# ULCERATIVE COLITIS: the patient has a history of intolerance
or failure of multiple medications for ulcerative colitis. She
has tried mesalamine and ___ and could not tolerate either. She
has been hospitalized in the past for ___ induced pancreatitis.
She usually needs steroids for symptomatic control and there was
previous discussions of using cyclosporine. Given concerning
signs of infection (pus in stool), steroids/cyclosporine were
held until C. difficile was found to be negative. Further stool
studies were negative for other infections. IV
methylprednisolone 125 mg was begun and ampicillin/sulbactam
continued. CT performed at ___ was unable to be
transferred digitally, requiring shipment by courrier. She
underwent flexible sigmoidoscopy on ___ which showed
extremely friable and erythematous mucosa with many ulcerations.
She had gradual improvement in her bowel movements over her stay
in both quantity and quality (decreased watery, decreased
blood). Her CRP subsequently downtrended nicely to 5.1 on
discharge (from 157 on admission). She was transitioned to
prednisone PO 40mg x2 weeks with a 5mg/d taper thereafter.
# MICROCYTIC ANEMIA: iron studies consistent with
iron-deficiency anemia. The patient has a history of GI
intolerance to oral formulations of iron supplementation and
needs IV iron infusions. She was transfused 1 u pRBC in the
setting of Hgb 6.8 and symptoms of lightheadedness and weakness.
Her H/H remained stable for the duration of her hospitalization
in the 8.2 range.
TRANSITIONAL ISSUES
Transitional issues:
-Continue prednisone 40 mg PO qd x2 week (until ___ and then
5mg/week taper
-Start Calcium and Vitamin D for long-term steroid use
-Per GI, no need for PCP ppx with bactrim at this time
-follow up with outpatient GI doctor
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apri (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg oral
daily
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
2. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
tablets Disp #*60 Tablet Refills:*0
3. Apri (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg oral
daily
4. PredniSONE 40 mg PO DAILY Duration: 2 Weeks
RX *prednisone 5 mg 8 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Ulcerative colitis flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for a flare of your ulcerative
colitis. We treated you with steroids, antibiotics and
transfused you blood. You underwent a flexible sigmoidoscopy
which showed ulcerations in your colon. You were seen by the GI
team. Your steroids were switched to oral steroids which you
will continue for a taper. Your antibiotics were able to be
stopped. The GI team is working to help make follow up
appointments with your primary GI doctor. We wish you the best
Followup Instructions:
___
|
10559801-DS-3 | 10,559,801 | 23,295,096 | DS | 3 | 2132-01-07 00:00:00 | 2132-01-09 10:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / doxycycline / clindamycin /
Penicillins / shellfish derived / cephalexin
Attending: ___.
Chief Complaint:
Recent Mechanical fall
Lumbar spine pain
left hip pain
Mid abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female who presents for trauma
evaluation after a fall on ___. The patient had a mechanical
fall from 2 steps on ___, +HS, -LOC, followed by pain in her
left hip and abdomen. She was seen at ___ where
trauma work-up showed an acute L1 compression fracture and a R
rectus sheath hematoma. Her hematocrit was stable over 2 days.
She was discharged to rehab, where serial hematocrit checks
showed a drop to 20 from her baseline of 27.5. When she arrived
to ___, she received one unit of RBCs.
On admission, she complained of lumbar spine pain, left hip pain
and mid abdominal pain. No changes in mental status, no nausea,
normal appetite and oral intake, normal bowel function.
Of note, she has a history of alcoholic liver cirrhosis and has
been under evaluation for liver transplant. She also had a
recent trauma in ___ consisting of a right thigh hematoma and
a right rectus sheath hematoma that required embolization by ___.
Past Medical History:
- Cirrhosis secondary to EtOH (with portal HTN and varices)
- MGUS
- Chronic alcoholic gastritis
- ___ esophagus
- HTN
- HLD
- Hypothyroidisim
- Diabetes mellitus
- Asthma
- Thrombocytopenia
- Retinal hemorrhage bilaterally
- Depression
- PTSD
- Colon adenoma
- B-cell lymphoma
- ___ cyst
Social History:
___
Family History:
Father - colon cancer, diabetes mellitus
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals: Temp 98.0 HR 82 BP 147/69 RR 16 SpO2 96% RA
General: awake, alert, oriented x 3
Cardiovascular: regular rate and rhythm
Pulmonary: normal respiratory effort, CTAB
Gastrointestinal: normal bowel sounds, abdomen soft,
non-distended, mild TTP in RLQ, no rebound or guarding
Extremities: hematoma on left hip, soft and minimally tender to
palpation; large ecchymosis right posterior-medial thigh
Pertinent Results:
ADMISSION LABS:
___ 12:56PM BLOOD WBC-6.1 RBC-2.06* Hgb-7.0* Hct-20.5*
MCV-100* MCH-34.0* MCHC-34.1 RDW-15.7* RDWSD-56.7* Plt Ct-50*
___ 12:56PM BLOOD Neuts-69.1 Lymphs-16.0* Monos-11.9
Eos-2.3 Baso-0.2 Im ___ AbsNeut-4.23# AbsLymp-0.98*
AbsMono-0.73 AbsEos-0.14 AbsBaso-0.01
___ 12:56PM BLOOD ___ PTT-34.6 ___
___ 12:56PM BLOOD Glucose-172* UreaN-38* Creat-1.1 Na-136
K-5.4* Cl-97 HCO3-25 AnGap-14
___ 01:30PM BLOOD ALT-29 AST-64* AlkPhos-174* TotBili-3.4*
___ 01:30PM BLOOD Albumin-3.2*
___ 09:47AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.5*
___ 01:41PM BLOOD Lactate-2.1* K-4.1
IMAGING:
___ CT chest/abdomen/pelvis
IMPRESSION:
1. 6.8 cm fluid collection in the right lower rectus abdominus
muscle measuring simple fluid density may represent an old
hematoma or seroma.
2. 3.2 x 2.8 cm acute subcutaneous hematoma along the left
lateral hip with surrounding subcutaneous edema and stranding.
3. Increased attenuation in the subcutaneous fat of the right
lateral thigh is nonspecific, but may also represent an old
hematoma. Please correlate with direct visualization and
physical exam.
4. Compression deformity of the L1 vertebral body is compatible
with known history of recent fracture.
___ CT head:
IMPRESSION:
There is no evidence of infarction,hemorrhage,edema,or
mass-effect. The ventricles and sulci are normal in caliber and
configuration. There is no evidence of fracture. Mucous
retention cysts are noted in the bilateral maxillary sinuses.
The visualized portion of the other paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
___ CT C spine:
IMPRESSION:
1. Multilevel grade 1 anterolisthesis of C2 through C6 is likely
degenerative in etiology given moderate to severe multilevel
degenerative changes noted throughout the cervical spine.
2. Ossification of the posterior longitudinal ligament at C6 and
C7 with spinal canal narrowing.
3. No evidence of fracture.
Brief Hospital Course:
Ms. ___ presented to the ___ Emergency Department on
___ from a rehab for trauma evaluation after a mechanical
fall on ___ which was treated at ___. At
the ___ ED she complained of lumbar spine pain, left hip pain
and mid abdominal pain. Her hematocrit was measured at 20, with
a baseline of 27.5, therefore she was given a unit of PRBC.
Imaging findings consist of an acute L1 compression fracture, an
acute on chronic right rectus sheath hematoma, and an acute left
thigh hematoma. She was hemodynamically stable, transferred to
the ward and was admitted to the acute care surgery service for
24 hours of observation, specifically to trend vitals and
hematocrit.
While with the acute care surgery service, she was on regular
diet. Pain was initially managed by PO oxycodone but was
subsequently transitioned to PO tramadol. Her home medications
were administered except spironolactone was given in ___ home
dose and lasix was held initially. Ecchymosis of the left thigh
was marked. Vital signs were routinely monitored and were
stable. Hematocrit was measured every six hours and was stable
ranging from 21.8-23.3. Of note, the patient has a history of
alcoholic cirrhosis and was found to be compensated throughout
her admission. Her LFTs were monitored and were normal. Given no
concerns for hemodynamic instabiity due to her recent trauma,
the patient was completely normalized and restarted on her
remaining home medications.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient worked with physical therapy
who recommended that she was suitable for discharge to home with
home physical and occupational therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 50 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Lactulose 15 mL PO TID
4. Atorvastatin 20 mg PO QPM
5. Furosemide 20 mg PO DAILY
6. HydrOXYzine 25 mg PO BID
7. TraMADol 100 mg PO Q8H:PRN Pain - Moderate
8. Rifaximin 550 mg PO BID
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Glargine 18 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Glargine 18 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: dc'ing oxy
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Atorvastatin 20 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. HydrOXYzine 25 mg PO BID
8. Lactulose 15 mL PO TID
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Rifaximin 550 mg PO BID
12. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Compression fracture of L1 vertebrae
Acute on chronic right rectus sheath hematoma
Left hip hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ for a trauma evaluation after a mechanical fall. You
were found to have a compression fracture of your L1 vertebrae,
an acute on chronic right rectus sheath hematoma, and a left hip
hematoma. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Thank you for allowing us to participate in your care!
Sincerely,
Your ___ Team
Followup Instructions:
___
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10559918-DS-18 | 10,559,918 | 29,005,270 | DS | 18 | 2178-08-24 00:00:00 | 2178-08-24 23:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
neutropenic fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ with follicular lymphoma with aggressive features on C5D9
Rit/CHOP, with Neulasta on ___, presenting with severe
weakness
and dyspnea on exertion, with moderate neutropenia and possible
pneumonia.
She was seen by her oncologist Dr. ___ on ___ with
plan
for C5 of Rit/CHOP that day. Plan was to taper prednisone again
at the end. Vincristine was decreased to 1mg given mild
paresthesias in fingers.
She was seen in her PCP's office today with weakness. Vital
signs
were T98.1 98/62 HR86 100% RA. She reported her last treatment
was the most difficult so far. She reports new dyspnea on
exertion noticed while going up and down the stairs, fatigue,
noise in ears, excessive flatulence. She denies any fever,
chills, nausea, vomiting, sore throat, cough, pain, body aches,
diarrhea, constipaton, dysuria.
CXR was obtained the office which showed "Density in the lingula
which may represent atelectasis, scarring or small infiltrate.
Followup x-rays are recommended to document resolution." She was
transferred to ___ for evaluation.
In the ED, initial VS were: T99.3 108 104/56 18 100% RA
Labs were notable for: WBC 1.9 with 7% bands, ANC 930. Chem-7
WNL. Lactate 1.1. UA neg.
Imaging included: none
Treatments received:
___ 15:29 IVF 1000 mL NS 1000 mL
___ 16:32 IV CefePIME 2 g
On arrival to the floor, patient had no acute complaints but
complained of generalized weakness and dyspnea on exertion with
occasional palpitations. She also recently had a LUE superficial
thrombus which was treated with warm compresses and has now
resolved.
REVIEW OF SYSTEMS: per HPI, otherwise negative in 10-point
review
Past Medical History:
PAST ONCOLOGIC HISTORY:
Dx'd grade ___ follicular lymphoma involving her cervical nodes
___. Cytogenetics showed 14q32 (IGH rearrangement). She
noted
some neck pain in late ___ after slipping on the stairs,
following which she developed a left sided sore throat. She was
initially treated with Pen for tonsillar enlargement without
improvement and she was seen by Dr ___ in ENT who
appreciated extensive additional cervical adenopathy, confirmed
by chest and neck CT scans. Endoscopic exam showed normal
vallecula, epiglottis, piriform sinus, false and true vocal
cords. Her enlarged tonsillar tissue extends down to the
hypopharynx and slightly longer descent on the left than the
right. FNA by Dr ___ lymphoma and she then underwent
an excisional bx at the ___ that confirmed a CD10+ B cell
follicular lymphoma. Ki67 was ___. She denies any wt loss,
fevers, night sweats or pruritis. Continues to have discomfort
swallowing although feels a bit better since the largest node
was
removed. Mild pain left anterior chest for several weeks
intermittantly. Wonders about possible chemical exposure
growing
up near a airport where lots of chemicals were used.
Chest CT scan MEEI: No hilar or mediastinal adenopathy. Mult
small liver lesions (? Cysts).
Exam notable for enlarged tonsils and bulky cervical and
supraclavicular nodes.
Labs showed normal CBC, LDH, immunoelectrophoresis and slightly
elevated beta 2 microglobulin (2.7). Negative hep serologies.
MRI showed multiple liver cysts.
___: 4 weekly infusions of Rituxan. Tolerated well.
Adenopathy decreased but still present.
___: First maintenance Rituxan.
___ maintenance Rituxan deferred due to lesions on
tonsils. Seen by Dr ___ felt they were tonsillar stones
and not worrisome.
___ maintenance Rituxan. Small left low cervical nodes
present (2 cm).
___: PET scan at ___ - Massive conglomerate of lymph
nodes
along the entire left cervical chain with intense FDG avidity
(14.4). No evidence of right sided cervical lymphadenopathy.
1.5
cm non-FDG avid left breast mass.
___: Core bx of left cervical node showed follicular
lymphoma but with high Ki 67 index (5%-50% focally) and new
cytogenetic changes:
CYTOGENETIC DIAGNOSIS:
46,X,-X,?del(11)(q22q23),del(13)(q12q14),
der(14)t(14;18)(q32;q21)psu dic(1;14)(p13;q32),add(16)(p12),
der(18)t(14;18)(q32;q21),+mar[8]/
46,XX[7]
INTERPRETATION/COMMENT: 55% of the metaphase lymph node cells
examinedhad an abnormal karyotype with the t(14;18)(q32;q21)
translocation thatFISH has confirmed has resulted in the
IGH/BCL2
gene rearrangement (seebelow) and several other chromosome
aberrations. There was no evidenceof rearrangement of the BCL6
and MYC genes. These findings areconsistent with transformation
of low grade follicular lymphoma to a higher grade.
___: Cycle 1 Rit/CHOP. Used chlortrimazole troches for
probable thrush.
___: Cycle 2 Rit/CHOP.
___: Cycle 3 Rit/CHOP. Pred tapered at end.
___: PET scan showed marked interval decrease in size and
avidity of left cervical mass. (SUV 3.3 from 14.4). Mild
residual asymmetric soft tissue fullness.
___: Cycle 4 Rit/CHOP - pred taper.
___ Cycle 5 Rit/CHOP.
PAST MEDICAL HISTORY:
-Malignant lymphoma, follicular
-Basal cell carcinoma, excised on nose
-Vaginal prolapse s/p mesh
Social History:
___
Family History:
No malignancies.
Physical Exam:
VS: 98.0 100/60 85 18 99%RA
GEN: Woman in no distress
HEENT: No scleral icterus, OP clear without lesions
NECK: No tonsillar or cervical lymphadenopathy
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes or rales
ABD: Soft, nontender, nondistended, normal bowel sounds
EXT: No ___ edema, calves symmetric, 2+ DP and ___ pulses
NEURO: Alert, oriented, interactive
Pertinent Results:
ADMISSION LABS:
___ 03:20PM BLOOD WBC-1.9* RBC-3.24* Hgb-10.1* Hct-31.0*
MCV-96 MCH-31.2 MCHC-32.6 RDW-14.8 RDWSD-51.5* Plt ___
___ 03:20PM BLOOD Neuts-42 Bands-7* ___ Monos-22*
Eos-2 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-0.93*
AbsLymp-0.48* AbsMono-0.42 AbsEos-0.04 AbsBaso-0.00*
___ 07:10AM BLOOD ___ PTT-27.3 ___
___ 03:20PM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-139
K-3.5 Cl-102 HCO3-26 AnGap-15
___ 03:20PM BLOOD ALT-31 AST-20 LD(LDH)-165 AlkPhos-90
TotBili-0.3
___ 03:20PM BLOOD Albumin-4.5 Calcium-9.6 Phos-3.2 Mg-2.0
UricAcd-4.3
___ 03:27PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-3.8*# RBC-2.90* Hgb-9.0* Hct-27.8*
MCV-96 MCH-31.0 MCHC-32.4 RDW-15.0 RDWSD-52.4* Plt ___
___ 07:10AM BLOOD Neuts-62 Bands-13* Lymphs-17* Monos-7
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-2.85 AbsLymp-0.65*
AbsMono-0.27 AbsEos-0.00* AbsBaso-0.04
___ 07:10AM BLOOD Plt Smr-LOW Plt ___
___ 07:10AM BLOOD Glucose-94 UreaN-10 Creat-0.8 Na-139
K-3.7 Cl-108 HCO3-24 AnGap-11
___ 07:10AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0
IMAGING:
CTA chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No evidence of pneumonia.
3. No lymphadenopathy.
4. Multiple hepatic hypodensities in the liver may reflect cysts
or biliary
hamartomas.
Brief Hospital Course:
___ with follicular lymphoma with aggressive features on C5D9
R/CHOP, with Neulasta on ___, presenting with severe weakness
and dyspnea on exertion, with moderate neutropenia and possible
pneumonia.
# Neutropenic Fever - ANC on admission 930, temp 99 did not
develop fever. Blood cultures sent, UA wnl, CXR at ___
concerning for pneumonia
# Weakness
# Dyspnea on exertion
The symptoms are likely due to chemotherapy. However, given
moderate neutropenia and elevated temp she was treated
empirically with IV antibiotics. UA was wnl, CT Chest did not
show infection or embolus. She remained afebrile, WBC rapidly
improved. No further indication for antibiotics.
#DOE - Likely ___ deconditioning, anemia. CT chest negative for
pneumonia, embolus or other lung abnormality. Able to walk
halls no resting or ambulatory hypoxia.
# Follicular lymphoma with aggressive features. Admitted on C5D9
of Rituxan/CHOP.
- completed prednisone taper
- She will f/u with Dr ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Lorazepam 1 mg PO Q6H:PRN nausea, anxiety, sleep
4. diclofenac sodium 1 % topical QID prn apply to site of pain
Discharge Medications:
1. diclofenac sodium 1 % topical QID prn apply to site of pain
2. Lorazepam 1 mg PO Q6H:PRN nausea, anxiety, sleep
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Shortness of breath
Neutropenic fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ - ___ was a pleasure caring for you during your
stay at ___. You were admitted with shortness of breath and
concern for fever and low white blood count as well as possible
pneumonia on chest xray. CT chest was performed which was
normal, no pneumonia or blood clot. Your white blood cell count
has improved significantly today and you do not need to continue
antibiotics.
Followup Instructions:
___
|
10560330-DS-3 | 10,560,330 | 29,617,114 | DS | 3 | 2183-12-07 00:00:00 | 2183-12-07 18:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sacral decub ulcer, UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx of advanced ___ presenting for evaluation of
large sacral decubitus ulcer initially to ___, now
transferred for surgical evaluation
of ulcer.
Patient with sacral wound which has progressively worsened over
the past several months. Per OMR notes and pt's family, pt has
been noted to be increasingly fatigued, lethargic, and anorexic.
At baseline, patient eats well and is more interactive. He was
noted to have several fevers to 101-102 which ultimately
prompted
presentation to ___ earlier today. On initial evaluation
___, pt was noted to be hemodynamically stable but
febrile.
His wound was found to be large, necrotic with possible fecal
drainage concerning for colonic fistualization. He was
empirically started on vanc/zosyn, surgery debrided his wound to
the level of fascia but noted significant undermining. Pt was
transferred to
___ for further surgical evaluation given these concerns.
In the ED, initial VS were: 99.1
76
106/53
18
99% RA
Exam notable for: foul smelling, 4x5cm decubitus ulcer with
necrotic issue overlying bone. wound tracks into left buttock
with scant brown drainage. there is no overlying fluctuanance or
cellulitis
Labs showed: WBC 16.3 (19.2 at OSH), lactate 2.9 -> 1.4 (5.7 at
OSH)
Imaging showed: CXR at OSH negative
CT A/P:
Disruption of the skin with subcutaneous stranding and foci of
air, which appears to communicate with the rectum (02:21). There
is no evidence of osseous involvement, though air and stranding
extend to the posterior sacrum (2:63). Soft tissue stranding and
air tracks along the perineum, primarily on the left side, and
into the left scrotum and subcutaneous tissues overlying the
left
pelvic wall. This raises concern for Fournier's gangrene.
Surgical consult is recommended.
Consults: Surgery - no clinical evidence of an acute surgical
issue, such as Fournier's gangrene on exam, will take to OR
tomorrow for debridement, infectious likely combination of wound
+ UTI
Patient received: Zosyn
Transfer VS were: 100.8 76
111/56
26
97% RA
On arrival to the floor, patient is unverbal. Wife at bedside
who
reports the history above. She clearly states he is DNR/DNI and
would not want an aggressive surgery. If the debridement will
entail extensive debridement than she would not want it. She
would like to have a discussion of this with her son tomorrow
before the OR.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Parkinsons disease
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.6 90 / 49 HR72RR20 96% on Ra
GENERAL: NAD, nonverbal, lying with eyes closed shut, small
frail
man
HEENT: dry MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: diffuse muscle atrophy
BACK: foul smelling, 4x5cm decubitus ulcer with necrotic issue
overlying bone. wound tracks into left buttock with scant brown
drainage. there is no overlying fluctuanance or cellulitis.
GU: Scrotum edematous, erythematous without necrosis
NEURO: unable to assess
DISCHARGE PHYSICAL EXAM:
========================
VS:24 HR Data (last updated ___ @ 916)
Temp: 98.1 (Tm 98.1), BP: 128/63, HR: 74, RR: 18, O2 sat:
99%, O2 delivery: RA
GENERAL: NAD, nonverbal, lying with eyes closed shut, small
frail
man
HEENT: dry MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: diffuse muscle atrophy
BACK: foul smelling, 4x5cm decubitus ulcer with necrotic issue
overlying bone. wound tracks into left buttock with scant brown
drainage. there is no overlying fluctuanance or cellulitis.
GU: Scrotum edematous, erythematous without necrosis
NEURO: unable to assess
Pertinent Results:
ADMISSION LABS:
==============
___ 07:50PM BLOOD WBC-16.3* RBC-2.68* Hgb-7.8* Hct-25.1*
MCV-94 MCH-29.1 MCHC-31.1* RDW-15.5 RDWSD-53.5* Plt ___
___ 07:50PM BLOOD Neuts-89* Bands-7* Lymphs-3* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-15.65*
AbsLymp-0.49* AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00*
___ 07:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-1+*
IRON STUDIES:
============
___ 08:45AM BLOOD calTIBC-96* VitB12-620 Hapto-274*
Ferritn-709* TRF-74* Iron-13*
___ 08:45AM BLOOD Ret Aut-1.1 Abs Ret-0.03
LACTATE:
========
___ 08:40PM BLOOD Lactate-2.4*
___ 12:07AM BLOOD Lactate-1.9
URINE STUDIES:
==============
___ 07:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:50PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 07:50PM URINE RBC-25* WBC-61* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 07:50PM URINE WBC Clm-RARE*
MICRO:
=======
___ 7:50 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
IMAGING:
========
___BD & PELVIS WITH CO
1. Large skin ulcer extending to the posterior sacral cortex.
Ulcers
extending to the bone often indicate osteomyelitis, but there is
no bony
erosion or aggressive appearing periosteal reaction. Soft
tissue air tracks along the ischioanal fossa, into the scrotum,
left greater than right, and into the subcutaneous tissues
overlying the left abdominal wall, presumably related to the
ulcer. Please correlate for any clinical evidence of an
aggressive soft tissue infection.
2. Diffuse anasarca.
DISCHARGE LABS:
===============
___ 08:45AM BLOOD WBC-16.7* RBC-2.85* Hgb-8.3* Hct-26.2*
MCV-92 MCH-29.1 MCHC-31.7* RDW-15.6* RDWSD-52.5* Plt ___
___ 01:13AM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-1+* Tear
Dr-OCCASIONAL
___ 08:45AM BLOOD ___ PTT-28.2 ___
___ 08:45AM BLOOD Glucose-107* UreaN-38* Creat-1.0 Na-150*
K-3.7 Cl-118* HCO3-20* AnGap-12
___ 08:45AM BLOOD LD(LDH)-140
___ 08:45AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.3 Iron-13*
___ 08:45AM BLOOD calTIBC-96* VitB12-620 Hapto-274*
Ferritn-709* TRF-74*
Brief Hospital Course:
___ w/ PMHx of advanced ___ Disease transferred for
surgical evaluation of large sacral decubitus ulcer found to
have ___ bottles GNR bacteremia, possible colonic fistulization,
and UTI on vanc/zosyn. Per ___ conversation on arrival to
medicine floor, family decided to pursue comfort measures.
ACUTE ISSUES:
=============
#Sacral decubitus ulcer (likely osteomyelitis):
#Colonic fistula
#GNR bacteremia with sepsis (WBC 15, T 100.8)
#UTI
S/p bedside debridement at OSH. Started on empiric vanc/zosyn.
Blood cultures positive for GNRs. Grossly positive UA c/f UTI.
Evaluated by ACS for debridement, although in speaking with
patient and family, this is not within goals of care.
Debridement would likely cause more pain in the short-term and
would take a long time to heal given the extensive and deep
wound to bone. Both son and wife in agreement that undergoing a
painful surgery is not something the patient would have wanted
at this point. They understand that he may die from this
infection, and have pursued comfort measures only. Pain
management with IV Dilaudid.
#Advanced ___ Disease:
#Goals of Care:
Patient is non-verbal and bedbound at baseline. As per wife,
patient has made clear he is DNR/DNI previously. Would not want
aggressive measures including surgery as above. Patient was
transitioned to CMO during this admission, with plan for
discharge to ___ in ___. He is currently NPO
given aspiration risk, although comfort feeding would also be
appropriate at this point. If family is willing to accept
aspiration risk, would recommend comfort feeding as tolerated.
TRANSITIONAL ISSUES:
====================
[ ] Patient transitioned to comfort measures only, discharge to
___ in ___
[ ] IV Dilaudid ___ Q2 PRN for pain
[ ] He is currently NPO given aspiration risk, although comfort
feeding would also be appropriate at this point. If family is
willing to accept aspiration risk, would recommend comfort
feeding as tolerated.
[ ] MOLST in chart
#CODE: DNR/DNI, CMO
#CONTACT: Next of Kin: ___
Relationship: WIFE
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. carbidopa-levodopa-entacapone ___ mg oral TID
2. LORazepam 0.5 mg PO PRN prior to MRI
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN
severe pain
RX *hydromorphone [Dilaudid] 1 mg/mL 1 by mouth every four (4)
hours Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sacral Wound ulcer
Osteomyelitis
Gram negative bacteremia
___ Disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were here for evaluation of your ulcer.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have an infection in your blood, which was
likely coming from your ulcer.
- We treated this infection initially with antibiotics.
- Our surgeons were consulted, but surgery was not within our
goals of care for Mr. ___, as this would likely increase
short-term pain and discomfort.
- Plan to go to a ___ facility and focus on comfort
measures.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10560947-DS-12 | 10,560,947 | 28,060,364 | DS | 12 | 2127-11-09 00:00:00 | 2127-11-12 22:03:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of 1 episode acute pancreatitis earlier this
year, non-functional left kidney with prior episodes of acute
renal failure, duodenal bulb ulcer, and early dementia referred
by his PCP to the ___ with his wife for abdominal pain associated
with several days of diarrhea worse than baseline, weakness,
dizziness, decreased appetite, and being more forgetful. He
describes his abdominal pain as RUQ, constant but with
intermittent spikes in severity, and with radiation to his back.
Also, acording to ___ signout, describes a ___ pound weight
loss over the past month in the setting of somewhat decreased
appetite. His pain has no association with food, including type
or timing. He denies fevers, chest pain, sob, cough, melena,
hematochezia, nausea, vomiting, or other complaints at this
time.
.
In the ___ he was found to have ___ with Cr of 3+ as well as
hyperkalemia with K of 5.7. EKG did not show any peaked T waves.
.
On arrival to the floor he has no idea why he was admitted to
the hospital but says that he hasn't eaten in several days. He
denies any pain, fevers, chills, SOD chest pain or diaphoresis.
Past Medical History:
1) prostate ca s/p prostatectomy
2) CCY at age ___
3) fem-pop bypass on L side for PVD
4) R leg fracture
5) bladder wall ca with 37 XRT tx's
6) endarterectomy of carotid artery on L, total occlusion of R
carotid artery
7) HTN
8) HL
Social History:
___
Family History:
father died of lung, stomach and colon cancer at age ___, mother
died of alzheimer's dz complications at age ___, and brother died
of alzheimer's dz complications at age ___.
Physical Exam:
Admission
Physical Exam:
Vitals: 99.7 140/62 54 18 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No astrixes
Discharge
Vitals: 97.7 166/84 70 20 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Faint heart sounds. Regular rate and rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present. Suprapubic
abdominal tenderness over his fem bypass sites, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission
___ 04:28PM BLOOD WBC-6.8 RBC-3.71* Hgb-12.3* Hct-35.4*
MCV-95 MCH-33.1* MCHC-34.7 RDW-14.4 Plt ___
___ 04:28PM BLOOD Neuts-61.3 ___ Monos-3.2 Eos-5.1*
Baso-0.9
___ 04:28PM BLOOD Plt ___
___ 09:05AM BLOOD ___ PTT-29.8 ___
___ 04:28PM BLOOD Glucose-77 UreaN-52* Creat-3.3*# Na-138
K-5.7* Cl-106 HCO3-22 AnGap-16
___ 04:28PM BLOOD ALT-14 AST-15 AlkPhos-78 TotBili-0.3
___ 04:28PM BLOOD Lipase-57
___ 04:28PM BLOOD Albumin-4.7 Calcium-9.5 Phos-5.4*# Mg-1.7
Discharge
___ 05:20AM BLOOD WBC-4.4 RBC-3.43* Hgb-11.2* Hct-33.3*
MCV-97 MCH-32.7* MCHC-33.7 RDW-14.4 Plt ___
___ 05:20AM BLOOD Plt ___
___ 10:35AM BLOOD UreaN-37* Creat-1.7* Na-143 K-4.7 Cl-111*
___ 05:20AM BLOOD Calcium-8.7 Phos-2.3* Mg-2.3
___ 09:05AM BLOOD PSA-1.7
CT PELVIS ABDOMEN
1. Examination of the pelvis is limited due to artifact from
radical prostatectomy. Within this limitation, sigmoid and left
colon diverticulosis without evidence of bowel wall thickening
or pericolonic fat stranding to suggest diverticulitis.
2. Extensive atherosclerotic arterial calcification consistent
with chronic renal disease including a 3.4 cm aneurysmal
dilatation of the infrarenal abdominal aorta. No evidence of
impending rupture.
Brief Hospital Course:
___ with history of 1 episode acute pancreatitis earlier this
year, non-functional left kidney with prior episodes of acute
renal failure, duodenal bulb ulcer, and early dementia admitted
to ___ for abdominal discomfort and ___.
# Acute renal failure: Patient was found to have elevated
creatinine on admission to 3.3. This was in the setting of
diarrhea and poor po intake. He had a CT abdomen and pelvis for
his abdominal pain that did not show any evidence of obstruction
or stone. He appeared dry on exam and was treated with
intravenous fluids with improvement in his creatine. His ACEi
was held during admission. Given that his blood pressures were
stable off his lisinopril, he was discharged with plans to hold
his lisinopril until follow up with his PCP. He should have his
electrolytes checked at that time to ensure that his creatinine
has normalized.
.
# Abdominal pain: Patient reported abdominal discomfort, nausea,
poor appetite and intermittent constipation and diarrhea for the
last few weeks. His abdominal pain was described mostly in the
RLQ and suprapubic region. His pain was inconsistently
reproducible on physical exam. His abdomen was otherwise soft
without rebound or guarding. He had a CT abdomen and pelvis
which showed no acute process. His UA was negative for
infection. His abdominal pain, nausea and diarrhea may have been
due to a viral gastroenteritis which has resolved. Stool studies
were negative for infection. Patient denied abdominal discomfort
and was able to tolerate a regular diet by time of discharge.
.
# Hyperkalemia: Likely in setting of ___. Continued to rise to
6.2. Repeat EKG showed no peaked T waves. Given albuterol nebs
and kayexalate with improvement in his K to normal range.
# Prostate Cancer: the patient has a history of prostate cancer
status post resection. In the outpatient setting his PSA has
been rising slightly over time. A repeat PSA in the hospital
showed further rise to 1.7, which should be worked up.
# Dementia: continued home medications.
.
# Gout: continued allopurinal renally dosed
.
# HLD: continued simvastatin
.
# HTN: continued anti htn meds with the exception of lisnopril
Transitional issues:
- patient was instructed to hold his lisinopril until follow up
the next week. if creatinine normalized, and blood pressure
elevated, this can be restarted
- at follow up, his electrolytes should be checked to ensure
normalization of creatinine
- rising PSA in patient with history of prostatectomy for cancer
should be evaluated
- no labs pending at time of discharge
- patient full code during this admission
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Allopurinol ___ mg PO DAILY
2. Donepezil 10 mg PO HS
3. Felodipine 15 mg PO DAILY
hold for sbp<100
4. Lisinopril 10 mg PO DAILY
hold for sbp<100
5. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp<100 or hr<50
6. pramipexole *NF* 0.25 mg Oral QHS
7. Simvastatin 10 mg PO DAILY
8. Sucralfate 1 gm PO TID
9. Zolpidem Tartrate 10 mg PO HS
hold for oversedation or rr<10
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Cyanocobalamin 500 mcg PO DAILY
13. Ranitidine 150 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Donepezil 10 mg PO HS
5. Felodipine 15 mg PO DAILY
hold for sbp<100
6. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp<100 or hr<50
7. pramipexole *NF* 0.25 mg Oral QHS
8. Simvastatin 10 mg PO DAILY
9. Sucralfate 1 gm PO TID
10. Vitamin D 1000 UNIT PO DAILY
11. Ranitidine 150 mg PO BID
12. Zolpidem Tartrate 10 mg PO HS
hold for oversedation or rr<10
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: acute kidney injury, hyperkalemia
Secondary diagnoses: Abdominal pain, Dementia, Gout,
hyperlipidemia, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted because you were having abdominal
pain and diarrhea. The etiology of your abdominal pain was not
identified, however you improved. You were also found to have
acute kidney injury and a high potassium level. This was most
likely related to not eating well and diarrhea. You were given
intravenous fluids and some medications with improvement in your
kidney function and potassium.
Also, your PSA (prostate hormone level) was checked during
admission and is higher than previous values. You should discuss
this finding with your primary doctor and your urologist.
The following changes have been made to your medication regimen:
Please HOLD your lisinopril until you follow up with your
doctor. You will need to have your blood work checked to make
sure that your electrolytes and kidney function are normalized
before restarting this medication.
Please continue taking all the rest of your medications as
directed and follow up with your doctors as ___.
Followup Instructions:
___
|
10561418-DS-12 | 10,561,418 | 29,991,254 | DS | 12 | 2158-05-30 00:00:00 | 2158-06-01 17:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___
Chief Complaint:
Chest pain s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M who presents 24 hours following
mechanical trip and fall, twisting right ankle and falling on
left arm, leg, and left side of chest. He reports having gone
home in the evening after the fall and being unable to sleep or
lie flat ___ pain and SOB. He endorses persistent left shoulder,
knee pain in addition to left chest pain which makes it
difficult
to breathe. He denies pain anywhere else. He denies fevers,
cough.
Past Medical History:
Past Medical History:
CAD
HTN
HLD
HIV
LBBB
Hyperglycemia
Gout
Anxiety
BCC
Past Surgical History:
Bilateral hip replacement
Lap appendectomy
Social History:
___
Family History:
Mother with MI. Father with PVD, aneurysm, CABG.
Physical Exam:
Admission Physical Exam:
Vitals: 97.9 87 191/89 24 92RA
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,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 98.4 PO BP: 122/70 HR: 58 RR: 16 O2: 96% RA
General: A+Ox3, NAD
CV: RRR
PULM: diminished at left lower base, otherwise CTA b/l. Normal
excursion, no crepitus.
ABD: soft, non-distended, non-tender to palpation, obese
Extremities: Warm, well-perfused b/l
Pertinent Results:
___ 08:12AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:12AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:12AM URINE MUCOUS-RARE
___ 06:05AM GLUCOSE-113* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19
___ 06:05AM WBC-8.5 RBC-5.61 HGB-14.3 HCT-45.3 MCV-81*
MCH-25.5* MCHC-31.6* RDW-17.0* RDWSD-46.6*
___ 06:05AM NEUTS-64.8 ___ MONOS-11.1 EOS-0.7*
BASOS-0.5 IM ___ AbsNeut-5.49 AbsLymp-1.90 AbsMono-0.94*
AbsEos-0.06 AbsBaso-0.04
___ 06:05AM PLT COUNT-194
IMAGING:
___: Chest (PA&LAT):
1. Low lung volumes, limiting assessment of the lung parenchyma.
However,
within these limits, no evidence of pneumothorax. Bibasilar
atelectasis,
right worse than left, though cannot exclude underlying
infection. If
clinically indicated, repeat chest radiograph with full
inspiration would be helpful.
2. Although no acute fracture or other chest wall lesion is
seen,
conventional chest radiographs are not sufficient for detection
or
characterization of most such abnormalities. If the
demonstration of trauma to the chest wall is clinically
warranted, the location of any referrable focal findings
should be clearly marked and imaged with either bone detail
radiographs or Chest CT scanning.
___: Left Elbow (PA&LAT):
Cortical irregularity along the lateral aspects of the radial
head-neck
junction, most likely representing prominent osteophytes
although a fracture is not excluded in the appropriate clinical
setting. A CT could be considered for further evaluation.
___: CXR: (PA&LAT):
Mildly worsened right basilar opacity, likely atelectasis,
pneumonitis cannot be excluded. Gastric distention
Brief Hospital Course:
Mr. ___ is a ___ M who presented to ___ 24 hours
following mechanical trip and fall. He reported persistent left
shoulder, left knee pain and left chest pain with breathing. He
had a chest x-ray which showed low lung volumes and no pleural
effusion or pneumothorax. The patient was ordered for a CT
chest to further evaluate for presence of rib fractures, but was
unable to tolerate CT imaging. Orthopaedics evaluated the
patient for his left elbow pain and saw no acute injury on
clinical exam. Orthopaedics recommended that CT chest could
help further assess the elbow, but as stated prior, the patient
could not tolerate the CT. Orthopaedics recommended a sling for
comfort and the patient was admitted to the ACS service for pain
control and pulmonary toilet.
While on the surgical floor, the patient was alert and oriented.
Pain was managed with oral oxycodone and acetaminophen with
good effect. The patient remained stable from a cardiovascular
and a pulmonary standpoint; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization. The
patient tolerated a regular diet. Intake and output were closely
monitored. The patient's fever curves were closely watched for
signs of infection, of which there were none. The patient's
blood counts were closely watched for signs of bleeding, of
which there were none. The patient received subcutaneous heparin
and ___ dyne boots were used during this stay and was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient worked with Physical
and Occupational therapy and he was cleared for home discharge.
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:
Docusate Sodium 100 mg PO/NG BID:PRN constipation
Aspirin 81 mg PO/NG DAILY
Losartan Potassium 100 mg PO/NG DAILY
Febuxostat 80 mg PO DAILY
Metoprolol Succinate XL 50 mg PO DAILY
Etravirine 200 mg PO BID
Atorvastatin 80 mg PO/NG QPM
amLODIPine 10 mg PO/NG DAILY
Citalopram 20 mg PO/NG DAILY
Raltegravir 400 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*120 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Take as needed. Available over the counter.
4. Senna 8.6 mg PO BID:PRN constipation
Take as needed. Available over the counter.
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Citalopram 20 mg PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Etravirine 200 mg PO BID
11. Febuxostat 80 mg PO DAILY
12. Losartan Potassium 100 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Raltegravir 400 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a fall. You had chest
x-rays which did not reveal any rib fractures. However, you may
still have rib fractures as these findings are best picked up on
a chest CT scan which you were unable to tolerate. You also had
an x-ray imaging of your left elbow which did not reveal any
acute fracture or dislocation. You have worked with Physical
and Occupational Therapy and are now medically cleared to be
discharged home to continue your recovery.
Please note the following discharge instructions:
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10561418-DS-13 | 10,561,418 | 29,774,968 | DS | 13 | 2158-08-31 00:00:00 | 2158-08-31 16:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Benadryl / allopurinol
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
DC cardioversion ___
History of Present Illness:
___ with history of HIV, CAD s/p silent MI, pre-operative atrial
tachycardia and DMII presenting from ___ clinic with fatigue
and dyspnea.
He presented to ___ clinic today with a four day history of
fatigue, shortness of breath and wheezing. He was concerned that
he had some kind of infection as he was feeling feverish, had a
slight cough and mild sore throat. Some of his symptoms were
improved with Tylenol. No recent travel, but was not very active
this past weekend. No swelling or leg pain.
CXR there showed enlarged cardiac silhouette with mild CHF. ECG
was showed atrial fibrillation with rates in the 130s. He was HD
stable at the time and transferred to ___ ED for further
assessment via ambulance.
In ___, he was scheduled to undergo hip surgery, but
while being prepared for induction he developed atrial
tachycardia x 20 beats with a heart rate of 130 bpm. He was
completely as symptomatic during that episodes. No additional
history of arrhythmias to his knowledge. He says he has no
history of atrial fibrillation but has had episodes in the past
of dyspnea and lethargy that feel similar to this presentation.
In the ED, initial vitals were: T98.4 89 114/90 24 96% RA.
Exam was notable for crackles at bilateral bases.
Labs notable for Hgb 13.4, pro-BNP 5034, CR 0.9 and troponin
negative x1.
CXR showed "mild to moderate cardiomegaly with mild vascular
engorgement and edema. Fullness of the right hilum is overall
similar to prior chest radiographs."
He was given: dilt PO, IV and eventually needed IV diltazem gtt.
He also was given lasix and lorazepam.
He urinated approximately 3L to the Lasix dose.
On the floor, he denied palpitations, chest pain, orthopnea,
worsened DOE, sick contacts, or headaches. He endorsed some
fatigue and subjective fevers as above. He also has recently
lost 25 lbs through a medically supervised weight loss program.
Past Medical History:
HIV on HAART, diagnosed ___ no history of complicated;
followed by ___ at ___
CAD: s/p silent myocardial infarction in RCA territory, recovery
low normal ejection fraction
LBBB on pre-op ECG prompted stress MIBI showing fixed defect
with mild partial reversibility
Moderate LVH, diastolic dysfunction
OSA on CPAP
Pulmonary hypertension
DM II, diet controlled
HTN
HLD
Obesity, morbid
Gout
Anxiety
BCC
Osteoporosis
Bilateral hip replacement in ___
Lap appendectomy
Social History:
___
Family History:
Mother died from MI. Father with PVD, aneurysm, CABGx4 and
cancer. Has sister and brother who are A&W.
Physical Exam:
ADMISSION EXAM
===============
Vital Signs: T98.2, BP 122/84, HR 101, RR 20, 92% on 2L CPAP.
General: Alert, oriented, no acute distress; habitus notable for
lipdystrophy
HEENT: Sclerae anicteric, MMM, oropharynx clear, upper and lower
dentures in place; EOMI, physiologic anisocoria (right pupil
8mm, left pupil 6mm), neck supple, JVP difficult to appreciate
but not obviously elevated
CV: Tachycardic rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Decreased at the right base, no wheezes, crackles or
rhonchi
Abdomen: Soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation; moves all extremities equally and
moves around in the bed unassisted
DISCHARGE EXAM
===============
Vitals: T=98.3 Tmax=AF HR=100-116 BP=128/68 ___ O2=95/2L
General: NAD
HEENT: clear oropharynx. cannot appreciate JVP ___ habitus
Lungs: Mild crackles in bibasilar lungs
CV: RRR, nl s1/s2
Abdomen: soft, nontender/nondistended
Ext: wwp, 1+ edema
Pertinent Results:
================
ADMISSION LABS
================
___ 05:55PM BLOOD WBC-6.4 RBC-5.33 Hgb-13.4* Hct-42.6
MCV-80* MCH-25.1* MCHC-31.5* RDW-15.9* RDWSD-44.9 Plt ___
___ 05:55PM BLOOD Neuts-54.5 ___ Monos-9.0 Eos-1.7
Baso-0.6 Im ___ AbsNeut-3.49 AbsLymp-2.18 AbsMono-0.58
AbsEos-0.11 AbsBaso-0.04
___ 05:55PM BLOOD ___ PTT-31.1 ___
___ 05:55PM BLOOD Plt ___
___ 05:55PM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-139
K-4.2 Cl-103 HCO3-24 AnGap-16
___ 05:55PM BLOOD proBNP-5034*
___ 05:55PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD cTropnT-<0.01
___ 05:55PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1
==================
DISCHARGE LABS
==================
___ 04:55AM BLOOD WBC-7.3 RBC-5.11 Hgb-13.5* Hct-41.2
MCV-81* MCH-26.4 MCHC-32.8 RDW-15.9* RDWSD-45.3 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD ___ PTT-35.2 ___
___ 04:55AM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-135
K-4.0 Cl-96 HCO3-28 AnGap-15
___ 04:55AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
=================
STUDIES
=================
Echo ___:
The left atrial volume index is severely increased. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION:
1) Low normal global LV systolic function in setting of mild to
moderate LV dilation (100 ml/m2).
2) Grade II diastolic dysfunction with elevated LVEDP and
severe ___ (52 ml/m2).
Brief Hospital Course:
SUMMARY: ___ h/o HIV, CAD s/p silent MI who presented with
dyspnea. Found to be in new atrial fibrillation with RVR with
pulmonary edema. He was diuresed with boluses of IV furosemide.
He was started on anticoagulation with rivaroxaban (anti-factor
Xa levels were checked due to high BMI and were within expected
range). He underwent a TEE and cardioversion on ___ with
conversion to sinus rhythm.
ACUTE ISSUES:
# Atrial fibrillation: First time occurrence of afib with RVR.
Initial rate control was achieved with diltiazem gtt and PO
metoprolol. He underwent a TEE and cardioversion on ___.
After the procedure he converted to a sinus rhythm. His
metoprolol was uptitrated to metoprolol succinate 75mg.
# Pulmonary edema: Patient presented with notable pulmonary
edema, likely CHF exacerbation in the setting of Afib with RVR.
He was diuresed with boluses ___ IV furosemide. He was
discharged on furosemide 20mg.
CHRONIC ISSUES:
# CAD s/p silent MI: no chest pain, no ST-T segment changes.
Continued metop, ASA81mg, statin.
# HIV: on ART with raltegravir, emtricitabine and tenofovir
alafen due to DM and osteoporosis. Does suffer from
lipodystrophy. No history of opportunistic infections. Follows
with HIV MD at ___. Has been suppressed and CD4 count last
___ was 694. Of note, he takes his medications in a
once daily manner to promote adherence, which has worked well
for him. He was given truvada rather than descovy while inhouse.
# HTN: continued home amlodipine and losartan.
# DM: diet controlled.
# OSA: continued home CPAP.
TRANSITIONAL ISSUES:
- Patient discharged on rivaroxaban 20mg daily
- Metoprolol XL uptitrated from 50mg to 75mg daily
- Patient discharged on furosemide 20mg daily
- Patient says that his insurance will expire on ___ and he
will need to establish care with a new set of doctors under
___
# Code: Full
# CONTACT: Name of health care proxy: ___
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam ___ mg PO QHS
2. LORazepam 2 mg PO DAILY
3. Ursodiol 300 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Raltegravir 800 mg PO DAILY
6. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral DAILY
7. amLODIPine 5 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Etravirine 400 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Febuxostat 80 mg PO DAILY
13. Losartan Potassium 50 mg PO DAILY
14. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Rivaroxaban 20 mg PO DINNER
Daily with the evening meal.
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Citalopram 20 mg PO DAILY
9. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral
DAILY
10. Etravirine 400 mg PO DAILY
11. Febuxostat 80 mg PO DAILY
12. LORazepam ___ mg PO QHS
13. LORazepam 2 mg PO DAILY
14. Losartan Potassium 50 mg PO DAILY
15. Raltegravir 800 mg PO DAILY
16. Ursodiol 300 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Atrial fibrillation
Acute diastolic heart failure
SECONDARY DIAGNOSIS
====================
HIV
Coronary artery disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because of a new irregular heart
rhythm called atrial fibrillation. You also had too much fluid
which made it hard to breathe. We gave you lasix to remove fluid
from your body, and performed a cardioversion to convert you
back to sinus rhythm.
After you leave the hospital:
- Please take your new medication, rivaroxaban, every day plus
furosemide
- We changed the dose of your metoprolol as well
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
10561450-DS-21 | 10,561,450 | 22,771,384 | DS | 21 | 2174-01-29 00:00:00 | 2174-02-02 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Augmentin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female who complains of ABD PAIN.
___ past medical history of hypertension presents with right
lower quadrant pain. Patient reports lack of energy and appetite
for several days. Yesterday, she began to develop crampy lower
abdominal pain and nausea. The pain is most severe in her right
lower quadrant. Today, pain improved the patient did develop
fever at home to 101. The patient has not vomited. She has no
chest pain or shortness of breath. Patient came in at ears fever
husband was concerned that she may have appendicitis. She has
not had diarrhea, black stools, bloody stools.
Past Medical History:
Low Ferritin
Hypothyroidism
L Scaphoid Fracture Managed with Casting
Social History:
___
Family History:
noncontributory
Physical Exam:
Temp: 98.2 HR: 95 BP: 128/67 Resp: 16O2 Sat: 98
Constitutional::Comfortable
Head / Eyes::Normocephalic, atraumatic
Chest/Resp::Clear to auscultation
Cardiovascular::Regular Rate and Rhythm, Normal first and second
heart sounds
GI / Abdominal::Soft, Nondistended. TTP in lower abdomen w/ pain
always radiating to RLQ. +guarding on RLQ.
GU/Flank::No costovertebral angle tenderness
Musc/Extr/Back::No cyanosis, clubbing or edema
Skin::No rash, Warm and dry
Neuro::Speech fluent
Psych::Normal mood, Normal mentation
Pertinent Results:
___ 04:40AM BLOOD WBC-10.1 RBC-4.26 Hgb-12.3 Hct-36.6
MCV-86 MCH-28.8 MCHC-33.5 RDW-12.9 Plt ___
___ 05:10AM BLOOD WBC-11.1* RBC-4.33 Hgb-12.7 Hct-37.0
MCV-85 MCH-29.3 MCHC-34.3 RDW-12.9 Plt ___
___ 01:48AM BLOOD WBC-10.1 RBC-3.94* Hgb-11.5* Hct-33.7*
MCV-86 MCH-29.2 MCHC-34.1 RDW-13.0 Plt ___
___ 04:07AM BLOOD WBC-14.2* RBC-4.48 Hgb-13.2 Hct-38.8
MCV-87 MCH-29.5 MCHC-34.1 RDW-13.0 Plt ___
___ 03:10AM BLOOD WBC-18.8*# RBC-5.06 Hgb-14.5 Hct-42.9
MCV-85 MCH-28.6 MCHC-33.8 RDW-13.0 Plt ___
___ 03:10AM BLOOD Neuts-84.2* Lymphs-8.5* Monos-6.7 Eos-0.3
Baso-0.2
___ 04:40AM BLOOD Plt ___
___ 05:10AM BLOOD Plt ___
___ 01:48AM BLOOD Plt ___
___ 01:48AM BLOOD ___ PTT-27.9 ___
___ 04:07AM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-119* UreaN-12 Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-30 AnGap-10
HCO3-27 AnGap-14
___ 04:07AM BLOOD CK(CPK)-22*
___ 03:10AM BLOOD ALT-17 AST-17 AlkPhos-57 TotBili-0.5
___ 04:07AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
Brief Hospital Course:
This is an otherwise healthy ___ year old woman who was found in
the emergency department to have acute perforated appendicitis.
She was admited to observation where she was monitored and
treated medically for her abdominal infection. No surgery was
required. She was clinically stable and responded apporpriately
to antibiotics. She was found in the hospital to have no onset
Afib with RVR. The majority of her hospital stay was spent
managing this condition. The patient had low blood pressures at
baseline. We attempted to control her Afib with metroprolol but
it caused asymptomatic hypotension in the patient and it was
held. She was started on diltizem which was able to control her
Afib. Cardiology was consulted who said warfarin was not
required for ___ CHADS of 1. She was started on daily aspirin.
She tolerated diet well and was fully ambulatory and was
clinically able to meet all of her ADLs. She was discharged on
HD7 to home to finish out a 2 week course of antibiotics.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Restasis (cycloSPORINE) 0.05 % ___ BID
2. Clotrimazole 1% Vaginal Cream 1 Appl VG HS
3. Tirosint (levothyroxine) 75-100 mcg Oral qd
4. Vivelle-Dot (estradiol) 0.1 mg/24 hr Transdermal EVERY OTHER
DAY
5. Vivelle-Dot (estradiol) 0.0375 mg/24 hr Transdermal EVERY
OTHER DAY
6. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit Oral
tid
Discharge Medications:
1. Clotrimazole 1% Vaginal Cream 1 Appl VG HS
2. Restasis (cycloSPORINE) 0.05 % ___ BID
3. Tirosint (levothyroxine) 75-100 mcg Oral qd
4. Vivelle-Dot (estradiol) 0.1 mg/24 hr Transdermal EVERY OTHER
DAY
5. Vivelle-Dot (estradiol) 0.0375 mg/24 hr TRANSDERMAL EVERY
OTHER DAY
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*16 Tablet Refills:*0
8. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 180 mg 1 capsule,extended
release 24hr(s) by mouth once a day Disp #*30 Capsule Refills:*1
9. Docusate Sodium 100 mg PO BID
10. liothyronine (bulk) 1.2 mcg PO QAM
11. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*24 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 1 TAB PO BID:PRN constipation
14. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
Oral tid
Discharge Disposition:
Home
Discharge Diagnosis:
acute perforated appendicitis
atrial fibrillation with rapid ventricular response
Discharge Condition:
Medically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for acute perforated
appendicitiis. You were treated nonoperatively. You were
started on antibiotics which you will complete a full course at
home. You were also found to have an abnormal heart rythm
called atrial fibrillation which we were able to control
medically. You were started on two medications (aspirin and
diltiazem) which you will continue to take until otherwise
directed by a cardiologist.
* Take your full course of Cipro (ciprofloxacin) and Flagyl
(metronidazole) as prescribed until the pill bottles are empty.
* Take one 325mg aspirin and one 180mg diltiazem extended
release pill daily.
* Follow up with your primary care provider within two days of
discharge.
* Follow up with cardiology (Dr. ___ within 2 days of
discharge. Call the office to make an appointment, or ask for a
referral from a cardiologist from your primary care physician.
We would ask that you make an appointment within ___ days of
discharge.
* Follow up with acute care surgery as directed below. We would
like to see you in ___ weeks. There you will discuss if further
surgery is indicated to remove your appendix.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* No strenuous activity until instructed by your surgeon.
Followup Instructions:
___
|
10561909-DS-16 | 10,561,909 | 22,435,447 | DS | 16 | 2178-01-15 00:00:00 | 2178-01-15 22:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F h/o diabetes, chronic back pain, recurrent SBO requiring
multiple surgeries who presents to the ED with hypotension after
reported fall. Admitted to ICU for monitoring of hypotension.
Pt was seen recently in the ED ___ for left wrist pain and
itching after splinted ___ from fall-related ulnar and distal
radius fractures. She had been feeling alright at home but today
felt fatigue, nausea, diffuse body aches and joint aches, with
subjective fevers at home. She had some mild headache but no
altered mental status/confusion or neck stiffness to suggest
meningitis. Patient may have had another fall last night.
.
ED course:
V/s: 97.6 109 127/74 20 95% on 2L NC. Developed fever to 102
(oral).
Pt was noted to have a nonproductive cough.
Interventions:
Pt was given morphine at 10:30 AM for total body aches. Also
given CTX, azithro, nebs for possible PNA and 2L IVF. Pt then
triggered for hypotension to 85 systolic from previous pressures
in 150s, moved from the periphery to the core and given an
additional 2L IVF NS along with vancomycin. Pt received 125mg
methylpred for wheezing. Flu swab sent. After total 4L sbp in
low-mid ___.
.
On arrival to the ICU, pt noted to be extremely somnolent which
had not been noted before. Could barely whisper her first name
and only opened her eyes for several seconds in response to
sternal rub and voice commands. Pt received 0.4mg narcan and
immediately became more alert, crying out that she was cold and
that her back was cold. Denied pain. Would not answer any
history questions other than , did not know the year. did know
that she was in the hospital and that it was ___. Pt was
also administered another liter of NS.
.
Spoke with Pts son who states that she has become increasingly
depressed although fully functional still at home. In the last
year bought a cemetery plot and whenever something happens to
her for example her recent wrist fracture she goes and visits
the plot.
.
Review of systems: unable to obtain fully, pt altered. Son saw
her day before yesterday and denies that she complained of the
following or that he noted any of the following.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
PMHx: DM, obesity, HTN, asthma, OA, jejunal divertic,
peritonitis, perforated viscus, chronic back pain, plantar
fasciitis
.
PSHx: Ex-lap/LOA, trigger finger, SBR, jujunal diverticulotomy,
TAH/BSO, tubal ligation
He surgical history began with a perforated
jejunal diverticulim in ___. Since that time she has required
multiple Exlaps, LOA for SBOs.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.5 (tylenol in ED) BP:103/52 P:83 R:21 O2: 99%RA
General: lethargic but arousable (for brief intervals) not
responding verbally appropriately, does not follow commands or
answer questions although oriented to her own name.
___ anicteric, MMM, oropharynx clear but dry mucous
membranes
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchorous breath sounds
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 10:25AM BLOOD WBC-12.1* RBC-3.84* Hgb-11.7* Hct-36.2
MCV-94 MCH-30.3 MCHC-32.2 RDW-12.9 Plt ___
___ 10:25AM BLOOD Neuts-83.8* Lymphs-6.9* Monos-5.3 Eos-3.6
Baso-0.4
___ 11:52AM BLOOD ___ PTT-28.8 ___
___ 10:25AM BLOOD Glucose-188* UreaN-12 Creat-0.7 Na-132*
K-4.3 Cl-97 HCO3-24 AnGap-15
___ 10:25AM BLOOD ALT-32 AST-43* AlkPhos-74 TotBili-0.3
___ 10:25AM BLOOD Lipase-25
___ 10:25AM BLOOD proBNP-136
___ 10:25AM BLOOD cTropnT-<0.01
___ 10:25AM BLOOD Albumin-3.9
___ 06:35PM BLOOD TSH-0.37
___ 10:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS
Barbitr-NEG Tricycl-NEG
___ 05:47PM BLOOD Type-ART pO2-109* pCO2-35 pH-7.39
calTCO2-22 Base XS--2
___ 10:28AM BLOOD Lactate-1.3
___ 01:37PM BLOOD Lactate-0.9
___ 05:47PM BLOOD Lactate-0.8 Na-137 K-3.7 Cl-108
___ 05:47PM BLOOD freeCa-1.10*
Brief Hospital Course:
___ y/o F h/o DM, multiple abdominal surgeries for SBOs, OA,
falls, presents with hypotension and fever, admitted to the FICU
for hypotension, found to have altered mental status.
#AMS - on arrival to the FICU noted to be lethargic not
responding well to commands, oriented only to name. ___
status improved with one dose of narcan, making medication
effect likely source of AMS as patient had received morphine in
ED, in addition to home morphine/oxycodone. In addition,
patient had received medications during her observation stay in
the Emergency Room just a day prior to this admission. She
insists that her chronic pain medications were not the cause of
her change in mental status and her hypotension, but rather that
the additional medications she received in the ED during her
observation stay were culprit. SHe insisted on being very
responsible regarding her medications. As medications have worn
off, patient is now awake and alert. Head CT negative for
subdural in the setting of fall. Patient was febrile in the ED,
but is now hemodynamically stable without other fevers and CXR
negative for pneumonia, making infection unlikely source of AMS.
Patient remained lucid for the remainder of the admission,
and was seen to be extremely anxious to go home.
#hypotension: Patient with hypotension to SBP ___ in the ED
(baseline SBP 110-160). BP now stable in 120s since admission
to the ICU. Given blood pressure normalized following clearance
of opioids, likely opioid-induced. No further evidence of
infection to support sepsis as etiology. Troponin x 2 negative
for evidence of cardiac ischemia. Systolic blood pressures
started to rise to 150 at the time of discharge so patient was
instructed to continue all of her home antihypertensives.
#h/o asthma
- pt was reportedly wheezy in ED. s/p 125mg solumedrol. Lungs
clear for the remainder of the admission.
#h/o anxiety - holding home diazepam in setting of AMS, but
patient was clearly anxious to be discharged from the hospital,
and insisted on repeating every detail of her history.
#h/o left wrist fracture - on long acting morphine and oxycodone
at home. in setting of AMS and lethargy/unresponsiveness, these
medications were initially held. However, these are patient's
long standing medications, so she will continue to use them, as
they have not caused lethargy or change in mental status in the
past. Vitamin D level ordered and is pending at time of
discharge.
#chronic back pain- patient to resume home medications on
discharge
Medications on Admission:
Medications: per pcp ___ ___
Medications - Prescription
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 vial inhaled four times a day as needed for
shortness of breath
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 (Two)
puffs(s)
inhaled q 4h for one month then qid as needed for as needed for
asthma - No Substitution
BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply bid twice a
day
as needed for itching
CHLOROQUINE PHOSPHATE - 250 mg Tablet - 1 Tablet(s) by mouth
twice a week
CLONIDINE - 0.1 mg Tablet - 1 Tablet(s) by mouth twice a day
CLOTRIMAZOLE - 1 % Cream - APPLY TO FEET ONCE A DAY ONCE A DAY
as
needed for FUNGAL INFECTION DISCONTINUE IF YOU EXPERIENCE ANY
ADVERSE REACTIONS OR RASHES
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth qhs prn
FLUTICASONE - 50 mcg Spray, Suspension - 1 puff(s) each nostril
twice a day for allergies/running nose
FLUTICASONE - 0.05 % Cream - apply to affected area twice a day
as needed for pruritis
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff po twice a day for asthma
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day for
swelling and blood pressure
GABAPENTIN - 600 mg Tablet - 1 Tablet(s) by mouth three times a
day for neuropathy
GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth once a day for
sugar
HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth three
times
a day as needed for itching
IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for
Nebulization - 1 vial inhaled three times a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day for
blood pressure
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth 2 q pm for
diabetes (also called GLUCOPHAGE)
MORPHINE - 30 mg Tablet Extended Release - 1 Tablet(s) by mouth
twice a day as needed for pain
OLOPATADINE [PATANOL] - 0.1 % Drops - 1 drop eqch eye twice a
day
OXYCODONE - 15 mg Tablet - 1 Tablet(s) by mouth three times a
day
as needed for pain
POLYETHYLENE GLYCOL 3350 - 17 gram Powder in Packet - 1
packet(s)
by mouth qd, as needed for hard stool
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime for
cholesterol
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day for
sadness, depression also called ZOLOFT
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for sleep
.
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for pain also called TYLENOL
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CARBAMIDE PEROXIDE - 6.5 % Drops - 3 drops(s) to right ear daily
as needed to soften ear wax
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth DAILY (Daily)
DEXTRAN 70-HYPROMELLOSE - Drops - 1 drop both eyes twice a day
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL TEARS] - Drops - 1 drop ___
four times a day as needed for eye irritation
bedtime as needed for constipation
NEOMYCIN-POLYMYXIN-PRAMOXINE [ANTIBIOTIC + PAIN RELIEF] - 0.35
%-10,000 unit-10 mg/gram Cream - apply to biopsy site tid-qid
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day for acid
POLYVINYL ALCOHOL - 1.4 % Drops - 1 ___ three times a day
SENNOSIDES [SENNA] - 8.6 mg Capsule - ___ Capsule(s) by mouth
once a day as needed for constipation - No Substitution
WHITE PETROLATUM-MINERAL OIL - Cream - pply to feet and hands
bidd as needed for dry, cracking skin
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. Patanol 0.1 % Drops Sig: 1 drop Ophthalmic twice a day: for
both eyes.
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO qhs prn as
needed for insomnia.
11. Valium 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea,
wheezing.
13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for itching.
14. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day as needed for pain.
15. oxycodone 15 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
16. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. polyethylene glycol 3350 Powder Sig: 1 pouch
Miscellaneous once a day.
18. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
three times a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sedation, hypotension, from medication effect
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 sedation and low blood
pressure, and this appears to have been caused by medications
that you received in the Emergency Room for your wrist pain.
Your blood pressures are now normal and you are in stable
condition. You may continue to take all of your home
medications.
Followup Instructions:
___
|
10561909-DS-17 | 10,561,909 | 21,458,031 | DS | 17 | 2178-01-29 00:00:00 | 2178-01-31 13:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with asthma, DM2, multiple
abdominal surgeries for SBOs after perforated jejunal
diverticulim in ___, and falls with recent Colles' fracture who
presented to the ED due to cough and dyspnea and is admitted to
the MICU due to elevated lactate.
.
Of note, she was recently admitted ___ for hypotension
after
reported fall (unclear etiology, hypotension resolved), as well
as altered mental status (presumably related to medications
received for her wrist fracture, resolved with Narcan). Of
note, on that presentation she received steroids in the ED
because she was wheezy but they were not continued. She was
initially admitted to the FICU but was transferred to the floor
and was discharged home. No elevated lactate during the
previous admission. No changes were made to her medications.
.
She reports that since discharge, she has felt quite weak. She
has had gradually worsening shortness of breath and wheezing
associted with a cough productive of white sputum. No fever but
has had chills and sweats. Non-exertional chest tightness
associated with the wheezing. Reports worsened symptoms upon
waking up in the AM. She continued using her Advair BID as well
as PRN Albuterol inhaler and nebs with minimal improvement. She
had a PCP visit to ___ her hospitalization on ___ (6 days ago)
and was started on Prednisone 20mg BID x3 days, decreased to
20mg daily three days ago (she did take it this AM). She says
that the dyspnea progressed, and today she tried taking a warm
shower to see if her symptoms got better but instead she felt as
if she was choking to death so she presented to the ED.
.
In the ED, initial VS were: T 98.2, HR 100, BP 148/66, RR 28,
POx 100% RA. On exam, she had scattered wheezes. She received
ASA and SL NTG; EKG was not concerning. Labs were notable for
WBC 15.4 (85.6% PMNs, no bands), Na 130, bicarb 16, and lactate
5.3. CXR showed no acute process. She complained of some mild
abdominal discomfort so given her h/o SBO's she underwent CT
abdomen that also showed no acute process. She received
Vanc/Zosyn, Albuterol/Ipratropium nebs, Insulin 6U for glucose
in the 300's, and Tylenol 1g PO. After 6L normal saline, repeat
lactate was 4.5 so she was admitted to the MICU.
.
On arrival to the MICU, she still feels very short of breath but
can speak in full sentences. Is worried that the Prednisone has
made her moody without helping much, and that it has made her
blood sugar out of control. Denies any fevers. No rhinorrhea
or sinus congestion. No sick contacts at home. No recent
antibiotics. She has continued left wrist pain from her
fracture. No more abdomnal pain - she says that the pain she
had in the ED was mild dull ___ pain that she thinks
was related to being hungry, as well as swallowing phlegm - and
did not feel like the pain she had during SBO's. No
constipation/obstipation. When asked if she thinks she has had
poor PO intake recently, she denies. Drinks a lot of water.
.
REVIEW OF SYSTEMS:
(+) Per HPI.
Also notable for continued back pain and left wrist pain, very
poorly controlled FSBS in the setting of Prednisone (up to
400's), continued polyuria related to her DM2 but no dysuria.
Also had mild headache related to coughing frequently but this
has resolved. Has intermittent reflux for which she takes OTC
medications, but none recently.
(-) Denies fever, recent weight loss or gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denies palpitations,
or weakness. Denies nausea, vomiting, diarrhea, constipation, or
changes in bowel habits. Denies dysuria or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
PAST MEDICAL HISTORY:
DM2 (on oral agents)
HTN
obesity
asthma
OA
jejunal diverticulitis
h/o peritonitis, perforated viscus
chronic back pain
plantar fasciitis
Colles fracture s/p fall ___
.
PAST SURGICAL HISTORY:
jujunal diverticulotomy
Ex-lap/LOA
trigger finger
SBR
TAH/BSO, tubal ligation
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.3 °F, HR 86, BP 119/87, RR 17, POx 98% RA
General: Elderly obese lady, oriented x3, no respiratory
distress (no pursed lips, she can speak in full sentences)
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse expiratory wheezes throughout all lung fields
bilaterally; no stridor; no rales or rhonchi
Abdomen: (+)bowel sounds; obese, midline scar is well-healed; no
hernia; mildly tender to very deep palpation of LLQ; otherwise
no other tenderness and no rebound
GU: foley in place, draining light yellow urine
Ext: thin, no edema, 2+ DP and ___ pulses; LUE with cast in place
Neuro: face symmetric, ___ biceps, hip flexors; finger-to-nose
intact
DISCHARGE EXAM:
Vitals: T97.9 94-114/53/60, 74-87, 98-99% RA
General: Elderly obese lady, oriented x3, no respiratory
distress (no pursed lips, she can speak in full sentences)
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse expiratory wheezes throughout all lung fields
bilaterally; no stridor; no rales or rhonchi
Abdomen: (+)bowel sounds; obese, midline scar is well-healed; no
hernia; mildly tender to very deep palpation of LLQ; otherwise
no other tenderness and no rebound
GU: foley in place, draining light yellow urine
Ext: thin, no edema, 2+ DP and ___ pulses; LUE with cast in place
Neuro: face symmetric, ___ biceps, hip flexors; finger-to-nose
intact
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-15.4* RBC-3.99* Hgb-12.3 Hct-37.6
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.4 Plt ___
___ 01:20PM BLOOD Neuts-85.6* Lymphs-7.7* Monos-3.7 Eos-2.6
Baso-0.3
___ 07:41PM BLOOD ___ PTT-23.8* ___
___ 01:20PM BLOOD Glucose-287* UreaN-27* Creat-1.0 Na-130*
K-4.8 Cl-95* HCO3-16* AnGap-24*
___ 01:20PM BLOOD ALT-25 AST-24 LD(LDH)-190 AlkPhos-67
TotBili-0.3
___ 07:41PM BLOOD Calcium-7.9* Phos-2.3* Mg-1.5*
___ 01:20PM BLOOD Albumin-4.2
___ 01:20PM BLOOD cTropnT-<0.01 proBNP-345
___ 01:22PM BLOOD Lactate-5.3*
DISCHARGE LABS
___ 05:46AM BLOOD WBC-12.9* RBC-3.36* Hgb-10.1* Hct-32.2*
MCV-96 MCH-29.9 MCHC-31.2 RDW-13.7 Plt ___
___ 05:46AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-135
K-4.9 Cl-103 HCO3-28 AnGap-9
LACTATE TREND:
___ 01:22PM BLOOD Lactate-5.3*
___ 03:35PM BLOOD Lactate-4.5*
___ 08:41PM BLOOD Lactate-2.6*
MICRO DATA:
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
EKG ___:
sinus tachycardia, rate 104, RBBB, LAD bifasicular block
(unchanged compared to prior)
.
CXR ___:
Low lung volumes. No acute intrathoracic process.
.
CT ABDOMEN/PELVIS W/CONTRAST ___ [preliminary report]:
1. No CT findings to explain patient's abdominal pain.
Post-surgical changes from prior small bowel anastomoses.
2. Diverticulosis without evidence of diverticulitis.
3. Multiple duodenal and small bowel diverticula.
Brief Hospital Course:
Ms. ___ is a ___ lady with asthma, diverticulitis
s/p SBO's with multiple abdominal surgeries, DM2 with Metformin
uptitrated last month, falls with recent Colles' fracture who
presents with continued cough/dyspnea, hyperglycemia, and
elevated lactate.
.
ACTIVE ISSUES:
.
#. SOB/wheezing: Asthma exacerbation, unclear trigger but may be
realted to seasonal allergies. She was continued on prednisone
and given nebulizers. She slowly improved. Her prednisone was
weaned down to 30 mg daily but was not weaned further because of
adrenal insufficiency (see below). She was restarted on her
other home asthma medications. her lisinopril was changed to
losartan for possibility lisinopril was contributing to
cough/wheezing.
.
#. Adrenal insufficiency: She had hypotension during this
admision as well as previous admissions. We held her prednisone
for one day and performed ___ stim test which showed that she
did not appropriately respond. We then consulted endocrinology
who recommended a very slow taper of her prednisone. She was
instructed to contine prednisone 30 mg daily for about 3 weeks
but she should follow up with endocrinology before tapering.
.
# Elevated lactate: Likely from medication and volume depletion.
She reports her metformin was recently uptitrated which may have
been contributing. Her metformin was stopped and she received
IVF and her lactate returned to normal.
.
#. Diabetes mellitus type 2: Her metformin and glipizide were
stopped on admission and she was started on insulin sliding
scale. Later her glipizide was restarted and her blood sugars
were relatively well controlled. She was instructed that she
should call her PCP if her blood sugars were high.
.
#. Hypertension, benign: She has been on lisinopil, clonidine
and lasix which were held in the setting of hypotension on
presentation (this was thought to be due, at least in part, to
adrenal insufficiency. No source of infection was identified).
She was later restarted on colidine at a lower dose and her
lisinopril was switched to losartan as above. Her lasix was not
continued on discharge.
.
INACTIVE ISSUES:
.
#. Hyperlipidemia: stable.
-continued Pravastatin
.
#. Depression: stable.
-continued Sertraline
.
#. Insomnia: stable
-continued trazodone PRN
.
#. Pain: reasonably controlled.
Pain from left Colles' fracture and chronic back pain.
-continue home Gabapentin, Morpine and PRN Oxycodone
.
TRANSITIONAL ISSUES:
-___ need insulin if blood sugars elevated on steroids and
without metformin
-Needs to be on long prednisone taper as directed by
endocrinology
-Blood cultures pending at time of discharge
-Would consider outpatient referral to Pulmonary.
Medications on Admission:
ASA 81mg daily
lisinopril 40 mg daily
clonidine 0.1 mg BID
pravastatin 40 mg daily
furosemide 20 mg daily
fluticasone-salmeterol 500-50 mcg/dose: 1 inh BID
ipratropium bromide 0.02 % neb TID
albuterol sulfate 90 mcg HFA: ___ puffs Q4H PRN
morphine 30 mg Extended Release BID PRN
oxycodone 15 mg TID PRN
gabapentin 600 mg TID
Valium 5 mg daily PRN anxiety [does not take every day]
Patanol 0.1 % 1 drop both eyes BID
metformin 500 mg: 1 tab QAM, 2 tabs QPM
glipizide 10 mg daily
sertraline 50 mg daily [but she does nto take this every day]
trazodone 50 mg QHS PRN insomnia
polyethylene glycol powder daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every eight (8) hours as needed for wheezing.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
8. morphine 15 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
9. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8
hours) as needed for pain.
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
11. diazepam 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Anxiety.
12. olopatadine 0.1 % Drops Sig: One (1) Ophthalmic BID (2
times a day).
13. glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
17. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Asthma exacerbation
Adrenal insufficiency
Lactic acidosis
Secondary Diagnoses:
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
Thank you for coming to the ___
___. You were admitted because you had an asthma
exacerbation. While here you had low blood pressure. This was
caused by a condition called adrenal insufficiency. You
developed this condition because of frequent steroid use for
your asthma. Because of this condition you will need to stay on
prednisone for a longer period of time and to follow up with an
endocrinologist. We also decreased the dose of clonidine you
were taking and stopped the furosemide. Please discuss these
changes with you primary doctor. You should also see a lung
doctor (___) for further management of your asthma.
We also stopped your metformin because you developed a condition
called lactic acidosis. Stopping this medication in addition to
starting prednisone may make your blood sugars increase. It is
important to eat a low carbohydrate diet to keep your blood
sugar controlled. If your blood sugars do rise please contact
your primary doctor. Please do not stop any medications until
you have spoken to your doctor.
Medication Recommendations
Please START:
-Prednisone 30 mg daily until your primary doctor or
endocrinologist instruct you to change this dose
-Losartan 100 mg daily
Please CHANGE:
Clonidine to 0.1 mg once daily
Please STOP:
Metformin
Lisinopril
Furosmide
Please continue taking all other medications as you have been
Followup Instructions:
___
|
10561909-DS-19 | 10,561,909 | 29,602,755 | DS | 19 | 2179-06-17 00:00:00 | 2179-06-21 21:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, dizziness, pruritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ h/o 4 exploratory laparotomies for SBO's,
diabetes, asthma, hypertension, adrenal insufficiency,
depression, pulmonary embolus, plantar fasciitis s/p two
operations, who p/w 4 week history of intermittent nausea,
abdominal pain, bloating, pruritus, and dizziness for about a
month. She states that she feels all the symptoms came on when
she started taking Coumadin, which she is taking for a history
of pulmonary embolism. On further questioning, however, she
started taking the coumadin ___ months ago, which is prior to
the onset of her symptoms. She denies any chest pain,
lightheadedness, headaches, fevers/chills.
In the ED, initial vs were: 98 86 149/80 20 97%RA. Labs were
unremarkable; CT head w/o contrast prelim showed No acute
intracranial hemorrhage. No fracture. Pt was seen by neuro in
ED, and exam did not show any CN deficit, no nystagmus,
cerebellar exams were intact; there was low suspicion for
ischemic infarction, and her light headedness was thought likely
___ poor oral intake ___ diabetic gasteroparesis, medication
that she takes for itching including hydroxyzine, and adrenal
insufficiency.
Upon arrival to the floor, VS: T 98, BP 152/95, HR 79, RR 18,
and SpO2 97. Ms. ___ complained of itching, a significant
headache, back pain, and dysuria. She indicated that she is not
feeling nauseous or dizzy and does not have abdominal pain.
Past Medical History:
ARTHRITIS
ASTHMA
BACK PAIN
CARPAL TUNNEL SYNDROME
DEPRESSION
HYPERTENSION
NOCTURNAL LEG CRAMPS
PAST SURGERY
PLANTAR FASCIITIS
PSORIASIS
RIB PAIN
COLLES' FRACTURE
? ADRENAL INSUFFICIENCY
PULMONARY EMBOLISM
COLONIC ADENOMA
OSTEOPOROSIS
Social History:
___
Family History:
Mother: HTN, CAD
Physical Exam:
Admission physical:
Vitals: T 98, BP 152/95, HR 79, RR 18, SpO2 97
General: A well-appearing Hispanic woman in mild distress from
headache.
HEENT: Normalocephalic, atraumatic, MMM
Neck: Supple
CV: RRR, no M/G/R, no elevated JVD
Lungs: Diffuse wheezing auscultated throughout lung fields.
Abdomen: Soft and non-tender, some scar tissue palpated and a
well-healed midline laparotomy scar present. Suprapubic
tenderness present.
GU: No foley
Ext: 2+ radial pulse
Neuro: Alert and oriented, full strength and ROM
Skin: No rashes noted
----------------
Discharge physical:
Vitals: T 98, BP 142/96, HR 70, RR 18, SpO2 98% on ra
General: A well-appearing Hispanic woman in no acute distress.
HEENT: Normalocephalic, atraumatic, MMM
Neck: Supple
CV: RRR, no M/G/R, no elevated JVD
Lungs: CTAB, no wheezes or crackles
Abdomen: Soft and non-tender, some scar tissue palpated and a
well-healed midline laparotomy scar present. Mild suprapubic
tenderness present.
GU: No foley
Ext: 2+ radial pulse
Neuro: Alert and oriented, full strength and ROM
Skin: No rashes noted
Pertinent Results:
Admission labs:
___ 02:50PM BLOOD WBC-9.8 RBC-4.20 Hgb-13.3 Hct-36.8 MCV-88
MCH-31.8 MCHC-36.2* RDW-12.4 Plt ___
___ 02:50PM BLOOD Neuts-71.8* Lymphs-15.0* Monos-8.2
Eos-4.6* Baso-0.4
___ 02:50PM BLOOD Plt ___
___ 02:50PM BLOOD ___ PTT-47.0* ___
___ 02:50PM BLOOD Glucose-153* UreaN-10 Creat-0.7 Na-137
K-4.6 Cl-100 HCO3-25 AnGap-17
___ 02:50PM BLOOD ALT-17 AST-27 AlkPhos-52 TotBili-0.3
___ 02:50PM BLOOD Lipase-52
___ 02:50PM BLOOD Albumin-4.2 Calcium-9.9 Phos-3.0 Mg-1.9
UA: unremarkable
Discharge labs:
___ 05:55AM BLOOD ___ PTT-46.0* ___
Imaging:
EKG ___: Sinus rhythm. Right bundle-branch block. Compared
to the previous tracing
of ___ no change
___ Head CT
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
Ms. ___ is a ___ ___ with h/o 4 exploratory
laparotomies for SBO's, diabetes, asthma, hypertension, adrenal
insufficiency, depression, pulmonary embolus, plantar fasciitis
s/p two operations, who p/w 4 week history of intermittent
nausea, abdominal pain, bloating, pruritus, and dizziness for
about a month. Also complaining of a headache and dysuria at
admission.
# Headache: Ms. ___ complained of a ___ headache upon
arrival to the floor. Her head CT was unremarkable, making
intracranial processes less likely. Symptoms most consistent
with a tension headache. She was given prn Tylenol for pain and
her bp was monitored. Her headache was resolved at the time of
discharge.
#Pruritis: Ms. ___ has diffuse pruritis in the absence of an
obvious skin rash. Ddx includes elevated bilirubin, uremia from
renal failure, and parasitemia given her elevated eosinophil
count. Elevated bilirubin and uremia less likely given normal
labs. She was prescribed Sarna lotion, fexofenadine 180 mg bid,
and mirtazapine for sleep/depression, and her symptoms improved
by discharge but were still present. She will need further
outpatient work-up.
# Abdominal pain/nausea: Ms. ___ complained of a 4-week
history of abdominal pain and nausea. Her symptoms were improved
at the time of admission and remained stable during
hospitalization. She did not require pain medications. In
addition, her UA was negative, ruling out UTI.
#Asthma: Ms. ___ did not complain of sob upon admission but
had diffuse wheezing upon exam. She was continued on her home
albuerol and Advair and her symptoms improved.
#DM: Upon hospitalization, SS insulin in place, held oral
hypoglycemics. Her home medications were restarted upon
discharge.
#HTN: Continued home losartan
#Chronic back pain: Continued lidoderm patch and tylenol
Transitional issues:
-Pt will require titration of her warfarin (was supratherapeutic
while admitted, INR 3.3 on ___. Pt to have f/u with her ___
who can manage warfarin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Januvia (sitaGLIPtin) 100 mg Oral daily
4. GlipiZIDE 10 mg PO BID
5. chloroquine phosphate 250 mg Oral daily
6. Senna 1 TAB PO BID:PRN constipation
7. HydrOXYzine ___ mg PO TID
8. Pravastatin 40 mg PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Mirtazapine 7.5 mg PO HS:PRN depression
11. Hydrocortisone 5 mg PO DAILY
12. Losartan Potassium 100 mg PO DAILY
13. Warfarin 5 mg PO 5X/WEEK (___)
14. Warfarin 7.5 mg PO 2X/WEEK (___)
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
shortness of breath
17. Lidocaine 5% Patch 1 PTCH TD DAILY PRN back pain
18. olopatadine 0.1 % ___ BID
19. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
20. Aspirin 81 mg PO DAILY
21. Simethicone 80 mg PO TID:PRN gas
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Lidocaine 5% Patch 1 PTCH TD DAILY PRN back pain
4. Losartan Potassium 100 mg PO DAILY
5. Mirtazapine 7.5 mg PO HS:PRN depression
6. Omeprazole 20 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
shortness of breath
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 5 mg PO 5X/WEEK (___)
12. Acetaminophen 650 mg PO Q4H:PRN pain
13. Fexofenadine 180 mg PO BID PRN itching
RX *fexofenadine 180 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
14. Sarna Lotion 1 Appl TP BID itching
RX *camphor-menthol Apply to areas of itch three times a day
Disp #*1 Bottle Refills:*3
15. chloroquine phosphate 250 mg Oral daily
16. GlipiZIDE 10 mg PO BID
17. Januvia (sitaGLIPtin) 100 mg Oral daily
18. olopatadine 0.1 % ___ BID
19. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
20. Simethicone 80 mg PO TID:PRN gas
21. Warfarin 7.5 mg PO 2X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Active problems:
#Headache
#Pruritis
#Abdominal pain/nausea
#Asthma
#DM
#HTN
#Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
___ for symptoms of abdominal pain, skin itching, and
dizziness. We performed a CT scan of your head, which showed
everything was normal. This means that you do not have a
persistent injury from your fall. We also gave you a new
medication, fexofenadine, to help with your itching. Your pain
resolved and you were discharged home. Please keep your
follow-up appointments upon discharge.
Your visiting nurse (___) will see you on ___
___ to check on your warfarin dose.
Followup Instructions:
___
|
10561929-DS-13 | 10,561,929 | 21,923,562 | DS | 13 | 2138-10-05 00:00:00 | 2138-10-08 19:20:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: The patient is a ___ woman with history of locally
advanced unresectable pancreatic adenocarcinoma s/p six cycles
of gemcitabine as well
as stereotactic radiotherapy/Cyberknife as of ___. She
was
hospitalized in ___ following respiratory arrest due to
hypertensive emergency and acute pulmonary edema while
undergoing
a CT scan. Over the past month she developed mahogany colored
stools along with abodminal bloating more pronounced now upon
arrival to the ___ s/p colonosocopy. She had an EGD/colonoscopy
today at ___ where the EGD was concerning for bleeding at the
CBD. She had overtly bloody stools with her movie prep but did
not have any before this. She does not report hematemesis. She
does not report chest pain. She has been feeling "OK" since her
code blue except that she has been more fatigued which she
attributes to the anemia as it improves after transfusion. She
reports chills without overt fevers. No weight loss. She has had
abdominal distension over the past month but today she has
noticed cramping and gas that prevents her from sleeping or
resting. She has not had any easy bruising or bleeding. She
does not report cough or URI sx. She has noticed some mild
hoarseness since her intubation. She has been able to eat
without difficulty. She does not report LH with standing or
dizziness. She is not on any anticoagulants except for baby
aspirin.
Her HCT was 17 at ___. 1 U PRBCS was started prior to
trasnfer.
In ER: (Triage Vitals:0 99.8 78 150/62 16 95% RA )
Meds Given: protonix 80 mg IV
Fluids given:IV with K
Radiology Studies: none
consults called: ERCP
Past Medical History:
1. History of hepatitis C virus cleared.
2. Hypertension.
3. GERD.
4. History of breast cancer status post left mastectomy in
___
no radiation or chemotherapy.
5. Status post left hip replacement in ___.
6. Status post cholecystectomy in ___ after cholecystitis.
7. Type 2 diabetes mellitus.
8. L herniorrhaphy
9. S/p L hip replacement in ___
10. S/p CCY in ___ after cholecystitis
11. Port-a-cath placed ___
12. Pancreatic adenocarcinoma s/p gemcitabine, cyberknife
Social History:
___
Family History:
Father lived to be ___ and died of old age and dementia after
breaking his hip. Father also with glaucoma. Sister at age ___
with AD in an ALF.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 99.1, 134-170/60-74, 72-87, 0.93ra
I/O - NPO + 800ivf/700urine + melanotic BM
Gen: NAD, AAOx3, comfortable and pleasant, lying in bed
HEENT: NC/AT, PERRLA, EOMI, sclera anicteric, oropharynx clear
without erythema or exudate, mucous membranes moist and pink, no
LAD
CV: mild tachycardia, normal S1 and S2, no m/r/g
Pulm: decreased breath sounds at bilateral bases, left worse
than right, dull to percussion, mild crackles
Abd: BS+, distended but soft, non-tender to palpation, no
palpable masses or hepatosplenomegaly, ___ sign negative
Rectal: deferred given presence of melanotic stool in basin
MSK: radial and dorsalis pedis pulses 2+ bilaterally, no c/c/e
Neuro: CNII-XII intact, moving all extremities, sensation
grossly intact
DISCHARGE PHYSICAL EXAM:
VS - Tc 98.5 Tm 99, BP 142/64 (110s-170s/40-60s), HR 72 (50-70s)
94% RA
I/O: 1770PO +253 IV/1550
Gen: NAD, AOx3, comfortable and pleasant, lying in bed
HEENT: NC/AT, EOMI, sclera anicteric, oropharynx clear without
erythema or exudate, mucous membranes moist and pink
CV: RRR, no m/r/g
Pulm: CTAB
Abd: Soft, mildly distended, non-tender to palpation, no
palpable masses.
Extremities: Trace pitting edema in lower extremities b/l. 1+
pitting edema in L arm (pt s/p mastectomy).
Neuro: CNII-XII intact, moving all extremities, sensation
grossly intact
Pertinent Results:
ADMISSION LABS:
___ 04:15PM GLUCOSE-75 UREA N-19 CREAT-0.7 SODIUM-145
POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-25 ANION GAP-11
___ 04:15PM estGFR-Using this
___ 04:15PM WBC-4.6 RBC-2.15* HGB-6.4* HCT-19.7* MCV-92
MCH-29.7 MCHC-32.4 RDW-16.2*
___ 04:15PM NEUTS-74.8* LYMPHS-15.7* MONOS-6.8 EOS-2.3
BASOS-0.4
___ 04:15PM PLT COUNT-269
___ 04:15PM ___ TO PTT-UNABLE TO ___
TO
Esophagogastroduodenoscopy.
___
DESCRIPTION OF PROCEDURE: The endoscope was advanced under
direct visualization. The esophagus appeared normal. View of
the stomach was normal. No gastritis or ulcers seen. There was
no blood in the stomach. View of the duodenum showed active
oozing of bright red blood from the second portion of the
duodenum at what appeared to be the ampullary region. No
obvious ulcer or Dieulafoy's lesion or AVM seen. There were
fresh red blood clots in that region. There was blood staining
in the duodenum distally but no obvious distal duodenal lesions.
Photographs were included in the hospital chart. The patient
tolerated the procedure well.
IMPRESSION: Active bleed from second portion of duodenum, rule
out bleeding from the ampulla or above and the pancreatic
biliary system.
Colonoscopy ___:
DESCRIPTION OF PROCEDURE: The endoscope was advanced to the
cecum. Ileocecal valve identified. Dark red stool was seen in
the cecum as well. No obvious obstructing lesion seen, although
vision compromised as above.
IMPRESSION: GI bleed, likely from upper source. Plans as
above.
___
KUB: ___ Reviewed images with radiology. Gaseous
distention of predominantly the large bowel, with air seen in
the rectum. No evidence of bowel obstruction or free air.
Metallic biliary stent in place.
DISCHARGE LABS:
___ 12:36PM BLOOD WBC-5.1 RBC-3.16* Hgb-9.6* Hct-29.5*
MCV-93 MCH-30.3 MCHC-32.5 RDW-15.1 Plt ___
___ 06:00AM BLOOD Glucose-210* UreaN-16 Creat-1.0 Na-140
K-3.6 Cl-106 HCO3-31 AnGap-7*
___ 06:00AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.8
Brief Hospital Course:
Mrs ___ is a ___ yo female with unresectable locally advanced
pancreatic adenocarcinoma s/p 6 cycles gemcitabine and
CyberKnife in ___, admitted from ___ with an
upper GI bleed seen on EGD. Transfused 1 unit of PRBCs at OSH,
and one unit ___ on arrival. Hct 19.7 was on arrival, rose to
25.6 at next draw. Pt underwent ERCP, which showed friable
mucosa with oozing at ampulla, intially unclear whether this was
scope trauma or primary bleed. Balloon extraction of CBD did not
reveal any bleeding or clots. Tagged RBC scan showed active
bleeding in epigastrum, possibly ampulla of Vater. Pt underwent
___ angiography and embolization on ___. Hct rose to ___ s/p
transfusion of 1 unit PRBCs and embolization, diet advanced. Hct
___ 26.8, raising concern, but recheck came back at 30 and
Hct remained essentially stable until discharge, varying around
a mean of ~ 30. Hospital course complicated by new Afib with
RVR, asymptomatic w/ stable VS, responding to diltiazem. Cause
was judged likely dehydration, as pt had been kept NPO with
fluids only cautiously administered (she was at risk for
hemodynamic instability given previous acute pulmonary edema and
respiratory arrest the prior month). Pt converted to sinus
rhythm after lasix was held and gentle fluid resuscitation was
initiated w/ po intake encouraged. Her diltiazem was changed
back to her home dose of labetolol at discharge. She was
discharged in stable condition on a decreased dose of home lasix
(120 mg daily, down from 200 mg), with close PCP, cardiology and
oncology follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Furosemide 200 mg PO DAILY
3. NPH 12 Units Breakfast
NPH 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Labetalol 400 mg PO BID
5. Lisinopril 20 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Labetalol 400 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Furosemide 120 mg PO DAILY
RX *furosemide 40 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. NPH 12 Units Breakfast
NPH 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Upper GI bleed
Atrial fibrillation with RVR
Secondary Diagnoses:
Pancreatic cancer
Pleural effusion
Chronic diastolic heart failure
Diabetes Mellitus
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 during your stay at ___.
You were admitted with low blood counts, and found to have
bleeding in your gastrointestinal tract. The bleeding vessel was
embolized, and your blood counts are now stable.
You also developed atrial fibrillation briefly during your
hospitalization. Your lasix was held temporarily and then
decreased in dose. Please weigh yourself every morning, and
call your MD if weight goes up more than 3 lbs.
Followup Instructions:
___
|
10561929-DS-14 | 10,561,929 | 25,466,468 | DS | 14 | 2141-10-26 00:00:00 | 2141-10-26 15:50:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Crestor
Attending: ___
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with previously treated locally advanced unresectable
pancreatic adenocarcinoma newly metastatic to bone planned to
reinitiate gemcitabine treatment today ___ who presents with
R flank pain.
In the ED, initial VS were 98.4 66 152/68 18 100% RA.
Labs notable for Chem-7 with BUN/Cr 40/1.1, CBC within patient's
baseline with H/H 10.5/32.3, LFTs with ALT 129 AST 104 AP 785
Tbili 0.5 Alb 4.0, UA with few bacteria and small ___ (neg
nitrites). CT A/P w/ con showed "known osseous metastasis with
acute T12 pathological fracture with posterior soft tissue
component and associated spinal canal narrowing likely the cause
of worsening right flank pain" otherwise stable changes. CXR
also showing T12 compression fracture but otherwise without
acute fracture. The patient is now admitted to OMED for further
treatment and management. VS prior to transfer 98.7 69 152/73 17
100% RA.
On arrival to the floor, patient reports feeling comfortable.
She notes that she had been having intermittent back pain, or
"back colds," for the past several months after her hip
replacement. These episodes of pain were relieved with hot
packs and Tylenol. Two days ago, however, patient noticed R
sided back pain similar in nature to her "back colds" but of
much worse severity. She took Tylenol and rested all day
yesterday with no relief and decided to present to the ___ for
further evaluation.
She denies recent f/c/n/v/d. She reports 2 days of constipation,
however, which is very atypical for her. No dysuria or changes
in urinary frequency or volume. No numbness/tingling.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Initially presented in ___ with painless jaundice and
hyperglycemia. CT performed at ___ identified a
pancreatic head mass measuring 2.4 x 2.8 cm. She was taken to
the operating room on ___ for attempted resection;
however, intraoperatively the tumor stained unresectable.
Biopsy of gastroduodenal retroperitoneal lymph node was positive
for adenocarcinoma. Ms. ___ began gemcitabine chemotherapy on
___. This was dose reduced to 800 mg/m2 with cycle
#1 due to neutropenia. She was treated with CyberKnife
stereotactic body radiotherapy, which completed ___.
Six cycles of gemcitabine completed ___. CA ___
rose in ___ and PET-CT ___ identified bone lesions.
Biopsy confirmed recurrent metastatic mucinous pancreatic
adenocarcinoma.
PAST MEDICAL HISTORY:
1. History of hepatitis C virus cleared.
2. Hypertension.
3. GERD.
4. History of breast cancer status post left mastectomy in
___
no radiation or chemotherapy.
5. Status post left hip replacement in ___.
6. Status post cholecystectomy in ___ after cholecystitis.
7. Type 2 diabetes mellitus.
8. L herniorrhaphy
9. S/p L hip replacement in ___
10. S/p CCY in ___ after cholecystitis
11. Port-a-cath placed ___
12. Pancreatic adenocarcinoma s/p gemcitabine, cyberknife
Social History:
___
Family History:
Father lived to be ___ and died of old age and dementia after
breaking his hip. Father also with glaucoma. Sister at age ___
with AD in an ALF.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.5 140/70 73 18 98RA 123.6lb
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, slightly tacky mucosal membranes
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4; R chest
with port, no overlying erythema
LUNG: clear to auscultation, no wheezes or rhonchi
MSK: no point tenderness over spine; R lower back mildly TTP
(patient reports tenderness is much better s/p morphine and pain
meds)
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: grossly intact, sensation intact throughout, moving all
extremities
SKIN: Warm and dry, without rashes
DISCHARGE PHYSICAL EXAM
VS: 98.1 122/60 65 16 96RA
GENERAL: NAD, sitting up in chair in LSO
CARDIAC: RRR, normal S1 S2, R chest with port, no overlying
erythema
LUNG: clear, no wheezes or rhonchi
ABD: +BS, distended but soft, NT; neg ___
EXT: nonedematous
PULSES: 2+DP pulses bilaterally
NEURO: grossly intact, sensation intact throughout, moving all
extremities
SKIN: Warm and dry, without rashes
Pertinent Results:
ADMISSION LABS
==============
___ 10:25AM BLOOD WBC-6.7 RBC-3.60* Hgb-10.5* Hct-32.3*
MCV-90 MCH-29.2 MCHC-32.5 RDW-15.2 RDWSD-50.3* Plt ___
___ 10:25AM BLOOD Neuts-85.4* Lymphs-8.0* Monos-5.1
Eos-0.5* Baso-0.5 Im ___ AbsNeut-5.70 AbsLymp-0.53*
AbsMono-0.34 AbsEos-0.03* AbsBaso-0.03
___ 05:30AM BLOOD ___ PTT-34.1 ___
___ 10:25AM BLOOD Glucose-215* UreaN-40* Creat-1.1 Na-139
K-4.1 Cl-104 HCO3-21* AnGap-18
___ 10:25AM BLOOD ALT-129* AST-104* AlkPhos-785*
TotBili-0.5
___ 10:25AM BLOOD Lipase-7
___ 10:25AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.7 Mg-2.2
___ 10:25AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:25AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 10:25AM URINE RBC-3* WBC-5 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
___ 10:25AM URINE CastHy-3*
___ 10:25AM URINE Mucous-RARE
DISCHARGE LABS
==============
___ 06:15AM BLOOD WBC-4.4 RBC-2.70* Hgb-8.1* Hct-25.1*
MCV-93 MCH-30.0 MCHC-32.3 RDW-15.0 RDWSD-50.4* Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-144* UreaN-49* Creat-1.0 Na-141
K-4.6 Cl-108 HCO3-26 AnGap-12
___ 06:15AM BLOOD ALT-50* AST-49* LD(LDH)-224 AlkPhos-775*
TotBili-0.4
___ 06:15AM BLOOD GGT-450*
___ 06:15AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.5
MICRO
=====
___ 10:25 am URINE CLEAN CATCH.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======
___ MR Spine:
1. Multilevel degenerative changes throughout the cervical
spine as described above, heterogeneous signal is noted at C6
vertebral body, suggestive of metastatic disease. No focal or
diffuse lesions are noted within the cervical spinal cord.
2. Multilevel degenerative changes and heterogeneous signal is
noted in the bone marrow, more significant at T3, T5, T6 and T8
vertebral bodies, consistent with metastatic disease.
Compression fracture with retropulsion identified at T12
vertebral body, causing anterior thecal sac deformity with no
evidence of cord compression, related with metastatic disease.
3. Multilevel multifactorial degenerative changes throughout
the lumbar spine as described above, more significant from L1/L2
through L3/L4 levels. There is mild retrolisthesis at L1 upon
L2 level, likely degenerative in nature. Perineural cyst is
identified at S2 level in the sacrum.
___ CT Abd/Pelvis w/ con: 1. Known osseous metastasis with
acute T12 pathological fracture with posterior soft tissue
component and associated spinal canal narrowing likely the cause
of worsening right flank pain. 2. CBD stent with stable degree
of intrahepatic biliary ductal dilation in this patient with
known pancreatic cancer. Similar overall pattern of periportal
and portacaval lymphadenopathy.
___ CXR: T12 compression deformity, with progressive loss
of vertebral body height. No evidence of pneumonia or edema.
Port-A-Cath appropriately positioned.
Brief Hospital Course:
___ with previously treated locally advanced unresectable
pancreatic adenocarcinoma newly metastatic to bone who presented
with R flank pain.
#R flank pain: ___ be ___ T12 pathological fracture with spinal
canal narrowing as seen on imaging (see results). No renal path
suggested on CT A/P. No UTI on UA. Spine MR revealing areas c/f
instability. Pain control was achieved with standing Tylenol,
oxycodone and morphine PRN for breakthrough; at rest, patient
had minimal discomfort. Neuro recommended using an LSO brace
when OOB; patient tolerated this well, although her pain was
aggravated with any activity. While in hospital, she was
started on XRT to the lesion of her T12 spine. She received her
___ of 5 XRT treatments on the day of discharge. Her last
session is scheduled for ___ at 1:45PM. Prior to discharge,
seen by ___ who recommended, discharge home with ___.
Patient ambulating in LSO brace with pain moderately well
controlled. ___ need further uptitration of pain medication.
#metastatic pancreatic adenocarcinoma: Was originally scheduled
to reinitiate gemcitabine today, but was admitted for R flank
pain. Continued chemotherapy to be discussed as an outpatient;
patient scheduled for follow up with her primary oncologist for
___.
#alk phos elevation: Could be hepatic vs from metastatic lesions
in bone. GGT showing that alk-phos elevations are due to both
liver and bone--both of which are involved in patient's
malignant process.
#pancreatic insufficiency: ___ adenocarcinoma. Continued home
creon with meals.
#constipation: Likely ___ pain medication use. Resolved with
aggressive bowel regimen including bisacodyl PO/PR, docusate,
senna, miralax. Occasionally c/o gas pains which were relieved
(at least in part) with simethicone.
#CHF, chronic diastolic: Stable. No issues. Continued home Lasix
40mg QD.
#diabetes, type II: Continued home NPH 14u in AM, 3u in ___.
Placed on HISS during hospitalization.
#HTN: Stable. Continued on home lisinopril 20.
#CAD: Followed closely by cards as outpatient. Continued home
pravastatin 20mg, lisinopril 20mg, and baby ASA.
#GERD: Stable. Continued home pantoprazole.
TRANSITIONAL ISSUES
===================
- Planned for total 5 sessions of XRT; s/p 4 in hospital, last
session ___ at 1:45PM
- Patient to wear LSO when out of bed
NEW MEDICATIONS
++Pain Regimen
Acetaminophen 500 mg PO Q6H
OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Lidocaine patch
++Bowel Regimen
Bisacodyl 10 mg PR QHS
Senna 8.6 mg PO BID
Docusate Sodium 200 mg PO BID
Polyethylene Glycol 17 g PO DAILY
CODE: Full
COMMUNICATION: Patient
EMERGENCY CONTACT HCP:
Name of health care proxy: ___
Relationship: Lawyer/ Friend
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. NPH 14 Units Breakfast
NPH 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Creon ___ CAP PO TID W/MEALS
4. Lisinopril 40 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 20 mg PO QPM
7. Acetaminophen 325 mg PO PRN arthritis pain
8. Vitamin D 1000 UNIT PO DAILY
9. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
Dose is Unknown Unknown oral Unknown
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours (4
times a day) Disp #*60 Tablet Refills:*0
2. Creon ___ CAP PO TID W/MEALS
3. Furosemide 40 mg PO DAILY
4. NPH 14 Units Breakfast
NPH 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 40 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Vitamin D 1000 UNIT PO DAILY
8. Bisacodyl 10 mg PR QHS
RX *bisacodyl 10 mg 1 suppository(s) rectally at bedtime Disp
#*14 Suppository Refills:*0
9. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth Every 12 hours
(2 times a day) Disp #*30 Capsule Refills:*0
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed for pain Disp #*90 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
Please hold if you have loose stools or more than 2 bowel
movements per day.
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
12. Senna 8.6 mg PO BID
Please discontinue if you have loose or frequent stools.
RX *sennosides 8.6 mg 1 tablet by mouth Every 12 hours (2 times
a day) Disp #*30 Tablet Refills:*0
13. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
Dose is Unknown ORAL Frequency is Unknown
14. Pravastatin 20 mg PO QPM
15. Outpatient Physical Therapy
16. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) 1 patch to R back/abdominal
pain region every morning Disp #*15 Patch Refills:*0
17. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 1 tablet by mouth 4 times a day as needed
for gas pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Acute T12 compression fracture
SECONDARY:
Metastatic pancreatic adenocarcinoma
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, Independent, LSO brace when out of
bed
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___ for worsening L flank pain. You
underwent several imaging studies that showed you have
metastatic lesions in your spine. These lesions are likely the
cause of your pain. You were seen by Neurosurgery and the
Radiation-Oncologists who felt that you would best be treated
with local radiation treatment to the lesions in the spine. They
also recommended that you keep on a back brace for whenever you
are out of bed.
While you were here, you underwent the first few treatments with
us in the hospital, which you appeared to tolerate well.
Prior to discharge, you were seen by physical therapy; they felt
you would be safe at home with adequate pain control. Please
continue to take your pain medications as prescribed. As these
pain medications can cause severe constipation, it is very
important you also continue taking your bowel medications. As
you are regaining your strength, visiting nurses and physical
therapy ___ visit you at home
We wish you the very best,
Your ___ Oncology Team
Followup Instructions:
___
|
10562117-DS-11 | 10,562,117 | 27,123,903 | DS | 11 | 2186-07-23 00:00:00 | 2186-07-23 20:33:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left-sided facial droop, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking female, was at home when she was
incontinent of urine and stool and developed a left sidedfacial
droop at approximately 9 pm on ___. Her son called ___ when she
started to complain of dizziness. After being taken to ___
___, a NCHCT was done which showed a large cerebellar bleed.
She was started on Nicardipine for a systolic in the 200's and
transferred, intubated, to ___. On arrival here, her blood
pressure management continued to be an issue.
Past Medical History:
HTN
DM2
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAMINATION:
Sedated and intubated; examined while off sedation
(prop/fent) for 20 minutes
Vitals: T: afebrile, 80, 130/60s on nicardipine gtt (initially
230s)
General: intubated, appears stated age
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Opens eyes to light touch, does not follow
commands, makes gutteral sounds through tube, nods yes/no but
indistinctly
-Cranial Nerves: left pupil 1.5>1, right pupil post-surgical;
left forced gaze deviation, eyes do not cross midline, negative
VOR, + corneals, + cough, + gag, ? left NLFF with symmetric
grimace
-Sensorimotor: Normal bulk and tone
RUE: localizes to pain
LUE: localizes to pain
RLE: withdraws
LLE: withdraws
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute.
-___, Gait: could not assess
=================
DISCHARGE EXAMINATION:
General: sleepy, arouses to voice but does not like to open eyes
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, nontender and ___ placement site is
clean with no exudates or erythema
Extremities: symmetric, warm, distal pulses palpable, no edema
Neurologic:
-Mental Status: Awakens to voice. Oriented to self and son. Able
to follow simple commands (open eyes, stick out tongue, raise
arms) when family gives instructions in ___. Mumbles often
incoherently with likely dysarthria.
-Cranial Nerves: R eye is surgical 2mm, pupils minimally
reactive to light. Slight left NLFF. No tongue deviation, shrugs
shoulders antigravity.
-Motor: Able to move all extremities easily antigravity.
Purposeful movements with bilateral upper extremities, and good
strength grossly ___ in both with resistance to examiner,
though patient cannot fully cooperate in confrontational
strength testing. No focal weakness noted.
-Sensory: Withdraws all extremities to light touch.
-Coordination/gait: Requires assistance for ambulation due to
deconditioning.
Pertinent Results:
LABORATORY TESTING
==================
___ 12:14AM BLOOD WBC-10.2* RBC-3.89* Hgb-11.6 Hct-35.2
MCV-91 MCH-29.8 MCHC-33.0 RDW-12.8 RDWSD-42.2 Plt ___
___ 01:44AM BLOOD ___ PTT-27.0 ___
___ 12:14AM BLOOD Glucose-253* UreaN-21* Creat-0.7 Na-134*
K-4.2 Cl-93* HCO3-26 AnGap-15
___ 12:14AM BLOOD ALT-14 AST-23 AlkPhos-70 TotBili-0.5
___ 12:14AM BLOOD Lipase-54
___ 02:08PM BLOOD Calcium-8.9 Phos-3.7 Mg-2.3
___ 2:34 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
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
DISCHARGE LABS:
___ 05:20AM BLOOD WBC-10.1* RBC-2.81* Hgb-8.5* Hct-27.0*
MCV-96 MCH-30.2 MCHC-31.5* RDW-14.3 RDWSD-47.8* Plt ___
___ 04:57AM BLOOD ___ PTT-26.7 ___
___ 05:20AM BLOOD Glucose-89 UreaN-18 Creat-0.6 Na-149*
K-4.0 Cl-116* HCO3-23 AnGap-10
___ 05:20AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7
IMAGING
=======
___ 12:13 AM CTA HEAD AND CTA NECK
1. Large right cerebellar intraparenchymal hemorrhage with
intraparenchymal extension and slight extension to the left
cerebellum.
2. Prominence of the ventricles in the setting of
intraventricular blood and posterior mass effect on the fourth
ventricle by the hematoma raises concern for possible
obstructive hydrocephalus.
3. Evidence of small 1-2 mm infundibula at the carotid termini.
4. Mild-to-moderate irregularity/narrowing of the bilateral MCA
M1 segments
(left greater than right).
5. Otherwise, no evidence of aneurysm, dissection occlusion head
neck. No
significant ICA stenosis by NASCET criteria.
6. Mild white matter small vessel disease.
7. Generalized parenchymal volume loss, likely age related.
8. Status post intubation with the endotracheal tube terminating
at the level of the carina. Consider retracting the
endotracheal tube by approximately 2-3 cm.
___ 8:06 AM CT HEAD W/O CONTRAST
1. Stable large acute cerebellar hematoma. Similar volume of
intraventricular hemorrhage, with some redistribution. Small
volume subarachnoid hemorrhage, likely from redistribution.
2. Nearly completely effaced fourth ventricle, prepontine
cistern, superior cerebellar cistern. Temporal horns are
prominent, may be from generalized moderate atrophy or early
hydrocephalus, follow-up recommended.
3. There is suggestion of arteriovenous shunting with early
opacification of the straight sinus on comparison CTA, consider
underlying vascular
malformation.
___ 2:08 ___ CT HEAD W/O CONTRAST
1. Increasing size of the ventricular system, consistent with
hydrocephalus. Stable intraventricular, subarachnoid hemorrhage.
2. Large cerebellar parenchymal acute hematoma, slightly
increased along the superomedial margin, otherwise stable.
Underlying structural abnormality, including vascular
malformation cannot be excluded.
3. Stable surrounding edema, significant mass effect within
posterior fossa, with nearly completely obliterated fourth
ventricle, prepontine cistern, completely effaced superior
cerebellar cistern. No tonsillar herniation.
___ 8:05 AM CT HEAD W/O CONTRAST
1. No significant change.
2. Stable large cerebellar parenchymal bleed, surrounding edema,
significant mass-effect in the posterior fossa, compression of
the brainstem, mild hydrocephalus.
3. Stable small volume intraventricular, subarachnoid
hemorrhage.
4. No tonsillar herniation.
___ 7:37 AM PORTABLE HEAD CT W/O CONTRAST
1. No significant change. No new bleeding.
2. Stable large cerebellar parenchymal hemorrhage with
surrounding edema
significant mass effect in the posterior fossa, brainstem
compression and mild hydrocephalus.
3. Stable small intraventricular and subarachnoid hemorrhage.
4. No gross herniation.
___ 6:28 ___ CT HEAD W/O CONTRAST
1. No significant interval change in a 4.6 x 4.3 cm right
cerebellar
parenchymal hematoma with extension into the left cerebellum,
and mass effect on the right quadrigeminal plate cistern and
fourth ventricle.
2. No significant interval change in subarachnoid, subdural, and
intraventricular hemorrhage, as described above.
3. No new hemorrhage.
___ 9:48 AM CT HEAD W/O CONTRAST
1. Unchanged 4.6 cm posterior fossa parenchymal hemorrhage,
predominantly
centered in the right cerebellar hemisphere. Additional mild
multi
compartment hemorrhage is also unchanged.
2. No new intracranial hemorrhage. No acute large territory
infarct.
3. No interval change in ventricular size.
4. Additional findings described above.
Brief Hospital Course:
Ms. ___ is an ___ ___ woman with PMH
notable for HTN, HLD, and ___ transferred from ___
after presenting with left-sided facial weakness and dizziness,
found to have a right cerebellar nontraumatic intraparenchymal
hemorrhage with intraventricular extension and cerebral edema.
Etiology consistent with HTN induced hemorrhagic stroke.
ICU COURSE:
Ms. ___ was evaluated by Neurosurgery in the ED, who did not
recommend surgical intervention. She was successfully extubated
following admission to the Neurosciences ICU, and her blood
pressures were initially managed with a nicardipine infusion,
which was subsequently transitioned to as-needed labetalol. Her
cerebral edema was managed with infusion of 3% saline, following
which repeat CT scans demonstrated stable hematoma size and
subtle interval progression of hydrocephalus. Her ICU course was
notable for a brief episode of atrial fibrillation with rapid
ventricular response, with her subsequent rates well-managed on
labetalol. Anticoagulation was held in the setting of her
intraparenchymal hemorrhage. She completed a course of
ceftriaxone for a K. pneumoniae urinary tract infection during
her admission.
Stroke Floor Course:
Ms. ___ was transferred from the Neuro ICU to the floor on ___.
#HYPERTENSION: Pt continued to have high BP. Her BP was
initially managed with labetalol 200mg q6h and hydralazine
___ prn with SBP goal <150. She continued to have high BP
and her home medications metoprolol and losartan were started in
addition to labetalol. Amlodipine was added on ___ and
uptitrated to 10 mg daily. She continued to have elevated blood
pressures, systolic blood pressures 110s to 150s.
#INTRACEREBRAL HEMORRHAGE: Her cerebral edema was managed with
3% saline infusion with Na/Osm goal ___. Her serum
Na/Osm levels remained within goal and 3% saline was
discontinued on ___. Sodium was kept elevated 150-155 with fluid
restriction, until allowed to liberalize on ___, without
concerns for brain edema. CT scan on ___ demonstrated stable
hematoma size with no acute changes. Her neuro exam improved
with resolution of left gaze preference and left facial droop
with intact BUE/BLE strength and sensory.
#DELIRIUM: Her mental status was notable for continuous delirium
and restlessness. While she did follow commands with her
daughter at bedside, she was not oriented to time or place and
was inattentive. She was given QUEtiapine 12.5 mg prn for
agitation. Delirium improved throughout admission.
#ARRHYTHMIA: While in the ICU, patient had single period of
irregular rhythm, and was not clearly felt to be atrial
fibrillation. She was kept on telemetry during admission and did
not have further episodes of arrhythmia. Given unclear atrial
fibrillation and risk for intracerebral bleeding, decision was
made to not start anticoagulation.
#TYPE 2 DIABETES: Her serum glucose levels were poorly
controlled and ___ was consulted. Per ___ recommendation,
pt was switched from NPH (8 units bid) to lantus (14 units qd)
and regular insulin (5 units q6h). On ___ lantus reduced to 10
units qd with discontinuation of regular insulin dose for ___
tube placement.
#NUTRITION/ASPIRATION: Due to failing swallow test, she was
initially kept NPO and given tube feeds with Glucerna 1.2 @
50cc/hour. ___ was placed on ___ by ACS, and feeds resumed 24
hours later.
#THRUSH: Nystatin 5ml qid given. Started on ___.
====================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
=====================
Transitional issues:
- Adjust insulin regimen as patient will reach full feeds on
___ (currently on reduced insulin).
- Patient needs titration to home diabetes regimen (medications
held during admission)
- Please titrate antihypertensives.
- Patient discharged with ___, can be discontinued when patient
reassessed and if able to take adequate nutrition by mouth.
- Aspirin held due to intracerebral hemorrhage. If patient has
indication for ASA, it can be restarted in 2 weeks, however ASA
should not be given for primary prevention as she has risk for
bleeding.
- Brief episode of irregular heart rate noted in the ICU,
possible atrial fibrillation. Please discuss with neurology
regarding anti-coagulation should patient have recurrent
episodes.
- Please follow up with ___ Diabetes, Neurology, and PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pioglitazone 15 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. GlipiZIDE 10 mg PO QAM
4. GlipiZIDE 5 mg PO QPM
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
7. Omeprazole 20 mg PO BID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Losartan Potassium 100 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Aspirin 81 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
14. Atorvastatin 10 mg PO QD
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Glargine 10 Units Dinner<br> Regular 2 Units Q6H
Insulin SC Sliding Scale using REG Insulin
3. Labetalol 200 mg PO Q6H
4. Nystatin Oral Suspension 5 mL PO QID Duration: 14 Days
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
6. Atorvastatin 10 mg PO QD
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Losartan Potassium 100 mg PO DAILY
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
12. Omeprazole 20 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Vitamin D 400 UNIT PO DAILY
15. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until evaluated by physician for indication
for aspirin (patient should not take ASA for prevention due to
bleeding)
16. HELD- GlipiZIDE 10 mg PO QAM This medication was held. Do
not restart GlipiZIDE until instructed by your doctor ___ dose
10mg qAM, 5mg qPM)
17. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until instructed
by your doctor
18. HELD- Pioglitazone 15 mg PO DAILY This medication was held.
Do not restart Pioglitazone until instructed by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Hemorrhagic Stroke
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 due to symptoms of dizziness and facial
weakness resulting from an ACUTE HEMORRHAGIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is disrupted due to bleeding. The brain is the part of your body
that controls and directs all the other parts of your body, so
damage to the brain from being deprived of its blood supply can
result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high blood pressure
diabetes
We are changing your medications as follows:
We temporarily stopped your diabetes medication (metformin,
pioglitazone, glipizide) and started insulin instead. This can
be transitioned back with advice from your doctor.
Please start taking amlodipine and labetalol for blood
pressure (in addition to home losartan and metoprolol)
Please take nystatin (total 14 days) for thrush, it was
started on ___.
Please stop taking aspirin.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, 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:
___
|
10562117-DS-13 | 10,562,117 | 27,925,679 | DS | 13 | 2186-08-20 00:00:00 | 2186-08-21 00:08:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin / clindamycin / Statins-Hmg-Coa Reductase
Inhibitors / ACE Inhibitors / valsartan
Attending: ___.
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ F h/o recent hemorrhagic stroke
in ___, HTN, HLD, and T2DM, admitted 1 week ago with
respiratory distress due to PE, aspiration, and pleural
effusions, course also notable for MSSA UTI treated with ___nd delirium, after which she was discharged to a
nursing facility and presented to the emergency room today after
multiple episodes of BRBPR, accompanied by lower abdominal pain.
Her daughter ___ states that she had been doing well in
rehab. Her mental status was slowly improving, and she felt that
she was about 40% back to her baseline after the initial insult
of her stroke in ___, with 75% improvement in her speech.
She also notes that although she has been taking stool softeners
at rehab, her stool output has not been consistent. She notes
that the blood per rectum began 2 nights ago, after what
appeared to be a large, hard, brown bowel movement. Several
similar episodes occurred in the subsequent ___ hours as well.
She also notes that the patient seemed more fatigued with lower
energy yesterday and was found to have orthostatic hypotension
(although concomitant supine hypertension). She has been on
Lovenox for her PE and has been on continuous tube feeds while
at rehab.
After the patient was admitted to the floor the case was
discussed with GI, with primary concern being bleed related to
large fecal ball, potentially from stercoral ulcer. After
initially failing an enema, she underwent bedside manual
disimpaction with removal of large amount of stool. Stool brown
with small amount of bright red blood coating.
ROS: As per HPI, and 10 point ROS completed and otherwise
negative. (obtained from patient and daughter together)
Past Medical History:
HTN
HLD
T2DM
Cerebellar hemorrhagic stroke w/ subsequent dysphagia and PEG
Social History:
___
Family History:
Not pertinent to current presentation with BRBPR
Physical Exam:
-Vitals: reviewed, tmax 98.1F, HR 61-66, BP 106/58-169/56
-General: NAD, laying comfortably in bed
-HEENT: atraumatic, normocephalic, moist mucus membranes, PERRL,
EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present, PEG
-GU: no foley, no CVA/suprapubic tenderness
-MSK: No pedal edema, no joint swelling
-Skin: No rashes, ulcerations, or jaundice
-Neuro: no focal neurological deficits, somnolent
Pertinent Results:
ADMISSION LABS
___ 12:01AM BLOOD WBC-4.9 RBC-3.00* Hgb-8.8* Hct-28.2*
MCV-94 MCH-29.3 MCHC-31.2* RDW-14.2 RDWSD-47.3* Plt ___
___ 12:01AM BLOOD Neuts-59.0 ___ Monos-10.7
Eos-7.6* Baso-0.4 Im ___ AbsNeut-2.88 AbsLymp-1.07*
AbsMono-0.52 AbsEos-0.37 AbsBaso-0.02
___ 12:01AM BLOOD ___ PTT-39.1* ___
___ 12:01AM BLOOD Glucose-154* UreaN-20 Creat-0.7 Na-141
K-4.3 Cl-101 HCO3-28 AnGap-12
___ 12:01AM BLOOD ALT-16 AST-31 AlkPhos-84 TotBili-0.3
___ 12:01AM BLOOD Albumin-3.0*
___ 07:08AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
___ 01:42AM BLOOD Lactate-1.3
DISCHARGE LABS
___ 07:00AM BLOOD WBC-3.8* RBC-2.96* Hgb-8.6* Hct-27.3*
MCV-92 MCH-29.1 MCHC-31.5* RDW-13.7 RDWSD-45.8 Plt ___
___ 07:00AM BLOOD Glucose-110* UreaN-10 Na-143 K-3.6 Cl-104
HCO3-27 AnGap-12
___ 07:08AM BLOOD TSH-5.0*
___ 07:00AM BLOOD Free T4-1.4
___ 07:10AM BLOOD T4-7.8 T3-75*
IMAGING/STUDIES
-CT Abdomen/pelvis w/ contrast ___: 1. Relative thickening of
the stomach in the region of the pylorus, difficult to exclude
mild inflammation and clinical correlation is advised. 2. Severe
fecal loading in the rectum.
Brief Hospital Course:
___ year old ___ F h/o recent hemorrhagic
cerebellar stroke ___ w/ residual dysphagia s/p PEG &
dysarthria complicated by provoked DVT/PE presented from rehab
with BRBPR due to stercoral ulcer w/ severe constipation s/p
manual disimpaction.
1. Bright red blood per rectum due to stercoral ulcer w/ severe
constipation
-Constipation noted on CT abdomen/pelvis s/p manual
disimpaction continued on aggressive bowel regimen with
resolution of constipation. Bowel regimen was increased from
prior to admission w/ goal of 1 loose bowel movement per day.
As per GI no further intervention needed and okay to resume
anticoagulation, and lovenox resumed ___ w/out any further
bleeding.
2. Acute encephalopathy h/o mild cognitive impairment s/p CVA
-Acute encephalopathy likely multifactorial in setting of
constiation, hospital acquired delirium, and language barrier.
Continue trazodone, seroquel, and ramelteon.
3. Orthostatic hypotension h/o HTN
-On admission SBP up to 190 but also with orthostatic
hypotension. Overall blood pressure improved/stabalized with IV
fluids continued on home antihypertensives (losartan,
amlodipine, labetalol). Patient's daughter noted labile blood
pressures at rehab. It is imperative to avoid hypertension
given recent hemorrhagic stroke but also complications from
hypotension and will need to continue to monitor closely.
4. Hypokalemia
-Replete and monitor.
5. ?Pyloric thickening on CT
-Unclear significance w/ low suspicion this is playing a role in
current presentation. GI does not recommend clear role for H
pylori testing at this point and risk of EGD likely outweigh
benefit.
6. Pleural effusions
-Suspect some improvement based on CT read and stable
respiratory status. Monitor respiratory status closely in
setting of IV fluids. Follow-up as planned in ___ clinic.
7. Elevated TSH
-TSH slightly elevated at 5.0 with free T4 within normal limits.
Elevate TSH may be fine given patient's age but want to avoid
hypothyroid given severe constipation and would continue
following outpatient.
CHRONIC MEDICAL PROBLEMS
1. DVT/PE: continue lovenox and monitor for bleeding.
2. DM: continue lantus and SSI.
3. GERD: continue pantoprazole
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 10 mg PO QHS
4. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
5. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN shortness of
breath
6. Labetalol 600 mg PO TID
7. Enoxaparin Sodium 60 mg SC Q12H
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Losartan Potassium 100 mg PO DAILY
10. Senna 17.2 mg PO QHS
11. Vitamin D 400 UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Docusate Sodium 100 mg PO Q12H
14. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
15. melatonin 5 mg oral QHS
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Omeprazole 20 mg PO BREAKFAST
18. TraZODone 50 mg PO QHS
19. Nystatin Oral Suspension 5 mL PO QID
20. QUEtiapine Fumarate 12.5 mg PO QHS please give early in the
evening
21. QUEtiapine Fumarate 12.5 mg PO QHS:PRN agitation
22. insulin regular human 3 U inhalation Q6H
23. Lantus Solostar U-100 Insulin (insulin glargine) 18 U
subcutaneous QPM
24. HumaLOG KwikPen Insulin (insulin lispro) ___ subcutaneous
Q6H:PRN
25. Sorbitol 30 ml Gtube QPM PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe constipation with stercoral ulcer
Bright red blood per rectum
Pulmonary Embolism
Hemorrhagic stroke
Dysphagia with PEG
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. ___,
You were admitted with bleeding per rectum found to have severe
constipation with an ulcer in the colon as the cause of
bleeding. You were manually disimpacted with manual removal of
stool from your rectum and started on aggressive medications
with resolution of your constipation. You will need to continue
these medications at discharge to prevent further constipation
from occurring.
It was a pleasure taking care of you.
-Your ___ team.
Followup Instructions:
___
|
10562293-DS-20 | 10,562,293 | 20,258,287 | DS | 20 | 2141-12-20 00:00:00 | 2142-01-05 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Penicillins / Bactrim / Reglan / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female who complains of right
lower quadrant pain. She states that this pain started
approximately 2 weeks ago when she was on a trip in ___. She
was seen at the time by an MD and diagnosed with a UTI and was
started on Levaquin. She finished her last dose yesterday and
since that time she has been having worsening pain. She states
the pain has always been in the RLQ and is sharp and worse when
she lifts her right leg straight off the bed or when she is
walking. No radiation. Has not had this previously. Of note,
states that she has never had any urinary symptoms even though
she was treated for a UTI. Has had on and off fevers, chills,
and sweats. Today, was seen at urgent care and sent for a CT
scan of the A/P, which revealed a ruptured appendicitis with
focal free air, and was sent to the ED for evaluation.
Past Medical History:
--stage I(T1bN0Mx) grade II left breast invasive ductal
carcinoma, ER/PR positive, Her 2/neu negative
--s/p bilateral mastectomy on adjuvant chemo with taxotere and
cytoxan
--Graves disease s/p PTU
--Graves ophthalmopathy s/p surgical correction ___
--Allergic rhinitis
--Migraines
--Anxiety
Social History:
___
Family History:
Her mother was diagnosed with DCIS at age ___ and treated with
lumpectomy and radiation therapy in ___, ___. A
maternal aunt was diagnosed with DCIS while premenopausal; she
had negative BRCA1-2 testing according to the patient. The
patient is of mixed Western European ethnic descent.
Physical Exam:
PHYSICAL EXAMINATION
Temp: 98.3 HR: 90 BP: 115/77 Resp: 18 O(2)Sat: 100 Normal
Constitutional: awake, alert, anxious, obvious pain
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, moderate to severe tenderness with
involuntary guarding to the RLQ, + psoas sign
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, CN II-XII intact, MAE
Psych: Normal mentation, Normal mood
Discharge Physical Exam:
VS: VSS, afebrile
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
RLQ
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
___ 05:50AM BLOOD WBC-8.3 RBC-2.92* Hgb-9.6* Hct-28.4*
MCV-97 MCH-32.8* MCHC-33.7 RDW-12.4 Plt ___
___ 01:10PM BLOOD WBC-8.0# RBC-3.50* Hgb-11.3* Hct-34.6*
MCV-99* MCH-32.4* MCHC-32.7 RDW-12.2 Plt ___
___ 05:50AM BLOOD Glucose-67* UreaN-8 Creat-0.6 Na-137
K-3.5 Cl-102 HCO3-22 AnGap-17
___ 01:10PM BLOOD ALT-5 AST-14 AlkPhos-48 TotBili-0.3
___ 05:54PM BLOOD Lactate-1.3
ABD/PELVIC CT
1. Ruptured appendicitis with a complex collection of
phlegmonous change,
fluid and air in the right lower quadrant. The fluid component
is minimal
comparatively to the surrounding inflammatory changes.
2. Up to 2.7 cm right adnexal cyst, within normal limits if the
patient is
premenopausal however the patient is postmenopausal this should
be further
evaluated with an ultrasound.
Brief Hospital Course:
___ with hx of breast ca s/p resection/chemo, on tamoxifen, now
with RLQ pain for ___emonstrating a complex
phelgmonous change in the RLQ with minimal fluid component,
presumed perforated appendicitis although appendix was not able
to be clearly identified. The patient was hemodynamically stable
and admitted to the ___ service for serial abdominal exams, IV
fluids and IV antibiotics.
On HD#2, the patient was feeling better and the her abdominal
exam was improved. The diet was progressively advanced to
regular. When tolerating a diet, the patient was converted to
oral antibiotics and pain medication with continued good effect.
The patient was voiding without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services,
with a 2-week course of cipro/flagyl.. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. She had a
follow-up appointment in the ___ clinic in two weeks to discuss
interval appendectomy.
Medications on Admission:
venlafaxine [Effexor XR], fluticasone [Flonase], albuterol
sulfate [ProAir HFA], tamoxifen
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
do not drink alcohol or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
5. Tamoxifen Citrate 20 mg PO DAILY
6. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
You were admitted to ___ with abdominal pain and were found to
have a perforated appendix on CT scan. You were managed with
bowel rest and IV antibiotics. Your pain has improved and your
diet has slowly been advanced. You are now tolerating a regular
diet and on oral antibiotics. You are ready to be discharged
home to continue your recovery . You will need to follow-up in
the ___ clinic at the appointment listed below in 2 weeks to
discuss having an interval appendectomy, once the inflammation
has subsided. Please complete the 2-week course of antibiotics.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10562309-DS-5 | 10,562,309 | 29,741,810 | DS | 5 | 2160-04-08 00:00:00 | 2160-04-09 19:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
lightheadedness, pre-syncope
Major Surgical or Invasive Procedure:
Coronary catheterization
History of Present Illness:
A ___ year old female with PMH anxiety/depression and ETOH abuse
(quit 4 months ago) is admitted for presyncope. She reports that
she was at award ceremony on the day of admission and that
people have been verbally abusive towards her and that made her
feel quite nervous though she reports feeling mild anxiety prior
to going to the ceremoy. She was brought to the hallway by her
friends where she drank orange juice and didn't feel much
improvement. She did not lose consciousness. She stated that
these symptoms are different from her anxiety episodes. EMS was
called and by report found her hypotensive to SBP 88 with HR
90's, and transferred her to ___ for evaluation.
.
In the ED, initial vitals were 98 81/58 28 100%, she was
tachypenic, diaphoretic and triggered for hypotension. EKG
showed LBBB with no prior for comparision. Labs were significant
for Trop-T: <0.01 Bicarb 20, K 3.0, Mg 1.8, Cr 1.6 (baseline 1)
with an anion gap of 20 and positive ketones in the urine.
Finger stick glucose was 170. WBC 11.3 with 74% PMN. Serum drug
screen was negative for ETOH and Acetaminophen. CXR was
negative. Patient given She was given 1L IVNS with Blood
pressure returning to 140/86. She was also given 40meq
potassium, Mag 2g, Thiamine 100mg and admitted to the ___ service. Vitals on transfer were 97.5po 77 140/86 20
100% ra.
.
Following admission patient anion gap closed to 7, Creatinine
normalized to 0.9. Early on the morning of transfer to the
cardiology service, she had 20 beat run of VTach, repeat cardiac
enzymes showed CK: 104 MB: 11 MBI: 10.6 Trop-T: 0.14. Repeat
EKG showed NSR with TWI in V1, V2, V3 and flat T wave in V4 (V3
and V4 changes new compared to old EKG), LBBB was no longer
apparent. Cardiology was consulted and accepted the patient for
acute coronary syndrome. Patient was given Aspirin 325 mg,
Atorvastatin 80 mg, Metoprolol Tartrate 12.5 mg PO/NG BID, and
started on heparin drip. She was not plavix loaded.
.
She stated that there was a possible MI ___ year ago, but it was
not confirmed. She denied current or prior history of dsypnea
whether on excertion or at rest, no PND or orthopnea or leg
swelling or palpitation. No history of stroke,ITA, DVT, PE or GI
bleed.
.
By report, PCP was contacted who confirmed that she has had
LBBB on prior EKG however no EKGS were faxed over. EKG from ___
___ ___ showed NSR with TWI in V1-V2, no LBBB, read of ekg
stated "LBBB no longer present".
.
Of note she was admited to ___ ___ for syncope with
facial trauma. EKG showed new LBBB. She had an ECHO which was
normal and was taken for persantine MIBI stress test which
showed no significant reversible perfusion defects and LEVF of
60%.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Depression
Anxiety
Alcohol abuse
HTN
Insomnia
Social History:
___
Family History:
father - lung cancer
Physical Exam:
VS: 98.5 127/88 84P 18 97%RA
Appearance: alert, anxious appearing, tremulous (pt states is
baseline), obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, ___ SEM at LUSB, no peripheral edema, 2+ dp/pt
bilaterally
Pulm: clear bilaterally
Abd: soft, obese, nt, nd, +bs
Msk: ___ strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn ___ grossly intact, no pronator drift, normal
finger-to-nose and heel-to-shin, downgoing toes, 2+ UE reflexes
b/l, 3+ patellar reflexes bilaterally
Skin: no rashes
Psych: appropriate, pleasant, anxious appearing
Heme: no cervical ___: guaiac negative with brown stool
Pertinent Results:
CBC and coagulation profile:
___ 07:40PM WBC-11.3* RBC-4.75 HGB-14.2 HCT-41.4 MCV-87
MCH-29.9 MCHC-34.3 RDW-12.7
___ 07:40PM NEUTS-74.5* ___ MONOS-4.2 EOS-1.5
BASOS-0.4
___ 07:10AM BLOOD WBC-6.0 RBC-3.78* Hgb-11.0* Hct-33.2*
MCV-88 MCH-29.2 MCHC-33.3 RDW-13.0 Plt ___
.
Blood chemistry:.
----------------
___ 07:40PM GLUCOSE-129* UREA N-21* CREAT-1.6* SODIUM-135
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-20* ANION GAP-23*
___ 07:40PM ALT(SGPT)-43* AST(SGOT)-35 LD(LDH)-208 ALK
PHOS-90 TOT BILI-0.6
___ 07:40PM LIPASE-34
___ 07:40PM ALBUMIN-4.7 CALCIUM-10.4* PHOSPHATE-3.4
MAGNESIUM-1.8
___ 07:40PM OSMOLAL-285
___ 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Cardiac markers:
----------------
___ 07:40PM cTropnT-<0.01
___ 04:20AM BLOOD CK-MB-11* MB Indx-10.6* cTropnT-0.14*
___ 10:30AM BLOOD CK-MB-9 cTropnT-0.11*
___ 04:20PM BLOOD CK-MB-7 cTropnT-0.07*
.
Urine:
------
___ 10:05PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
.
CXR:
----
___ CXR: reviewed by me; radiology read:
Within limitations of low lung volumes, no definite acute
pulmonary process identified.
.
EKG:
----
___ EKG: LBBB - old per PCP (present in ___ EKG: normal axis and rhythm, rate 67, no LBBB, new TWI
in V3 and flat T wave in V4 not present on prior EKG
.
PCP ___:
------------
___ electrolytes within normal limits, anion gap 15,
creatinine 1.0, wt 185 lbs
.
___ TTE per PCP:
EF 65%, mild LVH, LV outflow tract obstruction with 17 mmhg with
valsalva
Cultures:
---------
___ Urine culture : no growth
___ Blood culture: pending
.
Coronary Catheterization ___:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically apparent, flow-limiting
coronary artery
disease. The LMCA, LAD, LCx, and RCA were all normal in
appearence.
2. Left ventriculogram demonstrated normal LV systolic
function.
3. Limited resting hemodynamics revealed normal systemic blood
pressure
of 137/22 mmHg. There was elevated left ventricular filling
pressures,
with an LVEDP of 22 mmHg. There was no transvalvular gradient
to
suggest aortic stenosis.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal Left ventricular systolic function.
3. Moderatly elevated left ventricular filling pressures.
.
Echo ___:
-----
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with more prominent hypertrophy of the
basal septal segments. Left ventricular cavity size is smalll.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a moderate resting left ventricular outflow tract obstruction
(36 mmHg), which increased with the Valsalva manuever (57 mmHg).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is systolic anterior motion of the mitral valve
leaflets. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Concentric left ventricular hypertrophy with small
cavity size and moderate functional LVOT obstruction.
Hyperdynamic LV systolic function. Low estimated intracardiac
fililng pressures. Mild mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of ___, LVOT obstruction may be new, although
the prior study was reportedly limited. If clinically
appropriate, consider repeating a focused echocardiogram
following volume repletion.
Brief Hospital Course:
___ year old woman with depression, anxiety and history of
alcohol abuse was admitted after presyncopal event and found to
have multiple lab abnormalities including ketoacidosis,
hypokalemia and acute renal failure. She had cardiac
catheterization given concerning EKG changes with elevated
troponins which showed normal coronary vessels. Echo showed
hypertrophic cardiomyopathy of elderly. She is encouraged to
maintain adequate hydration and discharged in stable condition
with follow up appointments.
.
#Presyncope: hypotensive by EMS and at triage that was fluid
responsive suggests hypovolemic etiology of presyncope vs
vasovagal; lack of focal neurological deficits makes primary CNS
event unlikely; history not consistent with seizure; there was
initial concern for cardiac origin (she has LBBB that seemed
rate dependent) given new EKG changes (T wave inversion in V3
and flat T wave in V4 that were not present on prior EKGs). She
was in sinus rhythm and she did not complain of chest discomfort
or shortness of breath during her stay. She had 20 beats of NSVT
per telemetry which made it necessary for her to be transferred
to inpatient cardiology service. However, this can be a real
NSVT or anxiety related tachycardia with LBBB looking like NSVT.
Otherwise, she was in sinus rhythm. There was no coronary artery
disease on cardiac catehterization (please see results). ECHO
was pursued which showed hypertrophic cardiomyopathy of the
elderly in which part of the septum is hypertrophic and causes
obstruction when patient is dehydrated. She was discharged with
instructions to maintain adequate hydration and to get a new
cardiologist.
.
# Psychiatric issues: She has history of alcohol abuse but
reports stopping drinking for the last 4 months. Also had
history of valium abuse in the distant past per patient which
was used to treat her anxiety. During her stay, she was very
tearful and anxious expressing some paranoid ideations about the
staff. She was reassured and also was evaluated by social worker
who recommended some therapists and the patient seemed
receptive. She will be seeing Dr ___ soon who is aware
of her situation. The patient did not seem unsafe to follow up
as outpatient.
.
#Ketoacidosis: likely starvation ketoacidosis given rapid weight
loss (per PCP ___ 185 lbs on ___ now ___ lbs (pt reports 20
+ lbs wt loss since stopping alcohol); diabetic unlikely given
no previous diagnosis and glucose < 200; alcoholic ketoacidosis
also unlikely if patient truthful about not drinking (serum
ethanol negative); osmolar gap negative for other ingestions;
serum toxicology was negative. She received thiamine and folate
during her stay with good hydration. Her gap
closed.
.
#Acute renal failure: likely prerenal azotemia due to poor oral
intake. Received IV fluids and renal function improved.
Lisinopril was held in the setting of worsening kidney function.
.
#Leukocytosis: Resolved. Afebrile. It was likely acute phase
reactant, no signs or symptoms of infection. Urine culture
showed no growth. CXR no signs of infection. Antibiotics were
not administered possibility of infection was low.
.
#Depression/anxiety: We continued home fluoxetine 40 mg once
daily. Social worker followed her during her stay as above. She
will follow up with psychiatry as outpatient.
.
FULL CODE
Emergency contact: ___ (wife) ___
Email sent to PCP ___ not current PCP,
___ PCP) and sent letter
Medications on Admission:
Prozac 40 mg daily
Lunesta 3mg qhs
Lisinopril unknown dose
Discharge Medications:
1. metoprolol succinate 25 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*
2. eszopiclone 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertrophic cardiomyopathy of the elderly
.
Secondary: Anxiety, Depression, Acute renal failure (pre-renal)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
As you know, you were admitted to the ___
___ after nearly fainting. We examined the arteries
that supply blood to the heart and did not find any blockages.
We performed an ultrasound of the heart which showed that a part
of your heart is slightly larger than it should be which can
cause decreased blood flow when you are dehydrated. We believe
that this is the reason that you nearly fainted. We recommend
that you maintain adequate hydration, especially on warm days or
in warm environments. We recommend that you are seen by a
cardiologist please see your primary care provider for ___
recommendation for a new cardiologist.
.
Medication changes:
START Metoprolol
START Aspirin 81mg daily
Continue your previous medications as before the hospital stay.
Continue to take all of your other medications as directed
Followup Instructions:
___
|
10562506-DS-11 | 10,562,506 | 29,674,456 | DS | 11 | 2162-05-24 00:00:00 | 2162-05-25 16:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhrea, stomach pain
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ with history of COPD, RA, Crohns disease, fibromyalgia, now
presenting for evaluation of chronic diarrrhea and abdominal
pain from GI clinic.
She has had longstanding diarrhea and abdominal pain which she
reports is debilitating. Typically if she needs to be in public,
she will reduce PO intake for 2 days in order to attempt to
reduce the volume of her diarrhea. She wears adult diapers as
well as pads at baseline. She notes that she has had issues with
her bowels since her first pregnancy decades ago. In terms of
her crohn's history, she was diagnosed ___ years ago and has
undergone abdominal surgeries either for post-polypectomy bleed
from the colonoscopy that diagnosed the crohn's, or for a "touch
of cancer" that the patient reports. In fact, she had 5
surgeries ___ year ago within 5 weeks at ___ for a variety
of reasons (surgical reports in paper chart). She is unsure what
her abdominal anatomy is like now.
Three days ago she had acute worsening of diarrhea. She had over
a dozen watery stools. This was accompanied by chills and sweats
as well as low grade fevers. She also had RLQ abdominal swelling
and pain. Also had nausea with bilious vomiting. Reports being
unable to maintain PO intake during this time, was drinking
minimal fluids. These symptoms improved after about 2 days. She
describes this as typical of a Crohns flare for her, but the
flares can last up to 2 months at time. She is unable to
quantify how many days in a month she is symptomatic, but
endorses having diarrhea "all the time".
Today she is feeling better, and has had 3 watery bowel
movements which is a considerable improvement for her. Of note,
no recent abx usage. Notably, no vomiting today either.
As noted above, she was seen in our GI clinic for the first time
today, and was referred to the ED for further evaluation and
management. In the ED, initial vitals were: 98.1 91 161/77 15
98%RA. Exam notable to dry mucus membranes and skin turgor.
Abdominal exam notable for mild TTP in RLQ, no rebound/guarding.
Patient produced thin loose brown/yellow stool while in the ED.
No blood or melena. Initial labs notable for normal CBC,
unremarkable electrolyte panel. LFTs notable only for mildly
elevated AlkP. KUB without evidence of obstruction. CRP 5.0. GI
was consulted and recommended the patient remain NPO, IVF and
admit to medicine for possible MRE vs colonoscopy.
Past Medical History:
COPD (O2 at night)
RA
Crohns disease
Fibromyalgia
Hypothyroidism
GERD
s/p cholecystectomy
s/p appendectomy
s/p hysterectomy
s/p joint replacements (hips and knees)
restless leg syndrome
seizure disorder
OA
neuropathy
?h/o ovarian cancer
Social History:
___
Family History:
FAMILY HISTORY: Her mother had ___ disease, multiple
myeloma, and heart disease. Her father died at ___ with heart
disease and stroke. Her brother died at ___ with an aneurysm
causing motor vehicle accident. He had a history of seizures at
___ years old. She has a ___ daughter with seizures after
a motor vehicle accident and two sons. Nobody has neuropathy.
Physical Exam:
PHYSICAL EXAM:
Vitals: T99.1, BP 170/80, HR 83, RR 20, 96/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, slightly tender to palpation, RLQ>rest of the
abdomen, non-distended, bowel sounds hypoactive, no
organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Fingers and toes with deformity noted c/w known RA. Hands
appear to potentially have jacoud's arthropathy.
Neuro: ___ strength throughout the LEs. Sensation intact ___.
otherwise MAE.
Discharge:
PHYSICAL EXAM: 97.7 152/79 62 18 98RA
Vitals: RGeneral: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, slightly tender to palpation, RLQ>rest of the
abdomen, non-distended, bowel sounds present, no organomegaly,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: ___ strength throughout the LEs. Sensation intact ___.
otherwise MAE.
Pertinent Results:
Admission:
___ 03:46PM GLUCOSE-106* UREA N-12 CREAT-0.6 SODIUM-142
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 03:46PM estGFR-Using this
___ 03:46PM ALT(SGPT)-29 AST(SGOT)-25 ALK PHOS-135* TOT
BILI-0.3
___ 03:46PM LIPASE-10
___ 03:46PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
___ 03:46PM CRP-5.0
___ 03:46PM WBC-6.2 RBC-4.55 HGB-13.4 HCT-40.3 MCV-89
MCH-29.6 MCHC-33.3 RDW-14.3
___ 03:46PM NEUTS-68.4 ___ MONOS-4.6 EOS-2.6
BASOS-0.5
___ 03:46PM PLT COUNT-271
Final Report
EXAMINATION: MR ___
INDICATION: ___ year old woman with Crohns with multiple ABD
surgeries and
unclear history. // Elucidate her anatomy, evaluate for
stricture, fistula,
and evaluate severity of her Crohns.
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen
and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic
sequences performed
prior to, during, and following the administration of 0.1
mmol/kg of Gadavist
intravenous contrast (7 cc). Oral contrast consisted of 900 mL
of VoLumen. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: CT from ___.
FINDINGS:
MR ENTEROGRAPHY:
The patient is status post right hemicolectomy. The ileocolic
anastomosis
appears normal, without wall thickening. The caliber and
appearance of the the
rest of the bowel is normal. There are no abnormally dilated or
strictured
segments. The bowel wall has normal thickness and enhancement.
Bowel
motility is normal. Small hiatal hernia is present
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Visualized portions of the liver have homogeneous signal and
enhancement. No
focal liver lesions are seen. The portal and hepatic veins are
patent. There
is no intra or extra-hepatic biliary dilatation. The
gallbladder is
surgically absent. The intra and extrahepatic biliary ducts are
normal in
caliber.
There is atrophy of the pancreatic parenchyma, without
dilatation of the main
pancreatic duct and without focal lesions.
The spleen is normal in size.
There are subcentimeter cortical renal cysts bilaterally.
The adrenals are normal.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The bladder is normal. The uterus is surgically absent.
Artifacts from bilateral hip prostheses limit evaluation of the
pelvis.
No concerning osseous lesions are seen.
IMPRESSION:
Status post right hemicolectomy. No evidence of acute or chronic
bowel
inflammation.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on SAT ___
9:31 AM
Imaging Lab
COLONOSCOPY ___
Findings:
Protruding Lesions A single sessile 3 mm polyp of benign
appearance was found in the rectum. A single-piece polypectomy
was performed using a cold forceps in the rectum. The polyp was
completely removed.
Other Evidence of right colectomy/ileocecectomy with ileocolic
anastamosis was seen. The anastamosis appeared normal. The ileum
was explored for 10cm and appeared normal. Cold forceps
biopsies were performed for histology at the ileum and random
colon.
Impression: Evidence of right colectomy/ileocecectomy with
ileocolic anastamosis was seen. The anastamosis appeared normal.
The ileum was explored for 10cm and appeared normal. (biopsy)
Polyp in the rectum (polypectomy)
Recommendations: We will follow-up biopsies and inform patient.
Follow-up MRE evaluation
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. Specimens were taken
for pathology as listed above.
Brief Hospital Course:
ASSESSMENT AND PLAN:
___ with history of COPD, RA, Crohns disease, fibromyalgia, now
presenting for evaluation of chronic diarrrhea and abdominal
pain admitted from GI Clinic.
# Diarrhea--She was ruled out for C. diff and per patient this
is similar to her Crohn's flares, while CRP is negative there is
a small subgroup of Crohn's patients who has flares with normal
CRP. No evidence of obstruction on KUB. Infectious etiology was
possible; however, stool cx were negative and she never
developed a white count or spiked a fever. MRE results
unrevealing and reassuring against inflammatory conditions with
no evidence of an active Crohn's flare. MRE shows she's had a
right hemicolectomy w/ ilealcolic anastomosis.
We Sent Anti transglutaminase Ab; pending at discharge
We held abx, as suspicion for bacterial gastroenteritis was low.
The pts diarrhrea improved with time
# Neuropathy: seen by BI Neuro at ___, thought to be from
multiple surgeries, multifactorial, and cervical stenosis.
However, here her B12 level was low at 220. Could be d/t lack of
absorption from resections. However, Crohn's disease pt are at
increased risk of Pernicious Anemia, and while she is not
anemic, this could be the starting point of her decifiency.
-We sent IF Ab.
-Sent Cu, Zn, Vitamin E, Vitamin A, D to assess for other
deficiencies
-continued gabapentin, percocet home regimen
-Gave 1 B12 injection at 1000 mcg.
#Nausea - pt without nausea as cheif complaint; however, she
states that ___ hours after eating she develops nausea and
ocassionaly vomits. She denies early sataity. She states that
within 20 minutes of eating, she has diarrhea. Along with her ___
neuropathy, she could have nerve damage leading to gastroparesis
and d/t her multiple ABD surgery for bowel resection, could have
short gut syndrome and/or SIBO.
-Would consider workup for above etiology outpatient.
#Elevated AP - CD pt are at increased risk of Primary sclerosing
cholangitis and often only have symptoms of fatigue and itching.
Can also be elevated with illeus or an obstruction.
-Consider RUQ ultrasound outpatient.
#HTN - Admission BP of 170s, no dx of HTN previously.
-Started Lisinopril 10 mg.
-Started Amlodipine 5 mg.
-Should be titrated outpt.
# COPD
- continued symbicort
- O2 at 2L overnight per home regimen.
# RA--has evidence of both RA and OA on exam.
- control pain as below, otherwise not on any DMARDs.
# Fibromyalgia
- continued home pain regimen (gabapentin, percocet)
# Restless leg syndrome -Dx ___ years ago. Appears to have
dyskinesia on exam, likely from pramipexole. We continued
tizanidine, pramipexole, and clonazepam
Sent iron level; pndin at discharge
-We decreased pramipexole dose, and one could consider tapering
and then stopping due to dyskinesia.
# Hypothyroidism - TSH WNL
-continued home synthroid
# Potential for drug interaction/QT prolongation:
- Home medications, so will prescribe now
- Check EKG: QTC 433
#Vitamin D Deficiency - Level is 16. Started 50k weekly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 900 mg PO TID
2. Ranitidine 300 mg PO QHS
3. pramipexole 0.25 mg oral QHS
4. Cyclobenzaprine 10 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
7. zaleplon 10 mg oral QHS:PRN insomnia
8. Tizanidine 1 mg PO QHS
9. ClonazePAM 0.5 mg PO TID
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. ClonazePAM 0.5 mg PO TID
2. Cyclobenzaprine 10 mg PO BID
3. Gabapentin 900 mg PO TID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
6. pramipexole 0.125 mg oral QHS
RX *pramipexole [Mirapex] 0.125 mg 1 tablet(s) by mouth at
bedtime Disp #*30 Tablet Refills:*3
7. Ranitidine 300 mg PO QHS
8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
9. Tizanidine 1 mg PO QHS
10. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
11. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
12. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 1 tablet by mouth Q4H:PRN Disp #*60 Tablet
Refills:*3
13. Thiamine 100 mg PO DAILY
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
15. zaleplon 10 mg oral QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Crohn's Disease Flare
B12 deficient-induced Neuropathy
Vitamin D deficiney
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came to us with diarrhea and stomach pain. A colonoscopy and
MRE study showed no Crohn's activity, meaning the flare may have
resolved or something else caused your dirrhea. We took biopsies
of your colon and sent blood work looking for other
explanations. We did testing of various vitamin levels and found
that you are decifient in at least Vitamin D and Vitamin B12,
other vitamin levels are still pending and your GI doctor ___
follow up on these. We started you on B12 injections and oral
supplements for B12 and vitamin D. We will continue the workup
in clinic.
We wish you all the best,
Your ___ Team.
Followup Instructions:
___
|
10562589-DS-5 | 10,562,589 | 22,085,831 | DS | 5 | 2115-12-23 00:00:00 | 2115-12-27 20:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a reported history of HF
___ biventricular ICD, CAD, bradycardia, HTN, stroke on apixaban
who presented to the ___ ED on ___ with chest pain.
The patient has had an extensive past medical history and she
was
not certain on the details. She received most of her prior care
in ___. In ___, she had a stroke and was put on apixaban.
She states she does not have atrial fibrillation. She has
minimal
residual left lower leg weakness. In ___, she had her ICD
placed. She thinks she may have had 3 prior cardiac
catheterizations in the past but her blood vessels have never
had
blockages to intervene on. One of her cardiac catheterizations
was complicated by bleeding from her femoral site. Her
defibrillator has fired in the past, last ___ years ago when
she was hospitalized in ___ for shortness of breath. She
does not think she has ever had a heart failure exacerbation,
coronary artery disease, or MI. She is followed by a
cardiologist in ___, and was last seen by Dr. ___ at
___ in ___.
The patient's current symptoms developed on ___. The patient
was cleaning her home in preparation for starting her GED on
___ when she developed sudden onset substernal chest pain in
the ___ her chest. The pain did not radiate and it
subsided after 10 seconds after she stopped sweeping. She denied
diaphoresis, palpitations, or lightheadedness. She continued to
clean and developed recurrence of her substernal chest pain. On
one occasion, she felt lightheaded but did not syncopize. The
pain was not worse with deep inspiration.
She sleeps with 1 pillow at baseline and denies recent change.
She denies orthopnea or lower extremity swelling.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- Unknown Coronaries
- EF 28%
- SR biventricular ICD
3. OTHER PAST MEDICAL HISTORY
OSTEOARTHRITIS
STROKE
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
============================
ADMISSION PHYSICAL EXAMINATION:
============================
VS: 97.6 PO 144 / 91 Lying 60 18 98 Ra
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. no thrills or lifts.
LUNGS: 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.
EXTREMITIES: no peripheral edema, extremities cool
NEURO: CN2-12 intact, ___ strength of L hip flexors, ___ on
right, otherwise ___ in all other extremities, intact sensation
to light touch in b/l ___
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
============================
DISCHARGE PHYSICAL EXAMINATION:
============================
24 HR Data (last updated ___ @ 530)
Temp: 97.8 (Tm 98.4), BP: 129/80 (119-153/70-99), HR: 60
(59-62), RR: 18, O2 sat: 100% (98-100), O2 delivery: Ra
Fluid Balance (last updated ___ @ 530)
Last 8 hours Total cumulative -1000ml
IN: Total 0ml
OUT: Total 1000ml, Urine Amt 1000ml
Last 24 hours Total cumulative -1100ml
IN: Total 600ml, PO Amt 600ml
OUT: Total 1700ml, Urine Amt 1700ml
ADMISSION WEIGHT: 65.5kg
YESTERDAY WEIGHT: 65.7kg
TODAYS WEIGHT: pnd
TELE: atrial fibrillation
GENERAL: NAD, well appearing
HEENT: JVD flat
LUNGS: CTAB, no wheeze, no crackles
HEART: irregularly irregular, no g/m/r, TTP over sternum
EXT: WWP, 2+ distal pulses
Pertinent Results:
ADMISSION LABS
=============
___ 12:52PM BLOOD WBC-3.9* RBC-4.96 Hgb-10.8* Hct-35.4
MCV-71* MCH-21.8* MCHC-30.5* RDW-15.6* RDWSD-39.6 Plt ___
___ 12:52PM BLOOD Neuts-57.1 ___ Monos-8.8 Eos-5.4
Baso-1.0 Im ___ AbsNeut-2.21 AbsLymp-1.06* AbsMono-0.34
AbsEos-0.21 AbsBaso-0.04
___ 12:52PM BLOOD Plt ___
___ 12:52PM BLOOD Glucose-96 UreaN-16 Creat-1.0 Na-141
K-4.5 Cl-102 HCO3-28 AnGap-11
___ 12:52PM BLOOD CK-MB-5 proBNP-3970*
___ 12:52PM BLOOD cTropnT-0.02*
___ 09:41PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
___ 06:20AM BLOOD calTIBC-335 Ferritn-102 TRF-258
___ 06:20AM BLOOD TSH-2.7
___ 06:20AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:20AM BLOOD HCV Ab-NEG
___ 09:43PM BLOOD Lactate-1.9
DISCHARGE LABS
=============
___ 06:15AM BLOOD WBC-3.7* RBC-5.83* Hgb-12.6 Hct-41.0
MCV-70* MCH-21.6* MCHC-30.7* RDW-15.9* RDWSD-39.0 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-91 UreaN-16 Creat-1.0 Na-142
K-4.5 Cl-101 HCO3-24 AnGap-17
IMAGING
======
ETT
INTERPRETATION: ___ yo woman with HL, HTN, ___ pacemaker and
chronic
atrial fibrillation was referred to evaluate an atypical chest
discomfort. The patient completed 7 minutes of a modified ___
protocol
representing a fair exercise tolerance; ~ ___ METS. The exercise
test
was stopped at the patient's request secondary to fatigue. There
was a
discussion about aborting the exercise study and converting to a
pharmacologic study, however the patient refused the medication
as she
reportedly had the procedure in the past and reportedly "became
very
sick". Prior to exercise, the patient reported a sharp/stabbing,
right
sternal border chest discomfort similar to her admission
symptoms. The
area of discomfort was tender to minimal palpation. No chest,
back, neck
or arm discomforts were reported during exercise or recovery.
The rhythm
was atrial fibrillation with occasional isolated VPBs. One, 1.8
sec
pause was noted during exercise. There was resting hypertension
with a
blunted systolic blood pressure response to exercise. In the
presence of
beta blocker therapy, the peak exercise heart rate was blunted.
IMPRESSION: Fair exercise tolerance. Non-anginal symptoms
reported
prior to exexercise with no anginal symptoms during exercise and
ST
segments that are uninterpretable for ischemia in the presence
of
ventricular pacing. Blunted hemodynamic response to exercise.
pMIBI
FINDINGS: Left ventricular cavity size is enlarged. EDV 146
mL.
Resting and stress perfusion images reveal fixed moderate
inferior and lateral
wall defects.
Gated images reveal global hypokinesis.
The calculated left ventricular ejection fraction is 28 %.
IMPRESSION: 1. Moderate fixed inferior and lateral wall defects
2. Enlarged left
ventricle with EF 28 %.
TTE
The left atrial volume index is SEVERELY increased. No
thrombus/mass is seen in the body of the left atrium (best
excluded by TEE) The right atrium is mildly enlarged. There is
no evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal cavity size. There
is mild-moderate left ventricular regional systolic dysfunction
with hypokinesis of the inferior, inferolateral and apical walls
(see schematic) and mild global hypokinesis of the remaining
segments. Quantitative 3D volumetric left ventricular ejection
fraction is 31 %. Left ventricular cardiac index is normal (>2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Normal right ventricular cavity size with focal
hypokinesis of the apical free wall. The aortic sinus diameter
is normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. There is no evidence for an aortic
arch coarctation. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is mild
to moderate [___] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. The end-diastolic PR velocity is elevated
suggesting pulmonary artery diastolic hypertension. There is a
very small pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional and mild global systolic dysfunction. Mild-moderate
mitral regurgitation. Mild pulmonary artery systolic
hypertension. Very small pericardial effusion.
Brief Hospital Course:
===============
ADMISSION
===============
Ms. ___ is a ___ year old woman with a reported history of
HFrEF ___ biventricular ___ ___, CAD, persistent AF
___ now on apixaban, HTN, HLD, and CVA x5 last (___) who
presented to the ___ ED on ___ with exertional chest pain,
now ___ ETT, pMIBI and TTE admitted for workup up of chest pain
and likely HF exacerbation.
===============
ACTIVE ISSUES:
===============
#Atypical CP
Pt presents with substernal chest pain and a mild elevation in
cardiac troponin to 0.02 that trended to 0.02. She had a ETT
that showed a fixed moderate inferior and lateral wall defect.
Her ED EKG was v-paced rhythm without concerning findings for
ischemia. She had a TTE that showed EF of (28%) with
inferolateral wall motion abnormality, likely representing old
scar/ischemia. Per ___ Chart review she had a previous TTE from
___ that showed nearly akinetic inferior and inferolateral
walls. The patient has an extensive cardiac history including
likely coronary angiography in ___, but no records and no
catheterizations within the last ___ in ___. EP
interrogated her device and found no events. Her chest pain is
atypical, likely non-cardiac or perhaps related to hypokinetic
are seen on TTE. Given negative findings, she likely will not
benefit from coronary angiography at this time. Recommend
continuing ASA 81, restarting Atorvastatin 80 (which patient
declined during hospitalization).
#HFrEF:
Patient with EF of 28% on stress test which is stable from prior
per ___ records. She appears euvolemic on exam. TSH, spep, upep,
HIV, hepatitis serologies were negative. She was continued on
home Lasix 40mg PO BID and remained net even.
PRELOAD: Furosemide 40 mg PO/NG BID
AFTERLOAD: Lisinopril 40 mg PO/NG DAILY
NHBK: Carvedilol 25 mg PO/NG BID
Spironolactone 25 mg PO/NG DAILY
Outpatient provider should consider transitioning her to
___/ ___ to ___ if patient has pre-authorization,
can afford copay and is willing. She has a deep mistrust of the
medical system and is reluctant to take new/different
medications.
#Atrial fibrillation
___
She is rate controlled ___ and CRT-D. She is anticoagulated
on apixaban 5mg BID.
#Pancytopenia:
Regaring her pancytopenia, patient with low levels stable from
priors at ___ from ___. Given history of ?recent
homelessness, unclear whether this is d/t malnutrition. She has
a history of schizophrenia, and may take medications, e.g.,
antipsychotics, not on PAML leading to agranulocytosis. Would
consider outpatient retic count and HIV serology.
================
CHRONIC ISSUES:
================
#Prior stroke:
History of CVAx5 on apixaban as below.
- Continue apixaban as above
#Vitamin D deficiency:
-800U vitamin D3 daily
==================
TRANSITIONAL ISSUES
==================
[] Outpatient provider should consider transitioning her to
___/ ___ to ___ if patient has pre-authorization,
can afford copay and is willing. She has a deep mistrust of the
medical system and is reluctant to take new/different
medications.
[] Patient will require further workup for her pancyptopenia.
[] Patient would benefit from statin. Written for atorvastatin
80mg PO QHS, but has been refusing while in hospital.
# CODE STATUS: Full
# CONTACT: Son, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Apixaban 5 mg PO BID
4. Furosemide 40 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
3. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
4. Apixaban 5 mg PO BID
5. Carvedilol 25 mg PO BID
6. Furosemide 40 mg PO BID
7. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Heart Failure w/Reduced Ejection Fraction
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___.
WHY WAS I IN THE HOSPITAL?
You were admitted to the hospital because you had chest pain
that was concerning for a possible heart issue.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had an echocardiogram done which was similar to prior
echocardiograms.
- Our heart doctors examined your ___ and did not find any
issues with this.
- You were continued on your home medications.
- We added new medications called spironolactone, atorvastatin,
and aspirin to help your heart function better.
WHAT SHOULD I DO WHEN I GO HOME?
- Please make sure to follow up with your cardiologist/heart
failure provider. See below to see the date and times of your
upcoming appointments.
- Please take all of your medications exactly as prescribed.
- Please call your cardiologist or heart failure doctor if you
develop any chest pain
- Please weight yourself every day and call your cardiologist or
go to the emergency department if you gain more than 3 pounds in
2 days. Your discharge weight was 65.5 kg (144.4 lb).
Followup Instructions:
___
|
10562846-DS-5 | 10,562,846 | 21,802,601 | DS | 5 | 2148-09-22 00:00:00 | 2148-09-23 12:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee venom (honey bee)
Attending: ___.
Chief Complaint:
altered mental status, dens fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with history of alcohol abuse transferred from
OSH for recent fall, development of altered mental status, found
to have acute dens fracture. Patient is a poor historian ___ the
ED, confabulating and hallucinating. Per report from wife, he
had fallen on ___, and was experiencing headache and neck
pain. For the next two days, he tried using heat and cold
packs, tylenol, ibuprofen, all without improvement of symptoms.
On ___, he went to his doctor's office, saw one of the PAs
there, and was given a prescription for vicodin and flexeril
which did not give him any relief. On ___, he again saw his
PCP and had ___ of his neck performed which was reported to be
normal, so he was told to double his dose of vicodin. On ___,
patient was noted to be hallucinating, leaving messages on his
wife's ___ who was out of town. He was also calling for a
dog which wasn't there, telling nonsensical stories. Last night
he had gone over to his neighbors house and told them there
where 8 kids ___ his living rooom. His wife called EMS at that
time, but he refused to go, and so they didn't take him. Today,
he called his work and told them that he was training a new
driver, they had made a wrong turn, and the driver left him out
___ the woods. Police found him wandering the neighborhood and
brought him to OSH where he had a CT scan of his neck which
showed acute dens fracture.
.
___ the ED inital vitals were, 99.7 80 143/93 20 96%. Patient is
___ a hard collar. Mental status noted to be very altered. Was
seen by ortho spine service who did not recommend surgical
repair at this time, and recommended ___ J collar for
stablization of fracture, and MRI of C-spine. Neurology also
evaluated the patient, noted that he was confused, inattentive,
and confabulating. He was witnessed to be talking to people who
weren't there. No focal neurologic deficits were noted. CT
head did not show any acute intracranial findings. Neurology
comments that his encephalopathy, mild intention tremor, and
ataxia, are likely due to his chronic alcohol use. Patient's
wife reports that he goes through at least 2 liters of ___
___ a week. No history of DTs or withdrawal that the wife
knows. Patient was given thiamine and folic acid. MRI of
C-spine was unable to be performed ___ the ED as no one from his
family was available to discuss safety checklist.
.
Patient was initially assigned a medicine floor bed, however
developed tachycardia to the 150's along with hallucinations,
concerning for alcoholic withdrawal and alcoholic hallucinosis.
His serum alcohol tox screen was negative. He required physcial
restraints as he was very agitated. Was given diazepam IV 10 mg
x1, haldol 5 mg IV x2, and multiple administrations of IV
lorazepam. Heart rate improved to 110s, but patient's mental
status remains altered. No changes to his overall neurological
exam. Vitals prior to transfer to the ICU were: afebrile,
130/80s, HR 116, 18, 99%RA.
.
On the floor, patient is very sedated, not responding to
questions, not following commands. He appears very restless.
Past Medical History:
HTN
Alcohol abuse
Erectile dysfunction
h/o hepatitis C, genotype 2b - s/p interferon ___ ___ at
___ with reported negative f/u PCR on ___
h/o basal cell carcinoma
h/o C-spine fracture ___ MVA s/p C-spine fusion at age ___
s/p right inguinal hernia repair
h/o vitamin B12 deficiency
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission
Vitals: 99.0, 134/78, 92, 33, 96% RA
General: sedated, agitated, restless, not verbally
communicating, not following simple commands
HEENT: pupils small, not very reactive, MM dry, OP clear
Neck: neck supple, JVP not elevated, no LAD
Lungs: CTA b/l, no w/r/r
CV: S1S2, RRR, no m/r/g
Abdomen: soft, ND, NT, +BS, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge
Pertinent Results:
Admission Labs
___ 11:30AM BLOOD WBC-9.7 RBC-3.73* Hgb-13.0* Hct-37.1*
MCV-100* MCH-34.8* MCHC-34.9 RDW-11.6 Plt ___
___ 11:30AM BLOOD Neuts-77.9* Lymphs-13.6* Monos-7.9
Eos-0.3 Baso-0.3
___ 11:30AM BLOOD Glucose-106* UreaN-10 Creat-0.5 Na-136
K-5.0 Cl-99 HCO3-23 AnGap-19
___ 11:30AM BLOOD ALT-14 AST-42* AlkPhos-56 TotBili-1.2
___ 03:42AM BLOOD CK(CPK)-1296*
___ 11:30AM BLOOD Albumin-4.3 Calcium-8.9 Phos-4.1 Mg-1.8
___ 10:14 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
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.
UNASYN (AMPICILLIN/SULBACTAM) Sensitivity testing per
___ ___
___ ___ ___.
GRAM NEGATIVE ROD #1. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Blood cultures ___ and ___ are negative.
urine culture on ___ are negative.
CT C-spine
There is a nondisplaced fracture through the base of dens,
consistent with a type II fracture. There is no involvement of
the posterior elements or malalignment. There is no prevertebral
soft tissue swelling. The outline of the thecal sac is
maintained without evidence of canal narrowing. There are no
other fractures seen. There is ankylosis of the posterior spine
from C2 through C7 with cerclage wires ___ place. There are
multilevel degenerative changes with disc space narrowing and
calcification of the posterior longitudinal ligament at multiple
levels. The soft tissues including the thyroid gland are
unremarkable. Carotid calcifications are noted. There is no
evidence of soft tissue hematoma. Visualized lung apices are
clear.
___ CXR:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF 65%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
CT head ___: IMPRESSION: No evidence of hemorrhage or mass
effect.
Brief Hospital Course:
___ M with h/o EtOH abuse presenting with altered mental status
and acute dens fracture
.
#. Altered mental status/hallucinations Patient was initially
found by police wandering ___ woods after making nonsensical
phone calls to his office. CT scan at OSH revealed a
nondisplaced dens fracture. CT head was negative. Pt was noted
to be confused, inattentive and confabulating. Urine tox screen
was positive for opioids, which was expected given patient's
recent vicodin use for neck pain. AMS was attributed to vicodin
and alcohol withdrawal(TSH was wnl, no evidence of ischemia, CE
were negative, B12, folate were wnl.) Patient was treated with
daily thiamine, folate and multivitamin along with standing
valium and haldol with PRN ativan. Mental status improved
considerably and by the time of discharge he appeared to be
close to his baseline (although his wife states that his
cognition has declined overall ___ the past six months) PCP may
want to consider outpatient neuropsychiatric testing to evaluate
for underlying dementia on the account of his long history of
drinking. Repeat head CT to eval for possible subacute subdural
bleeding was negative. I discussed with the patient the
importance of alcohol cessation and he showed some insight and
was ___ agreement that he should stop drinking. He was seen by
psychiatry and social work, and he did not want to be enrolled
___ a program for his drinking, stating that "I will do it on my
own".
.
# fevers/Leukocytosis: ___ the ICU, pt was treated for aspiration
PNA with unasyn (___) and azithro ___ sputum
cx is sensitive to levofloxacin so it was switched on ___. He
completed a ten day course of levofloxacin while ___ the hospital
.
#. Dens fracture - CT C-spine shows nondisplaced type II dens
fracture. Ortho spine recommends ___ weeks of wearing the
___ collar. No surgical intervention is recommeded. He was
counselled not to drive, and he will see the orthopedic surgeon
___ outpatient followup ___ the beginning of ___. He was
counselled at great length to avoid any narcotic analgesics for
neck pain, and to take tylenol or motrin as needed.
.
#HTN - Restarted home PO metoprolol.
.
#Mobility: patient required use of a walker. He was evaluated
by physical therapy, who felt that he could return home as long
as he was under strict supervision.
#Insomnia: Patient's wife states that he often returns to
drinking on account of insomnia. I gave him a prescription for
trazodone.
Medications on Admission:
vicodin ___ mg - ___ tablets q4-6hrs prn pain
flexeril 10 mg q6h prn back pain
lomotil 2.5/0.025 - 2 tabs daily prn diarrhea
metoprolol succinate 50 mg daily
multivitamin 1 tab daily
ecotrin - unknown dosage
epi-pen prn anaphylaxis
Discharge Medications:
1. trazodone 50 mg Tablet Sig: ___ Tablets PO at bedtime as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
2. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin Childrens 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
alcohol withdrawal
acute dens fracture
pneumonia
delirium
Discharge Condition:
Mental Status: Confused - very mild, and very intermittent
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hospitalized for alcohol withdrawal, an acute dens
fracture (a bone ___ the spine ___ your neck), and pneumonia. You
had some confusion ___ the hospital as well, but this has been
resolving nicely. You should not drink alcohol anymore. You
should wear the ___ J collar at all times. You CANNOT drive
until you are re-evaluated by the orthopedic surgeon ___ ___.
You can take trazodone at night for your insomnia.
Followup Instructions:
___
|
10563076-DS-20 | 10,563,076 | 28,493,198 | DS | 20 | 2135-09-18 00:00:00 | 2135-09-19 07:07:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Left-sided face pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This was not a code stroke
NIHSS performed within 6 hours of presentation at: 3pm ___
NIHSS Total: 1*
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1* (sensation of 'pressure' on L face)
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
HPI:
___ with PMH of NIDDM, HTN, HLD who presented to the ED with L
face pressure. Neurology was consulted due to c/f ?stroke.
LKW was night of ___. Patient states that when she woke up
around 7 AM on day of presentation, she had a pressure sensation
on the left side of her face, involving the areas around her
left
eye, temple, forehead. She also thought that the left side of
her face might have been slightly droopy, but she thinks that
those symptoms went away, although she was not able to give me a
timeframe. She also thinks that she may have had blurry vision
this morning, which went away after she had some apple juice.
Patient states that on ___ of last week, her primary care
provider started her on a new medication for diabetes, Jardiance
(Empagliflozin). Since that time, she has had intermittent
headaches, loose bowels, increased urinary frequency, nausea,
fatigue. She also had her flu shot ___ of last week.
Patient
states that over the past 2 weeks, since starting the new
medication, she has had issues with low blood sugar, with values
down to the ___ to ___. She states that she has had
intermittent
episodes of headache, sweating, shakiness associated with low
blood sugars. She did not check her blood sugar when she woke
up
this morning with her left face pressure. However, she states
that she did feel better after her husband brought her some
apple
juice.
At time of neurology evaluation in the ED, patient states that
her symptoms were improving, although she still had some
left-sided face pressure. She would rate her symptoms as 70%
compared to 100% when she woke up this morning. Blood glucose
was 251 in the ED, although patient had had apple juice prior to
arriving.
Patient states that over the past year she has had intermittent
right hand swelling with associated numbness during these
episodes of swelling. At the time of neurology evaluation, she
denied numbness. Patient also endorsed intermittent episodes of
tingling in her left fingertips when standing up from a seated
position. No tingling at the time of neurology evaluation. She
also states that she had a TIA several years ago when she
presented with left arm numbness. She denies any current
symptoms of left arm numbness. She does endorse chronic
numbness
on the top of her left foot, worse with standing for long
periods
of time, which she attributes to her flatfoot.
ROS:
12 systems reviewed and negative except as noted above
Past Medical History:
Hypertension
Non-insulin-dependent diabetes
Hyperlipidemia
TIA
Social History:
___
Family History:
Father has diabetes and stroke
Brothers have diabetes
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: T: 97.9 BP: 187/78 HR: 95 RR: 16 SaO2: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert. Able to relate history. Attentive,
Language is fluent with intact comprehension. Normal prosody.
There were no paraphasic errors. Able to name both high and low
frequency objects, although called "hammock" a "swing". Able to
read without difficulty. No dysarthria. Able to follow both
midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI. Normal
saccades. VFF to confrontation.
V: Facial sensation intact to light touch, although patient
endorses sensation of "pressure" on her left side
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: No pronator drift.
[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
*Handgrip was slightly weaker on her right side compared to her
left. Per patient, this has been chronic over several months at
least.
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception in bilateral big toes. No
extinction
to DSS. Romberg absent. Pinprick sensation intact in V1-3
distribution bilaterally on face.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 2 1 0
R 2 1 2 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
DISCHARGE PHYSICAL EXAMINATION:
General: NAD.
HEENT: MMM
Neck: Supple.
Pulmonary: Normal work of breathing on RA
Cardiac: Warm, well-perfused, no edema
Neurologic:
-Mental Status: Alert. Able to relate history. Attentive,
Language is fluent with intact comprehension. No dysarthria.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI.
V: Facial sensation intact to light touch
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: not tested
XI: not tested
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal tone. No pronator drift. No orbiting.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch. No extinction
to DSS.
-Reflexes: Toes downgoing. No clonus.
-Coordination: No intention tremor. Normal finger-tap
bilaterally.
-Gait: deferred
Pertinent Results:
Imaging:
IMAGING:
CT/CTA head/neck:
IMPRESSION:
1. Head CT: Normal head CT.
2. CTA Head: Atherosclerotic plaque at the bilateral carotid
siphons resulting in severe narrowing of the right supraclinoid
ICA and mild left supraclinoid ICA stenosis. The
3. Mild irregular luminal narrowing of the right PCA P2 segment
may reflect atherosclerotic disease. Otherwise, the
___ appears patent without evidence for high-grade
stenosis, occlusion or aneurysm formation.
4. CTA Neck: Trace atherosclerotic calcifications at the
bilateral carotid bifurcations without internal carotid artery
stenosis on either side. The vertebral arteries appear within
normal limits. No evidence of dissection.
MRI brain: FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are normal
in caliber and configuration. Periventricular and subcortical T2
and FLAIR hyperintensities are nonspecific. The principal
intracranial flow voids are preserved. The paranasal sinuses and
mastoid air cells appear clear. The orbits and globes appear
within normal limits.
IMPRESSION:
1. Normal study.
TTE: LVEF 71%. IMPRESSION: Suboptimal image quality. No evidence
for right-to-left intracardiac shunt at rest or with maneuvers.
No structural cardiac source of embolism (e.g.patent foramen
ovale / atrial septal defect, intracardiac thrombus, or
vegetation) seen.
===========
___ 06:50AM BLOOD WBC-3.5* RBC-4.68 Hgb-12.6 Hct-38.6
MCV-83 MCH-26.9 MCHC-32.6 RDW-14.2 RDWSD-42.4 Plt ___
___ 12:40PM BLOOD WBC-4.8 RBC-4.82 Hgb-12.9 Hct-39.7 MCV-82
MCH-26.8 MCHC-32.5 RDW-14.3 RDWSD-42.7 Plt ___
___ 04:06PM BLOOD Neuts-61.1 ___ Monos-9.0 Eos-1.2
Baso-0.6 Im ___ AbsNeut-3.14 AbsLymp-1.43 AbsMono-0.46
AbsEos-0.06 AbsBaso-0.03
___ 06:05AM BLOOD ___ PTT-34.5 ___
___ 06:15AM BLOOD Glucose-154* UreaN-14 Creat-0.8 Na-140
K-4.7 Cl-104 HCO3-26 AnGap-10
___ 06:50AM BLOOD Glucose-155* UreaN-17 Creat-0.9 Na-140
K-5.1 Cl-102 HCO3-27 AnGap-11
___ 12:40PM BLOOD Glucose-528* UreaN-16 Creat-0.9 Na-136
K-5.1 Cl-97 HCO3-27 AnGap-12
___ 06:05AM BLOOD Glucose-182* UreaN-14 Creat-1.0 Na-142
K-5.4 Cl-104 HCO3-26 AnGap-12
___ 04:06PM BLOOD Glucose-233* UreaN-15 Creat-1.0 Na-136
K-8.4* Cl-101 HCO3-24 AnGap-11
___ 06:50AM BLOOD ALT-9 AST-16 LD(LDH)-208 CK(CPK)-108
AlkPhos-57 TotBili-0.3
___ 06:05AM BLOOD ALT-11 AST-15 CK(CPK)-135 AlkPhos-64
TotBili-0.5
___ 04:06PM BLOOD ALT-<5 AST-58* AlkPhos-51 TotBili-0.4
___ 06:15AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
___ 06:50AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.5 Mg-2.1
___ 06:05AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.3 Cholest-234*
___ 06:05AM BLOOD %HbA1c-10.1* eAG-243*
___ 06:05AM BLOOD Triglyc-65 HDL-83 CHOL/HD-2.8
LDLcalc-138*
___ 12:40PM BLOOD Beta-OH-0.5*
___ 06:05AM BLOOD Triglyc-65 HDL-83 CHOL/HD-2.8
LDLcalc-138*
___ 06:05AM BLOOD TSH-2.1
___ 12:56PM BLOOD ___ pO2-46* pCO2-56* pH-7.31*
calTCO2-30 Base XS-0 Comment-GREEN TOP
___ 07:23PM BLOOD K-4.4
___ 01:00PM URINE Color-Colorless Appear-CLEAR Sp
___
___ 04:06PM URINE Color-Colorless Appear-CLEAR Sp
___
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose->1000* Ketone-10* Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-SM*
___ 04:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose->1000* Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.0
Leuks-MOD*
___ 04:06PM URINE RBC-<1 WBC-1 Bacteri-FEW* Yeast-NONE
Epi-1
___ 04:06PM URINE Hours-RANDOM
___ 04:06PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 4:06 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Patient Summary:
___ with PMH of IDDM, HTN, HLD, TIA who presented to the ED with
L face pressure, transient blurry vision, possible ?Left face
droop now resolved, in setting of starting a new medication for
diabetes, Empagliflozin (Jardiance). Most likely etiology of her
symptoms is transient symptomatic hypoglycemia, as patient
states she has had
multiple episodes of hypoglycemia since starting the new
medication
and her symptoms improved after drinking apple juice. However,
in a
patient with diabetes, hypertension and previous TIA, she stroke
also
needed to be considered. L face pressure would be an unusual
presentation for stroke, but patient did endorse possible L
facial droop prior to arriving to ED, so TIA was theoretically
possible
as well. She was admitted to the stroke service for stroke/TIA
workup.
#Stroke/TIA workup:
#Symptomatic hypoglycemia
- Her CT head did not show any large infarct or hemorrhage. Her
vessel imaging showed atherosclerotic calcifications of the
bilateral cavernous carotid arteries, with severe narrowing of
the right supraclinoid segment and focal narrowing of the
proximal right internal carotid artery, just after the
bifurcation but otherwise no large vessel occlusion. She had an
MRI brain without contrast that did not reveal any acute
strokes, just mild changes consistent with chronic small vessel
disease.
- Stroke risk factors: She does have poorly controlled diabetes
(HbA1c 10.1) and hyperlipidemia (LDL 138), which increases her
risk of strokes. She is already on a statin (atorvastatin 20mg),
which she should continue. She was continued on her home ASA
81mg daily. Her home enalapril was held while inpatient and her
BP was allowed to autoregulate with goal SBP < 180 while workup
was ongoing. See below for diabetes.
# CV:
- She had cardiac enzymes. She was monitored on cardiac
telemetry with no atrial fibrillation noted. BP was allowed to
autoregulate as above (goal 140-180s). Home antihypertensives
were held.
# IDDM:
A1c 10.1. Started on Insulin sliding scale. Had a DS of 498, so
was ordered STAT urine ketones, serum beta-hydroxybutyrate, VBG
and Chem. Held home Jardiance due to frequent episodes of
hypoglycemia per patient after starting this medication.
Restarted at discharge but will need close f/u with outpatient
providers. Patient is currently followed by an endocrinologist
in ___ and is interested in transferring care to ___
___, so an outpatient referral was requested.
# GI/Nutrition:
- She was kept NPO until she passed the ___ water swallowing
screen. She was transitioned to Diabetic/Cardiac heart healthy
diet thereafter.
# UTI
- She was also found to have a UTI with moderate leuks on UA.
She was discharged on nitrofurantoin to complete a five day
course
# Toxic/Metabolic/electrolytes
- LFTs were unremarkable.
- K was hemolyzed, repeated and within normal limits
- Negative urine and serum toxin screens
TRANSITIONAL ISSUES
1) Patient's symptoms most likely secondary to symptomatic
hypoglycemia (multiple episodes since starting Jardiance). Her
history and imaging were not consistent with TIA or stroke.
Her stroke risk factors include the following:
1) DM: A1c 10.1%
2) Atherosclerotic calcifications of the bilateral cavernous
carotid arteries, with severe narrowing of the right
supraclinoid segment and focal narrowing of the proximal right
internal carotid artery, just after the bifurcation
3) Hyperlipidemia: LDL 138 on atorvastatin 20mg daily
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 138) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No - Reason - 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 - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Enalapril Maleate 2.5 mg PO DAILY
3. Jardiance (empagliflozin) 10 mg oral DAILY
4. Montelukast 10 mg PO DAILY
5. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
6. BD Ultra-Fine Nano Pen Needle (pen needle, diabetic) 32 gauge
x ___ miscellaneous TID
7. NovoLOG Flexpen U-100 Insulin (insulin aspart U-100) 100
unit/mL (3 mL) subcutaneous TID W/MEALS
8. Tresiba FlexTouch U-200 (insulin degludec) 200 unit/mL (3 mL)
subcutaneous QHS
9. Voltaren (diclofenac sodium) 1 % topical QID
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Tresiba 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin degludec [Tresiba FlexTouch U-100] 100 unit/mL (3
mL) AS DIR 18 Units before DINR; Disp #*4 Syringe Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. BD Ultra-Fine Nano Pen Needle (pen needle, diabetic) 32
gauge x ___ miscellaneous TID
RX *pen needle, diabetic ___ Tier Unifine Pentips] 32 gauge X
___ as previously instructed to check BGM 6 times a day Disp
#*180 Each Refills:*0
5. Enalapril Maleate 2.5 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic hypoglycemia
Insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the ___ Neurology service with symptoms
of L face pressure, transient blurry vision, possible ?Left face
droop now resolved, in setting of starting a new medication for
diabetes, Empagliflozin (Jardiance) with concern for a Transient
Ischemic Attack or a Mini stroke. Your admission found that
your symptoms were most likely secondary to hypoglycemia (Low
Blood Sugar). You also had multiple episodes of hypoglycemia
during this admission and poorly controlled hypertension (high
blood pressure).
You were seen by our Diabetes specialist colleagues (___), to
help with your diabetes management.
Medication Changes:
We discontinued your Empagliflozin (Jardiance).
We changed your insulin regiment as follows.
- Continue Tresiba 18 units at supper
- Continue reduced Humalog (which can be interchanged with
Lantus) to 3 units plus correction scale
- HS scale ___
- Change diet to diabetic consistent
Please continue to take your previously prescribed Lipator.
Follow up with Follow up with ___ outpatient clinic,
appointment made with
Dr. ___ ___ @ 2:30pm. ___, ___
___, ___. Your medication will be further
optimized at that time and you will receive ongoing education.
You are to follow up with ___ for ongoing management of your
diabetes and with your primary care provider.
Thank You for the opportunity to partake in your care,
The ___ Neurology Team.
Followup Instructions:
___
|
10563286-DS-3 | 10,563,286 | 21,190,656 | DS | 3 | 2147-04-23 00:00:00 | 2147-04-23 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
ACE Inhibitors / Statins-Hmg-Coa Reductase Inhibitors /
atorvastatin
Attending: ___.
Chief Complaint:
Confusion and falls.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ RH M with PD diagnosed in ___,
AFib on Coumadin s/p pacemaker placement, HTN, HLD who was
recently admitted to ___ after a fall in which he suffered
multiple rib fractures (the details of the fall are unclear as
it
appears to have been unwitnessed and the patient cannot provide
a
history. Presentation was prompted by complaint or RUQ pain to
his son). Documentation from ___ is limited, but it appears that
during the course of the admission he developed some delirium
Per
his granddaughter who is at the bedside, he has had some decline
in his cognitive function over the past 6 months, since his
wife,
who had ___ passed away. In the last six months he has
sold his business, resigned from a leadership position at the
___ and given up other activities due to his worsening
dementia. However, despite some decline in his cognitive
function
he had been getting by living alone until his recent fall. While
at ___ he apparently had some significant worsening in his
mental
status. He was seen by psychiatry who started Seroquel 25mg BID,
Depakote 250mg BID, trazodone hs. His home sinemet ___ 5x
per
day, rasagiline 1mg daily, artane were continued. Exelon 1.5mg
BID also started briefly, but then discontinued due to "concern
for side effects with polypharmacy." For pain control he was
given oxycodone and Lidoderm patch. His stay lasted from ___ to
___ at which time he was discharged to a rehab facility in a
brief moment of mental clarity per his granddaughter. Upon
arrival to the rehab facility the staff apparently took a look
at
his medication list and felt that they were not equipped to
handle his needs. He may also have attempted to climb out of bed
and suffered a fall. He was then brought to the ___ ED and
admitted to the ___ Service. There as initially
concern for a pneumonia and he received one dose of antibiotics
in the ED. This was not continued on the floor as there did not
seem to be strong evidence of an infection. UA was normal and no
clear metabolic abnormalities were seen on lab testing.
Patient is incoherent and unable to provide ROS
Past Medical History:
PD diagnosed in ___
AFib on Coumadin s/p pacemaker placement
HTN
HLD
GERD
Depressoion
LBBB
Social History:
___
Family History:
Unavailable
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
Vitals:
Tm 98.2 Tc 97.8 104-124/62-71 18 94-98%RA
GEN: Awake, sitting on bed, attempting to get up and leave room,
somewhat redirectable.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
RESP: non-labored
CV: WWP
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
Alert, oriented to self only.
Unable to related history. Speaks in hypophonic voice about
mostly non-sensical topics. States his coffee is for football.
Looks at his watch and says he is late and needs to get to his
car. Upon my entering the room, he says he knows who I am and
that my father had just been in the room, etc.
Inattentive, unable to test formally
Language is fluent with intact comprehension.
Normal prosody.
Difficulty with simple commands.
Unable to copy simple square, moves off paper and begins to
scribble on table with pen.
CN:
II:
PERRLA 3 to 2mm and brisk.
III, IV, VI: EOMI, no nystagmus. Saccadic intrusions present.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub conversation.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk. Mild increase in tone L>R, difficult to
differentiate rigidity from paratonia. Strong grasp reflex
bilaterally. Finger tapping is clumsy and very low amplitude.
Supination/pronation bradykinetic, clumsy. Tone is increase in
BLE
No adventitious movements. No asterixis.
Full strength throughout
Reflexes:
Bi Tri ___ Pat
L ___ 2
R ___ 2
Coordination:
No intention tremor, rest tremor in left hand, pill-rolling. No
dysmetria on FNF bilaterally.
Gait:
Good initiation. Mildly increased base, mild stoop, somewhat
unsteady, appears to sway to left at times.
.
.
========================
DISCHARGE PHYSICAL EXAM
========================
VS 98.3 (Tmax) 102-140/64-87 HR 75-88, RR 18, 96-97% on RA
General - NAD
Mental Status - Alert and oriented x3
Cranial Nerves - Face symmetric
Motor - No pronator drift. Minimal rigidity only with
augmentation even when examined before AM dose of Sinemet.
Decrement in b/l UE with rapid alternating movements with mild
clumsiness as well.
Sensory - Light touch intact in all four extremities
Gait - Good initiation, small stride length, very stable.
Pertinent Results:
==================
ADMISSION LABS
==================
___ 11:40PM GLUCOSE-103* UREA N-26* CREAT-1.2 SODIUM-134
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-22 ANION GAP-15
___ 11:40PM estGFR-Using this
___ 11:40PM WBC-5.6 RBC-4.33* HGB-13.2* HCT-40.3 MCV-93
MCH-30.5 MCHC-32.8 RDW-14.7 RDWSD-50.7*
___ 11:40PM NEUTS-59.0 ___ MONOS-11.6 EOS-3.0
BASOS-0.9 IM ___ AbsNeut-3.29 AbsLymp-1.40 AbsMono-0.65
AbsEos-0.17 AbsBaso-0.05
___ 11:40PM PLT COUNT-206
.
.
===============
IMAGES
===============
CT head:
IMPRESSION:
No acute intracranial process. Parenchymal atrophy.
.
CT cspine:
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel, multifactorial degenerative changes as described
above.
.
CXR:
1. Obscuration of the left hemidiaphragm, likely reflecting
combination of pleural effusion and atelectasis, although
developing consolidation cannot be excluded.
2. Right lower lung atelectasis and small pleural effusion.
3. Prior right posterior eighth rib fracture.
Brief Hospital Course:
___ with parkinsons disease, likely underlying dementia, atrial
fibrillation on coumadin, recent falls with rib fractures who
presents from nursing facility with confusion.
.
#Acute encephalopathy ___ iatrogenic polypharmacy and likely
underlying dementia#
It is not clear after discussion with patient's HCP whether
patient has underlying dementia - however from discussion with
his daughter and assessment of his mental status after
improvement in delirium it is quite likely. The patient has
reportedly has had memory difficulty and intermittent confusion
for an extended period of time. Had a fall and went to ___
___ where he was placed Depakote and Seroquel 25mg
BID and trazodone QHS for agitation/confusion. He was also
started on Tamsulosin for urinary retention. CT head unrevealing
other than parenchymal atropy. No apparent metabolic
derangements. Infectious workup negative, labs without
leukocytosis, CXR showing atelectasis and small pleural
effusions and UA bland. After discontinuation of Depakote,
Seroquel, trazodone, and tamsulosin, as well as simplification
of his ___ regimen, his delirium improved and he was
alert, oriented x3 at the time of discharge and acting
appropriately. However, given persistent impairment in memory,
he was started on Rivastigmine 1.5mg BID for cognitive reasons
and tolerated it well.
.
#Parkinsons Disease-
His home regimen of Sinemet 100mg 5x/day was simplified to
4x/day (QID) which resulted in good control of his ___
symptoms. Initially his rasagiline was continued but after
talking to his daughter, it appears that this medication was
stopped prior to admission, therefore, we stopped it without any
increased rigidity. His Artane was also stopped due to
possibility of anticholinergic side effects causing worsened
mental status. Despite all these simplifications, his rigidity
was very mild even when seen prior to AM sinemet dose.
Therefore, he was discharged on only Sinemet QID and his
medications can be titrated per Dr ___ as an outpatient.
Physical therapy and occupational therapy both worked with him
and felt that he was a candidate for acute rehab. Daughter does
not think he will be able to live with her as she will not be
able to get him up and down stairs in her home and skilled
nursing facility placement after acute rehab was addressed and
will likely be pursued after discharge.
.
#Recent mechanical fall complicated by posterior R 8th rib
fracture: Patient denied any significant pain. Pain controlled
with Tylenol and lidocaine patch during this admission. He was
previously given oxycodone which was not continued especially
given his confusion.
.
#Atrial Fibrillation- INR initially supratherapeutic. Per ___
records, it had been subtherapeutic requiring increase in dose.
Per daughter he was taking 5mg daily which we have continued.
INR was therapeutic during this admission on 5mg daily. Would
recommend repeated INR checks to ensure that his level is within
goal 2.0-3.0. Continued on Toprol 25mg daily.
.
#HTN-Stable. Losartan
.
#Depression- Was taking paxil 20mg QHS at home which was
continued.
.
#Urinary Retention - Had retention at OHS requiring Tamsulosin -
we stopped this due to possibility of anticholinergic side
effects. Monitored patient was had initially had intermittent
incontinence that resolved during this admission and PVR was 0.
.
# TRANSITIONAL ISSUES #
- Changed Sinemet dosing to QID
- Started Rivastigmine
- Stopped Artane and Rasagiline
- Stopped Tamsulosin
- Stopped Depakote and standing Seroquel
- Stopped Trazodone
- Will need INR monitoring after discharge. Next INR draw in
several days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY
2. Losartan Potassium 12.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Rosuvastatin Calcium 20 mg PO QPM
7. Paroxetine 20 mg PO DAILY
8. TraZODone 50 mg PO QHS:PRN insomnia
9. Valproic Acid ___ mg PO Q12H
10. QUEtiapine Fumarate 25 mg PO BID
11. Tamsulosin 0.4 mg PO QHS
12. Trihexyphenidyl 2 mg PO TID
13. Rasagiline 1 mg PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO QID
2. Losartan Potassium 12.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Paroxetine 20 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO QPM
7. Warfarin 5 mg PO DAILY16
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. rivastigmine tartrate 1.5 mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1.) Toxic Metabolic Encephalopathy
2.) ___ Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to the hospital as you were very confused
likely due to medication side effects. Your medications were
changed as following:
We STOPPED your Seroquel, Artane, Depakote, rasagiline,
trazodone.
We STARTED a medication called Rivastigmine twice daily in order
to help with your thinking.
Your Sinemet dose was CHANGED to 1mg QID (four times daily).
You were seen by physical therapy who felt that you would
benefit from acute rehab.
With these medication changes your mental status improved
greatly.
Followup Instructions:
___
|
10563306-DS-4 | 10,563,306 | 27,492,752 | DS | 4 | 2139-10-04 00:00:00 | 2139-10-04 16:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / codeine / erythromycin base
Attending: ___.
Chief Complaint:
R open distal ___ tib-fib Fx and left closed bimal ankle Fx
Major Surgical or Invasive Procedure:
___ - R tibial nail, L ankle ORIF
History of Present Illness:
___ presents as transfer from outside hospital with reported
right open tib-fib fracture and left closed ankle fracture. Pt
states she has chronic dizziness and peripheral neuropathy
secondary to longstanding lupus. She lost her balance tonight
while walking down the stairs to her basement, and fell down
approximately 4 steps. She had immediate pain in bilateral
legs,
worse on the right side, with bone "sticking out" of her right
leg. She was unable to stand after the fall. She initially
presented to OSH where x-rays showed above injuries and she was
then transferred to ___ for further management. she denies
HS/LOC or other injuries sustained in the fall. Noted left
ankle
became progressively more swollen and painful during transport
to
OSH. Denies new numbness/parasthesias. No other complaints
Past Medical History:
SLE, currently not on medication (was on azathioprine and
prednisone for ___ years, stopped 14 months ago d/t lack of
benefit
from the medication)
Chronic dizziness
Peripheral neuropathy
Tubal ligation
Tonsillectomy
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD
b/l ___: splints c/d/I, SILT over distal toes, wiggles toes, toes
wwp
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R open distal ___ tib-fib Fx and left closed bimal ankle
Fx and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for R tib
nail, L ankle ORIF, 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
NWB LLE in splint, TDWB RLE in splint, 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:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Senna 17.2 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h prn Disp #*80
Tablet Refills:*0
6. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*28 Syringe
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R open distal ___ tib-fib Fx and left closed bimal ankle Fx
Discharge Condition:
Stable
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:
- NWB LLE in splint, TDWB RLE in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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
Physical Therapy:
___: NWB LLE in splint, TDWB RLE in splint
Treatments Frequency:
___: NWB LLE in splint, TDWB RLE in splint
Followup Instructions:
___
|
10563851-DS-16 | 10,563,851 | 28,162,644 | DS | 16 | 2143-09-23 00:00:00 | 2143-09-23 15:58:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
falls/confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo male with PMH notable for DMII c/b
peripheral neuropathy, HTN, and depression presents with a 1
week h/o multiple falls. The patient reports that prior to this
week he only fell infrequently, last in the summer. His first
fall was ___ morning. He then fell again on ___ and at
that time was confused and called EMS. He was then eventually
taken to ___ where he had an unremarkable work-up
and discharged home in the course of a single day. His children
who brought the patient into the ED today report that he has an
additional 6 falls since his discharge. The patient reports that
he has trouble with his balance and with walking and that he has
fell due to these reasons. The patient's son reports that he has
needed help standing from the couch for years and the patient
reports that he has a lot of trouble climbing stairs. Patient's
children also report shuffling gait for some time.
In the ED, initial VS were 96.8 93 144/77 22 97%RA. He was
evaluated by neurology who felt that these falls were likely
multifactorial and that he has had increased falls/confusion
over the last 6 months. DDx per neuro for the confusion is
likely a toxic/metabolic process either due to an underlying
infection, polypharmacy or toxic drug levels. This is on top of
a likely developing dementia and given this he may not be taking
his medications perhaps appropriately. Neuro recommended
checking CK (2900), B12 (466), folate (6.0), LFTs all WNL except
AST 75, amitriptyline level, urine/serum tox. TSH was 0.84. CBC
and Chem 10 were unremarkable. Head CT showed tiny subgaleal
hematoma at the right vertex. Right cerebellar encephalomalacia
without CT evidence for acute intracranial process. CXR
unremarkable. EKG unremarkable.
Transfer VS 97.5 95 ___ 100%RA. On arrival to the floor,
patient confirms that he has falled multiple times in the last
week.
ROS:
He denies head trauma and LOC. The patient denies associated CP,
SOB, and diaphoresis. He denies N/V, diarrhea, fever, chills,
abdominal pain, cough, dysuria. Patient does endorse some
lightheadedness with position changes esp sitting to standing.
Additionally, patient endorses pain specifically from his knees
to hips when he is walking, L>R. He endorses a mild cough x
weeks.
Past Medical History:
Diabetes - last A1C 8.9, followed by ___
Peripheral Neuropathy
Depression
HTN
HLD
Social History:
___
Family History:
Brother with h/o stroke. Patient has 2 children in good health.
Physical Exam:
Admission Exam:
VS - 97.7, 155/64, 94, 18, 97%RA
GEN - overweight, awake, alert, NAD, oriented x 3
HEENT - NCAT, PERRL, EOMI, MMM, no JVD
CV - RRR, no m/r/g
Lungs - CTAB
ABD - +BS, obese, soft, NT/ND, no rebound/guarding
EXT - WWP, trace edema
NEURO - AxOx3, able to state months of year forward and
backward, able to name most recent holiday, current and future
president
CN II-XII intact, strength ___ in UE and distal ___, 4+/5 in
proximal ___, sensation to light touch intact, some tremulousness
with FTN, gait exam deferred on the floor
Discharge Exam:
GEN - overweight, awake, alert, NAD, oriented x 3
HEENT - NCAT, PERRL, EOMI, MMM, no JVD
CV - RRR, no m/r/g
Lungs - CTAB
ABD - +BS, obese, soft, NT/ND, no rebound/guarding
EXT - WWP, trace edema
Pertinent Results:
Admission Labs:
___ 07:35PM BLOOD WBC-10.4 RBC-5.08 Hgb-14.9 Hct-43.6
MCV-86 MCH-29.4 MCHC-34.2 RDW-13.8 Plt ___
___ 07:35PM BLOOD Neuts-71.8* ___ Monos-5.8 Eos-2.1
Baso-0.5
___ 07:35PM BLOOD Glucose-154* UreaN-13 Creat-0.9 Na-138
K-4.7 Cl-98 HCO3-30 AnGap-15
___ 06:44AM BLOOD ALT-27 AST-75* CK(CPK)-2900* AlkPhos-84
TotBili-0.5
___ 06:44AM BLOOD Lipase-15
___ 07:35PM BLOOD Calcium-9.8 Phos-3.7 Mg-2.3
___ 06:44AM BLOOD VitB12-466 Folate-6.0
___ 07:35PM BLOOD TSH-0.84
___ 06:44AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-POS
___ 08:48PM BLOOD Ethanol-NEG
Urine:
___ 09:36PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:36PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:36PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 09:36PM URINE CastHy-9*
___ 09:36PM URINE Mucous-RARE
___ 06:18PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Imaging:
CT Head w/out contrast ___: IMPRESSION: Tiny subgaleal
hematoma at the right vertex. Right cerebellar encephalomalacia
without CT evidence for acute intracranial process.
CXR ___: IMPRESSION: Likely left base atelectasis. Mild
cardiomegaly.
Discharge Labs:
___ 08:00AM BLOOD WBC-8.4 RBC-4.85 Hgb-14.3 Hct-41.7 MCV-86
MCH-29.5 MCHC-34.3 RDW-13.9 Plt ___
___ 08:00AM BLOOD Glucose-166* UreaN-15 Creat-0.7 Na-136
K-4.1 Cl-100 HCO3-27 AnGap-13
___ 08:00AM BLOOD CK(CPK)-695*
___ 08:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.3
Pending Labs:
___ 11:05AM BLOOD PEP-PND
___ 08:48PM BLOOD AMITRIPTYLINE-PND
___ 09:15AM URINE U-PEP-PND
Brief Hospital Course:
___ yo male with PMH DMII, depression now admitted with multiple
falls and confusion that is likely multifactorial in etiology.
Active issues:
#COGNITIVE DECLINE: Speaking with his daughter ___, she
reported a subacute history of memory difficulties. Neurology
exam showed impaired construction and short term memory. CT
head showed a tiny subgaleal hematoma at the right vertex and
right cerebellar encephalomalacia without evidence for acute
intracranial process. Infectious evaluation (blood/urine
culture, CXR) not revealing. Urine and serum tox screen
negative. The cause may be either polypharmacy/medication side
effects versus dementia. Medication side effects (TCA when
combined with lyrica and cymbalta) were considered and his
amitriptyline will be weaned over the next several weeks and
discontinued. On day 3 of admission, the developed myoclonic
jerks where were thought to be related to abrupt cessation of
amitriptyline. As a result he was restarted at a lower dose with
plan for the following taper: Day ___: 50mg PO qAM and 75mg
PO qPM Day ___: 25mg PO qAM and 50mg PO qPM Day ___:
25mg PO BID Day ___: 25mg po qHS Day 28=stop.
Pseudodementia was considered as he has not been taking
cymbalta. Would recommend full neuro-psychological evaluation
for dementia as outpatient.
.
#GAIT INSTABILITY: He has a history of poor mobility but over
the past week prior to admission had increasing frequency of
mechanical falls. Neurology was consulted and exam showed short
and large fiber neuropathy, which is likely contributing to
falls. SPEP, B12, and TSH were within normal limits.
Orthostatics were initially positive so given IVF and on
re-check were normal. No evidence of arrhythmia on telemetry.
Would recommend optimizing glycemic control to further limit
progression of diabetic neuropathy. He also had some proximal
lower extremity muscle weakness with elevated CK. The elevated
CK may be due to muscle injury from recent fall. Statin myopathy
was considered and his atorvastatin was stopped. His CK trended
down from 2900 to 690 at the time of discharge. Would
recommending rechecking at next appointment and if still
elevated would evaluate further for primary myopathy (check ___,
ESR) . Would also recommend EMG for further evaluation of
neuropathy and myopathy. Physical therapy was consulted for
gait and balance safety training.
Chronic issues:
#DMII: Held home onglyza, metformin, amaryl and maintained on
insulin sliding scale. His home meds were restarted on
discharge. Will follow up with ___ for further management.
.
#Peripheral neuropathy: ___ not be taking medications
appropriately. Continued home lyrica. Held amitriptyline on
admission as concern for toxicity (see above).
#HTN: Continued home lisinopril. Patient had been on amlodipine
but was not taking this medication. Patient's hypertension was
poorly controlled during this admission and he was restarted on
amlodipine 10mg daily. When this was not sufficient, he was
started on chlorthalidone 12.5mg daily. He will need outpatient
follow-up of electrolytes and possibly uptitration of his
chlorthalidone.
#HLD: Held statin in setting of elevated CK and proximal muscle
pain/weakness. Will not restart at discharge.
#Depression: Stable. Patient was not taking home cymbalta, so
continued to hold. Monitor mood while weaning off TCA.
#Peripheral vascular disease: Noted to have decreased pulses in
lower extremtities consistent with prior exam by Dr. ___
___ his vascular surgeon. When previously evaluated by
vascular in ___ and angiogram was recommended. This has
not yet been done. Dr. ___ and spoke with the
patient about rescheduling.
TRANSITIONAL ISSUES:
[ ] outpatient neuro-psychological testing to evaluate for
dementia
[ ] recheck CK and if abnormal further evaluation for myopathy
[ ] outpatient EMG to evaluate for neuropathy and myopathy
[ ] chemistry on ___ given new RX of chlorthalidone, if
electrolyte abnormalities then d/c thiazide and consider
alterative
[ ] follow up with vascular surgery for arteriogram to evaluate
for PVD
-___ need uptitration of chlorthalidone to achieve improved BP
control.
CONTACT:
-Emergency contacts: daughter ___ ___ (cell);
son ___ ___ (cell)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Onglyza *NF* (saxagliptin) 5 mg Oral daily
2. Lisinopril 40 mg PO DAILY
3. Amitriptyline 100 mg PO QAM
4. Amitriptyline 150 mg PO QPM
5. Pregabalin 75 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Atorvastatin 10 mg PO DAILY
8. Amaryl *NF* (glimepiride) 2 mg Oral BID
9. Duloxetine Dose is Unknown PO Frequency is Unknown
Patient not taking as prescribed
10. Amlodipine Dose is Unknown PO Frequency is Unknown
Patient not taking as prescribed
Discharge Medications:
1. Amitriptyline 50 mg PO QAM
2. Amitriptyline 75 mg PO HS
3. Amlodipine 10 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Pregabalin 75 mg PO DAILY
6. Chlorthalidone 12.5 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Amaryl *NF* (glimepiride) 2 mg ORAL BID
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Onglyza *NF* (saxagliptin) 5 mg Oral daily
14. Outpatient Lab Work
Please check Chem 10 on ___ and give results to MD at
rehab and fax results to ___, MD at ___
(patient's PCP).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Statin-induced myositis
Altered mental status and falls secondary to polypharmacy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted with confusion and multiple falls at home. We
think this is in part related to some of the medications you've
been taking. Specifically, Amitriptyline at high doses can cause
some of these symptoms. For this reason, we have started you on
a slow taper of this medication over the next 4 weeks.
Additionally, you may need to taper off of your lyrica too, but
this will be determined by your primary care provider. Finally,
you also had some thigh muscle pain. We believe this is related
to the atorvastatin you were taking which can sometimes cause
muscle breakdown and we saw evidence of mild muscle breakdown on
your bloodwork (an elevation of a protein marker called "CK").
Followup Instructions:
___
|
10563942-DS-15 | 10,563,942 | 21,916,624 | DS | 15 | 2159-01-01 00:00:00 | 2159-01-01 23:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / nafcillin / daptomycin
Attending: ___.
Chief Complaint:
Rhabdomyolysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o MSSA osteomyelitis of the left foot, DM, and HTN
here with daptomycin induced rhabdomyolysis. Patient has been
having ongoing care of right diabetic foot ulcer since ___
with wound care and antibiotic regimens including keflex and
doxycycline. He transitioned his podiatric care to Dr. ___ at
___, underwent debridement of bony prominence around the
talo-navicular joint
of his right foot, per op note bone appeared c/w osteomyelitis
and bone cultures grew MSSA. In conjunction with infectious
disease team, plan was put in place for 6 week course of IV
antibiotics. Started on IV nafcillin on ___, developed rash in
___. Subsequently he was switched to IV daptomycin by Dr.
___ specialist). Patient began noticing right shoulder
pain after initiation of daptomycin. CK was noted to be
elevated on ___ at ___. Daptomycin was subsequently
discontinued (original stop date of antibiotic course was ___.
Repeat labs on ___ showed CK of ___, patient was called by
Dr. ___ to come urgently to ED for suspected dapto induced
rhabdomyolysis.
In the ED, initial vs were: 97.6 81 148/64 16 99% RA. Labs were
remarkable for CK of 13,038. Patient was given 2 liters of NS
and aspirin 324 mg given troponin of 0.06. EKG was sinus rhythm
with APCs, c/w prior ECGs, no st-t wave changes. Vitals on
Transfer: 97.8 69 136/62 16 98% RA.
On the floor, the patient reports feeling well. He is without
complaints. No chest pain, sob, fever/chills/night sweats,
diarrhea, dysuria, hematuria.
Past Medical History:
Diabetes mellitus
Hypertension
Gout
Hyperlipidemia
Right Partial nephrectomy at ___
BPH
H/o nephrolithiasis
Social History:
___
Family History:
Aunt with colon cancer (deceased)
Father with CAD/angina
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
Vitals: T:97.6 BP:100/82 P:76 R:18 O2:100% O2
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no CVA tenderness
Ext: Warm, well perfused, 1+ DP pulses, dressing in place over
right foot wound, clean and dry, no clubbing, cyanosis or edema
Skin: no rashes or excoriations noted
Neuro: Moving all extremities, speech fluent
DISCHARGE PHYSICAL EXAM:
====================
Vitals: T:97.6-98.3, BP:137-142/61-65 P:62-69 ___ O2:96-99%
O2
24hr UOP: -3500; I/O 8hr +400/-965
General: Alert, oriented, no acute distress, laying in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no CVA tenderness
Ext: Warm, well perfused, 1+ DP pulses, dressing in place over
right foot wound, clean and dry, no clubbing, cyanosis or edema
Skin: no rashes or excoriations noted
Neuro: Moving all extremities, speech fluent
Pertinent Results:
LABS:
======
___ 12:25PM BLOOD WBC-9.0 RBC-3.94* Hgb-11.9* Hct-36.6*
MCV-93 MCH-30.3 MCHC-32.6 RDW-16.0* Plt ___
___ 02:15PM BLOOD WBC-9.4 RBC-3.78* Hgb-11.5* Hct-34.6*
MCV-92 MCH-30.3 MCHC-33.2 RDW-15.4 Plt ___
___ 06:50AM BLOOD WBC-6.9 RBC-3.29* Hgb-10.1* Hct-30.1*
MCV-92 MCH-30.8 MCHC-33.7 RDW-15.4 Plt ___
___ 07:38AM BLOOD WBC-5.6 RBC-3.07* Hgb-9.4* Hct-28.5*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.5 Plt ___
___ 12:25PM BLOOD Neuts-79.8* Lymphs-15.2* Monos-4.8 Eos-0
Baso-0.2
___ 02:15PM BLOOD Neuts-78.7* Lymphs-16.6* Monos-4.3
Eos-0.1 Baso-0.3
___ 12:25PM BLOOD UreaN-33* Creat-1.5*
___ 02:15PM BLOOD Glucose-310* UreaN-34* Creat-1.5* Na-130*
K-5.3* Cl-99 HCO3-19* AnGap-17
___ 04:30PM BLOOD Glucose-217* UreaN-32* Creat-1.4* Na-134
K-4.4 Cl-103 HCO3-22 AnGap-13
___ 06:50AM BLOOD Glucose-132* UreaN-27* Creat-1.3* Na-140
K-4.5 Cl-109* HCO3-22 AnGap-14
___ 07:38AM BLOOD Glucose-127* UreaN-25* Creat-1.4* Na-141
K-4.6 Cl-112* HCO3-21* AnGap-13
___ 09:40AM BLOOD Glucose-156* UreaN-26* Creat-1.4* Na-138
K-4.3 Cl-105 HCO3-23 AnGap-14
___ 12:25PM BLOOD ALT-189* AST-422* ___
TotBili-0.4
___ 02:15PM BLOOD ___
___ 06:50AM BLOOD CK(CPK)-8653*
___ 07:38AM BLOOD CK(CPK)-4394*
___ 09:40AM BLOOD CK(CPK)-2237*
___ 02:15PM BLOOD Calcium-9.5 Phos-3.5 Mg-1.9
___ 06:50AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
___ 07:38AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.1
___ 09:40AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
MICRO: None
IMAGING/STUDIES:
==============
ECG (___): Sinus rhythm. Frequent premature atrial
contractions. Compared to the
previous tracing of ___ ectopy is new.
CXR (___): IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ with h/o DM, HTN and right foot MSSA osteomyelitis s/p
surgical debridement and IV abx now with daptomycin induced
rhabdomyolysis.
# Rhabdomyolysis: Likely secondary to daptomycin, which was
discontinued on ___ after noting elevated CK. CK peaked at ~13K
during admission. Improved with IVF. CK at 2237 on day of
discharge. UOP was adequate and creatinine was in line with
previous baseline as per webOMR.
# Right foot osteomyelitis: s/p surgical debridement in ___. Antibiotic course has been completed (6 weeks IV
nafcillin and daptomycin). Patient will follow up with ___
___ podiatry (performed his surgery) in 2 weeks after
discharge. Per Dr. ___ ___, there is no need for further
antibiotics.
# Tropinemia: Noted on admission. Likely secondary to elevated
CK. Low likelihood of ACS. ECG without concerning findings.
Patients w/out chest pain. Continue home ASA 81 mg daily.
# Hypertension: BP stable on floor, largely in the 130s-140s
systolic during admission. Continued home HCTZ. Held his home
lisinopril and atenolol in setting of rhabdo given risk for ___.
As BPs were stable during admission , he was discharged off
atenolol and lisinopril. Recommend that these medications be
restarted after lab check at discharge follow up appointment.
# HLD: held statin in setting of rhabdo. Patient was discharged
off this medication given elevated CK and risk of
rhabdomyolysis. Recommend restarting on ___ follow up
pending repeat lab testing.
# DM2: on Januvia and glipizide as outpatient, held these while
inpatient as non-formulary. His diabetes was managed with a
diabetic diet and insulin sliding scale.
# Gout: continued home allopurinol.
# BPH: continued home tamsulosin and finasteride.
# ?CKD: per webOMR, creatinine has ranged from 1.4 and 1.7 prior
to this admission. During this admission creainine ranged from
1.3-1.5. Patient reports no known history of kidney disease.
Recommend possible nephrology referral as outpatient for
continued managed of his possible CKD.
TRANSITIONAL ISSUES:
# Rhabdomyolysis: patient admitted with rhabdomyolysis, thought
secondary to daptomycin. This antibiotic should be avoided going
forward. Patient's statin held while inpatient given muscle
injury. Recommend holding statin and ace-inhibitor until labs
rechecked by PCP on ___.
# Right foot osteomyelitis/foot ulcer: patient is s/p
debridement in ___ by Dr. ___ podiatry and 6 weeks of
antibiotics. Per Dr. ___ infectious disease, patient does
need any further antibiotic treatment. Should have follow up
with podiatry (Dr. ___ in 2 weeks for ongoing care of his foot
wound.
# Possible chronic kidney disease: Patient creatinine levels at
1.3-1.5 during this admission. This is in line with previous
admission labs. His eGFR is ~50ml/min. Recommend nephrology
referral for management/work up of his renal disease.
# Hypertension: patient continued on his HCTZ during admission.
BPs remained largely in 130s-140s. Lisinopril held given risk
for ___ in setting of rhabdomyolysis. Atenolol held as renally
cleared. Lisinopril and atenolol were held on discharge,
recommend reassessing labs, including kidney function on PCP
follow up and restarting home anti-hypertensives at that time if
indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Januvia (sitaGLIPtin) 100 mg oral daily
8. Lisinopril 40 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Allopurinol ___ mg PO DAILY
6. GlipiZIDE 10 mg PO BID
7. Januvia (sitaGLIPtin) 100 mg oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Rhabdomyolysis
Secondary diagnosis:
- HTN
- Diabetes mellitus
- Right foot osteomyelitis s/p debridement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for muscle
injury due to one of the antibiotics you were taking for your
foot infection. You were given fluids to prevent kidney injury
and your labs were monitored to ensure resolution of your muscle
injury. You improved and it was determined you were safe to be
discharged to home. Your atenolol, lisinopril, and statin were
held during your admission. You should not restart these until
speaking with your primary care physician. You should monitor
your blood pressures at home, if they are consistently elevated
(BP > 150), please call your primary care physician regarding
restarting your lisinopril and atenolol. Should you develop
muscle pain, difficulty with urination, increased foot pain or
fevers, please seek evaluation at a medical facility or at your
nearest emergency department.
- Your ___ Team
Followup Instructions:
___
|
10564147-DS-15 | 10,564,147 | 23,699,704 | DS | 15 | 2146-01-17 00:00:00 | 2146-01-17 16:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Codeine / Vicodin /
Opioids-Morphine & Related
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o CAD s/p CABG in ___, diastolic CHF, HTN, CKD, GERD,
hypothyroidism, depression/anxiety, osteoporosis with
compression fractures, history of hip fracture complicated by
prosthetic joint infection, low back pain, and insomnia who
presented from her PCP's office with O2 saturation down to 81%
on RA after minimal ambulation. The patient endorsed mild
worsening dyspnea on exertion, although this is of unclear
chronicity per her nephew who was present. She denies any cough
or fever. Patient has a history of chronic left lower extremity
swelling which has been stable for years since multiple
orthopedic hip surgeries, but
otherwise denied any DVT/PE risk factors including prior history
of DVT/PE, no active malignancy, hemoptysis, use of exogenous
estrogen, recent surgery or trauma within the last 4 weeks,
immobilization, long plane flights or car rides, or personal or
family history of thrombophilia.
Past Medical History:
CAD, chronic DIASTOLIC heart failure, GERD, HLD, HTN,
hypothyroid
BACK PAIN, COMPRESSION FRACTURES, osteoarthritis
DEPRESSION, anxiety
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals: ___ 2347 Temp: 98.0 PO BP: 112/71 L Lying HR: 78
RR: 18 O2 sat: 93% O2 delivery: Ra
I 1400 O 1700
-GEN: AAOx3. Comfortable. Not on oxygen during exam.
-HENT: Moist mucus membranes, atraumatic, normocephalic
-Eyes: anicteric sclerae, no conjunctival pallor. Pupils equal
and reactive to light with consensual response bilaterally.
-NECK: JVD not appreciated.
-PULM: Crackles at bases, no wheeze, no respiratory distress.
-Cardiac: systolic flow murmur II/VI, RRR
-GI: Soft, non-tender, non-distended.
-MSK: Warm, well-perfused, no edema
-NEURO: A&Ox3, No focal neurologic deficits on exam.
-MSK: Weaker in L leg compared to R. No swelling or pain in
lower extremities. Tenderness at calves resolved.
Pertinent Results:
ADMISSION LABS
___ 01:05PM BLOOD WBC-6.1 RBC-4.43 Hgb-13.6 Hct-43.2 MCV-98
MCH-30.7 MCHC-31.5* RDW-15.4 RDWSD-55.1* Plt ___
___ 01:05PM BLOOD ___ PTT-29.1 ___
___ 02:36PM BLOOD Glucose-122* UreaN-58* Creat-1.3* Na-143
K-4.6 Cl-98 HCO3-28 AnGap-17
___ 02:36PM BLOOD proBNP-965*
___ 06:00AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2
___ 06:00AM BLOOD VitB12-653 Folate-8
___ 08:50AM BLOOD TSH-3.7
___ 01:11PM BLOOD ___ pO2-28* pCO2-81* pH-7.31*
calTCO2-43* Base XS-9
___ 01:11PM BLOOD Lactate-1.4
DISCHARGE LABS
___ 06:45AM BLOOD WBC-7.4 RBC-4.02 Hgb-12.3 Hct-38.6 MCV-96
MCH-30.6 MCHC-31.9* RDW-14.5 RDWSD-51.3* Plt ___
___ 06:45AM BLOOD Glucose-100 UreaN-60* Creat-1.4* Na-138
K-4.3 Cl-92* HCO3-31 AnGap-15
___ 06:45AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 06:50AM BLOOD ___ pO2-155* pCO2-51* pH-7.44
calTCO2-36* Base XS-9
IMAGING
=======
CT Chest W/OUT CONTRAST ___:
1. Left lower lobe atelectasis, likely from aspiration. No
pulmonary edema.
2. Main pulmonary artery dilatation to 3.2 cm, with heavy
calcification of the coronary arteries, aortic arch and head and
neck vessels. Moderate aortic valvular calcification and mild
calcification of the mitral annulus.
3. 4 mm stable right upper lobe nodule, no further follow-up is
necessary.
___ BILATERAL ___: No evidence of deep venous thrombosis in
the right or left lower extremity
veins.
CXR ___:
1. Re-demonstration of patchy left basilar opacities, likely
reflective of chronic bronchitis and bronchiectasis with
scarring. No definite new focal consolidation to suggest
pneumonia identified.
2. Moderate cardiomegaly with mild pulmonary vascular
congestion.
Brief Hospital Course:
___ h/o CAD s/p CABG in ___, diastolic CHF (LVEF >55% in ___,
HTN, CKD, and depression/anxiety who presented from her PCP's
office with O2 saturation down to 81% RA after minimal
ambulation.
#Acute hypoxic hypercapnia respiratory failure
#Acute HFpEF Exacerbation
#Community acquired pneumonia
Orthopedic, volume overloaded, elevated JVD, diffuse crackles,
and elevated BNP concerning for fluid overload due to acute on
chronic diastolic heart failure. CXR with consolidation
concerning for pneumonia. No signs of ischemia on EKG. Patient
was digressed with furosemide 10mg/hour drip then transitioned
to Torsemide 40 mg from preadmission dose of 20 daily. She
completed a course of antibiotics (ceftriaxone/azithromycin) for
pneumonia with Ipratropium/albuterol; Legionella, strep pneumo
antigens, Bcx were all negative. After achieving euvolemia and
completion of antibiotics she remained hypoxic with intermittent
desats to ___ and remained on ___ NC at times over the next ___
hours. Bilateral LENIs negative and held off on CTA given Wells
score of 0 with no specific clinical signs of PE (and risk for
worsening renal function given ___. She had CT chest w/o
contrast on ___ that showed no significant pulmonary edema,
small amount of LLL atelectasis, no emphysema, and main
pulmonary artery 3.2 cm. Her VBGs are suggestive of some chronic
retention. We suspect this is a subacute to chronic process; she
may have an underlying disorder such as central sleep apnea
given her cardiac history and/or pulmonary hypertension. On day
of discharge (___) her ambulatory O2 sats had improved to 88-90
range w/ resting O2 sats consistently ___ on RA. The patient
declined home O2 and expressed an understanding of the risks.
She was scheduled for a f/u apt with Pulmonology for
consideration of further workup for hypoxemia. She is scheduled
for outpatient PFTs. She also has follow up with her ___ clinic
on ___. Discharge weight 67.1 kg.
#Hypertension: Continued amlodipine 5 mg daily, losartan 50 mg
daily
#CAD s/p CABG: Continued ASA 81mg, atorvastain 80mg, metoprolol
100mg BID
#Hypothyroidism: Continued levothyroxine 100mcg. TSH 3.7
#Depression/Anxiety: Continued sertraline 100 mg daily
#Insomnia: Continued lorazepam 0.5mg qHS PRN
#Macrocytic Anemia: Folate 8. B12 653 --> unlikely vitamin
deficiency. Smear shows metas, myelos and pros.
====================
Transitional Issues:
-f/u with primary care clinic ___ to assess oxygenation, volume
status
-Discharge weight 67.1 kg. Discharge diuretic torsemide 40
daily. Please adjust as needed.
-Pulmonary f/u apt ___. also scheduled for PFTs
-consider outpatient echo, sleep study, CPET as further workup
of hypoxemia
-Abnormal blood smear (metas, myelos, pros). Consider further
malignancy workup as outpatient
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (nephew) ___
>30 minutes spent on discharge planning
Medications on Admission:
1. Losartan Potassium 50 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Metoprolol Tartrate 100 mg PO BID
5. Torsemide 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 0.5 mg PO QHS:PRN insomnia
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing RX *albuterol
sulfate [ProAir HFA] 90 mcg 2 puff inhaled q6h prn Disp #*1
Inhaler Refills:*3
2. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by
mouth daily Disp #*60 Tablet Refills:*3
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 0.5 mg PO QHS:PRN insomnia
9. Losartan Potassium 50 mg PO DAILY
10. Metoprolol Tartrate 100 mg PO BID
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hypoxemia, Heart failure with preserved ejection
fraction
Secondary: Anemia, Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were brought to the Emergency Department from your primary
care physician's office where your oxygen saturation was found
to be low (81%) when walking.
-You were found to have fluid in your lungs.
WHAT DID YOU DO FOR ME WHILE I WAS IN THE HOSPITAL?
-We treated you with diuretics to help with the fluid in your
lungs.
-We think it is unlikely that you had pneumonia. However, since
we could not rule out the possibility that a pneumonia may have
contributed to your shortness of breath, we treated you with
antibiotics.
-We monitored your kidney function.
-You received a CT scan of your chest which did not show
pneumonia or other lung diseases.
-We adjusted the dose of your home diuretic, Torsemide, to 40mg
per day.
-You received ultrasounds of your legs which did not show
evidence of a blood clot.
-Your oxygen levels improved before discharge but are still
lower than normal.
WHAT SHOULD I DO WHEN I GO HOME?
-It is important that you take Torsemide at your new dose of
40mg per day every day.
-You will follow up with your primary care physician, ___.
___.
-You should weigh yourself on a daily basis to see whether you
may be retaining fluid. If your weight changes more than 3 lbs
from your normal weight, you should see Dr. ___.
-You should follow up with the lung doctors. ___ are scheduling
an appointment for you.
We wish you the very best!
Your ___ Team
Followup Instructions:
___
|
10564151-DS-8 | 10,564,151 | 22,973,963 | DS | 8 | 2163-01-17 00:00:00 | 2163-01-21 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Febrile neutropenia
Major Surgical or Invasive Procedure:
BM biopsy ___
History of Present Illness:
___ y/o M with MDS ___ URD allo D 198 today (D0 ___, with
prolonged admit for allo and subsequently requiring TAVR for AS
on ___ with subsequent relapse of MDS, ___ dacogen (C1D11),
now presenting w/ fever and neutropenia.
Has been feeling run down/fatigued x1 week in setting of low
counts requiring transfusions after starting dacogen. ___ had plt
trnafsusion this morning at 10 AM and noted fever at home at 5pm
to 100.6. He was premedicated for the platelet transfusion he
reports. ALso notes rash that his wife noted this evening when
it
was in the ER. Not itchy and he thinks it has largely resolved
since it was noted. Located mostly on upper chest/neck. No open
sores or lesions otherwise. Denies back pain.
Denies cough, shortness of breath, no diarrhea, no vomiting, no
dysuria, has some residual ___ edema but much better compared to
prior before the TAVR and remains stable. No fevers prior to
this
one today in recent weeks. has noted faitigue in the past week
___ starting dacogen and low counts. Does states that he has
noted some urinary "dribbling" of late, though not painful. N
hematuria. No diarrhea nausea or vomiting.
Note that after his allo transplant, subsequently noted to have
increasing CMV VL with increasing fatigue. He was started on
Valganciclovir 900 mg twice per day as of ___. Within 48
hours of starting this medication, he started to feel better
with
less fatigue. CMV VL slowly improved but with noted drop in
counts; switched to maintenance dosing of Valganciclovir and
then
discontinued as of ___ Acyclovir).
Recrudescence
of CMV viremia and restarted Valganciclvir at 950 mg daily on
___.
ED COURSE:
T 101.5, HR 103 BP 156/67 RR 18 99% RA. GIven 1L IVF and
cefepime at midnight. chemistry reassuring, ANC 210, Hct 20.8,
plts 29 (down from ___ earlier today). AP 245 (has been in this
range) but other LFTs unremarkable. INR 1.0. Lactate 0.9. CXR
with small bilateral pleural effusions otherwise unremarkable.
ON arrival to the floor he has no complaints states that he
feels
quite well. Temp is 102.7 but doesn't feel febrile he reports.
No
cough, chest pain, diarrhea, nausea/vomiting, dysuria.
Past Medical History:
ONCOLOGIC/TREATMENT HISTORY:
* In ___, enlarged right axillary lymph node biopsied and
shown to be Hodgkin's lymphoma. Received mantle radiation and
splenectomy, which was negative for his disease.
* In ___, relapsed with lymphadenopathy in his neck with
pathology consistent with nodular lymphocyte predominant
Hodgkin's lymphoma. Treatment with MOP (mechlorethamine,
vincristine and procarbazine), which completed in ___.
* Did well until the ___ when developed night
sweats, weight loss of 20 lbs. Restaging PET/CT scan on
___ showed marked increased FDG avid adenopathy within
the neck, chest abdomen and pelvis. Left cervical lymph node
biopsy on ___ showed morphologic and immunophenotypic
findings consistent with relapsed lymphocyte predominant
Hodgkin's lymphoma. Bone marrow biopsy on ___ showed a
B-cell lymphoproliferative disorder with immunostaining profile
consistent with his lymphocyte predominant Hodgkin's lymphoma.
* Status post one cycle of Rituxan from ___ to
___ with follow up PET scan on ___ showing overall
improvement in FDG avid disease burden, but with a new focus of
FDG avidity in the lower abdomen.
* Due to this new area, Mr. ___ underwent four weeks of
Rituxan, completed on ___ with follow up PET scanning on
___ showing a decrease in the size of the iliac chain
lymph nodes with no longer FDG avidity noted. Repeat bone marrow
biopsy on ___ showed no evidence for lymphoma.
* Four-week cycle of Rituxan in ___ with follow up PET scan
showing continued nodal involvement of the bilateral iliac
areas, but without increased tracer uptake.
* Underwent stem cell collections in ___ with plerixa for
given his decreased disease burden.
* Follow up CT scan on ___ showed essentially stable
disease, although the right pelvic area was decreased in size,
then received another cycle of Rituxan in ___. Repeat PET
imaging on ___ showed a new focal area of increased FDG
avidity with SUV max of 6.6 along the known right internal iliac
chain nodal conglomeration but without any other new uptake
identified. Size of the nodal chain unchanged in size.
* FDG tumor imaging on ___ showed the previously noted
nodal conglomeration measuring 55 x 30 mm in the right lower
pelvis is overall unchanged in size, however, note of 25 mm
focus within this conglomerate demonstrating increased FDG
avidity with SUV max of 17, previously 6.6. A second large
celiac nodal mass is non-FDG avid, measuring 37 x 25 mm with
multiple other bilateral iliac chain lymph nodes are stable and
not demonstrating FDG avidity.
* Initiated treatment on ___ on Protocol ___ A Phase
___ Open-label study of Pralatrexate and Gemcitabine and
Vitamin B12 and Folic acid Supplementation in Patients with
Relapsed or Refractory Lymphoproliferative Malignancies. He is
status post 10 cycles but received C10 D1 treatment only and
required an admission for fever. He did not receive D 15
treatment. Off study as of ___.
* PET scan on ___ shows focal right pelvic FDG uptake
adjacent to the urinary bladder with SUV max 14.6 corresponding
to 1.8 cm nodule associated with the right pelvic side wall
lymph node conglomerate. No other areas of FDG-avid disease.
* XRT to right pelvis from ___ to ___.
* FDG tumor imaging from ___ shows multiple new FDG avid
lesions, mainly in the pelvic region although they remain ~ 1 -
2 cm's in size. CT scan in ___ shows no change in size of
lymph nodes.
* FDG tumor imaging from ___ showed innumerable new FDG
avid lesions and previously seen FDG-avid nodes have enlarged
and demonstrate increased uptake. The largest lymph nodes now
measure from 3 - 5 cm in size.
* Given Rituxan on ___ and ___ cycle of Bendamustine on
___ and ___.
* ___ cycle of Bendamustine/Rituxan on ___. PET scan on
___ showed marked decrease in size of previously seen
lymph nodes in the mesenteric, iliac, and pelvic chains with no
FDG avid lymph nodes. The only per size criteria pathologically
enlarged lymph node is a non FDG avid right mesenteric
nodemeasuring 31 x 16 mm. 2. No new lesions.
* ___ cycle of Bendamustine/Rituxan on ___.
* ___ cycle of Bendamustine/Rituxan on ___. PET scan on
___ showed no FDG avid lymphadenopathy identified with
previously seen lymph nodes further decreased in size.
* ___ cycle of Bendamustine/Rituxan on ___
* PET scan in ___ showed no FDG-avid adenopathy. Last CT in
___ and in ___ showed overall stable known mesenteric and
right pelvic lymphadenopathy with no new enlarged lymph nodes
within the chest, abdomen, or pelvis.
* CT scan on ___ showed interval growth in mesenteric and
bilateral external iliac lymphadenopathy.
* ___, started Zydelig 150 mg twice per day.
* POC placed on ___
* ___ to ___, 4 doses of Rituxan.
* ___, noted for dropping platelet count. BM aspirate with
multiple cytogenetic abnormalities with MDS.
PAST MEDICAL/SURGICAL HISTORY:
1. Coronary artery disease status post LAD and diagonal branch
PCI in ___, no angina. Recent stress test in ___ without EKG
changes with noted dyspnea on exertion.
2. Recent echo on ___ with normal left ventricular wall
hickness and cavity size with hyperdynamic systolic
function(LVEF > 75%). Severe calcific aortic valve stenosis.
Mild mitral and mild to moderate aortic regurgitation.
3. Hypertension.
4. Hyperlipidemia.
5. Right bundle-branch block.
6. Surgical procedure for anal fissure in ___.
7. Sleep apnea, uses CPAP.
8. Herpes zoster in ___.
9. Splenectomy in ___.
Social History:
___
Family History:
Sister died in her ___ from melanoma. No other family history
of cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T 102.7 HR 106 RR 20 96%RA
General: NAD, ambulating around the room, comfortable
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, but has III/VI systolic m urmur
PULM: crackles at bases bilaterally/symmetric ___ way up lung
fields no wheezing
GI: BS+, soft, NTND, no masses or hepatosplenomegaly. midline
abd scar
LIMBS: 1+ pitting edema bilaterally but no clubbing, tremors,
or
asterixis; no inguinal adenopathy
SKIN: Rash is fading already per pt and is subtle on exam, most
prominent on upper shoulders over clavicles and lower parts of
neck, no blistering lesions, also present on lower back and
lower
extremities but very faded in these areas. No skin breakdown or
blisters
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact.
DISCHARGE PHYSICAL EXAM:
Vitals: afebrile ___ 142/74 18 94RA
Gen: Pleasant gentleman, well appearing, NAD
HEENT: MMM, OP with well healing blister on R buccal mucosa, few
small palatal petichiae, no thrush
CV: RRR, III/VI systolic murmur loudest RUSB
LUNGS: Diminished breath sounds in lung bases bilaterally.
Otherwise clear.
ABD: Soft, NTND, NABS
EXT: WWP, no edema
SKIN: Mild erythema of the palms and soles of feet, otherwise no
rashes
NEURO: A&Ox3, moving all extremities equally
LINES: L port, c/d/i
Pertinent Results:
ADMISSION LABS:
___ 08:52AM BLOOD WBC-0.5* RBC-2.48* Hgb-7.9* Hct-23.1*
MCV-93 MCH-31.9 MCHC-34.2 RDW-15.2 RDWSD-46.1 Plt Ct-14*#
___ 08:52AM BLOOD Neuts-28* Bands-0 Lymphs-59* Monos-4*
Eos-9* Baso-0 ___ Myelos-0 AbsNeut-0.14*
AbsLymp-0.30* AbsMono-0.02* AbsEos-0.05 AbsBaso-0.00*
___ 08:52AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
___ 08:52AM BLOOD Plt Smr-RARE Plt Ct-14*#
___ 10:50PM BLOOD ___ PTT-36.5 ___
___ 10:50PM BLOOD Glucose-100 UreaN-21* Creat-1.0 Na-139
K-3.7 Cl-105 HCO3-27 AnGap-11
___ 10:50PM BLOOD ALT-34 AST-31 LD(___)-266* AlkPhos-245*
TotBili-0.9
___ 10:50PM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.2 Mg-1.8
___ 06:00AM BLOOD Hapto-<10*
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-0.6* RBC-2.77* Hgb-8.3* Hct-24.7*
MCV-89 MCH-30.0 MCHC-33.6 RDW-13.5 RDWSD-44.2 Plt Ct-11*#
___ 12:00AM BLOOD Neuts-20* Bands-0 Lymphs-78* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.12*
AbsLymp-0.47* AbsMono-0.01* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-108* UreaN-23* Creat-0.9 Na-140
K-3.3 Cl-106 HCO3-26 AnGap-11
___ 12:00AM BLOOD ALT-23 AST-29 LD(___)-251* AlkPhos-206*
TotBili-0.5
___ 12:00AM BLOOD TotProt-5.1* Albumin-3.2* Globuln-1.9*
Calcium-8.2* Phos-2.7 Mg-2.1
===========================================================
MICRO:
Respiratory viral screen and culture neg
___ 5:42 am Immunology (CMV) Source: Line-POC.
**FINAL REPORT ___
CMV Viral Load (Final ___:
1,810 IU/mL.
___ 12:00 am Immunology (CMV) Source: Line-poc.
**FINAL REPORT ___
CMV Viral Load (Final ___:
227 IU/mL.
Blood cultures: ___ x2, ___ x 1: all neg
urine cx: neg
HBV Viral Load (Final ___: Not detected
___ 7:06 pm BONE MARROW
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
============================================================
IMAGING/STUDIES:
___ CT SINUS
1. Mild sinus disease, as described above.
2. Mild leftward deviation of the nasal septum causing slight
lateral
displacement of the left middle terminate.
___ CT CHEST
Mild bronchial cuffing and septal thickening are best explained
by pulmonary edema, in the presence of new small nonhemorrhagic
layering pleural effusions and plain radiographic evidence of
sudden onset.
___ RUQ ULTRASOUND
Cholelithiasis with mild gallbladder distention and mild wall
edema. Mild
wall edema is new from prior studies, however degree of
distension is less
than what was seen in ___. In the absence of
pericholecystic fluid and with a negative sonographic ___
sign, acute cholecystitis is felt to be less likely, and wall
edema may be attributed to global volume overload. Close
clinical follow-up is recommended, and short interval repeat
right upper quadrant ultrasound or HIDA scan could be
considered.
___ ECHOCARDIOGRAM
The left atrium is moderately dilated. Normal left ventricular
wall thickness, cavity size, and regional/global systolic
function (biplane LVEF = 65%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. A ___ 3 aortic
valve bioprosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and high
normal transvalvular gradients. The effective orifice area/m2 is
moderately depressed (0.75; nl >0.9 cm2/m2) Trace aortic
regurgitation is seen. The mitral valve leaflets and annulus are
moderately thickened/calcified. The gradient is increased, but
there is no mitral stenosis. There is no mitral valve prolapse.
Mild to moderate (___) mitral regurgitation is seen. The
severity of mitral regurgitation may be UNDERestimated due to
acoustic shadowing (suggested by high mean mitral gradient).
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Well seated ___ 3 Bioprosthesis with high normal
gradient and normal EOA but slightly depressed EOA/m2. Trace
aortic regurgitation. Mild-moderate mitral regurgitation.
Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the ___ 3 bioprosthesis is similar. The mean mitral valve
gradient and the estimated PA systolic pressure are now higher.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ Portable CXR
IMPRESSION: Compared to chest radiographs since ___, most
recently ___.
Mild opacification at the lung bases has improved. This could
have been due to dependent edema as well as aspiration or
pneumonia, provided patient has been treated with antibiotics.
Heart size is normal. Small pleural effusions are likely. No
pneumothorax.
Left central venous infusion port catheter ends close to the
superior
cavoatrial junction.
==========================================================
PATHOLOGY
___ BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:
HYPOCELLULAR BONE MARROW WITH TRILINEAGE DYSPOIESIS AND
INCREASED BLASTS
CONSISTENT WITH ACUTE MYELOID LEUKEMIA, THERAPY-RELATED. SEE
NOTE.
NOTE: By immunohistochemistry CD34 highlights myeloblasts
occupying 50% of cellularity. CD117 highlights approximately 50%
myeloid precursors. E-cadherin and glycophorin highlight small
portion of erythroid precursors. Myeloperoxidase labels 20% of
cellularity. Overall, the findings are consistent with
involvement by acute myeloid leukemia. Given the patient's
karyotype on the current and a previous marrow, the findings are
consistent with therapy-related acute myeloid leukemia.
Bone marrow immunophenotyping:
INTERPRETATION: Immunophenotypic findings show the presence of
8.5% myeloblasts in a sample with limited cellularity. Blasts
percentage is best assessed on morphologic grounds, hence
correlation with marrow findings (see separate pathology report
___ is recommended.
Brief Hospital Course:
___ yo M h/o MDS ___ URD allo-HSCT ___, TAVR for AS ___,
subsequent relapse of MDS now on decitabine C1, who presented
with febrile neutropenia.
# Neutropenic fever: Patient presented with ongoing fevers,
otherwise well appearing with all other vital signs stable. No
source was identified despite extensive workup including
multiple studies for bacterial, fungal, mycobacterial, and
fungal sources. He was continued on vancomycin, cefepime,
metronidazole, posaconazole, valganciclovir, and lamivudine.
Fevers resolved. Vancomycin and metronidazole were discontinued,
and cefepime was transitioned to levaquin. He remained afebrile
and was discharged on levaquin, posaconazole, valganciclovir and
lamivudine to be continued as determined by his outpatient
providers.
# Myelodysplastic syndrome: ___ URD allo-HSCT ___, with
subsequent relapse in ___, now on decitabine. Bone marrow
biopsy was done here with increase in blast percentage meeting
criteria for therapy-related AML. Prophylaxis with atovaquone,
acyclovir, and posaconazole was continued. Discharged with plan
to return for second cycle of decitabine as an outpatient.
# Severe aortic stenosis ___ TAVR in ___: Patient does not
require chronic diuresis. He had some volume overload in house
in setting of large volumes of IV antibiotics, requiring
intermittent diuresis with IV Lasix. He had repeat
echocardiogram which showed slight worsening of prior mitral
regurg and pulmonary hypertension. He is not on antiplatelet or
anticoagulation agent given thrombocytopenia but may require
these if counts improve.
# Atrial fibrillation: Has prior history of RVR with
hypotension; remained in sinus rhythm here. Continued home
diltiazem. Not on anticoagulation given his thrombocytopenia.
# Coronary artery disease: Left heart cath from ___ with
80% diagonal lesion with plans for medical management. Contineud
home statin. Aspirin held as above for thrombocytopenia.
# Gastroesophageal reflux disease: Longstanding with h/o
radiation. Continued home nexium, prn famotidine.
# Sleep apnea: Continued CPAP.
====================
TRANSITIONAL ISSUES:
====================
[] Pt to f/u with ___ in clinic on ___ with plan to start second cycle of decitabine if doing well.
[] Pt come in for labwork (CBC w/diff, chem7, LFTs) ___
with tranfusions prn for Hgb <7, plt<10 until f/u on ___
[] If/when platelet counts improve, consider restarting
antiplatelet/anticoagulation given recent TAVR and history of
atrial fibrillation.
[] Valgancyclovir dosing changed to treatment dose of 900mg BID
[] Discharged on levaquin 750mg daily (___) for neutropenic
fever to be continued at the discretion of his oncologist.
Please monitor QTc while on levaquin and posaconazole. QTc
stable at 456 on day of discharge.
[] Started on lamivudine (___) to prevent HBV reactivation
[] Fluconazole was discontinued this admission in favor of
posaconazole per ID recommendations in setting of neutropenic
fever from unknown source.
- CODE STATUS: Full
- CONTACT INFORMATION: ___ (wife/HCP): (c)
___, (h) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 1500 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. NexIUM 24HR (esomeprazole magnesium) 20 mg oral BID
4. Famotidine 20 mg PO DAILY:PRN heartburn
5. Fluconazole 200 mg PO Q24H
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. FoLIC Acid 1 mg PO DAILY
8. LORazepam 0.5 mg PO Q8H:PRN nausea/anxiety/insomnia
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. PredniSONE 2.5 mg PO DAILY
11. ValGANCIclovir 900 mg PO Q24H
12. Vitamin D 1000 UNIT PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Famotidine 20 mg PO DAILY:PRN heartburn
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. LORazepam 0.5 mg PO Q8H:PRN nausea/anxiety/insomnia
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. PredniSONE 2.5 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. LaMIVudine 100 mg PO DAILY
RX *lamivudine 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
15. Posaconazole Delayed Release Tablet 300 mg PO DAILY
RX *posaconazole [Noxafil] 100 mg 3 tablet(s) by mouth daily
Disp #*90 Tablet Refills:*0
16. ValGANCIclovir 900 mg PO BID
17. NexIUM 24HR (esomeprazole magnesium) 20 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Neutropenic fever
Secondary
Myelodysplastic syndrome
Severe aortic stenosis ___ transcatheter aortic valve
replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with fever while your white
blood cell count was very low (neutropenic fever). You were
started on broad spectrum antibiotics. We did a number of tests
to look for the source of the fever but did not identify it. You
were given blood and platelet transfusions as needed. You were
discharged home to complete more treatment as an outpatient. It
is extremely important that you call your doctor or go to the ER
as soon as possible if you start to feel unwell or have fever.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
10564547-DS-17 | 10,564,547 | 25,833,640 | DS | 17 | 2148-10-29 00:00:00 | 2148-10-29 16:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right foot cellulitis
Major Surgical or Invasive Procedure:
___
1. Right common femoral endarterectomy and patch closure using
bovine pericardium.
2. Endovascular stenting of right external iliac artery using a
7 x 60 Complete stent and post dilation using a 6 mm balloon.
History of Present Illness:
Ms. ___ is an ___ yo woman with a PMH of HTN, PAD, MGUS, PMR,
RA, and COPD who presents to ___ for R foot cellulitis. She
was seen at ___ on ___ for a 1-week history of
increasing swelling and pain over the toes of R foot. No injury
she can recall. She was finding it more difficult to walk. She
was noted to have diffuse erythema and swellig with a black
blister on toes and decreased pulse. She also has a baseline
SEM. She was referred to ___ for further evaluation.
In the ED, VS: 97.4 83 188/82 18 97% Labs significant for a
normal CBC/BMP/lactate. She was given levofloxacin and CTX in
the ED and blood cx were drawn. Podiatry was consulted and
reviewed her imaging studies, which showed no acute fractures.
She was transferred to medicine for IV abx. Upon transfer, VS
98.1 67 156/81 16 94% RA
On the floor, Ms. ___ had no complaints and said her foot
only hurt when she walked. She is frustrated that she is in the
hospital.
Past Medical History:
HYPERCHOLESTEROLEMIA
Intolerance of drug
TOBACCO USE
HYPERTENSION - ESSENTIAL
OSTEOPOROSIS, UNSPEC
AORTIC VALVE INSUFFIC
Advanced directives, counseling/discussion
CATARACT - NUCLEAR SCLEROTIC SENILE
MACULAR CYST / HOLE
PAD (peripheral artery disease)
MGUS (monoclonal gammopathy of unknown significance)
PMR (polymyalgia rheumatica) dx ___ on chronic prednisone
COPD, mild
ENROLLED - PRIMARY CARE CASE MANAGEMENT (___) (NOT DX, FOR PROB
LIST ONLY)
RA - started plaquinel ___
Social History:
___
Family History:
father with DM
Physical Exam:
ADMISSION PHYSICAL:
PHYSICAL EXAM:
Vitals - 98.1 67 156/81 16 94% RA
GENERAL: NAD
HEENT: AT/NC
NECK: nontender supple neck
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: Patient with erythema and mild swelling over the
dorsum of her foot. She stated it looked better than earlier in
the day. A black blister noted on the side of the small toe.
Tender to palpation
PULSES: absent DP pulses bilaterally
NEURO: Alert and communicating well, moving all extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
========================
DISCHARGE PHYSICAL EXAM:
VS: T: 98.0 HR: 71 BP: 138/68 RR: 17 SaO2: 93%RA
GEN: NAD, A&O
CV: RRR
PULM: CTA bilaterally
ABD: Soft, non-tender, mildly distended
EXT: R groin site c/d/i. Dry gangrene of the distal right fifth
toe.
PULSES: ___ dopplerable bilaterally
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
___ 04:49AM 11.9 3.85 12.7 38.4 100 33.1 33.2 14.0
313
___ 06:39AM 9.6 3.43 11.1 33.9 99 32.4 32.7 14.4
231
___ 05:20AM 10.5 3.22 10.4 31.8 99 32.3 32.7 14.3
193
___ 05:20AM 9.3 3.31 11.0 33.2 100 33.1 33.0 14.0
151
___ 07:00PM 9.6 3.38 11.1 33.7 100 32.9 33.0 13.9
160
___ 04:22AM 8.8 3.81 12.5 37.7 99 32.7 33.0 14.0
156
___ 07:00AM 7.2 3.73 12.2 36.6 98 32.7 33.4 14.0
159
___ 07:32AM 11.7 4.07 13.1 40.2 99 32.3 32.7 14.2
178
___ 01:11AM 7.8 4.41 13.9 42.9 97 31.6 32.5 14.0
179
___ 06:55AM 8.0 4.71 15.5 46.6 99 33.0 33.3 14.0
188
___ 07:30AM 9.8 4.81 15.7 47.8 99 32.7 32.9 13.8
211
___ 09:17PM 9.0 4.81 15.7 46.8 97 32.7 33.6 14.0
190
RENAL & GLUCOSE Glu BUN Cr Na K Cl HCO3 AnGap
___ 04:49AM 158 17 0.4 136 4.4 100 24 16
___ 06:39AM 87 13 0.5 136 4.4 ___
___ 05:20AM 82 13 0.4 133 4.0 ___
___ 05:20AM ___ 138 4.4 ___
___ 05:20AM ___ 138 3.6 ___
___ 07:00PM 144 10 0.5 138 4.0 ___
___ 04:22AM 126 13 0.5 144 3.7 ___
___ 07:00AM 78 16 0.6 142 3.7 ___
___ 07:32AM ___ 142 5.0 ___
___ 01:11AM 100 25 0.7 143 3.7 ___
___ 06:55AM 88 17 0.5 142 3.7 ___
___ 07:30AM 95 19 0.5 139 4.2 ___
___ 09:17PM 125 20 0.5 143 3.9 ___
CHEMISTRY TotProt Ca Phos Mg
___ 04:49AM 8.3 3.9 2.1
___ 06:39AM 8.1 2.5 2.1
___ 05:20AM 8.0 2.7 2.1
___ 05:20AM 8.3 3.2 2.2
___ 05:20AM 8.2 4.3 2.4
___ 07:00PM 7.9 3.7 1.8
___ 04:22AM 8.1 2.9 2.0
___ 07:00AM 8.4 3.7 2.2
___ 07:32AM 9.0 4.1 2.2
___ 01:11AM 8.8 5.0 2.4
___ 06:55AM 9.7 4.2 2.2
___ 07:30AM 9.6 3.8 2.2
=================================
___ ___:
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Small amount of subcutaneous edema around right ankle at
site of patient's injury.
FOOT ANKLE PLAIN FILM
IMPRESSION:
No acute fracture or dislocation.
===============================
___ ARTERIAL STUDIES:
IMPRESSION:
On the right there is critical limb ischemia. With multilevel
disease
including severe inflow disease above the groin. The left there
is severe peripheral vascular disease with multilevel
involvement including the inflow with additional forefoot
ischemia in the critical range. If clinically indicated
recommend further imaging. ABI 0.31 and 0.35 in DP, and ___
respectively.
===========================
___ CTA Aorta/BiFem/Iliac
IMPRESSION:
1. Extensive and multifocal atheromatous disease, as described
above, with occlusion of the bilateral superficial femoral
arteries and distal reconstitution via small branches at the
level of ___ canal.
2. Near complete occlusion of the right common femoral artery
just prior to its bifurcation.
3. Occlusion of the posterior tibial arteries bilaterally.
4. Cholelithiasis
===========================
___ EKG Stress
IMPRESSION: No anginal symptoms or additional ST segment changes
noted
from baseline to vasodilator stress. Frequent APBs noted
throughout the
procedure. Resting systolic hypertension with appropriate
hemodynamic
response to the Persantine infusion. Nuclear report sent
separately.
FINDINGS:
Left ventricular cavity size is normal with EDV of 65 mL.
Slight attenuation at the base of the inferior wall is likely
secondary to attenuation. Rest and stress perfusion images
otherwise reveal uniform tracer uptake throughout the left
ventricular myocardium. No reversible focal perfusion
abnormality is demonstrated.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is normal at
65%.
IMPRESSION:
No focal perfusion abnormality. Normal LVEF 65%.
==========================
___ VENOUS DUPLEX BILATERAL UPPER & LOWER
- Patent bilateral basilic and cephalic veins.
- Patent bilateral great and small saphenous veins. Both small
saphenous veins have scattered calcifications.
=========================
___ ARTERIALS
IMPRESSION:
Interval improvement of the right inflow post stenting and
endarterectomy. Otherwise, significant left greater than right
inflow and SFA disease.
=========================
___ CT ABD/PELV w/ contrast
IMPRESSION:
1. Small bowel containing right inguinal hernia without evidence
of
strangulation or obstruction is similar in appearance to prior
CT ___. Oral contrast is visualized within the
herniated bowel loops as well as within the distal small bowel
and colon.
2. New small left and small to moderate right pleural effusions
with associated bibasilar atelectasis.
3. Atherosclerotic disease of the abdominal and pelvic arterial
vasculature.
=========================
___ ABD UPRIGHT/SUPINE
IMPRESSION:
Small bowel containing right inguinal hernia without evidence of
obstruction or free intraperitoneal air.
Brief Hospital Course:
___ w/ HTN, PAD, and AV insufficiency who was admitted ___
with R toe gangrene. CTA demonstrated R ilio-femoral disease and
R SFA occlusion. She was treated with antibiotics and underwent
preoperative stress testing which was negative, as well as
preoperative vein mapping. She then underwent R femoral
endarterectomy with right external iliac stent ___.
Of note, the acute care surgery service was consulted to
determine if her R femoral hernia needed repair simultaneously.
Together with Dr. ___ the acute care surgery team, it
was felt that because the patient was asymptomatic and
there was no visible bowel, we would defer repair of the hernia.
She remained stable post-operatively and was transferred to the
floor for further care. On POD2, she developed atrial
fibrillation with RVR, requiring atenolol and diltiazem for rate
control. Her abdomen was also distended. CT abdomen/pelvis
showed the large known hernia, but no evidence of bowel
obstruction or strangulation.
She received furosemide on POD3 for fluid overload.
On POD4, her abdomen remained distended, but KUB showed no
evidence of colonic distension or obstruction. She was
transitioned to PO antibiotics on POD4. Prior to discharge, her
abdominal distension improved significantly, and she was
tolerating a diet and having bowel movements. Lisinopril 10mg
daily was added to her medication regimen to better control her
hypertension. She was discharged to rehab on POD6, ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Alendronate Sodium 70 mg PO 1X/WEEK (___)
5. Aspirin 325 mg PO DAILY:PRN pain
6. calcium carbonate-vitamin D3 600mg (1,000mg) -1,000 unit oral
daily
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. Levofloxacin 750 mg PO Q48H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*1
3. Alendronate Sodium 70 mg PO 1X/WEEK (___)
4. calcium carbonate-vitamin D3 600mg (1,000mg) -1,000 unit oral
daily
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
7. Atenolol 50 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth qdaily Disp #*30
Tablet Refills:*0
11. 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 #*14 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
13. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
___ cause constipation. Use with laxatives.
RX *oxycodone 5 mg ___ capsule(s) by mouth q4 hours Disp #*30
Capsule Refills:*0
14. Acetaminophen 650 mg PO Q6H:PRN pain/headache
15. Bisacodyl ___AILY:PRN constipation
16. Docusate Sodium 100 mg PO BID
17. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth DAILY Disp #*60 Tablet
Refills:*1
18. Hydroxychloroquine Sulfate 200 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
PRIMARY:
Cellulitis
Dry Gangrene
Peripheral Vascular Disease
right lower extremity ischemia with ulcer
SECONDARY:
HYPERCHOLESTEROLEMIA
TOBACCO USE
HYPERTENSION - ESSENTIAL
OSTEOPOROSIS, UNSPEC
AORTIC VALVE INSUFFIC
Advanced directives, counseling/discussion
CATARACT - NUCLEAR SCLEROTIC SENILE
MACULAR CYST / HOLE
PAD (peripheral artery disease)
MGUS (monoclonal gammopathy of unknown significance)
PMR (polymyalgia rheumatica) dx ___ on chronic prednisone
COPD, mild
RA - started plaquinel ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___:
You were hospitalized at ___
for a foot infection. You were treated with IV antibiotics. You
were found to have a blood blister on your right pinky toe which
continued to worsen over your stay. This was likely trauma
induced but was not healing because you were found to have poor
peripheral circulation to your leg. Arterial blood flow studies
confirmed this. You were transferred to the vascular surgery
service for further management of these issues.
VASCULAR SURGERY DISCHARGE INSTRUCTIONS:
MEDICATION:
Take Aspirin 81(enteric coated) once daily
Take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10564547-DS-19 | 10,564,547 | 20,471,993 | DS | 19 | 2151-01-09 00:00:00 | 2151-01-10 10:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Left heart catheterization ___
History of Present Illness:
___ with history of HTN, PAD and COPD who was recently admitted
for flash pulmonary edema due to hypertensive emergency who was
found to have severe aortic stenosis(elected for outpatient work
up) presents with progressive dyspnea and left sided chest
pressure x1day.
Patient states the onset of her symptoms was gradual after she
exerted herself. He chest pressure is located on her left chest
and is without radiation. Upon arrival to the emergency room the
patient received 20 Lasix IV with good urine output and
resolution of her symptoms. She is currently chest pain free.
Per EMS the patient was hypoxic to the ___, though has not had
hypoxia while in house.
ROS: no fevers/chills. No palpitations. No cough. No n/v/d,
Prior 1 week of diarrhea which has since resolved, though still
notes loose stool. No dysuria or frequency.
In the ED, initial vitals were:
T 97.6 HR 86 BP 183/73 R 20 SpO2 100% Nasal Cannula
- Labs notable for:
Lg Leuks, Few Bacteria and 19 WBC on UA
Trop-T: <0.01
proBNP: 2611WBC 17
Hgb 8.9
- Imaging was notable for: CXR with mild cephalization.
Increased lung volumes, mild blunting of costophrenic angles and
loss of left heart border (my interpretation)
- Patient was given:
___ 23:04 IV Furosemide 20 mg
___ 23:04 IH Albuterol 0.083% Neb Soln 1 NEB
___ 23:04 IH Ipratropium Bromide Neb 1 NEB
___ 01:26 IV Azithromycin (500 mg ordered)
___ 01:26 IV CeftriaXONE 1 g
Upon arrival to the floor, patient reports resolution of dyspnea
and chest pain.
REVIEW OF SYSTEMS: per HPI
Past Medical History:
HYPERTENSION
HYPERCHOLESTEROLEMIA
AORTIC VALVE INSUFFIC
PAD status post gangrene of her toe, underwent surgery
endarterectomy and stent ___
Postop atrial fibrillation after vascular surgery which resolved
MGUS
PMR dx ___ on chronic prednisone
COPD, mild
RA - started plaquinel ___
OSTEOPOROSIS
Social History:
___
Family History:
father with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: T 98.2 BP 138/89 HR 73 R 20 SpO2 100% RA Wt 41kg
GEN: NAD
HEENT: elevated JVP to midneck at 45 degrees
___: regular, ___ SEM RUSB
RESP: Mild end expiratory wheezing, mild basilar crackles
ABD: NTND
EXT: warm, no edema
NEURO: CNII-XII grossly intact strength ___ UE and ___ b/l
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.6 122-140/58-71 ___ 18 95/97/RA
I/O: 8H: ___ 24H: 1120/1250+
Wt: 40.1kg (___) 40.1kg (___) NR (___)
GEN: lying in bed, somnolent but arousable, NAD
HEENT: patient with mild bruising skin of R lower face,
improving from prior. speech clear.
CV: regular, ___ SEM most notable at ___, late peaking
RESP: LCTAB, however patient with poor inspiratory effort
ABD: NABS, abdomen soft, nt
EXT: WWP, no edema. R shoulder swollen anteriorly compared to
L, mildly warm but not erythematous, with limited ROM compared
to L in regards to ADduction/ABduction or internal/ext rotation.
TTP over distal clavicle. Overall improved from yesterday.
NEURO: CNII-XII intact, MAE, speech clear and fluent
Pertinent Results:
Admission labs
===============
___ 10:50PM ___ PTT-30.6 ___
___ 10:50PM NEUTS-83.5* LYMPHS-6.4* MONOS-6.1 EOS-3.1
BASOS-0.4 IM ___ AbsNeut-14.79* AbsLymp-1.13* AbsMono-1.08*
AbsEos-0.54 AbsBaso-0.07
___ 10:50PM WBC-17.7*# RBC-2.88* HGB-8.9* HCT-30.3*
MCV-105* MCH-30.9 MCHC-29.4* RDW-15.2 RDWSD-58.4*
___ 10:50PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.6
MAGNESIUM-2.6
___ 10:50PM CK-MB-4 proBNP-2611*
___ 10:50PM cTropnT-<0.01
___ 10:50PM ALT(SGPT)-22 AST(SGOT)-40 CK(CPK)-69 ALK
PHOS-108* TOT BILI-0.3 DIR BILI-<0.2 INDIR BIL-0.3
___ 10:50PM GLUCOSE-118* UREA N-25* CREAT-0.7 SODIUM-140
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
___ 10:51PM O2 SAT-47
___ 10:51PM ___ PO2-30* PCO2-52* PH-7.31* TOTAL
CO2-27 BASE XS--1
___ 12:55AM URINE RBC-2 WBC-19* BACTERIA-FEW YEAST-NONE
EPI-2
___ 12:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 06:05AM CK-MB-4 cTropnT-0.01
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-13.2* RBC-2.72* Hgb-7.9* Hct-26.1*
MCV-96 MCH-29.0 MCHC-30.3* RDW-17.9* RDWSD-62.7* Plt ___
___ 06:05AM BLOOD Neuts-79* Bands-0 Lymphs-10* Monos-7
Eos-2 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-___*
AbsLymp-1.52 AbsMono-1.06* AbsEos-0.30 AbsBaso-0.00*
___ 05:40AM BLOOD Glucose-90 UreaN-41* Creat-0.8 Na-137
K-3.9 Cl-103 HCO3-23 AnGap-15
___ 05:40AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.7*
___ 05:45AM BLOOD CRP-74.8*
___ 07:50AM BLOOD SED RATE-Test
___ 11:30 am JOINT FLUID Site: SHOULDER
RIGHT SHOULDER JOINT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
IMAGING
=========
CXR ___
IMPRESSION:
Interval improvement in bibasilar opacities and pulmonary
vascular congestion, likely representing resolving edema.
CT Chest ___ IMPRESSION: Severe aortic valve and annular
calcification. Moderate coronary artery calcifications. No
aneurysmal dilatation of the ascending aorta. No calcification
of the anterior aspect of the ascending aorta. Normal aortic
branch pattern. Moderate to severe centrilobular and paraseptal
emphysema with mild, diffuse bronchial wall thickening and mild
bronchiectasis in keeping with smoking related lung changes.
Superimposed interstitial thickening may represent superimposed
interstitial edema or residual/resolving pneumonia. Small
right-sided pleural effusion. Mild dilatation of the pulmonary
truncus and pulmonary hypertension should be excluded. A couple
of sub 4 mm pulmonary nodules and mild irregular thickening of
the right inferior pulmonary ligament do not pose clinical risk
of malignancy.
CTA Chest ___:
IMPRESSION:
1. No acute process.
2. Severe atherosclerosis. For measurements of iliofemoral
vessels please see dedicated cardiac CT.
3. Cholelithiasis.
Preliminary CT Chest Cardiac Morph:
IMPRESSION:
Aortic valve stenosis without evidence of aortic aneurysm.
Measurements as provided above (measurements are slightly
impaired by motion artifact). Marked atherosclerotic disease as
well as prior intervention (right external iliac stent) and
occlusion of the superficial femoral arteries bilateral with
narrowing of the arterial lumen to less than 6 mm bilateral.
Patent subclavian arteries bilaterally with lumen diameter less
than 6 mm.
Trans apical or trans aortic (direct) arterial access advised.
Severe pulmonary emphysema with associated bronchial wall
thickening and retained secretions suggesting bronchial
inflammation. Subsegmental atelectasis of the lateral segment of
the right middle lobe.
Dilated pulmonary arteries suggest pulmonary hypertension.
RHC ___
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is without significant disease.
* Left Anterior Descending
The LAD is calcified, with 40-50% eccentric mid following a
small aneurysmal region.
The ___ Diagonal is with mild disease.
* Circumflex
The Circumflex is calcified, with 50% mid.
The ___ Marginal is without significant disease.
* Right Coronary Artery
The RCA is 100% occluded proximally, with right-to-right and
left-to-right collaterals to the distal vessel.
Impressions:
Moderate LAD and LCx disease
Chronic total occlusion of the RCA
X ray R shoulder ___
IMPRESSION:
No acute fracture or dislocation involving the right shoulder.
Brief Hospital Course:
___ with severe AS presents with dyspnea and chest pressure.
ACTIVE ISSUES:
#Aortic Stenosis, severe: aortic valve area of 0.4 cm2 with mean
aortic valve gradient of 40 mm Hg found on last hospitalization.
Due to failure of outpatient trial given quick readmission after
last admission, decision was made to undergo TAVR workup while
patient was kept impatient and patient was followed by TAVR
team. She was determined to be high risk for surgical valve
replacement x2. She underwent cardiac catheterization on ___
which showed Moderate LAD and LCx disease and Chronic total
occlusion of the RCA. She underwent tooth extraction by ___.
Continued clopidogrel and statin. She underwent planning CT for
TAVR but due to complicated access issues it was determined that
patient would likely need trans-aortic approach, and she decided
not to pursue TAVR at this time. Discharged on 10mg furosemide
daily with cardiology follow-up.
#R shoulder pain.
On ___ patient developed new leukocytosis to 23 and new onset R
shoulder pain with swelling concern for septic joint vs
pseudogout. Evaluated by Rheum ___ who recommended U/S guided
aspiration. ESR low, CRP high. XR shoulder showing no acute
fracture or dislocation. Joint aspiration performed ___ but
were unable to send crystals. Gram stain unrevealing.
#Dyspnea and chest pressure: Multifactorial, PNA vs. volume
overload from worsening aortic stenosis vs. COPD. HD1, pt was
febrile to ___ w/ increasing leukocytosis. CXR showed
opacification in the axillary region of the right lung,
consistent w/ aspiration PNA. She was started on
vancomycin/cefepime/azithromycin, later switched to levaquin
through ___. Given elevated proBNP 2611 and CXR w/ mild
congestion on admission, she was diuresed with ___ IV Lasix
prn. Pt has reported history of COPD, but not on inhalers at
home and patient is unaware of this diagnosis. She was given
standing duonebs. No signs of ischemia on ECG or enzymes. Her
dyspnea and chest pressure improved with treatment of her PNA.
On repeat CXR ___ patient's PNA noted to be resolved.
#Leukocytosis: WBC 13 on admission. Uptrended to 20 on HD1.
Concern for PNA vs UTI. Admission UA with 19 WBCs, although
repeat UA clean. Blood, urine cultures no growth. She was
treated for HCAP with cefepime/azithromycin and transitioned to
PO levofloxacin ending ___. Her respiratory examination
improved and she remained stable on RA. Her leukocytosis
remained stable with WBC ___. On ___ patient had
leukocytosis to 23 associated with R shoulder pain that
downtrended to 13.2 day of discharge.
# Macrocytic anemia: Hgb range previously ___. MCV 100, Hgb
8.9 -> slowly drifting, ___ 7.1 on ___. Improved to 8.5
after transfusion on ___ with drop to 7.5 following dental
procedure. Normal B12, TSH. Iron studies wnl.Patient received
second unit of PRBCs ___ without issue.
#Hypertension: continued Metoprolol Succinate XL 50 mg PO BID,
which was later decreased to once daily ___ lower BPs. Losartan
Potassium increased to 100 mg PO/NG DAILY.
#Diarrhea: # Diarrhea: patient had diarrhea x1 week at
admission. Received antibiotics at last hospitalization for UTI.
C. diff negative. Possible antibiotic associated. Now resolved.
CHRONIC ISSUES:
#PAD: gangrene of her toe endarterectomy and stent ___.
Continued Plavix and Statin.
#Osteoporosis: Continued home calcium, vitamin D.
TRANSITIONAL ISSUES
===================
# New medications:
- Furosemide 10mg daily
- Aspirin 81mg daily
- Lidocaine Patch (to Shoulder) daily
# Changed medications:
- Losartan increased from 50mg to 100mg daily.
# Patient should have a follow-up appointment within one week
with cardiologist
# Should have CHEM10 drawn within one week of discharge given
new initiation of Lasix.
# Home fluid restriction: 1.5-2L daily
# CODE: DNR/DNI (Confirmed)
# CONTACT: ___ (___) ___
___ (c)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Calcium Carbonate 1500 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Metoprolol Succinate XL 50 mg PO BID
7. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*1
2. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth DAILY
Disp #*30 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % APPLY TO RIGHT SHOULDER DAILY Disp #*15 Patch
Refills:*0
4. Losartan Potassium 100 mg PO DAILY
RX *losartan 50 mg 2 tablet(s) by mouth DAILY Disp #*60 Tablet
Refills:*0
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Calcium Carbonate 1500 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Severe ___ acquired pneumonia
Diarrhea
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you. You were admitted to ___
because you were short of breath and had chest pressure. We
found that you have a pneumonia. We gave you antibiotics and
your breathing improved. You were also seen by the structural
heart team and underwent workup for an aortic valve replacement.
For now, you have decided that you would not like to pursue the
TAVR at this time.
You will be started on a few new medications:
- Furosemide (Lasix): to help prevent the accumulation of
fluid on the lungs
- Aspirin: To protect the arteries around your heart
- Lidocaine Patch: For your shoulder pain.
You had only one medication change:
- Losartan was increased from 50mg daily to 100mg daily (for
your blood pressure)
Please take your medications as prescribed, and follow up with
your PCP and cardiologist.
Weigh yourself every morning, call MD if weight goes up more
than 2 lbs in one day, or 4 pounds in one week.
Please take all medications as prescribed and keep all scheduled
appointments. Should you have a worsening or recurrence of the
symptoms that originally brought you to the hospital, experience
any of the warning signs listed below, or have any other
symptoms that concern you, please seek medical attention.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
10564547-DS-22 | 10,564,547 | 22,969,056 | DS | 22 | 2152-09-17 00:00:00 | 2152-09-17 20:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
___ Balloon Valvuloplasty, aortic valve
History of Present Illness:
Ms. ___ is a ___ year old female with PMHx significant
for HFpEF, Afib on apixaban, CAD (moderate LAD and LCx disease,
chronic total occlusion of the RCA), PAD, severe aortic stenosis
0.4, COPD, hypertension, and hyperlipidemia who presented to the
ED with acute-onset worsening dyspnea and wheezing.
Patient states that her SOB had a gradual onset, starting around
8pm, when she suddenly noticed it was harder to breathe, started
wheezing, and had trouble lying flat. She also started to
develop
a non-productive cough at that time. No fevers and denied any
chest pain, but did endorse some non-specific chest "discomfort"
earlier in the week, that did not recur when she was feeling SOB
last night. Was started on nebulizer treatment in EMS, and on
arrival to ED was satting 92% on RA.
In the ED,
Initial vitals were: HR 112, BP 163/98 - 207/114, RR ___,
Satting 95% BiPap
Exam notable for: Severe JVD. Severe respiratory distress,
tachpneic, with crackles and wheezing. Warm and mentating well.
Labs notable for:
VBG: pH 1.29, pCO2 52, pO2 95, HCO3 26
CBC: WBC 21.3 (74.4% neutrophils, 16.4% lymphocytes), Hgb 12.3,
Plt 237
BNP: Na 146, K 5.0, Cl 107, Bicarb 24, BUN 30, Cr 1.0, glucose
200
LFTS: AST 44, ALT 17, AP 126, TBili 0.6, Alb 4.2
proBNP: ___
Trop-T: 0.46
Studies notable for:
- CXR: Moderate pulmonary edema with right greater than left
small pleural effusions and cardiomegaly.
- EKG showing upsloping ST elevation in AVR, V1-V2, noted
diffuse
depressions in leads I, AVL, II, AVF, V4-V6
In ED, patient was given: sublingual nitro x2, nitro drip, ASA
324mg, 40mg IV Lasix, heparin gtt. Code STEMI was called given
her ST elevations noted on EKG, but on evaluation by cardiology
fellow, was felt not to need urgent catheterization, with
elevations possibly attributed to demand ischemia/strain i/s/o
pulmonary edema and hypertensive urgency.
Of note, the patient had a recent admission in ___,
with
a similar presentation of flash pulmonary edema, with inciting
trigger attributed to her underlying aortic stenosis rather than
a new ischemic event. She states that since her discharge, she
has been feeling very well at home, denying any recent SOB other
than her episode last night. She is very independent, and
frequently walks around the hallways in her apartment with a
walker ___ daily. She does occasionally get chest
discomfort/"pressure" associated with exertional activities,
ranging from washing her nightgown to repositioning her couch,
which has been going on for several months. She intermittently
feels SOB at these times as well.
On arrival to the CCU, patient appears much more comfortable,
and
states that SOB has significantly improved since starting BiPAP
and receiving Lasix in ED. Denies chest discomfort and states
that she has not had any current chest discomfort at all since
her symptoms began last night.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
Cardiac History:
- HFpEF
- CAD (last cath ___: LAD 40-50% calcified, LCx 50% mid
calcified, RCA 100% CTA)
- Severe AS (Peak Velocity: 5.2m/sec, PG ___, MG 60mmHg, ___
Valve Area 0.6cm²). Did not want TAVR in the past and too high
risk for SAVR
- PAD with right iliac stent
Other PMH:
- HTN
- HLD
- History of MGUS
- Mild COPD, current smoker ___ cigarettes)
- PMR, previously on chronic prednisone
- RA, previously on ___
Social History:
___
Family History:
father with DM
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: HR 92, BP 105/56, RR 16, 98% 4L NC
GENERAL: Elderly, frail-appearing woman, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP 6cm.
CARDIAC: IV/VI systolic murmur at RUSB with radiation to
carotids. Normal rate, irregular rhythm. No rubs or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
mildly labored, but no accessory muscle use. Crackles mid-way up
her lung fields.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: AAOx3, no gross deficits, CN II-XII intact.
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
24 HR Data (last updated ___ @ 714)
Temp: 97.5 (Tm 98.4), BP: 116/55 (103-128/51-72), HR: 69
(60-78), RR: 16 (___), O2 sat: 93% (93-98), O2 delivery: RA,
Wt: 90.7 lb/41.14 kg
Fluid Balance (last updated ___ @ 709)
Last 8 hours Total cumulative -400ml
IN: Total 0ml
OUT: Total 400ml, Urine Amt 400ml
Last 24 hours Total cumulative -310ml
IN: Total 890ml, PO Amt 890ml
OUT: Total 1200ml, Urine Amt 1200ml
GENERAL: Elderly, frail-appearing woman, NAD.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. No JVD.
CARDIAC: +S1, with loud S2. Grade ___ late peaking
crescendo-decrescendo systolic murmur over RUSB with radiation
to
carotids; grade ___ holosystolic murmur over LLSB and grade ___
holosystolic murmur in mitral area
GROIN: Resolving ecchymosis over L groin. R groin (access site)
has no evidence of hematoma or bleeding, no dressings in place.
LUNGS: No chest wall deformities or tenderness. Respiration is
mildly labored, but no accessory muscle use.
EXTREMITIES: Warm, well perfused. No edema.
NEURO: No gross deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:32AM BLOOD WBC-21.3* RBC-4.08 Hgb-12.3 Hct-41.1
MCV-101* MCH-30.1 MCHC-29.9* RDW-15.6* RDWSD-57.1* Plt ___
___ 05:32AM BLOOD Neuts-74.4* Lymphs-16.4* Monos-5.3
Eos-2.7 Baso-0.5 Im ___ AbsNeut-15.88* AbsLymp-3.49
AbsMono-1.14* AbsEos-0.57* AbsBaso-0.10*
___ 05:32AM BLOOD ___ PTT-22.1* ___
___ 05:32AM BLOOD Glucose-200* UreaN-30* Creat-1.0 Na-146
K-5.0 Cl-107 HCO3-24 AnGap-15
___ 05:32AM BLOOD ALT-17 AST-44* AlkPhos-126* TotBili-0.6
___ 05:32AM BLOOD cTropnT-0.46* proBNP-6773*
___ 05:32AM BLOOD Albumin-4.2 Calcium-9.2 Phos-5.0* Mg-2.6
___ 05:36AM BLOOD ___ pO2-95 pCO2-52* pH-7.29*
calTCO2-26 Base XS--1
___ 05:36AM BLOOD O2 Sat-91
___ 12:15PM BLOOD Lactate-1.6
INTERVAL PERTINENT LABS:
========================
___ 05:32AM BLOOD cTropnT-0.46* proBNP-___*
___ 11:40AM BLOOD CK-MB-6 cTropnT-0.57*
___ 08:05PM BLOOD cTropnT-0.63*
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-11.5* RBC-3.24* Hgb-9.8* Hct-32.6*
MCV-101* MCH-30.2 MCHC-30.1* RDW-15.3 RDWSD-56.6* Plt ___
___ 06:45AM BLOOD Glucose-91 UreaN-39* Creat-1.1 Na-144
K-4.4 Cl-104 HCO3-28 AnGap-12
___ 06:45AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.5
IMAGING and PROCEDURES:
=======================
CXR ___
IMPRESSION:
Moderate pulmonary edema with right greater than left small
pleural effusions and cardiomegaly.
TRANSTHORACIC ECHO ___
CONCLUSION:
There is mild symmetric left ventricular hypertrophy with a
normal cavity size. Overall left ventricular systolic function
is normal. However, the inferobasal segment is thin and
hypokinetic. Quantitative biplane left ventricular ejection
fraction is 69 %. The aortic valve leaflets are severely
thickened.
There is mild [1+] aortic regurgitation. The mitral valve
leaflets are moderately thickened. There is moderate mitral
annular calcification. There is moderate to severe [3+] mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The tricuspid valve
leaflets are mildly thickened. There is moderate to severe [3+]
tricuspid regurgitation. Due to acoustic shadowing, the severity
of tricuspid regurgitation may be UNDERestimated. There is
moderate pulmonary artery systolic hypertension. In the setting
of at least moderate to severe tricuspid regurgitation, the
pulmonary artery systolic pressure may be UNDERestimated.
Compared with the prior TTE (images reviewed) of ___ ,
the findings are similar. Inferobasal segment was thin and
hypokinetic/akinetic in prior study.
BALLOON VALVULOPLASTY ___
The patient was not a candidate for TAVR due to diminished
arterial diameter precluding a ___ Fr sheath.
Using a Preclose method a ___ Fr and then ___ Fr long sheath was
placed in the right femoral artery. A ___ Fr tempoary pacemaker
was placed in the right ventricular apex for rapid ___ bpm
pacing during
balloon inflations. Balloon aortic valvuloplasty was performed
using a 18 mm Z-Med II balloon with two inflations -- due to a
residual gradient -- a 18 mm True Balloon was inflated twice.
This resulted in a 27 mm Hg gradient
(> 10 mm Hg reduction). The right sheath was removed without
complications. The pacemaker was removed. The patient was
transported to the CCU in stable condition.
Complications: There were no clinically significant
complications
Brief Hospital Course:
___ year old woman with HTN, PAD, CAD, COPD, h/o flash pulmonary
edema ___ hypertensive emergency, severe AS ___ 0.6) who
presents with several hours of SOB, found to have hypertensive
emergency and pulmonary edema requiring BiPAP support, with ST
elevations on EKG and severely elevated troponin. She was
initially treated with heparin drip due to concern for ACS,
however, it was determined that her pulmonary edema was likely
from her aortic stenosis and so she was referred for TAVR. Due
to small vasculature, TAVR was unable to be performed but she
did undergo balloon valvuloplasty.
#CORONARIES: LAD 40-50% calcified, LCx 50% mid calcified, RCA
100% CTA
#PUMP: ___ TTE LVEF 75% with mild LV hypertrophy. Severe
aortic stenosis. Moderate to severe pulmonary hypertension.
Moderate mitral regurgitation.
#RHYTHM: NSR
ACUTE ISSUES:
=============
# Flash pulmonary edema
# Severe aortic stenosis, s/p TAVR
Very similar to prior presentation in ___ (dyspnea, chest
discomfort). She initially presented with ST elevations in V1
and aVR with diffuse ST depression concerning for ischemia. She
required BiPAP in the ED, but was eventually transitioned to
nasal cannula after IV Lasix. She was started on nitro and
heparin drips in the CCU as well, however these were
subsequently discontinued as her symptoms were thought to be due
to her aortic stenosis. Limited TTE was performed on ___,
demonstrating an EF of 69% and inferobasal hypokinesis, similar
to prior study. She was ultimately recommended for TAVR. On
___ she was taken to the cath lab, but the original plan for
TAVR was unable to be executed due to her diminished vessel
caliber. She did, however, undergo successful balloon
valvuloplasty with 27 mmHg gradient (> 10 mm Hg reduction).
There were no complications.
# HFpEF
Patient with chronic HFpEF, EF 75% on TTE from ___, reduced to
69% on TTE performed on ___. She was functionally euvolemic on
exam, with no elevation in JVD. Had elevated proBNP, which could
be indicative of a HF exacerbation, but was more likely related
to her flash pulmonary edema event or myocardial ischemia. The
patient received 40mg IV Lasix for her flash pulmonary edema in
ED, after which her SOB resolved; no further diuresis was
administered, as she was euvolemic on exam. She was also
successfully weaned off nitro gtt on arrival to CCU. No
additional afterload agents were added, as BP remained in goal
range after resolution of her flash edema. She was discharged on
metoprolol succinate 25 mg PO for neuro-hormonal blockade. She
was discharged on her home dose of Lasix (20 mg daily).
# Hypertensive urgency
Initially presented with BP pf 207/114 in ED, and was started on
nitro gtt, with prompt resolution of her hypertension. Most
likely, her hypertension was a result of her flash pulmonary
edema, rather than an inciting factor; HTN resolved with
treatment of her flash edema. She does not appear to be on any
BP medications at home. BP stable in low 100s systolic since
arrival to CCU.
# CAD
Patient with multi-vessel CAD. Her home aspirin was discontinued
in favor of clopidogrel and apixaban. She was maintained on
atorvastatin 40.
# Atrial Fibrillation
Diagnosed with AF during prior hospitalization and started on
apixaban for anticoagulation. Recently started on amiodarone as
an outpatient for Afib as well, when she was noted to be
tachycardic to the 120s at her most recent cardiology
appointment. In the CCU, her home apixaban was held but
eventually restarted after her procedure. Home regimen of
amiodarone 200mg PO daily was continued.
# Leukocytosis
WBC of 21.3 on admission; patient appears to have a chronic
elevated WBC, although this is well above her baseline. Most
likely a reactive leukocytosis in the setting of her flash
episode. CXR was clear. UA was suggestive of infection, however
the patient denied UTI symptoms. Antibiotics were not started,
and CBC was closely monitored, trending down to 11.5.
# ___
Cr 1.0, from baseline 0.7. Likely elevated in the setting of
transient hypoperfusion during her ischemic episode and flash
pulmonary edema event. Cr was 1.1 on discharge.
# Delirium
Patient had several episodes of confusion and agitation while in
the CCU. She was given PRN zyprexa with good effect. It was not
continued on discharge.
CHRONIC ISSUES:
===============
# COPD
# Respiratory Acidosis
On home nebulizer for COPD; was started on Duonebs on admission.
Respiratory acidosis on admission appeared to be at her
baseline.
# HLD
Continued atorvastatin 40mg qPM
TRANSITIONAL ISSUES:
====================
[] continue monitoring AS as likely will have transient benefit
from balloon angioplasty, patient did not desire the
trans-apical approach required for TAVR thus this could not be
completed on her
[] patient was on daily apixaban 2.5 mg daily prior to
admission, this was increased to 2.5 mg BID per atrial
fibrillation indications
#CONTACT/HCP:
___
Relationship: Friend
Phone: ___
Other Phone: ___
#Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Benzonatate 100 mg PO TID
4. Furosemide 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
8. Atorvastatin 40 mg PO QPM
9. Metoprolol Succinate XL 25 mg PO BID
10. Amiodarone 200 mg PO DAILY
11. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q24H Duration: 3 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate [Kapspargo Sprinkle] 50 mg 1 capsule(s)
by mouth daily Disp #*30 Capsule Refills:*0
5. Amiodarone 200 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Ferrous Sulfate 325 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
-Severe aortic stenosis
-Flash pulmonary edema
SECONDARY
-Heart failure preserved ejection fraction
-Atrial fibrillation
-___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had accumulated some fluid in your lungs due to the
abnormal valve in your heart
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You underwent a procedure to open up your heart valve
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs. Your weight on discharge was
41.1 kg or 90.7 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
===========================
Followup Instructions:
___
|
10564547-DS-23 | 10,564,547 | 20,878,598 | DS | 23 | 2152-09-23 00:00:00 | 2152-09-23 14:15:00 |
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 hip pain
Major Surgical or Invasive Procedure:
Right hip trochanteric fixation nail
History of Present Illness:
___ female presents with the above fracture s/p mechanical fall.
Patient is minimally ambulatory at baseline and intermittently
uses a walker. Patient left here yesterday after an angioplasty
of her aorta, despite a TAVR being the better option and at home
when she woke up she performed her morning routine and then sat
down and as she attempted to stand up she fell over onto her
right side and struck her head. Patient is anticoagulated.
Patient endorses pain of the right hip.
Past Medical History:
Cardiac History:
- HFpEF
- CAD (last cath ___: LAD 40-50% calcified, LCx 50% mid
calcified, RCA 100% CTA)
- Severe AS (Peak Velocity: 5.2m/sec, PG ___, MG 60mmHg, ___
Valve Area 0.6cm²). Did not want TAVR in the past and too high
risk for SAVR
- PAD with right iliac stent
Other PMH:
- HTN
- HLD
- History of MGUS
- Mild COPD, current smoker ___ cigarettes)
- PMR, previously on chronic prednisone
- RA, previously on plaquinel
Social History:
___
Family History:
father with DM
Physical Exam:
GEN: well appearing, NAD, sleeping comfortably in bed
CV: slightly tachycardic
PULM: non-labored breathing on 2L, muffled airway with noisy
breathing
Right lower extremity:
-Dressing in place, clean and dry
-SILT in S/S/T/DP/SP nerve distributions
-Firing ___
-Warm and well perfused, +dorsalis pedis pulse
Pertinent Results:
___ 04:43AM BLOOD WBC-13.6* RBC-3.01* Hgb-8.3* Hct-27.0*
MCV-89.7 MCH-27.6 MCHC-30.7* RDW-UNABLE TO RDWSD-UNABLE TO Plt
___
___ 04:43AM BLOOD Glucose-100 UreaN-29* Creat-1.0 Na-139
K-5.4 Cl-106 HCO3-21* AnGap-12
Brief Hospital Course:
Ms. ___ is a ___ y/o female with history of Afib on Apixiban,
severe aortic stenosis ___ 0.6 on ___ s/p balloon
angioplasty ___, CAD (chronic total occulsion of RCA), HFpEF,
PAD s/p right ileal stent ___, HTN, and COPD who presented
after mechanical fall and Right hip fracture. She was recently
discharged home after balloon valvuloplasty on ___. She was
evaluated by orthopedic surgery who recommended surgical
fixation of the right femur fracture after evaluation by
medicine. The patient was ultimately admitted to the Acute Care
Surgery Service per trauma pathway with plan to transfer to
medicine vs orthopedic surgery for pre-operative care.
Medicine was consulted and recommended treating Klebsiella and
proteus in the urine with Bactrim. Given her acute on chronic
anemia they recommended 1 unit packed red blood cells with close
monitoring for fluid overload and Lasix as needed if patient
becomes hypoxic. Consider vitamin K 5 mg for elevated INR. For
further pre-operative work up, a TTE should be obtained.
Cardiology recommended proceeding with OR for femur fixation
given urgency of operation. She appears to be euvolemic without
signs or symptoms of acute ischemia. Given her cardiac risk the
Plavix and Eliquis can be held for surgery but she should be
maintained on aspirin and metoprolol.
ORTHOPEDIC SURGERY
Brief hospital course insert previous hospital course the
patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for right
trochanteric fixation nail, 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 ___ rehabilitation was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the right lower extremity, and
will be discharged on home Eliquis 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. Clopidogrel 75 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. ipratropium bromide 17 mcg/actuation inhalation Q6H:PRN
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO DAILY
5. TraMADol ___ mg PO Q4H:PRN pain
6. Vitamin D 800 UNIT PO DAILY
7. Amiodarone 200 mg PO DAILY
8. Apixaban 2.5 mg PO BID
9. Atorvastatin 40 mg PO QPM
10. Clopidogrel 75 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. ipratropium bromide 17 mcg/actuation inhalation Q6H:PRN
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip intertrochanteric fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated on right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add tramadol as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take home Eliquis as prescribed
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
URINARY CATHETER:
- You have been discharged with a Foley catheter in place in the
setting of urinary retention. This may happen in the setting of
surgery and anesthesia, as well as being admitted to the
hospital and ambulating minimally.
- You may remove the Foley catheter on ___, with a trial
of void thereafter.
- You may find that walking may help with return of bladder
function.
HEART RATE:
- Please monitor your heart rate. While in the hospital, your
home metoprolol was fractionated to 12.5mg q6hr to manage your
intermittent atrial fibrillation. Please call your PCP for
management/uptitration of metoprolol.
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 weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
Physical Therapy:
___
Treatments Frequency:
Please follow up for your postop visit and staple removal.
Followup Instructions:
___
|
10565203-DS-4 | 10,565,203 | 28,400,087 | DS | 4 | 2180-05-30 00:00:00 | 2180-05-30 18:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine
Attending: ___.
Chief Complaint:
Shortness of breath, worsening renal function
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ year old male with history of
long-standing type II DM complicated by peripheral neuropathy
and
retinopathy, CKD III, HTN, HLD who presents with one-month
history of worsening shortness of breath, orthopnea, fatigue,
and
lower extremity swelling, found to have worsening renal function
in the outpatient setting, referred to the ED for further
evaluation.
He was recently seen by his PCP for worsening lower extremity
edema, initially thought to be secondary to amlodipine, which
was
discontinued. On follow-up one week later, had significantly
worsening fatigue, dyspnea on exertion walking across the room,
and no interval change in lower extremity edema. Found to have
worsening renal function with creatinine to 3.8 and BNP 1500.
Was recommended to have a urgent renal follow-up however unable
to obtain until ___, was subsequently referred to the ED given
concern for acute on chronic kidney disease.
In the ED, initial vitals were:
T 97.9 HR 72 BP 161/70 RR 16 O2 94%RA
Exam notable for:
- Gen - Speaking in full sentences, not in acute distress
- Chest - Bilateral crackles
- Abd - Soft, non-tender, mildly distended
- Ext- 2+ bilateral ___ pitting edema
Labs notable for:
- WBC 6.9, Hb 8.6, HCT 27.8, PLT 276
- BUN 51, Cr 3.3
- MB 3, troponin 0.09
- Urine Na 52, Cr 89, total protein 439, prot/cr 4.9, albumin
271.1, alb/Cr 3046.1
Imaging was notable for:
CXR ___: Interval development of moderate cardiomegaly with
mild pulmonary edema and small bilateral pleural effusions.
Probable bibasilar atelectasis.
Patient was given:
- IV Lasix 40
Consults:
- Renal: Recommended check urine lytes, save urine sample, renal
US, serum albumin and LFTs, after urine collected trial diuresis
Lasix ___
SUBJECTIVE: Upon arrival to the floor, patient confirms the
above
history. He states he was initially in his usual state of health
until 1 month prior when he subsequently came back from
___.
He subsequently had worsening shortness of breath, at baseline
he
used to previously be able to walk unrestricted. Now gets severe
shortness of breath when walking across the room. Also endorses
orthopnea and PND. Has also had progressive fatigue over the
last
month. Per his wife, also has worsening lower extremity edema.
He
has also noticed increasing abdominal distention. Of note,
patient also states that starting one week prior he has noticed
decreased urine output. Denies any recent fevers, chills, cough,
nausea, vomiting, dysuria, or burning on urination.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
DIABETES TYPE II
HYPERTENSION
CHRONIC KIDNEY DISEASE
CATARACT
VMT
DIABETIC RETINOPATHY
Social History:
___
Family History:
No family history of diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: ___ ___ Temp: 97.8 PO BP: 159/68 R Lying HR:
73 RR: 17 O2 sat: 91% O2 delivery: 2L
GENERAL: Comfortable appearing, in NAD, no labored breathing,
speaking in full sentences
HEENT: NC/AT, PERRLA, EOMI
NECK: Supple, no lymphadenopathy, JVD 15cm +HJR
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: Bibasilar rales, no wheezes or rhonchi
ABDOMEN: Distended, soft, nontender throughout. Normoactive
bowel
sounds. No rebound or guarding.
EXTREMITIES: Trace pitting edema to mid shins bilaterally
NEUROLOGIC: CN II-XII intact. No focal neurological deficits
SKIN: No obvious rashes, ulceration or skin breakdown
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 98.3 167 / 68 70 17 94 Ra, I/Os: ___
GENERAL: Comfortable appearing elderly gentleman, in NAD
speaking in full sentences
HEENT: NC/AT, PERRLA, EOMI, MMM
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: No crackles. No wheezes or rhonchi. No increased work of
breathing.
ABDOMEN: Soft, non-tender, non-distended. No rebound or
guarding.
EXTREMITIES: Trace pitting edema to mid shins bilaterally
NEUROLOGIC: CN II-XII intact. No focal neurological deficits
SKIN: No obvious rashes, ulceration or skin breakdown
Pertinent Results:
ADMISSION LABS:
___ 10:35AM BLOOD WBC-6.9 RBC-3.14* Hgb-8.6* Hct-27.8*
MCV-89 MCH-27.4 MCHC-30.9* RDW-15.5 RDWSD-48.5* Plt ___
___ 10:35AM BLOOD Neuts-71.6* Lymphs-17.5* Monos-7.9
Eos-2.0 Baso-0.6 Im ___ AbsNeut-4.95 AbsLymp-1.21
AbsMono-0.55 AbsEos-0.14 AbsBaso-0.04
___ 10:35AM BLOOD ___ PTT-28.9 ___
___ 10:35AM BLOOD Glucose-163* UreaN-51* Creat-3.3* Na-145
K-4.1 Cl-106 HCO3-24 AnGap-15
___ 10:35AM BLOOD ALT-15 AST-22 CK(CPK)-516* AlkPhos-83
TotBili-0.3
___ 10:35AM BLOOD CK-MB-3 ___ 10:35AM BLOOD Albumin-3.6
___ 09:55PM BLOOD TotProt-6.3* Calcium-8.9 Phos-4.8*
Mg-2.9*
PERTINENT LABS:
___ 07:25AM BLOOD Ret Aut-2.7* Abs Ret-0.08
___ 10:35AM BLOOD cTropnT-0.09*
___ 09:55PM BLOOD CK-MB-4 cTropnT-0.08*
___ 07:25AM BLOOD calTIBC-277 VitB12-412 Folate-11
Ferritn-53 TRF-213
___ 09:55PM BLOOD PTH-133*
___ 09:55PM BLOOD 25VitD-10*
___ 09:55PM BLOOD PEP-NO SPECIFI
DISCHARGE LABS:
___ 05:50AM BLOOD Glucose-78 UreaN-67* Creat-3.7* Na-146
K-3.8 Cl-103 HCO3-27 AnGap-16
___ 05:50AM BLOOD Calcium-8.9 Phos-6.1* Mg-2.4
IMAGING/RESULTS:
CXR (___):
IMPRESSION:
Interval development of moderate cardiomegaly with mild
pulmonary edema and
small bilateral pleural effusions. Probable bibasilar
atelectasis.
BILATERAL LENIS (___):
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
RENAL US (___):
IMPRESSION:
No hydronephrosis.
TTE (___):
Conclusions
The left atrial volume index is mildly increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>65%). The estimated
cardiac index is normal (>=2.5L/min/m2). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. Tricuspid annular plane systolic excursion is
normal (2.4 cm; nl>1.6cm) consistent with normal right
ventricular systolic function. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is high normal. There is no pericardial effusion. A left pleural
effusion is present.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of long-standing
type II DM complicated by peripheral neuropathy and retinopathy,
CKD, HTN, HLD who presents with one-month history of worsening
shortness of breath, orthopnea, fatigue, and lower extremity
swelling, found to have worsening renal function in the
outpatient setting, referred to the emergency department for
further evaluation, with nephrotic range proteinuria.
ACUTE ISSUES
=================
# ___ on CKD
# Nephrotic Syndrome
# Acute hypoxemic respiratory failure
# Lower extremity edema
Patient has history of CKD in setting of long standing DM/HTN.
His baseline Cr over last 6 months was 2.7-3.2; he presented
from outpatient setting with Cr of 3.8 and significantly volume
overloaded causing acute hypoxemic respiratory failure and lower
extremity edema. Work up demonstrated nephrotic range
proteinuria with prot/Cr of 4.9. Work up demonstrated elevated
PTH and low vitamin D. SPEP/UPEP normal. Renal US demonstrated
no hydronephrosis. TTE was normal. Bilateral LENIs without
evidence of thrombosis. It was felt that his renal dysfunction
was ultimately due to his longstanding DM and HTN. He was
diuresed with IV Lasix with resolution of respiratory failure
and lower extremity edema. He was transitioned to po torsemide
40mg daily to remain euvolemia. Discharge Cr 3.7. Discharge
weight 74.1kg.
#HTN
Patient's blood pressure was elevated during hospitalization.
His home labetalol was increased to 600mg BID. His home
lisinopril 40mg daily and diltiazem 180mg daily were continued.
His home chlorthalidone was discontinued as it is less likely to
be effective in setting of severe CKD.
#DM type II
Patient was initially continued on home insulin 70/30 24 units
breakfast and 14
units dinner with HISS for additional coverage. He was routinely
having low BGs in the afternoon, ranging from 45-65. His insulin
regimen was changed to insulin 70/30 20 units with breakfast and
14 units with dinner.
# Troponin elevation
Troponin elevation 0.09 from previous ___ year prior. EKG
without evidence of ischemic changes. Troponins downtrended
without chest pain. Elevation likely in the setting of CKD.
CHRONIC ISSUES
==================
# Anemia
Found to have normocytic anemia hemoglobin 8.6 on admission.
Work up indicated anemia in setting of renal dysfunction. Hgb
remained stable during hospitalization.
#HLD
Cont home atorvastatin 20mg daily
#CAD prevention
Reportedly takes ASA 500mg daily, unclear indication.
Transitioned to ASA 81mg.
TRANSITIONAL ISSUES:
[ ] Discharge weight: 74.1kg
[ ] Discharge Cr: 3.7
[ ] Discharged on torsemide 40mg daily - consider uptitration
for euvolemia
[ ] Consider further uptitration of labetalol or additional
anti-hypertensive agents if BP remains elevated
[ ] Consider increasing insulin regimen pending outpatient BG
control; his home insulin regimen was decreased during this
[ ] Aspirin dose reduced to 81mg for primary prevention; please
clarify indication for full dose asa as an outpatient and resume
if clinically indicated
[ ] Consider increasing atorvastatin to 40-80mg for high dosage
given history of DM
[ ] Follow up with renal as outpatient - consideration of
possible renal biopsy for further elucidation of underlying
renal disease
# CODE: Full Code
# CONTACT: Wife ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 500 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Lisinopril 40 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Diltiazem Extended-Release 180 mg PO DAILY
6. 70/30 24 Units Breakfast
70/30 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. 70/30 20 Units Breakfast
70/30 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Labetalol 600 mg PO BID
RX *labetalol 300 mg 2 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
5. Atorvastatin 20 mg PO QPM
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
___ on CKD
Acute hypoxemic respiratory failure
Lower extremity edema
SECONDARY DIAGNOSES:
Troponin elevation
Anemia
Type II DM
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization.
WHY WERE YOU ADMITTED?
- You were admitted because you had difficulty breathing and
swelling in your lungs.
WHAT HAPPENED DURING YOUR HOSPITALIZATION?
- You were found to have too much fluid in your body causing the
problems you presented with.
- You were given a medication (Lasix) through your IV to help
remove the fluid from your body.
- You were started on a medication (torsemide) to prevent the
fluid from coming back.
- You had imaging of your heart which showed it was working
well.
- Your blood pressure medications were changed to better control
your blood pressure.
- Your insulin dose was changed to better control your diabetes.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- You should take all of your medications as prescribed.
- You should follow up with your doctors as noted below.
- You should weigh yourself daily and call you doctor if your
weight increases by 3lbs over two days
- You should call your doctor if you have worsening shortness of
breath or leg swelling
Again, it was a pleasure taking care of you!
All the best,
Your ___ team
Followup Instructions:
___
|
10565287-DS-10 | 10,565,287 | 22,972,173 | DS | 10 | 2171-10-10 00:00:00 | 2171-10-12 11:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with a history of infectious colitis and
ovarian cyst who was seen in the ED on ___ for sudden onset of
nausea, vomiting, and near-continuous diarrhea and lower
abdominal pain. She was diagnosed with cystitis w/
pyelonephritis based on her U/A and CVA tenderness and was
started on ciprofloxacin. Today, she returned to the ED with
worsened nausea, vomiting, and lower abdominal pain; her
diarrhea has largely resolved although she did have episodes of
loose stool this morning and yesterday evening. The patient
states that she was unable to tolerate PO or meds after leaving
the ED yesterday. Since then she has had subjective fevers,
chills, and worsening nausea/abdominal pain. She now reports
___ sore, achy abdominal pain along with ___ episodes of emesis
which she described as "dark" in color that occurred yesterday
evening and once this morning. The patient also reports that her
period started yesterday and could be contributing to her lower
abdominal pain as she has a history of significant pain
associated with her periods. The patient also has a history of
ruptured ovarian cyst w/ ovarian torsion in the past, but there
was no evidence of this on U/S in the ED. In the ED, the
patient's vitals were 98.9 74 126/77 16 100%; she was not
having any dark-colored emesis but endorses crampy lower
abdominal pain and severe nausea. A pelvic ultrasound was
negative for ovarian torsion with possible colitis, and a CT
abdomen showed She received reglan/zofran for nausea with good
control and 3L of fluid. Her ROS is otherwise negative.
Past Medical History:
- Depression
- PTHD
- ADHD
- Anxiety
- Right ovarian cyst removal
- Infectious colitis - ___ norovirus
- Hemorrhoids - started after episode of colitis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL
Vitals- 99.2 109/57 54 18 99% RA
General- Lethargic, oriented and able to answer questions
HEENT- Sclera anicteric, oropharynx clear
Neck- Supple, no LAD
Lungs- CTAB
CV- RRR, normal S1/S2, no murmurs/rubs/gallops
Abdomen- Soft, non-distended, hypoactive bowel sounds, tender to
palpation in the LLQ/RUQ, no organomegaly, no CVA tenderness,
tender to palpation on rear LLQ
Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Motor function grossly normal
DISCHARGE PHYSICAL
Vitals- 98.3-98.6 ___ 52-65 16 98-99% RA
General- Alert, oriented, much improved mood from yesterday
HEENT- Sclera anicteric, oropharynx clear
Neck- Supple, no LAD
Lungs- CTAB
CV- RRR, normal S1/S2, no murmurs/rubs/gallops
Abdomen- Soft, non-distended, hypoactive bowel sounds, mildy
tender to palpation in the RUQ but improved from yesterday
Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 08:55AM GLUCOSE-115* UREA N-14 CREAT-0.7 SODIUM-143
POTASSIUM-3.0* CHLORIDE-108 TOTAL CO2-22 ANION GAP-16
___ 08:55AM ALT(SGPT)-19 AST(SGOT)-15 ALK PHOS-50 TOT
BILI-0.4
___ 08:55AM LIPASE-27
___ 08:55AM ALBUMIN-4.3
___ 08:55AM WBC-12.1* RBC-3.64* HGB-11.4* HCT-35.1*
MCV-97 MCH-31.4 MCHC-32.5 RDW-13.6
___:55AM NEUTS-66.9 ___ MONOS-8.0 EOS-0.4
BASOS-0.4
___ 09:10AM URINE RBC-8* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 09:10AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ CT ABDOMEN & PELVIS:
1. Intramural fat within bowel of colon suggesting prior chronic
inflammation. Distal bowel partially collapsed, difficult to
assess, though mild hyperemia in the mesentery and prominent
mucosal enhancement may suggest an acute colitis.
2. Mild periportal edema and pericholecystic fluid likely
reflective of recent fluid administration. No surrounding
stranding, non distention, and no stones-cholecystitis felt less
likely.
___ TRANSVAGINAL ULTRASOUND:
No abnormality identified. Though patient reports history of
oophorectomy, right ovary is identified.
Brief Hospital Course:
___ female with recent diagnosis of pyelonephritis presenting
with nausea, vomiting and colitis seen on CT A/P.
# Pyelonephritis. The patient was seen in the ED on ___ and
diagnosed with pyelonephritis based on her U/A and exam, and she
was treated with ciprofloxacin. She was discharged but returned
to the ED because she was unable to take POs. On admission on
___, she was switched to IV ceftriaxone because of
vomiting/failure to take PO. On admission her exam was
improving, with no CVA tenderness, her U/A improved from ___,
and the patient continued to report no symptoms associated with
urination. Ciprofloxacin was resumed for discharge with a plan
for three additional days (7 day course).
# Nausea/Abdominal pain, presumed colitis. The patient's
symptoms and her imaging, including significant diarrhea with
sudden onset on ___, were concerning for infectious colitis. At
the time of admission, the patient's diarrhea had slowed, and
she was supported with IV fluids, IV zofran, and
prochlorperazine. On the day of discharge, she had no diarrhea,
an improved appetite, her diet was advanced and she was
tolerating POs.
# Hypokalemia. The patient presented with potassium 3.0 in ED,
presumed to be due to vomiting. She was repleted in the ED and
the following day on the floor for persistently low potassium.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Concerta (methylphenidate) 36 mg oral Daily
2. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Concerta (methylphenidate) 36 mg oral Daily
2. Ciprofloxacin HCl 500 mg PO Q12H
Please complete your course of antibiotics for your kidney
infection.
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
infectious colitis
pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for diarrhea, back pain, and
inability to tolerate food. You improved. You also were recently
treated for a kidney infection and this was improving. You did
have signs of infection/inflammation in your colon so you likely
did have a likely viral GI illness. We wish you all the best.
Followup Instructions:
___
|
10565419-DS-4 | 10,565,419 | 26,758,717 | DS | 4 | 2147-06-08 00:00:00 | 2147-06-10 08:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Temporary hemodialysis line placement on ___
History of Present Illness:
___ male with history of alcoholic cirrhosis, ESRD on
dialysis (___) who presents with left leg swelling and fever.
Patient reports 1 day of left lower extremity erythema and
discomfort. He was getting dialysis where he had a temperature
of 101 °F. Liver team recommended patient present to ___
for evaluation. Patient also was reporting cough. He denies any
chest pain, abdominal pain, dysuria, diarrhea, melena,
hematochezia, nausea, emesis, worsening abdominal distention. No
alcohol for over 6 months.
Past Medical History:
Alcoholic cirrhosis decompensated by ascites, encephalopathy,
and
HRS (on dialysis)
Alcoholic neuropathy
Anxiety
Depression
GERD
HLD
Tobacco abuse
Sleep apnea
Gout
H/o C. diff
Anemia
S/p ___
Social History:
___
Family History:
Parents with hypertension and hyperlipidemia. No cardiovascular
disease or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
General: no acute distress
HEENT: Normal oropharynx, no exudates/erythema. Scleral icterus
Cardiac: RRR , +tender over R upper chest HD port
Pulmonary: Clear to auscultation bilaterally with good aeration,
no crackles/wheezes
Abdominal/GI: Soft, distended, nontender
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted.
Bilateral pedal edema
Neuro: Sensation intact upper and lower extremities, strength
___ upper and lower, no focal deficits noted, moving all
extremities
Derm: Erythema, warmth, tenderness over the left shin
DISCHARGE PHYSICAL EXAM:
======================
GENERAL: Sitting comfortably in bed
HEENT: PERRL, EOMI. Sclera icteric. MMM.
NECK: JVP not elevated.
CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. ___
murmur throughout precordium no rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
CHEST: Small area of erythema above line: likely related to
insertion. No tenderness, no drainage
ABDOMEN: Obese. Normal bowels sounds, non-tender to deep
palpation in all four quadrants. mildly distended with prominent
stretch marks. Some prominent veins in abdomen.
EXTREMITIES: No clubbing, cyanosis. Pulses DP/Radial 2+
bilaterally. 2+ edema bilaterally
SKIN: Warm. Cap refill <2s. poorly demarcated erythema of LLE,
marked and dated receding from lines. Similar erythema also on
RLE. Decreased tenderness with underlying edema though no
drainage/crepitus/area of fluctuance.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Intact
serial 7's. Intact memory. Minimal asterixis.
Pertinent Results:
ADMISSION LABS:
==============
___ 12:48AM BLOOD WBC-7.0 RBC-2.99* Hgb-8.1* Hct-26.0*
MCV-87 MCH-27.1 MCHC-31.2* RDW-18.8* RDWSD-59.3* Plt ___
___ 12:48AM BLOOD Neuts-75.5* Lymphs-10.8* Monos-12.5
Eos-0.6* Baso-0.3 Im ___ AbsNeut-5.26 AbsLymp-0.75*
AbsMono-0.87* AbsEos-0.04 AbsBaso-0.02
___ 12:48AM BLOOD ___ PTT-40.1* ___
___ 12:48AM BLOOD Glucose-110* UreaN-16 Creat-5.1* Na-136
K-4.3 Cl-98 HCO3-29 AnGap-9*
___ 12:48AM BLOOD ALT-12 AST-34 AlkPhos-101 TotBili-2.0*
___ 12:48AM BLOOD Albumin-3.4* Calcium-8.6 Phos-3.2 Mg-2.1
MICRO DATA:
==========
___ 10:15 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Susceptibility testing performed on culture # ___
(___).
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ line placement
MPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled
dialysis line.
The tip of the catheter terminates in the right atrium. The
catheter is ready
for use.
DISCHARGE LABS:
==============
___ 06:56AM BLOOD WBC-5.1 RBC-3.05* Hgb-8.2* Hct-26.7*
MCV-88 MCH-26.9 MCHC-30.7* RDW-19.1* RDWSD-59.9* Plt ___
___ 06:56AM BLOOD ___
___ 06:56AM BLOOD Glucose-99 UreaN-27* Creat-7.8*# Na-141
K-4.5 Cl-98 HCO3-22 AnGap-21*
___:56AM BLOOD ALT-<5 AST-63* LD(LDH)-177 AlkPhos-108
TotBili-1.5
___ 06:56AM BLOOD Albumin-3.4* Calcium-9.3 Phos-6.1* Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ year old man with alcoholic cirrhosis
decompensated by ascites, encephalopathy, and HRS (now on HD) on
liver-kidney transplant list who presents with fever and left
leg swelling, found to have MSSA infection likely ___
cellulitis/line infection
ACTIVE ISSUES:
============
# Non-purulent Cellulitis/GPC bacteremia
Fever to ___ F on ___ while getting dialysis. While at
dialysis, he was also noted to have a cough and swollen leg. On
admission, an erythematous tract overlying his tunneled line
with associated tenderness was noted above dressing. ___ blood
cultures from ___ grew MSSA and these were the last positive
cultures. He also had a fever up to 102.8 on ___ and has been
afebrile since. His chest x-ray was clear. TTE was negative on
___, and per ID, TEE was not necessary. CVC was removed on
___, and a temporary HD line was placed on ___. He was
discharged on a 4-week course of cefazolin.
# Alcoholic cirrhosis
Dischage MELD 25, Child Class C (decompensated by ascites,
encephalopathy, and HRS). Last drink in ___.
- Transplant evaluation: listed per patient though still needs
teeth extracted. Currently waitlisted iso bacteremia.
- Ascites: no tappable pocket seen on ___. Small volume on CT
AP ___. He received volume control with HD. He is not on
diuretics. Discharge weight on ___: 238 lbs.
- Bleed: none currently, but had prior hemorrhoidal bleeding.
___ EGD and colonoscopy without varices.
- Encephalopathy: history of HE, had asterixis in the setting of
bacteremia, but no signs of confusion. Continued on home
lactulose and rifaximin
- SBP: no history
- Screening: EGD ___ with reflux esophagitis but no varices.
Records in chart ___ RUQ US with cirrhosis and no HCC
- Nutrition: nutrition consult, low Na diet, nephrocaps, folate,
thiamine. Nepro supplements. Patient was educated on low salt
diet (was found to get extra food from home during admission
that was not compliant with diet)
# ESRD on HD
He was diagnosed with HRS in ___ and started on HD ___. He
receives Midodrine pre HD. He missed HD on ___ and received it
on ___ instead due to line holiday. Next HD session: ___ at
his outpatient center.
# Coagulopathy
INR is 1.5 in the setting of alcoholic cirrhosis. No current
bleeding.
CHRONIC/STABLE ISSUES:
======================
# At risk for malnutrition
In the setting of chronic liver/kidney disease, he was on 2g
sodium diet with Nepro supplements and continued nephrocaps,
folate, thiamine. There was continued education to him and his
family regarding importance of adhering to a 2g sodium diet.
# Anemia and thrombocytopenia
In the setting of chronic disease/cirrhosis. In addition, he has
a history of hemorrhoidal bleeding. No evidence of current
bleeding.
# Insomnia
He was given trazodone prn
# Anxiety and depression
Continued home Seroquel qhs
# Alcoholic neuropathy
Continued home gabapentin 300 mg PO TID
# GERD
Continued home pantoprazole, calcium carbonate PRN
TRANSITIONAL ISSUES:
==================
[ ] He will need to continue IV Cefazolin after HD for 4 weeks;
day 1: ___. OPAT will follow (until ___
Medication dosing:
Cefazolin 2 g IV 2X/WEEK (MO,WE) and Cefazolin 3 g IV 1X/WEEK
(FRI)
[] OPAT labs: WEEKLY: CBC with differential, BUN, Cr
Please fax to ___ OPAT clinc - FAX: ___
Please obtain all labs at dialysis
[ ] Per ID, he should get his teeth extracted for transplant
evaluation while he is on antibiotics.
[ ] Follow up with Liver transplant to see if you can be
re-activated for transplant
[] Patient with small area of erythema above line appears to be
related to insertion at this time.
# CODE: full (confirmed)
# CONTACT: ___ (mother)
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Midodrine 10 mg PO 3X/WEEK (___) give prior to HD
2. Thiamine 100 mg PO DAILY
3. rifAXIMin 550 mg PO BID
4. Pantoprazole 40 mg PO Q24H
5. Nephrocaps 1 CAP PO DAILY
6. Lactulose 30 mL PO BID
7. Gabapentin 300 mg PO TID
8. FoLIC Acid 1 mg PO DAILY
9. Calcium Carbonate 500 mg PO TID:PRN acid reflux
10. Zinc Sulfate 220 mg PO DAILY
11. QUEtiapine Fumarate 25 mg PO QHS
Discharge Medications:
1. CeFAZolin 2 g IV 2X/WEEK (MO,WE)
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV ___
and ___ Disp #*6 Intravenous Bag Refills:*0
2. CeFAZolin 3 g IV 1X/WEEK (FR)
RX *cefazolin in dextrose (iso-os) 1 gram/50 mL 3 g IV ___
Disp #*4 Intravenous Bag Refills:*0
3. Calcium Carbonate 1500 mg PO TID W/MEALS
4. Lactulose 30 mL PO TID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. Midodrine 10 mg PO 3X/WEEK (___) give prior to HD
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. QUEtiapine Fumarate 25 mg PO QHS
11. rifAXIMin 550 mg PO BID
12. Thiamine 100 mg PO DAILY
13. Zinc Sulfate 220 mg PO DAILY
14.Outpatient Lab Work
OPAT labs: WEEKLY: CBC with differential, BUN, Cr
Please fax to ___ OPAT clinc - FAX: ___
Please obtain all labs at dialysis
ICD 10: Methicillin susceptible Staphylococcus aureus infection,
unspecified site. ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
MSSA bacteremia
ESRD
SECONDARY
==========
Alcoholic neuropathy
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came into the hospital because you were found to have a
fever and leg swelling at dialysis.
What did you receive in the hospital?
- Antibiotics to treat the infection in your blood
- Took a picture of your heart to assess if the infection went
to your heart
- Removed your hemodialysis line and replaced it with a new line
What should you do once you leave the hospital?
- Please continue antibiotics for 4 weeks (until ___, and you
will receive the antibiotics at dialysis
- Please get your dental work done for transplant work up while
you are on antibiotics (before ___ as part of your transplant
evaluation.
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10565694-DS-21 | 10,565,694 | 29,322,463 | DS | 21 | 2152-04-19 00:00:00 | 2152-04-19 12:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Vancomycin Hcl / Zyvox
Attending: ___.
Chief Complaint:
Draining surgical wound
Major Surgical or Invasive Procedure:
I&D L distal femur replacement ___
I&D L knee with gastroc flap closure ___
Angio with SFA stenting ___
History of Present Illness:
___ h/o bilateral TKA in ___ with complicated history with
infected L TKA requiring multiple revisions and most recently a
distal femur replacement with Dr. ___ on ___. He
presented to the ___ ER on ___ with one day h/o Lt knee
erythema and incisional drainage with inflammatory markers
elevated with
CRP of 261.
Past Medical History:
HTN
Left biceps tendon repair
OA
s/p appendectomy
GERD s/p lap esophageal sphincter repair
Bilateral PJI as outlined in HPI
Social History:
___
Family History:
Father deceased from complications of CHF. Mother is alive at
___ and healthy. No family history of MI or malignancy.
Physical Exam:
NAD, AOx3, resting comfortably
Breathing comfortably on RA
RRR peripherally
Abdomen soft, non-distended
LLE:
Skin graft with 80% take, minimal drainage. No erythema.
No sensation in s/s/DP/SP/T distribution. Beginning to have
occasional burst of tingling.
___ Motor ___
1+ ___.
Pertinent Results:
___ 05:10AM BLOOD WBC-9.1 RBC-3.49* Hgb-8.7* Hct-27.6*
MCV-79* MCH-24.9* MCHC-31.5* RDW-15.4 RDWSD-44.2 Plt ___
___ 05:10AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-132*
K-4.7 Cl-93* HCO3-25 AnGap-19
___ 05:13AM BLOOD CK(CPK)-1470*
___ 05:10AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.0
___ 10:23AM BLOOD Albumin-2.9* Iron-13*
___ 10:23AM BLOOD calTIBC-216* TRF-166*
Brief Hospital Course:
Mr. ___ was admitted on ___ for persistent drainage
from surgical wound with concern for infection. He was taken to
the OR on ___ with Dr. ___ debridement and placement
of wound vac. Infectious disease was consulted for antibiotic
assistance. He was growing Group B streptococcus, enterobacter
aerogenes, and enterococcus species. He was started on
Daptomycin and cefepime per infectious disease recommendations.
on ___ he returned to the OR for a wound vac change and
further debridement. On ___ he returned to the OR for more
extensive debridement where the femoral modular components were
removed, washed extensively, and polyethylene exchange was
performed. During the course of the operation, injury to the
superficial femoral artery occurred which was repaired with ___
prolene. Plastic surgery assisted with soft-tissue defect with
medial and lateral gastroc flaps with skin graft.
Post-operatively patient had palpable ___. The DP became only
dopplerable throughout the night and in the morning was barely
able to be dopplered. The foot appeared mottled and cold and
that time. CTA demonstrated flow void past mid-distal SFA with 2
vessel reconstitution at the ankle. Vascular surgery was
consulted who recommended ABI/areterial duplex which showed L
ankle ABI 0.7 and also clot/stenosis and mid-distal SFA. He was
started on a heparin drip. During the time ___ was dopplerable
and foot perfusion was improving clinically. On ___ L
brachial PICC was placed for IV antibiotics. On ___, patient
was taken to angio with vascular surgery and a stent was placed
with reconstitution of DP flow. On ___ patient worked with
___ and was assessed to require rehab on discharge. On ___
patient was medically cleared for discharge, tolerating PO, pain
controlled on PO medications, and having BM and passing flatus.
OPAT was set up for antibiotics by infectious disease team prior
to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Gabapentin 300 mg PO QAM
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Cyclobenzaprine 10 mg PO QID:PRN spasms
7. Enoxaparin Sodium 40 mg SC Q12H
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
Pain - Moderate
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. TraZODone 50 mg PO QHS:PRN insomnia
14. Minocycline 100 mg PO Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CefePIME 2 g IV Q8H
RX *cefepime [Maxipime] 2 gram 2 g IV every 8 hours Disp #*105
Each Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*28
Tablet Refills:*0
4. Daptomycin 850 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 850 mg IV daily Disp #*35 Vial
Refills:*0
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC every twelve (12) hours
Disp #*20 Syringe Refills:*1
11. Ferrous Sulfate 325 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Gabapentin 300 mg PO QAM
14. Hydrochlorothiazide 25 mg PO DAILY
15. Lisinopril 20 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*150 Tablet Refills:*0
18. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
infected left distal femoral replacement
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. Medications:
1. Oxycodone-You have been given medications for pain control.
Please do not drive, operate heavy machinery, or drink alcohol
while taking these medications. As your pain decreases, take
fewer tablets and increase the time between doses. This
medication can cause constipation, so you should drink plenty of
water daily and take a stool softener (such as Colace) as needed
to prevent this side effect. Call your surgeons office 3 days
before you are out of medication so that it can be refilled.
These medications cannot be called into your pharmacy and must
be picked up in the clinic or mailed to your house. Please
allow an extra 2 days if you would like your medication mailed
to your home.
2. Lovenox- This is to help prevent blood clots in your leg.
Continue to take until ___ or until told to stop by your
surgeon
3. Plavix- This medication was started as recommended by the
vascular surgery team as a stent was placed in your L femoral
artery. Continue this medication until ___ or told to stop
by the vascular surgery team.
4. Aspirin 81mg- This medication was started as recommended by
the vascular surgery team as a stent was placed in your L
femoral artery. Continue this medication until ___ or told
to stop by the vascular surgery team.
5. Daptomycin and cefepime- These are antibiotics given IV for
treatment of L knee infection. You will have labs drawn weekly
to follow the response of infection to the antibiotics and also
to monitor any side effects.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Some swelling is to be expected. DO NOT ICE the
knee as this may damage the skin flap which was placed by
plastic surgery.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
9. WOUND CARE: You will have daily dressing changes with ___
nursing to monitor your incisions and also to change the
dressing on the flap and skin graft. This should be replaced
with adaptic, gauze, and ACE wrap.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Touch down weight-bearing on the left lower
extremity. Mobilize with assistive devices (___) if
needed. No active or passive range of motion at the knee. Please
wear ___ locked in extension and AFO when ambulating.
Physical Therapy:
TDWB in ___ at all times, AFO when amulating
No AROM/PROM of knee.
Treatments Frequency:
Please leave staples and stitches to be removed at plastics
and/or orthopaedics appointment.
Daily dressing changes for skin graft on anterior tibia.
Adaptic, gauze, ACE. All other incisions may be covered with dry
gauze.
Antibiotics as prescribed.
Followup Instructions:
___
|
10565694-DS-22 | 10,565,694 | 29,938,607 | DS | 22 | 2152-06-22 00:00:00 | 2152-06-22 12:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
Vancomycin Hcl / Zyvox
Attending: ___.
Chief Complaint:
Left knee pain and continued bleeding
Major Surgical or Invasive Procedure:
___: I&D and wound vac placement in left lower
extremity(orthopaedics)
___: I&D and wound vac placement in left lower extremity
(plastic surgery)
___: I&D and wounc vac placement in left lower extremity,
take-back to OR for continued bleeding in immediate
postoperative period (orthopaedics)
___: I&D and wound vac placement in left lower
extremity(plastic surgery)
___: Explant of left distal femoral prosthesis, placement
of antibiotic cement spacer stabilized by femoral and tibial
intramedullary nail (orthopaedics)
___
1. Surgical preparation site left knee 15 x 10 cm.
2. Freed myocutaneous latissimus flap from right back to the
left knee.
3. Vein grafting for an atrial venous loop.
4. Split-thickness skin grafting 7 x 20 cm x2.
___:
1. Split-thickness skin grafting, left leg, 30 x 45 cm.
2. Preparation of site 30 x 45 cm, left leg.
___:
1. Irrigation and debridement left superior medial thigh wound
2. Closure of left superior medial thigh wound
History of Present Illness:
Mr. ___ is a ___ year old male with history of bilateral
TKR and multiple prosthetic joint infections s/p multiple
revision operations, most recently in the left knee. During the
course of his latest left knee infection he underwent left knee
debridement with placement of a medial gastroc flap. He was
discharged from ___ on ___ for this episode of care but
presented to the ED on ___ with prolonged bleeding after a
dressing change by ___ from the superomedial aspect of the flap.
The patient was admitted to ___ and underwent an I&D on the
morning of ___.
Past Medical History:
HTN
Left biceps tendon repair
OA
s/p appendectomy
GERD s/p lap esophageal sphincter repair
Bilateral PJI as outlined in HPI
Social History:
___
Family History:
Father deceased from complications of CHF. Mother is alive at
___ and healthy. No family history of MI or malignancy.
Physical Exam:
Vitals: AVSS
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,
normoactive bowel sounds, no palpable masses
LLE: - Extensive wound on anterior aspect of leg from proximal
tibial through mid femur. Covered by myocutaneous latissimus
flap and skin graft. Wound bed is pink and perfused with no
active bleeding or drainage. Staples present medially to secure
flap. 3 smaller wounds to medial, lateral and posterior leg.
Healthy granulation tissue with some fibrinous exudate. Full,
painless AROM/PROM of hip and ankle. No knee ROM. ___
fire. Dec sensation from knee down, which pt reports is
baseline. 1+ ___ pulses, foot warm and well-perfused.
Pertinent Results:
ADMISSION LABS:
___ 02:58PM GLUCOSE-120* UREA N-9 CREAT-0.8 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-27 ANION GAP-17
___ 02:58PM estGFR-Using this
___ 02:58PM WBC-7.6 RBC-3.99* HGB-9.8* HCT-31.2* MCV-78*
MCH-24.6* MCHC-31.4* RDW-15.3 RDWSD-43.0
___ 02:58PM NEUTS-73.9* LYMPHS-15.0* MONOS-7.2 EOS-2.0
BASOS-0.7 IM ___ AbsNeut-5.61 AbsLymp-1.14* AbsMono-0.55
AbsEos-0.15 AbsBaso-0.05
___ 02:58PM PLT COUNT-609*
___ 02:58PM ___ PTT-57.4* ___
.
DISCHARGE LABS:
++++++++++++++++++++++++++++++++++++
.
MICROBIOLOGY:
___ 3:30 pm TISSUE Site: KNEE LEFT ANTERIOR KNEE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 3:25 pm JOINT FLUID Site: KNEE LEFT DEEP KNEE
FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ (___) ON
___ @
2:10PM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Daptomycin AND DOXYCYCLINE Sensitivity testing per ___
___
___. SENSITIVE TO Daptomycin MIC 0.75 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVE TO DOXYCYCLINE.
DOXYCYCLINE sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 8 I
VANCOMYCIN------------ 2 S
.
___ 3:32 pm TISSUE Site: KNEE LEFT KNEE
PROSTHESIS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
___ ALBICANS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. SPECIATION REQUESTED BY ___
___.
Yeast Susceptibility:. Fluconazole MIC 0.25 MCG/ML=
SUSCEPTIBLE.
Results were read after 24 hours of incubation.
Sensitivity testing performed by Sensititre.
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 3:20 pm TISSUE Site: KNEE DEEP LEFT KNEE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
.
___ BLOOD CULTURE X 2: NEGATIVE
.
___ 5:05 pm TISSUE Site: KNEE LEFT KNEE
PROSTHESIS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
Reported to and read back by ___ (___) ___.
TISSUE (Final ___:
___ ALBICANS. MODERATE GROWTH.
Yeast Susceptibility:.
Fluconazole MIC=0.5MCG/ML = SUSCEPTIBLE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
___ PARAPSILOSIS. MODERATE GROWTH. Yeast
Susceptibility:.
Fluconazole MIC 1.0 MCG/ML = SUSCEPTIBLE.
Results were read after 24 hours of incubation.
Sensitivity testing performed by Sensititre.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
___ ALBICANS. ID PERFORMED ON CORRESPONDING ROUTINE
CULTURE.
___ PARAPSILOSIS.
ID PERFORMED ON CORRESPONDING ROUTINE CULTURE.
POTASSIUM HYDROXIDE PREPARATION (Final ___: BUDDING
YEAST.
.
Time Taken Not Noted Log-In Date/Time: ___ 5:16 pm
FOREIGN BODY Site: KNEE
TOTAL KNEE FOR SONICATION/LEFT PROTHESIS.
**FINAL REPORT ___
Sonication culture, prosthetic joint (Final ___:
Reported to and read back by ___ AT 3:21 ___ ___.
___ PARAPSILOSIS. >100 CFU/10 ML.
This test has not been validated for yeast, please
interpret the
results with caution. Clinical correlation is
recommended.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
___ ALBICANS. ___ CFU/10 ML.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 4:50 pm TISSUE Site: KNEE
TIBIAL INTERMEDULLARY MEMBRANE OF LEFT KNEE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
___ PARAPSILOSIS. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___:
___ ALBICANS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
.
___ 4:40 pm FOREIGN BODY Site: KNEE
LEFT KNEE PROTHESIS # 2.
**FINAL REPORT ___
Sonication culture, prosthetic joint (Final ___:
___ PARAPSILOSIS. >100 CFU/10 ML.
This test has not been validated for yeast, please
interpret the
results with caution. Clinical correlation is
recommended.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
___ ALBICANS. ___ CFU/10 ML.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 1:00 am SWAB Site: TIBIA #1 POST LAVAGE LEFT
TIBIA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
YEAST, PRESUMPTIVELY NOT C. ALBICANS. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
ID PERFORMED ON CORRESPONDING ROUTINE CULTURE.
.
___ 12:50 am SWAB Site: FEMUR #2 POST LAVAGE LEFT
FEMUR.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
___ ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
YEAST, PRESUMPTIVELY NOT C. ALBICANS. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
___ PARAPSILOSIS. Yeast Susceptibility:.
Fluconazole MIC 1 MCG/ML = SUSCEPTIBLE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines. Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
.
___ 1:00 am SWAB Site: KNEE #3 POST LAVAGE LEFT
KNEE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
YEAST, PRESUMPTIVELY NOT C. ALBICANS. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
___ PARAPSILOSIS. Yeast Susceptibility:.
Fluconazole MIC 1 MCG/ML = SUSCEPTIBLE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines. Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
.
IMGAGING:
radiology Report KNEE (AP, LAT & OBLIQUE) LEFT Study Date of
___ 6:59 ___
IMPRESSION:
Status post left total knee arthroplasty. Continued re-
demonstration of a tibial periprosthetic fracture with interval
callus formation. No definite cortical destruction to suggest
osteomyelitis. Diffuse soft tissue swelling about the knee with
small locules of subcutaneous gas, similar to prior.
.
Radiology Report KNEE (2 VIEWS) LEFT PORT Study Date of
___ 12:39 ___
IMPRESSION:
The patient is after total hip replacement and partial
replacement of the mid distal femur. The appearance of the
hardware is unremarkable. Vascular stent is in place most
likely in the mid distal superficial femoral artery.
.
Radiology Report ART DUP EXT LO UNI;F/U PORT Study Date of
___ 11:20 AM
IMPRESSION:
Patent SFA stent with velocities ranging from 79-96 cm/sec.
.
Radiology Report VENOUS DUP UPPER EXT BILATERAL PORT Study Date
of ___ 11:20 AM
FINDINGS:
RIGHT:
The cephalic vein measures 0.2-0.5 cm throughout its course.
The basilic vein measures 0.1-0.2 cm throughout its course.
PICC line is noted in the proximal basilic vein.
LEFT:
The cephalic vein measures 0.2-0.6 cm throughout its course.
The basilic vein measures 0.08 - 0.15 cm throughout its course.
.
Radiology Report TIB/FIB (AP & LAT) LEFT Study Date of
___ 10:56 AM
IMPRESSION:
No evidence of early hardware complication after revision
arthroplasty and
placement of an antibiotic spacer.
.
Brief Hospital Course:
Mr. ___ was admitted from the ___ ED on ___ for
postoperative wound dehiscence and flap necrosis and underwent
I&D and wound vac placement in his left lower extremity on ___.
At the time of his initial debridement, pressure ulcers were
discovered in his Achilles and posterior leg area and a wound
care consult was subsequently placed. The patient was continued
on ASA/Plavix given his recent history of placement of a
peripheral arterial stent after a vascular surgery consult on
___ and placed on subQ heparin BID for DVT prophylaxis. The
patient required 34 transfusions of PRBCs in the postoperative
period to maintain his Hgb>8.
.
The patient returned to the OR for repeat I&Ds and wound vac
exchanges on ___ with plastic surgery, ___ with orthopaedic
surgery and ___ with plastic surgery. The patient's I&D on
___ was complicated by wound vac malfunction necessitating a
return to the OR in the immediate perioperative period repeat
wound vac exchange. During each I&D, the patient required
several transfusions of PRBCs to maintain his Hgb >8. On ___,
the patient underwent explant of his prosthesis, placement of
antibiotic cement spacer that was stabilized with an
intramedullary nail in the femur and tibia. The surgery was
prolonged but the patient tolerated the operation without any
acute events. He was transferred to the ICU post-operatively for
hypotension secondary to acute blood loss anemia. He required
several transfusions of PRBCs postoperatively to achieve a goal
Hct of 30 per plastic surgery request. On ___ the patient
underwent free myocutaneous latissimus flap from his right back
to his left knee as well as vein grafting of r an
arterial-venous loop, and split-thickness skin fat. He was again
transferred to the ICU post-operatively for hypotension due to
acute blood loss anemia requiring multiple transfusions. He
responded well an was subsequently transitioned to the floor.
Patient's dressings were changed every other day and patient was
taken back to the ___ on ___ for split thickness skin
graft over his left thigh wound. A vacuum dressing was placed
and removed on ___ll skin grafts appeared
well-healing. Daily dressing changes were performed. On
___, sutures were removed from his bilateral legs and
staples were removed from his left proximal thigh. His left
proximal thigh wound subsequently dehisced and he returned to
the OR on ___ for wound irrigation, debridement and
closure.
Infectious disease was consulted on ___ and recommended the
patient continue his daptomycin (875 Q24H), cefepime 2g Q12H and
fluconazole 400mg Q24H. They also recommended initiating
metronidazole 500 mg Q8H. At this point, the patient had
evidence of a polymicrobial infection based on cultures from his
initial I&D on ___. He has been maintained on this regimen
since ___ based on definitive culture and sensitivity results.
.
Throughout his hospital course, the patient continued to have no
motor abilities distal to his knee. His pedal pulse remained
palpable throughout his course and he endorsed intermittent
paresthesias throughout his left lower extremity which have
grown increasingly strong. The patient has maintainted his
ability to self-turn every 2 hours and his pressure ulcers which
were present on admission remained stable.
.
On ___, the patient's most recent type and screen revealed the
presence of anti-E antibodies and an extended red cell
genotyping was subsequently sent for analysis. The patient did
not have an elevated haptoglobin or manifest any symptoms of a
delayed or acute hemolytic reaction throughout his hospital
course and he responded appropriately to transfusions of PRBCs.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
2. Multivitamins 1 TAB PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
4. TraZODone 50 mg PO QHS:PRN insomnia
5. lisinopril-hydrochlorothiazide ___ mg oral DAILY
6. Cyclobenzaprine 20 mg PO BID:PRN back pain
7. melatonin unknown mg oral QHS
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. CefePIME 2 g IV Q8H infection
4. Clopidogrel 75 mg PO DAILY
5. Daptomycin 850 mg IV Q24H
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluconazole 400 mg IV Q24H
9. Gabapentin 300 mg PO TID
10. Heparin 5000 UNIT SC BID prophylaxis
11. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN Pain -
Severe
12. LORazepam 0.5 mg PO Q4H:PRN for anxiety
13. MetroNIDAZOLE 500 mg IV Q8H
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
15. Ranitidine 75 mg PO BID
16. Senna 8.6 mg PO BID
17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
18. Acetaminophen 650 mg PO Q6H
19. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
20. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Mild
21. Multivitamins 1 TAB PO DAILY
22. TraZODone 50 mg PO QHS:PRN insomnia
23. HELD- lisinopril-hydrochlorothiazide ___ mg oral DAILY
This medication was held. Do not restart
lisinopril-hydrochlorothiazide until you follow-up with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Left lower extremity wound
Discharge Condition:
Gen: middle-aged male in no acute distress
Neuro: baseline mental status, alert, oriented, appropriate
Wound: R back wound - JP in place with serosanguinous drainage.
Mild ___ erythema. LLE: large flap over anterior
aspect of left knee extending into thigh and leg. Skin graft
well-healing. Lateral leg wound with area of skin graft loss
over superior 25%. Medial leg wound with well-healing skin
graft. Posterior leg wound with well-healing skin graft.
Ambulatory status: partial weight-bearing LLE.
Discharge Instructions:
-You should keep your left lower extremity elevated when you are
not standing to urinate and/or not standing and pivoting to
chair and not walking around with crutches, to help with
swelling and drainage. The free flap that was placed over your
knee and should not be dependent for more than 5 minutes at a
time.
-You may bear partial weight on your left lower extremity
-Report any change in color of your flap area including
increased redness and/or any dusky or darkened appearance to the
office.
-DAILY dressing changes to left knee flap: xeroform sheets to
flap/skin graft sites covered by fluffed gauze and/or unfolded
kerlix (DO NOT WRAP KERLIX CIRCUMFERENTIALLY). Wrap from toes to
upper thigh in soft cottony WEBRIL wrap (multiple layers), wrap
ACE bandages lightly over webril from toes to thigh. Please pad
the heel well with at least 10 layers of webril.
-Your right posterior latissimus incision can be left open to
air.
-The right posterior latissimus JP drain should be left in place
to continue draining the liquefying hematoma.
-You should continue to sponge bathe until otherwise directed at
your follow up appointment. No tub baths until directed by your
doctor.
.
Diet/Activity:
1. You may resume your regular diet and continue your protein
shakes 3x/day.
2. Avoid heavy lifting and do not engage in strenuous activity
until instructed by your doctor.
.
Medications:
1. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
2. Take prescription pain medications for pain not relieved by
tylenol.
3. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10565694-DS-23 | 10,565,694 | 27,190,359 | DS | 23 | 2152-07-09 00:00:00 | 2152-07-09 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
Vancomycin Hcl / Zyvox
Attending: ___.
Chief Complaint:
LLE flap changes and fevers
Major Surgical or Invasive Procedure:
CT guided drainage of/and placement of an ___ pigtail
catheter into ___ fluid collection LLE. (removed
___
History of Present Illness:
Mr. ___ is a ___ year old male with history of bilateral
TKR and multiple prosthetic joint infections s/p multiple
revision operations, most recently of the left knee including
multiple I+D, antibiotic spacer, and latissimus free
myocutaneous flap with AV loop, who now presents from rehab to
the ED for left lower extremity flap changes and fevers. The
patient was most recently admitted on ___ for left lower
extremity wound bleeding and infection, for which he underwent
multiple procedures.
.
The patient was discharged to rehab on ___ after a
prolonged hospitalization. ID followed him as an inpatient for
cultures positive for coag negative Staph, Bacillus species, and
multiple strains of ___, for which he was treated with and
discharged on cefepime, daptomycin, flagyl, and fluconazole.
.
He re-presents to the emergency room for concern of left lower
extremity flap color changes and fevers from 99-101 over the
last few days. He noted the flap paddle to have a different
appearance today during his dressing change with black edges
along the proximal aspect of the flap. He denies chills, nausea,
vomiting, diarrhea, cough, shortness of breath, chest pain, and
changes in urinary symptoms. No surrounding erythema or purulent
drainage from leg. His right back drain was accidentally pulled
a few days ago, which since has been intermittently drained
scant amounts of serous fluid.
Past Medical History:
HTN
OA
s/p appendectomy
GERD s/p lap esophageal sphincter repair
Bilateral PJI as outlined in HPI
.
Past Surgical History:
Left biceps tendon repair
Appendectomy
Lap esophageal sphincter repair
Multiple surgeries for bilateral prosthetic joint infection
after
TKR
Social History:
___
Family History:
Father deceased from complications of CHF. Mother is alive at
___ and healthy. No family history of MI or malignancy.
Physical Exam:
GEN: A&O, NAD
CV: RRR
PULM: Breathing comfortably on room air
BACK: right latissimus incision healing well; no evidence of
hematoma. Drain site with minimal serous drainage. No erythema,
induration, or fluctuance.
ABD: Soft, NT, ND
Ext: Left lower extremity with flap paddle with proximal paddle
necrosis, appearing superficial; mild hyperemia flap more
distally. Surrounding skin graft over healthy appearing muscle.
AV loop Dopplerable arterial and venous signals. Unable to
locate signal in flap paddle. Some areas of skin graft
non-healing more distally. Posterior lower leg wounds stable
with interval
healing. Right lower extremity incisions healing well.
Pertinent Results:
ADMISSION LABS:
___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:00PM PLT COUNT-488*
___ 10:00PM NEUTS-76.3* LYMPHS-10.2* MONOS-11.7 EOS-1.2
BASOS-0.2 IM ___ AbsNeut-6.97* AbsLymp-0.93* AbsMono-1.07*
AbsEos-0.11 AbsBaso-0.02
___ 10:00PM WBC-9.1 RBC-3.78* HGB-8.9* HCT-29.6* MCV-78*
MCH-23.5* MCHC-30.1* RDW-15.5 RDWSD-44.2
___ 10:00PM URINE UHOLD-HOLD
___ 10:00PM URINE HOURS-RANDOM
___ 10:00PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-95 TOT
BILI-0.2
___ 10:00PM estGFR-Using this
___ 10:00PM GLUCOSE-121* UREA N-8 CREAT-0.5 SODIUM-128*
POTASSIUM-4.2 CHLORIDE-89* TOTAL CO2-24 ANION GAP-19
___ 10:11PM LACTATE-1.5
.
DISCHARGE LABS:
___ 09:46AM BLOOD WBC-6.5 RBC-4.09* Hgb-9.8* Hct-30.9*
MCV-76* MCH-24.0* MCHC-31.7* RDW-15.4 RDWSD-42.0 Plt ___
___ 09:46AM BLOOD Neuts-74.8* Lymphs-10.9* Monos-11.4
Eos-1.5 Baso-0.5 Im ___ AbsNeut-4.85 AbsLymp-0.71*
AbsMono-0.74 AbsEos-0.10 AbsBaso-0.03
___ 09:46AM BLOOD Glucose-103* UreaN-6 Creat-0.5 Na-130*
K-3.5 Cl-94* HCO3-23 AnGap-17
___ 09:46AM BLOOD ALT-8 AST-13 AlkPhos-102 TotBili-0.2
___ 09:46AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
.
IMAGING:
Radiology Report CT LOWER EXT W/C BILAT Study Date of ___
2:27 AM
IMPRESSION:
1. Somewhat limited evaluation of the left thigh due to hardware
artifact.
Triangular area of fluid and stranding measuring approximately 3
cm in
greatest width could represent phlegmon or possibly early
abscess.
2. Low-density collection encircling the distal femur could
represent abscess or an antibiotic capsule.
3. Diffuse skin thickening of the left thigh likely represents
cellulitis.
4. No fluid collection in the right thigh.
.
Radiology Report ___ DUP EXTEXT BIL (MAP/DVT) Study Date of
___ 2:36 AM
IMPRESSION:
Limited evaluation of the left lower extremity veins as
described above. No evidence of deep venous thrombosis in the
imaged right or left lower extremity veins.
.
Radiology Report CHEST (PA & LAT) Study Date of ___ 10:56
AM
IMPRESSION:
Low lung volumes. Right PICC terminates in the low SVC. No
evidence of acute cardiopulmonary process.
.
Radiology Report US INTERVENTIONAL PROCEDURE Study Date of
___ 9:39 AM
IMPRESSION:
Unsuccessful attempt ultrasound-guided drainage of the left
thigh fluid
collection.
.
Radiology Report CT INTERVENTIONAL PROCEDURE Study Date of
___ 11:53 AM
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
.
MICROBIOLOGY:
___ 9:26 am ABSCESS Source: left leg.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
___ ALBICANS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. WORK UP PER ___. ___ ___ ___ .
Yeast Susceptibility:.
Fluconazole MIC<=0.25MCG/ML= SUSCEPTIBLE.
Antifungal agents reported without interpretation lack
established
CLSI guidelines Results were read after 24 hours of
incubation.
Sensitivity testing performed by Sensititre.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ for observation and treatment of fevers and LLE flap
changes. On hospital day #2, a CT demonstrated a fluid
collection containing gas and a surrounding rim around the
prosthesis. A pigtail catheter was inserted and 80 cc of
brownish purulent fluid was aspirated with a sample sent for
microbiology evaluation.
.
Neuro: The patient was re-started on outpatient PO pain
medications on admission with good pain control.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was maintained on regular diet on admission.
Intake and output were closely monitored.
.
ID: The patient was started on IV cefepime, daptomycin,
fluconazole, and flagyl on admission and ID consult was
requested. Microbiology from ___ pigtail placement revealed
___ albicans. Initially, fluconazole was discontinued in
favor of Micafungin until sensitivities for the ___ revealed
it was sensitive to fluconazole. Fluconazole was resumed and
Micafungin discontinued. The patient's temperature was closely
watched for signs of infection. Upon discharge, the OPAT ID
discharge antibiotic regimen was Daptomycin IV, ertapenem IV and
fluconazole PO through ___. Patient will have follow up
appointment with Dr. ___ in ID in ___.
.
Prophylaxis: The patient received subcutaneous heparin, aspirin
and plavix.
.
At the time of discharge on hospital day # 11, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, voiding without assistance, and pain was well
controlled. ___ drain was putting out scant drainage so was
d/c'd by ___ prior to discharge home with service.
Medications on Admission:
CEFEPIME - cefepime 2 gram solution for injection. 2 grams IV
every eight (8) hours
CYCLOBENZAPRINE - cyclobenzaprine 10 mg tablet. 1 tablet(s) by
mouth Four times a day prn
DAPTOMYCIN - daptomycin 500 mg intravenous solution. 850 mg IV
once a day
ENOXAPARIN [LOVENOX] - Dosage uncertain - (Prescribed by Other
Provider)
FLUCONAZOLE - fluconazole 200 mg tablet. 2 tablet(s) by mouth
once a day
FLUTICASONE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation
aerosol inhaler. 2 puffs two times per day. Rinse mouth after
use. - (Not Taking as Prescribed)
GABAPENTIN - gabapentin 100 mg capsule. TAKE ___ CAPSULE(S) BY
MOUTH EVERY MORNING - (Not Taking as Prescribed: using as
needed)
GABAPENTIN - gabapentin 300 mg capsule. capsule(s) by mouth as
directed - (Prescribed by Other Provider)
HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 325
mg tablet. TAKE 1 TO 2 TABLETS BY MOUTH 3 TO 4 TIMES A DAY AS
NEEDED FOR PAIN
LISINOPRIL-HYDROCHLOROTHIAZIDE - lisinopril 20
mg-hydrochlorothiazide 25 mg tablet. TAKE 1 TABLET EVERY DAY
MINOCYCLINE - minocycline 100 mg capsule. 1 capsule(s) by mouth
twice a day
OXYCODONE - oxycodone 5 mg capsule. ___ capsule(s) by mouth
every ___ hours as needed for pain
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet. ___ to 1 tablet(s)
by mouth as directed
TADALAFIL [CIALIS] - Cialis 20 mg tablet. TAKE ___ TO 1 TABLET
BY MOUTH AS DIRECTED
TRAZODONE - trazodone 50 mg tablet. TAKE ___ TABLETS BY MOUTH
AT BEDTIME AS NEEDED
Medications - OTC
ACETAMINOPHEN [8 HOUR PAIN RELIEVER] - 8 HOUR PAIN RELIEVER 650
mg tablet,extended release. 1 tablet(s) by mouth every 6 hours
as needed for pain - (Prescribed by Other Provider)
BISACODYL [DULCOLAX (BISACODYL)] - Dosage uncertain -
(Prescribed by Other Provider)
FERROUS SULFATE [FEOSOL] - Feosol 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth daily - (Prescribed by Other Provider)
MULTIVITAMIN - multivitamin capsule. one Capsule(s) by mouth
once a day - (OTC)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aquaphor Ointment 1 Appl TP DAILY
RX *white petrolatum [Aquaphor Original] 41 % Apply to skin
graft donor sites once a day Refills:*0
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
5. Daptomycin 850 mg IV Q24H
RX *daptomycin 500 mg 850 mg IV Every 24 hours Disp #*100 Vial
Refills:*0
6. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*14
Syringe Refills:*1
7. Ertapenem Sodium 1 g IV 1X Once/day Duration: 1 Dose
at least 4wks (___) or ongoing until definitive management
of surgical flap
RX *ertapenem [Invanz] 1 gram 1 gm IV Every 24 hours Disp #*40
Vial Refills:*0
8. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*80
Tablet Refills:*0
9. LORazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
10. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
11. Aspirin 325 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Hydrochlorothiazide 25 mg PO DAILY
16. Lisinopril 20 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
19. Ranitidine 75 mg PO BID
20. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) lower extremity flap color changes and fevers
2) ___ abscess LLE.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). ___ LLE
Discharge Instructions:
-You should keep your left lower extremity elevated when you are
not standing to urinate and/or not standing and pivoting to
chair and not walking around with crutches, to help with
swelling and drainage.
--You may not bear weight on your left lower extremity
-Report any change in color of your flap area including
increased redness and/or any dusky or darkened appearance to the
office.
-DAILY dressing changes to left knee flap: adaptic to flap/skin
graft sites Wrap from toes to upper thigh in soft cottony WEBRIL
wrap (multiple layers), wrap ACE bandages lightly over webril
from toes to thigh. Please pad the heel well with at least 10
layers of webril.
-You may shower once drain has been out for 48 hours and then
re-wrap left leg.
-apply aquaphor to skin graft donor sites daily
.
Diet/Activity:
1. You may resume your regular diet and continue your protein
shakes 3x/day.
.
Medications:
1. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
2. Take prescription pain medications for pain not relieved by
tylenol.
3. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10565694-DS-25 | 10,565,694 | 22,222,740 | DS | 25 | 2152-11-19 00:00:00 | 2152-11-19 21:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin Hcl / Zyvox
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ history of bilateral TKA (___), multiple joint
infections (currently w/ R knee w/ antibiotic spacer; on
suppressive minocycline and fluconazole) who is admitted with
fever and leukocytosis concerning for recurrent infection.
The patient presented to his vascular surgeon in routine follow
up where he was found to have chronic edema of the LLE and had
his leg wrapped tightly in a compression wrap. One hour later he
had a fever and called his PCP, who told him to present to the
___.
The patient presented first to the ___ where he had blood
cultures x2, a negative flu swab, was found to have WBC of 28,
and then was sent in town. At ___, he underwent a CT of the
LLE that showed no obvious drainable collection. He had an
arthrocentesis of the left knee that showed only 5000 WBCs. He
was given cefepime 2g, daptomycin 850 mg, clindamycin 600 mg,
and micafungin 100 mg, then was admitted to medicine.
On arrival to the floor, he was febrile to 102, although was
well-appearing.
REVIEW OF SYSTEMS
GEN: fevers as per HPI
CARDIAC: denies chest pain or palpitations
ENT: no sore throat or new rhinorrhea
PULM: denies new dyspnea or cough
GI: no diarrhea or constipation. No nausea. No abdominal pain.
GU: denies dysuria or change in appearance of urine
Full 14-system review of systems otherwise negative and
non-contributory.
Past Medical History:
Orthopedic history:
- ___: bilateral TKA; early post-op course was c/b R knee
MSSA/Staph epi PJI s/p washout, liner exchange, prolonged abx
(the right knee prosthesis has had no problems since and remains
in situ)
- ___: CoNS PJI of L knee s/p removal of hardware, daptomycin
course, replacement of hardware; maintained on suppressive
dicloxicillin and rifampin
- ___: Recurrent CoNS PJI of L knee; underwent resection L
knee arthroplasty with L distal femur replacement and antibiotic
spacer; was treated with 6 weeks daptomycin.
- ___: I&D L distal femur replacement, I&D L knee with
gastroc flap closure. Cultures grew enterococcus and GBS and he
was plaved on suppressive minocycline. Had intra-op injury of
the SFA and required stenting.
- ___: Explant of left distal femoral prosthesis, placement
of antibiotic cement spacer stabilized by femoral and tibial
intramedullary nail. Cultures grew ___ albicans and ___
parapsilosis and he was placed on suppressive fluconazole.
- ___: excision of chronic wounds (LLE lateral wound 3x5 cm,
RLE medial 3x1 cm) and STSG to bilateral legs).
Other medical and surgical history:
-HTN
-OA
-obesity
-s/p appendectomy
-GERD s/p lap esophageal sphincter ___
Social History:
___
Family History:
Father deceased from complications of CHF. Mother is alive at
___ and healthy. No family history of MI or malignancy.
Physical Exam:
VITALS: temp 102.7, 159/74, 99, 18, 93%
GEN: obese M in NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: mildly distended. Nontender to deep palpation. Bowel sounds
present.
MSK: No visible joint effusions or deformities.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: RLE with numerous scars from skin grafting and TKA,
otherwise unremarkable. LLE edematous, mildly erythematous and a
bit hard on palpation(although patient says it is always that
way). Pt has a deep tract in the lateral aspect of the knee, a
poorly healing but not frankly purulent 7 cm incision on the
medial aspect of the thigh, and a heel ulcer. While the leg is
strikingly abnormal, there is no obvious cellulitis or any
obvious wound infections.
Pertinent Results:
Admission labs:
___ 03:02PM WBC-19.1* (93% polys) RBC-4.50* HGB-10.5*
HCT-32.4* MCV-72* MCH-23.3* MCHC-32.4 RDW-17.1* Plt 291
___ 11:30PM GLUCOSE-97 UREA N-23* CREAT-1.3* SODIUM-133
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-20*
___ 11:53PM LACTATE-1.2
Arthrocentesis:
___ 09:40AM JOINT FLUID TNC-___* ___ POLYS-94*
___ MONOS-1
CT L Lower extremity ___:
1. Subcutaneous emphysema along the proximal fibula near the
lateral
subcutaneous tissue defect near the knee joint, which may be
secondary to
instrumentation which was performed immediately prior to the
scan by the
plastic surgery team [plastics note confirms this].
2. Diffuse skin thickening and edema throughout the leg. No
focal drainable fluid collection.
3. Intramedullary rods spanning the entire lower extremity. No
significant
interval change in the appearance of the femoral cortex. Likely
healing
periprostatic fracture in the tibia.
4. Calcified lower extremity arteries with likely 2 vessel
runoff, though
evaluation is limited due to phase contrast.
5. Difficult to evaluate patency of the femoral artery vascular
stent due to streak artifacts. Patent distal femoral artery and
proximal popliteal artery adjacent to the stent.
Brief Hospital Course:
___ w/ history of bilateral TKA (___), multiple joint
infections (currently w/ R knee w/ antibiotic spacer; on
suppressive minocycline and fluconazole) who is admitted with
fever and leukocytosis concerning for recurrent infection.
#FEVER AND LEUKOCYTOSIS
#CHRONIC INFECTIONS OF LLE
No obvious cellulitis or purulent wound on the LLE. MRI showed
possible abscess in RLE but not involving the prosthesis. Of
note, left arthrocentesis drained largely
bloody aspirate (RBC 5500with WBC ___, and 94% polys) with
no growth to date, does not appear consistent with joint
infection. Per prior culture data (previously grown CoNS, GBS,
enterococcus, ___ albicans and ___ parapsilosis), he was
started on daptomycin, unasyn and fluconazole with improvement
in his WBC (23 to normal), CRP (266 to 220). Per discussion with
ortho, no plan for drainage and continuation of abx was planned.
He was discharged on IV daptomycin (via PICC placed 5.1) and PO
fluconazole until he follows up at ___ clinic on ___, and then
re-image.
___: Pre-renal; resolved fluids
#CHRONIC PAIN OF LLE: Continued PRN oxycodone and Tylenol
#HTN: Initially held lisinopril and HCTZ for now due to concern
for insipient sepsis. Resumed after BPs trended up during days 2
onwards
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Aquaphor Ointment 1 Appl TP TID:PRN itchy/dryness
3. Cyclobenzaprine 10 mg PO QID:PRN spasm
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Minocycline 100 mg PO Q12H
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
10. TraZODone 100 mg PO QHS:PRN insomnia
11. Fluconazole 400 mg PO Q24H
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Aquaphor Ointment 1 Appl TP TID:PRN itchy/dryness
3. Dakins ___ Strength 1 Appl TP ASDIR
4. Daptomycin 850 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 850 mg IV once daily Disp #*500
Vial Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluconazole 400 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 2 tablet(s) by mouth daily
Disp #*80 Tablet Refills:*0
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
9. Cyclobenzaprine 10 mg PO QID:PRN spasm
10. Hydrochlorothiazide 25 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
SOFT TISSUE INFECTION OF LEFT LOWER EXTREMITY
HISTORY OF BILATERAL KNEE ARTHROPLASTY SECONDARY TO
OSTEOARTHRITIS
HISTORY OF RECURRENT PROSTHETIC INFECTIONS OF LEFT KNEE
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 were admitted to the hospital due to a recurrent infection
in your left leg. An MRI showed a possible fluid collection in
your left thigh. We started antibiotics (daptomycin, unasyn,
fluconazole) with which your inflammatory markers improved. You
will need to take antibiotics (daptomycin and fluconazole) via a
PICC line for an extended period until you see your infectious
disease doctor in clinic.
Followup Instructions:
___
|
10566394-DS-18 | 10,566,394 | 22,830,016 | DS | 18 | 2135-06-29 00:00:00 | 2135-06-30 18:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Right wrist pain (musculoskeletal)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with polysubstance abuse and suicidal intent
who presents from ___ with a swollen and painful right
hand for the past 24 hours.
Patient stated that she initially presented to the ___
around one week ago because she had passive suicidal intent and
was seeking help. She was admitted and found incidentally to
have an ear/sinus infection for which she was given Keflex and
Bactrim before a bed was found for her at ___
(psychiatric facility) pending transfer to a more long term
psych facility on ___.
This morning (___), she reports waking up with severe
unilateral swelling in her R hand and wrist along with pain.
Pain best described as "tingling, spiking", and worse with
contact. No recent trauma. No elbow, shouler, or neck pain.
No right arm/wrist weakness. She went to see the nurse at
___ and was given motrin, a split and told she had carpal
tunnel syndrome. Noted low grade fever at ___, no
subjective fevers or chills. No hand weakness. The pain did
not decrease and she was sent to ___ ___ for evaluation.
Regarding her drug dependence, she recently suffered a
miscarraige, and relapsed with both cocaine use and heroin use,
both injected, in various spots in her arms, including both
antecubital fossa and the left (but NOT the right) hand.
Initial VS in the ___: 98.2 ___ 18 95%
Patient was given clonazepam and assessed for upper and lower
extremity thrombi before being transferred to the floor for
further management. VS prior to transfer: 97.7 88 94/62 18 98%RA
On the floor, she was had a flat affect and seemed lethargic in
speech and mannerisms. She was able to recount her HPI, and her
mood was somewhat labile. She stated she had more pain in her
hand as the swelling came down.
Past Medical History:
per outside records:
-Mood disorder NOS
-PTSD
-Polysubstance abuse
Social History:
___
Family History:
(per outside records)
Unknown (foster care)
Physical Exam:
Physical Exam:
Vitals: T: 98 BP: 94/60 (100/54) P: 94 R: 20 O2: 95%(RA)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, soft S1 + normal S2, II/VI systolic
murmur without any rubs or gallops
Abdomen: non-tender
Ext: warm, well perfused, 2+ pulses, R hand swelling less
noticeable today. No specific dermatomal pattern to the
remaining numbness (centered mostly around thumb) and no motor
deficits could be elicited, though she did have some pain with
strong grip
Exam upon discharge:
T 98.1 104/50 HR 74 RR 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, soft S1 + normal S2, II/VI systolic
murmur without any rubs or gallops
Abdomen: non-tender
Ext: warm, well perfused, 2+ pulses, R hand swelling not noted
today. No specific dermatomal pattern to the remaining numbness
(centered mostly around thumb) and no motor deficits could be
elicited, though she did have mild pain with strong grip
Pertinent Results:
Admission Labs:
___ 02:18PM BLOOD WBC-4.9 RBC-3.99* Hgb-11.8* Hct-36.4
MCV-91 MCH-29.5 MCHC-32.3 RDW-12.4 Plt ___
___ 02:18PM BLOOD Neuts-40.3* Lymphs-49.3* Monos-3.6
Eos-6.1* Baso-0.6
___ 02:18PM BLOOD Plt ___
___ 01:35PM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-135 K-4.3
Cl-101 HCO3-24 AnGap-14
___ 02:07PM BLOOD Lactate-2.3*
Discharge Labs:
No new labs
Images:
UNILAT LOWER EXT VEINS RIGHT ___ 2:49 ___ "No evidence of
deep vein thrombosis in the right leg." (prelim)
UNILAT UP EXT VEINS US RIGHT ___ 2:49 ___ "Small clot in the
cephalic vein near the antecubital fossa. No deep vein
thrombosis in the right arm." (prelim)
WRIST(3 + VIEWS) RIGHT ___ 8:15 ___ "No acute fracture or
dislocation. No findings to suggest inflammatory arthritis."
TTE (Complete) Done ___ at 2:29:48 ___ "The left atrium is
normal in size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen."
Brief Hospital Course:
___ year old woman with several psychosocial issues including
suicidal ideation, mood disorder and polysubstance abuse
presenting with a new onset swelling and pain of the R hand in
the setting of recent drug use.
# Right hand pain: Pt presented with 24 hour history of right
hand swelling and pain with some rubor and dolor without calor.
She admitted to recently having injected heroin and cocaine into
both antecubital fossae and her left hand, but denied injecting
into her right hand. There was no evidence of trauma and a
hand/wrist Xray did not show any fractures or arthritic
processes in the joints. She was pain controlled with motrin
and the swelling decreased to normal by the time of discharge.
# Heart murmur: Pt was found to have a ___ systolic ejection
murmur in the ___. She was admitted with some concern for
endocarditis given her previous IV drug use. However, she
remained afebrile during her stay and a TTE performed ___ showed
normal heart valves without any vegetations. Blood cultures
were taken in the ___ and we will follow up on them if they
result positive.
# Constipation: Pt stated that she had not had a bowel movement
in 16 days despite being given senna, moviprep and milk of
magnesia. She was given mirilax and had a successful bowel
movement overnight. We will advise her to continue with a
regular bowel regimen.
# Mood disorder: Patient has several psychosocial disorders and
was previous admitted to ___ until a bed opened
at a more long term psychiatric facility. She is anxious
because she needed to return to ___ before ___ in order
to be eligible for the bed being held for her at her final
location (___). She denied active SI and HI, and was not
on suicide precautions prior to transfer. ___ was in
effect (cannot leave AMA). She was kept on her home dosages of
psych medications with good effects.
Transitional Issues
-Pt does not have a PCP. We have suggested ___ in
___ since it is near her home, and she agreed.
Medications on Admission:
(per ___ records)
-Klonopin 0.5 mg PO TID PRN
-Klonopin 1 mg PO QHS
-Neurontin 600 mg PO TID PRN
-Celexa 20 mg PO QHS
-Doxepin 15 mg PO QHS
-Suboxone 8 mg sublingual QAM
-Bactrim DS BID, today day ___
-Keflex ___ mg QID, today day ___
-Depakote 250 mg QID
-Trazadone 50 mg PO HS PRN
-Prazosin 1 mg HS
Discharge Medications:
1. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for hand pain for 5 days.
2. Doxepin
Please resume your previous dose of doxepin on discharge (15 mg
by mouth at bedtime).
3. prazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. buprenorphine-naloxone ___ mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual DAILY (Daily).
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days: finish ___.
6. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day) for 2 days: finish ___.
7. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QID (4 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Right wrist pain (musculoskeletal)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with
right hand swelling and pain as well as a new heart murmur.
While you were here, you had a hand xray which showed broken
bones or problems in the joints. You also had a heart
ultrasound (also called "echocardiagram") to confirm that there
were no abnormalities with your heart valves, this was normal,
which is obviously good news. You were given motrin and your
hand pain and swelling improved during your stay here. You are
now able to return to ___ to continue your
treatment.
You should START taking motrin for hand pain as needed.
You should CONTINUE your course of antibiotics for 2 more days.
You should continue to take all other medications as prescribed
by your doctors, no other changes were made to your medications
Followup Instructions:
___
|
10566481-DS-20 | 10,566,481 | 25,510,413 | DS | 20 | 2128-03-05 00:00:00 | 2128-03-12 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine
Attending: ___
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterization (left) ___
History of Present Illness:
___ w/COPD, HTN presenting with 1 week of increasing SOB, awoken
from sleep this morning approximately 0200 with chest pressure
and dyspnea "like an elephant sitting on my chest",
nonradiating, presented to ___ where he was noted to
have minimal septal STEs, no reciprocal changes, trop 0.14
(assay to 0.01). CXR showed concern for infiltrate. The patient
has a chronic cough but had a change in his sputum in the last
two days, now with thick yellow sputum which is new. Received
levaquin 750mg, ASA, 600mg plavix, SL NTGs with resolution of
pain, UFH 4000U bolus and 1000 U/hr infusion, transferred to
___ for further management. Remained asymptomatic since the
initial SL nitro. No significant ECG changes on arrival here.
In the ED, initial vitals were: pain ___ 165/73 14 98% RA
- Labs were significant for INR 2.6, plt 95->102, H/H
___, HCO3 19, trop 0.08 (at 15:40), lactate 1.2,
UA unremarkable. Guaiac negative.
- Imaging includes CXR which showed pulmonary edema, b/l small
pleural effusions, left heart border obscured with possible PNA
- Cardiology was consulted, who recommended metoprolol, heparin
gtt and nitro gtt for control of BP. These were started.
Vitals prior to transfer were: pain 0 97.8 69 142/52 18 97% RA
Upon arrival to the floor, the patient has no chest pain and is
comfortable.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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:
-COPD
-HTN
-GERD
-hypothyroidism
-Rheumatoid arthritis
-prostate cancer (not mets) s/p cryosurgery, no longer active
issue
-s/p removal of unclear part of small bowel for unclear reason
Social History:
___
Family History:
Brother had an MI at age ___, now deceased
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 156/84 71 16 98% RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: nromal rate, regular rhythm, S1/S2, ?S3 gallop present
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, +varicosities b/l ___, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII intact, no focal deficits, gait deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0, 120-146/58-73, 60-70, 20, 97% RA
Ins/Outs: 240/400 (MN), 2332/___ (24H)
Weights: 83.7
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: nromal rate, regular rhythm, S1/S2, ?S3 gallop present
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, +varicosities b/l ___, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII intact, no focal deficits, gait deferred.
Pertinent Results:
ADMISSION LABS
==============
___ 03:40PM BLOOD WBC-6.9 RBC-2.80*# Hgb-9.0*# Hct-25.6*#
MCV-92 MCH-31.9 MCHC-34.9 RDW-15.1 Plt Ct-95*#
___ 03:40PM BLOOD Neuts-82.7* Lymphs-9.1* Monos-7.5 Eos-0.4
Baso-0.3
___ 03:40PM BLOOD ___ PTT-120.2* ___
___ 03:40PM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-140
K-3.6 Cl-112* HCO3-19* AnGap-13
PERTINENT LABS
==============
___ 06:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Burr-OCCASIONAL
___ 07:30AM BLOOD ___
___ 03:40PM BLOOD cTropnT-0.08*
___ 12:16AM BLOOD CK-MB-2 cTropnT-0.09*
___ 07:30AM BLOOD CK-MB-1 cTropnT-0.08*
___ 01:05PM BLOOD CK-MB-2 cTropnT-0.06*
___ 12:16AM BLOOD Hapto-250*
___ 03:43PM BLOOD Lactate-1.2
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-4.9 RBC-2.96* Hgb-8.9* Hct-27.2*
MCV-92 MCH-29.9 MCHC-32.6 RDW-15.1 Plt ___
___ 12:55PM BLOOD ___
___ 06:00AM BLOOD Glucose-120* UreaN-31* Creat-0.9 Na-141
K-4.2 Cl-106 HCO3-28 AnGap-11
___ 06:00AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
RELEVANT STUDIES
================
- EKG (___): Sinus rhythm. A-V conduction delay. Probable
prior inferior wall myocardial infarction.
- ECHO (___): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the distal septum.The
remaining segments contract normally (LVEF = 55 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD (mid LAD
distribution).
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
- LEFT HEART CATH (___): 95% LAD stenosis.
1. Single-vessel disease in a pt with NSTEMI and CAD.
2. Given overlap of Afib and ACS and pt age, a bare metal stent
was placed.
3. Consider an abbreviated course of triple therapy as risk of
bleeding and risk of stroke and stent thrombosis dictates.
Brief Hospital Course:
Mr. ___ is a ___ with PMH significant for HTN, tobacco
abuse, COPD and h/o DVTs who presented to ___ with
chest pressure and shortness of breath which awoke him from
sleep. His EKG showed minimal STEs and a troponin leak which
peaked at 0.14 and he was diagnosed with an NSTEMI. He was also
started on antibiotics for possible PNA seen on CXR. His
antibiotic course will be completed on ___. Cardiac echo
showed an EF of 55% with some mild focal hypokinesis of the
distal septum, consistent with mid LAD blockage. He was
transferred to ___ for cardiac catheterization which he
underwent on ___ and showed a 95% stenosis of the LAD. A bare
metal stent was placed and patient was continued on ASA 81mg
daily, plavix 75mg daily, atorvastatin 80mg daily. He had
persistently elevated blood pressures throughout his
hospitalization which were likely a combination of underlying
hypertension plus lack of sleep and stress of being in the
hospital. Patient's medications were uptitrated and he was
discharged on Imdur 90mg daily and lisinopril 40mg daily. He was
given specific blood pressure parameters to follow and his
daughter will be assisting in his monitoring until he can be
seen by his primary care doctor. He was continued on his home
metoprolol XL at discharge. Blood pressure at discharge was
150/62. His daughter brought in an electric BP cuff from home
and this was correlated with our hospital BP cuff. The electric
cuff reading was 151/67. He was provided with specific
instructions which was relayed to his daughter as well in
person. Patient lives in senior housing and has an emergency
pull cord in his apartment which activates local emergency
services. He was instructed to use this should he remain
hypotensive or symptomatic from a BP perspective.
There was concern for a right femoral bruit at the cath access
site which was further evaluated by ultrasound. There was no
pseudoaneurysm, fluid collection or abnormal flow throughout the
vessel. He was considered safe for discharge.
TRANSITIONAL ISSUES:
====================
#New Medications: isosorbide mononitrate, lisinopril, aspirin
81mg, atorvastatin, clopidogrel and levofloxacin (until ___
only)
#Pending results: Blood cultures, finalized cardiac
catheterization report
#Follow up appointments: PCP, ___
[] needs blood pressure check in PCP office in ___ days
[] needs to see PCP ___ ___ days (patient and discharging MD ___
call on morning of ___ to get appointment)
[] consider repeating TTE in ___ weeks
[] Next INR should be checked on ___
[] stop levofloxacin on ___
[] BLOOD PRESSURE INSTRUCTIONS:
- your daughter will check your blood pressure for you multiple
times a day for the next few days
- should you feel lightheaded or dizzy, you should sit or lie
down immediately. Always get up slowly from a chair or bed to
prevent dizziness and falls. Should your symptoms not improve
you should call ___ or pull the emergency cord in your apartment
to activate emergency responders
- you will take all your medications as prescribed. PLEASE DO
NOT SKIP DOSES OF ANY MEDICATIONS UNLESS YOU NEED TO TITRATE FOR
BLOOD PRESSURE CONTROL
- you will not drive for the next week until your blood pressure
regimen can be finalized by your primary care doctor
- please do not lift more than 10lbs for the first week
following your procedure
- should your blood pressure be persistently low (< 100 top
number), DO NOT take your blood pressure medications. Drink 1
large glass of water then recheck your blood pressure every 15
minutes. If no improvement after 1 hour, call your primary care
doctor for further instruction.
- get up slowly from a chair or when getting out of bed. If you
are lightheaded or dizzy, SIT BACK DOWN or wait until the
dizziness stops to begin walking.
- should your blood pressure be < 80/50. CALL ___ IMMEDIATELY.
- should your blood pressure be consistently elevated
(>180/100), you should call your primary care doctor for further
instruction or present to the nearest hospital immediately for
further evaluation
- should you have constant headaches, vision changes (blurry
vision, double vision), facial drooping, slurred speech or
one-sided body weakness AND your blood pressure is >180/100,
CALL ___ IMMEDIATELY.
***YOUR GOAL BLOOD PRESSURE RANGE IS 140-150/50-60***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. PredniSONE 2 mg PO DAILY
5. SulfaSALAzine_ 1000 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Warfarin 4 mg PO DAILY
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. PredniSONE 2 mg PO DAILY
7. SulfaSALAzine_ 1000 mg PO DAILY
8. Warfarin 4 mg PO DAILY
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
11. Clopidogrel 75 mg PO DAILY
TAKE FOR 30 DAYS (___), DO NOT STOP TAKING BEFORE THEN FOR
ANY REASON.
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*0
13. Levofloxacin 750 mg PO DAILY Duration: 2 Days
Last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
14. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Outpatient Lab Work
ICD-9 code: ___
Please draw INR on ___ and fax results to Dr. ___ at
___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
NSTEMI
Hypertension
Community acquired pneumonia
SECONDARY DIAGNOSES:
====================
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for chest pressure
and shortness of breath. You were diagnosed with a heart attack.
You underwent a cardiac catheterization which showed a blockage
in one of the main arteries of your heart. We opened this
blockage with a stent and your symptoms improved. You had no
complications following the procedure.
Your blood pressure remained elevated throughout your
hospitalization. We increased your medication and started you on
new medications to control your blood pressure. Your blood
pressure was still elevated at discharge but we agreed to let
you leave under the following conditions:
- your daughter will check your blood pressure for you multiple
times a day for the next few days
- you will call you primary care doctor in the morning and
arrange for a follow up visit in the next ___ days
- call your ___ clinic in the morning to schedule a INR
check on ___
- if you cannot get a sooner follow up visit with your primary
care doctor, arrange for a clinical nurse visit for a blood
pressure check within ___ days
- should you feel lightheaded or dizzy, you should sit or lie
down immediately. Always get up slowly from a chair or bed to
prevent dizziness and falls. Should your symptoms not improve
you should call ___ or pull the emergency cord in your apartment
to activate emergency responders
- you will take all your medications as prescribed. PLEASE DO
NOT SKIP DOSES OF ANY MEDICATIONS UNLESS YOU NEED TO TITRATE FOR
BLOOD PRESSURE CONTROL
- you will not drive for the next week until your blood pressure
regimen can be finalized by your primary care doctor
- please do not lift more than 10lbs for the first week
following your procedure
BLOOD PRESSURE INSTRUCTIONS
===========================
- should your blood pressure be persistently low (< 100 top
number), DO NOT take your blood pressure medications. Drink 1
large glass of water then recheck your blood pressure every 15
minutes. If no improvement after 1 hour, call your primary care
doctor for further instruction.
- get up slowly from a chair or when getting out of bed. If you
are lightheaded or dizzy, SIT BACK DOWN or wait until the
dizziness stops to begin walking.
- should your blood pressure be < 80/50. CALL ___ IMMEDIATELY.
- should your blood pressure be consistently elevated
(>180/100), you should call your primary care doctor for further
instruction or present to the nearest hospital immediately for
further evaluation
- should you have constant headaches, vision changes (blurry
vision, double vision), facial drooping, slurred speech or
one-sided body weakness AND your blood pressure is >180/100,
CALL ___ IMMEDIATELY.
***YOUR GOAL BLOOD PRESSURE RANGE IS 140-150/50-60***
We strongly recommend that you quit smoking. This is one of the
best things you can do for your health. Please take all your
medications as prescribed. DO NOT STOP YOUR ASPIRIN OR
CLOPIDOGREL (PLAVIX) FOR ANY REASON UNLESS TOLD TO DO SO BY YOUR
CARDIOLOGIST. Stopping these medications too soon can cause
another heart attack and can lead to death.
We are also discharging you with antibiotics to complete your
treatment course for pneumonia. You will take 1 pill a day on
___ and ___ to complete your treatment course.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Cardiology team
Followup Instructions:
___
|
10566618-DS-20 | 10,566,618 | 25,958,748 | DS | 20 | 2112-07-15 00:00:00 | 2112-07-17 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of alcohol cirrhosis complicated
by
ascites and suspicious lesion concerning for ___ who is listed
for liver transplant and recent decompensation following
debridement of HS-related scrotal abscess (___) who
presented
following a clinic follow up with concerning labs including
worsening thrombocytopenia, hyponatremia, leukocytosis.
He has a history of severe HS with recent decompensation
___ of his cirrhosis in the setting of right hemiscrotal
abscess treated I & D under general anesthesia and course of
clindamycin/Bactrim.
He was then recently admitted to ___ from ___ due to acute
on chronic anemia secondary to bleeding HS facial lesion. He had
an EGD during the admission that showed grade I-II varices and
PHG. Since discharge he had a follow-up appointment on ___ that
showed a creatinine of 1.4 from baseline of 1.0-1.2 with
hyponatremia to 131. His diuretics were held and he presented
for
f/u to clinic on ___ at which time his diuretics were restarted
at a reduced dose of Lasix 20 mg daily and spironolactone 50 mg
daily (although he has not started taking them yet). He was also
prescribed 10 mg midodrine TID but has not picked up the
medication yet. At that time he reported a weight gain of around
10 lbs while off diuretics.
He had repeat labs drawn which were pertinent for WBC of 11.8,
platelets of 38 (prior 75), and Na 127 (prior 133). He was
contacted and told to go to the ___ ED for evaluation.
He has felt fatigued over the last couple of days and noticed
that his mental acuity feels below baseline. He doesn't have any
issues with his memory or any confusion, but it he noticed that
activities have been taking more mental effort than normal and
he
is overall mentally slower. He also feels that his "balance is
off." This has happened once before in ___ when his
medications
were being titrated but had been resolved since then until
today.
He did not have any falls but feels that he is off balance when
walking.
He has been feeling chills over the last few days to weeks
saying
that "it feels like it is still winter". Otherwise he denies
fever, cough, sore throat, headache, chest pain, shortness of
breath at rest, dysuria, urgency, frequency, N/V, or diarrhea.
He
did have some upper abdominal pain extending across the upper
abdomen which he feels is related to increased size of his
abdomen.
He does not have any specific concern for a skin infection. He
has chronic lesions related to HS on his face, neck, head,
groin,
axillae, and legs. They are painful at baseline but he has not
noticed any new focal areas of pain, bleeding, swelling, warmth,
drainage. The main area that is bothering him are the neck
lesions but does not feel like a noticeable change from
baseline.
He has noticed increased abdominal swelling over the last few
weeks as well as increased lower extremity swelling. No
shortness
of breath at rest but he does experience some on exertion. He
has
never had a paracentesis or SBP.
He further denies any history of variceal bleeding and reports
that he had the EGD completed in ___ and that he is on Nadalol
20 mg daily. No melena, BRBPR, hematemesis, or skin bleeding.
In the ED initial vitals: T 98.9, HR 89, BP 123/68, RR 17, O2
sat
100% on RA
- Exam notable for: icteric sclera, distended abdomen, 2+
pitting
edema to knee, +asterixis and ataxia
- Labs notable for:
serum tox negative
CBC: ___
Chem7: ___
LFTs: ALT 49 AST 104 Alk Phos 140 Tbili 9.2 Alb 1.5
Coags: ___ 31.5 PTT 53.3 INR 2.9
- Imaging notable for:
RUQUS: Main Portal vein and right and left branches are patent.
The right hepatic vein is patent and the left hepatic vein is
incompletely visualized. Cirrhotic liver with a 9 mm echogenic
lesion in the right hepatic lobe, unchanged. Further evaluation
of the liver lesion can be obtained with dedicated liver CT/MR.
___ ascites.
NCHCT
1. No acute large territory infarction or intracranial
hemorrhage.
2. No hydrocephalus.
3. Mild global atrophy, advanced for age.
CXR
No acute intrathoracic process.
- Consults: Hepatology
- Patient was given: 75 g albumin (25%)
On the floor, patient reports that he overall continues to feel
fatigue but other than being very hungry nothing in particular
is
bothering him.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- Alcohol cirrhosis complicated by Grade I/II varices, ?HCC
(monitoring mass with imaging), and portal hypertension listed
for liver transplant
- Diffuse hidradenitis suppurativa complicated by multiple
abscesses in past
- Remote C. difficile
- Chronic anemia
- EtOH use disorder complicated by withdrawal seizures, now in
remission
Social History:
___
Family History:
Sister - liver disease s/p DDLT, renal failure
Brother - EtOH use disorder, EtOH withdrawal seizures
Mother and father - both died of cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: ___ Temp: 98.1 PO BP: 103/62 HR: 86 RR: 18 O2 sat:
97% O2 delivery: RA
GENERAL: Chronically ill appearing male in NAD
HEENT: Scleral icterus. EOMI, PERRL. MMM.
NECK: supple, no LAD, no JVD.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended abdomen with tense ascites. Nontender to
palpation throughout without rebound or guarding.
EXTREMITIES: 2+ pitting edema to the mid-shin. 2+ DP pulses.
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis. He is able to name the months of the year backwards
but missed one month.
SKIN: Widespread scarred plaques with some appearing keloidal
distributed on head, face, neck, axillae, groin, and legs. Groin
exam is pertinent for mild amount of bleeding but no purulent
drainage, fluctuance, warmth.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1513)
Temp: 97.3 (Tm 98.6), BP: 113/73 (94-114/54-73), HR: 57
(57-78), RR: 18, O2 sat: 100% (95-100), O2 delivery: Ra, Wt:
172.1 lb/78.06 kg
GENERAL: Chronically ill appearing male in NAD
HEENT: Scleral icterus. EOMI, PERRL. MMM.
NECK: supple, no LAD, no JVD.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, mild trace expiratory wheezes diffusely
ABDOMEN: Distended abdomen with tense ascites. Non-tender to
palpation throughout without rebound or guarding.
EXTREMITIES: 1+ pitting edema to the mid-shin. 2+ DP pulses.
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis.
SKIN: Widespread scarred plaques with some appearing keloidal
distributed on head, face, neck, axillae, groin, and legs. R
face
lesions now without bleeding. Groin exam is pertinent for mild
amount of bleeding but no purulent drainage, fluctuance, warmth.
RECTAL EXAM: No external bleeding HS lesions, hemorrhoids. No
internal hemorrhoids, polyps palpated. Red blood on glove.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:15PM ASCITES TOT PROT-0.6 GLUCOSE-124 ALBUMIN-0.3
___ 07:15PM ASCITES TNC-127* RBC-382* POLYS-33* LYMPHS-12*
MONOS-0 EOS-1* MESOTHELI-20* MACROPHAG-34* OTHER-0
___ 01:40PM GLUCOSE-107* UREA N-20 CREAT-1.2 SODIUM-130*
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-18* ANION GAP-14
___ 01:40PM ALT(SGPT)-49* AST(SGOT)-104* ALK PHOS-140* TOT
BILI-9.2*
___ 01:40PM ALBUMIN-1.5* CALCIUM-7.9* PHOSPHATE-4.1
MAGNESIUM-1.8
___ 01:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG
___ 01:40PM WBC-7.8 RBC-2.49* HGB-8.5* HCT-26.5* MCV-106*
MCH-34.1* MCHC-32.1 RDW-16.0* RDWSD-61.3*
___ 01:40PM NEUTS-68.4 LYMPHS-16.6* MONOS-11.0 EOS-2.2
BASOS-0.5 IM ___ AbsNeut-5.34 AbsLymp-1.30 AbsMono-0.86*
AbsEos-0.17 AbsBaso-0.04
___ 01:40PM PLT COUNT-82*
___ 01:40PM ___ PTT-53.3* ___
___ 12:50PM GLUCOSE-79
___ 12:50PM UREA N-21* CREAT-1.4* SODIUM-127* POTASSIUM-4.9
CHLORIDE-96 TOTAL CO2-17* ANION GAP-14
___ 12:50PM estGFR-Using this
___ 12:50PM ALT(SGPT)-53* AST(SGOT)-97* ALK PHOS-170* TOT
BILI-10.2*
___ 12:50PM ALBUMIN-1.7*
___ 12:50PM ETHANOL-NEG
___ 12:50PM WBC-11.8* RBC-2.62* HGB-9.0* HCT-27.8* MCV-106*
MCH-34.4* MCHC-32.4 RDW-16.2* RDWSD-62.3*
___ 12:50PM PLT COUNT-38*
___ 12:50PM ___
PERTINENT STUDIES:
==================
___ Imaging DUPLEX DOPP ABD/PEL
1. Patent hepatopetal flow in the main portal vein and right and
left branches. Left hepatic vein is poorly visualized.
2. Cirrhotic liver with a 9 mm echogenic lesion in the right
hepatic lobe,
unchanged. Further evaluation of the liver lesion can be
obtained with
dedicated liver CT/MR.
3. Moderate ascites.
___ Imaging CHEST (PA & LAT)
No acute intrathoracic process.
___ Imaging CT HEAD W/O CONTRAST
1. No acute large territory infarction or intracranial
hemorrhage.
2. No hydrocephalus.
3. Mild global atrophy, advanced for age.
___ Imaging CHEST (PRE-OP PA & LAT)
No focal consolidation or acute findings in the chest.
DISCHARGE LABS:
===============
___ 09:05AM BLOOD WBC-8.0 RBC-2.45* Hgb-8.3* Hct-25.9*
MCV-106* MCH-33.9* MCHC-32.0 RDW-18.6* RDWSD-72.4* Plt Ct-66*
___ 09:05AM BLOOD ___ PTT-55.1* ___
___ 09:05AM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131*
K-4.4 Cl-102 HCO3-20* AnGap-9*
___ 09:05AM BLOOD ALT-42* AST-82* AlkPhos-173* TotBili-7.0*
___ 09:05AM BLOOD Albumin-1.9* Calcium-7.8* Phos-3.4 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ male with medical history notable
for alcoholic cirrhosis complicated by ascites, esophageal
varices, suspicious lesion concerning for ___, active on liver
transplant list, with recent hospitalization due to
decompensated cirrhosis in the setting of a debridement for an
HS-related groin abscess. He presented following a clinic
appointment due to thrombocytopenia, hyponatremia, and
leukocytosis. These abnormalities quickly resolved after 1 day
with minimal intervention. Subsequently however developed acute
on chronic anemia requiring a total of 2 units of packed red
blood cells during the hospitalization due to persistent
bleeding from facial and perianal hidradenitis suppurativa
lesions. He was given topical agents per dermatology, as well as
vitamin K and FFP with cessation of bleeding as well as
stabilization of blood counts. His hospitalization was extended
due to offer for liver transplant, however did not occur due to
technical issues involving the donor.
TRANSITIONAL ISSUES:
====================
[ ] Please note patient has not been taking tiotropium due to
cost. ___ consider alternative LAMA if feasible.
[ ] Patient has repeat imaging scheduled on ___ to evaluate for
liver lesion
ACUTE ISSUES:
=============
#Acute on chronic anemia
Baseline hemoglobin in the ___ range. Had slow downtrend during
admission to high 6 range twice during hospitalization. As
result received a total of 2 units packed red blood cells. He
was never hemodynamically unstable during this admission. He was
noted to have intermittent bright red blood per rectum, however
with normal rectal exam and so thought to be due to perianal
lesions of hidradenitis.
#Hidradenitis suppurativa
Has had HS for approximately 2 decades, most recently following
with Dr. ___ in infectious disease clinic and Dr. ___ in
dermatology. HS has been refractory to most outpatient
therapies. Tentative outpatient plan to receive Humira, however
still receiving vaccinations required before initiation this.
Additionally concern regarding usage of Humira in higher MELD
scores although this is not an absolute contraindication. As
above, lesions from face and ___ area were bleeding during
hospitalization necessitation transfusion. Patient received IV
Vitamin K and one unit of FFP with adequate resolution of
bleeding. Dermatology was consulted while inpatient, recommended
aluminum chloride, however this was non-formulary and could not
be consistently utilized.
#Decompensated Alcoholic Cirrhosis
MELDNa at discharge ***. Childs Class C. Cirrhosis complicated
by varices, portal hypertension, ascites, and coagulopathy. He
is listed on transplant list. During admission, had possible
donor offer, however due to logistical issues on the side of the
donor this did not occur. Home diuretics were briefly held
during admission due to concerns for GI bleeding, however these
were restarted while in-house. Paracentesis done on admission
without evidence of SBP.
___
#Hyponatremia
Presented with hyponatremia and ___ thought to be due to
pre-renal physiology in cirrhotic individual. Received albumin
challenge with resolution of electrolyte abnormalities and ___.
CHRONIC/STABLE ISSUES:
======================
# Liver lesion concerning for ___
Segment 7 lesion 1.5 cm not meeting OPTN criteria for ___
- Repeat imaging planned for ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Furosemide 20 mg PO DAILY
3. Gabapentin 300 mg PO QHS
4. Nadolol 20 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheeze
9. Artificial Tears 2 DROP BOTH EYES Q4H:PRN dry eyes
10. Midodrine 10 mg PO TID
Discharge Medications:
1. aluminum chloride 20 % topical DAILY:PRN
Use on facial lesions
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheeze
3. Artificial Tears 2 DROP BOTH EYES Q4H:PRN dry eyes
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Midodrine 10 mg PO TID
8. Nadolol 20 mg PO DAILY
9. Spironolactone 50 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
#Anemia
#Hidradenitis Suppurativa
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for coming to ___ for your care. Please read the
following instructions carefully:
Why was I admitted to the hospital?
-You were admitted to the hospital because your blood work was
abnormal
-We were also concerned that you were losing blood from your
skin lesions
What was done for me while I was here?
-We gave you medications to help stop the bleeding
-The dermatologists came to see you to help us treat your HS
What do I need to do when I leave the hospital?
-Please take your medications as listed below
-Please keep your appointments as listed below
We wish you the best with your care,
-Your ___ care team
Followup Instructions:
___
|
10566658-DS-21 | 10,566,658 | 24,322,378 | DS | 21 | 2181-02-26 00:00:00 | 2181-02-26 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / mirtazapine
Attending: ___.
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with h/o HTN, DMT2, hydrocephalus
(s/p VP shunt), abdominal hysterectomy, recurrent UTIs, chronic
constipation, who presents after an episode of syncope.
She reported feeling nauseated and weak this morning. Her
daughter reports that at 10:30 AM she suddenly slumped over in
her chair, with her eyes open and not responding. The episode
lasted about a minute. Patient remembers this event and denied
any preceding palpitations, chest pain, shortness of breath, and
diaphoresis. After the episode, she subsequently had a large,
watery, non-bloody episode of diarrhea. EMS was called and the
patient came to the ___ ED.
Of note, the patient and her daughter report that she had a
slight cold last week with rhinorrhea. She also had "a couple"
episodes of diarrhea last week. Bowel movements had been normal
this week until the diarrhea today. She states that she usually
has a BM every ___ days.
Pre-hospital BP was ___ with HR in ___.
In the ED - Initial vitals were: temp 97.6 F, BP 98/54
(improving to 150/50s), HR ___, RR 16, 98% RA
- Exam notable for: Awake and mentating appropriately, although
appears fatigued. No focality on exam. abdomen soft. good cap
refill.
- Labs notable for:
WBC 9.4, Hgb 14, plts 212, INR 1.2
Na 141, K 4.8, Cr 1.2, serum glucose 212
Lactate 2.1
Clean UA
- Imaging was notable for:
NCHCT ___:
No acute intracranial process. No hydrocephalus. Known residual
soft tissue the right cerebellopontine angle cistern is not
clearly delineated by CT scan. Hyperdense extra-axial mass
overlying the left parietal lobe, not significantly changed
since ___ though larger compared to ___. This is most likely a
meningioma.
CXR No acute cardiopulmonary process.
- Patient was given: 500 CC IV fluids
Upon arrival to the floor, patient reports that she feels
generally weak, which is how she has felt for "some time now".
She denies any fever or chills, abdominal pain, dysuria,
palpitations, chest pain, headache, confusion. She states that
right after the event this morning, she felt "poor" but denied
any confusion or disorientation.
Past Medical History:
acoustic neuroma status post removal in ___ s/p hydrocephalus
and vp shunt placement
sciatica
hypertension
hypercholesterolemia
hypothyroidism
GERD
diabetes mellitus
osteoporosis
recent episode of bronchitis treated with z pack
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM
==========================
VITAL SIGNS: T 97.8, BP 189/72, HR 72, RR 18, O2 100%RA
GENERAL: Elderly lady, well-appearing in NAD.
HEENT: Previous cataract surgery. EOMI.
NECK: Supple, nontender.
CARDIAC: NR, RR. Nl S1, S2. No m/r/g.
LUNGS: CTAB.
ABDOMEN: +BS. Soft, nontender, nondistended.
EXTREMITIES: Trace ankle edema b/l.
NEUROLOGIC: AOx3. Moving all limbs appropriately. Sensation
intact BUE/BLE.
SKIN: No rashes/lesions.
DISCHARGE EXAM
============
___ 0750 Temp: 98.3 PO BP: 149/72 HR: 71 RR: 16 O2 sat: 96%
O2 delivery: Ra
GENERAL: Elderly lady, well-appearing in NAD.
HEENT: Previous cataract surgery. EOMI.
NECK: Supple, nontender.
CARDIAC: NR, RR. Nl S1, S2. No m/r/g.
LUNGS: CTAB.
ABDOMEN: +BS. Soft, nontender, nondistended.
EXTREMITIES: Trace ankle edema b/l.
NEUROLOGIC: AOx3. Moving all limbs appropriately. Sensation
intact BUE/BLE.
SKIN: No rashes/lesions.
Pertinent Results:
ADMISSION LABS
========================
___ 12:00PM BLOOD WBC-9.4 RBC-4.70 Hgb-14.0 Hct-42.7 MCV-91
MCH-29.8 MCHC-32.8 RDW-13.3 RDWSD-44.0 Plt ___
___ 12:00PM BLOOD Neuts-72.1* ___ Monos-5.5 Eos-1.5
Baso-0.4 Im ___ AbsNeut-6.79* AbsLymp-1.89 AbsMono-0.52
AbsEos-0.14 AbsBaso-0.04
___ 12:00PM BLOOD Glucose-212* UreaN-18 Creat-1.2* Na-141
K-4.8 Cl-103 HCO3-23 AnGap-15
___ 12:00PM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1
MICROBIOLOGY
=======================
Urine culture negative
RELEVANT STUDIES
=======================
___ CXR PORTABLE AP: No acute cardiopulmonary process.
___ CT HEAD W/O CONTRAST:
No acute intracranial process. No hydrocephalus.
Known residual soft tissue the right cerebellopontine angle
cistern is not
clearly delineated by CT scan. Hyperdense extra-axial mass
overlying the left parietal lobe, not significantly changed
since ___ though larger compared to ___. This is most likely
a meningioma.
DISCHARGE LABS
=======================
___ 07:50AM BLOOD WBC-4.9 RBC-4.03 Hgb-11.9 Hct-37.2 MCV-92
MCH-29.5 MCHC-32.0 RDW-13.3 RDWSD-44.7 Plt ___
___ 08:05AM BLOOD Glucose-104* UreaN-15 Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-27 AnGap-11
___ 08:05AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ woman with PMH HTN, DM2,
hydrocephalus s/p VP shunt, recurrent UTIs who presented after
an episode of unresponsiveness witnessed by her daughter.
ACUTE ISSUES
========================
# Syncope, Likely Vasovagal vs orthostatic:
Admitted after episode of unresponsiveness most consistent with
vasovagal syncope given that this occurred after BM.
Alternatively may be orthostatic given +orthostatic vitals
during working with ___ despite IVF (see below). She had no
post-ictal state and ACS work-up was negative (neg trops, EKG
NSR without ST changes). She remained hypertensive during
admission but anti-hypertensives not adjusted since risk of
hypotension felt to outweigh benefit of aggressive anti-HTN
regimen. Telemetry was discontinued since she had no concerning
arrhythmias.
#Orthostatic hypotension: may be due to autonomic insufficiency
in the setting of chronic medical problems. ___ be contributing
to her loss of consciousness as above although vagal episode
more consistent with current presentation (which had occurred
after BM and episode was not after standing). Ultimately,
medications were not aggressively adjusted due to her resting
hypertension; did not want to decrease anti-HTN regimen given
this HTN. Notably she is not on any vasodilators or diuretics
which would be worse for orthostasis.
#Urinary frequency: this was patient's major concern during
hospital course. Unclear etiology since UA negative x2 ***** for
infection and for glucosuria. No urinary retention seen on
bladder scan x2. No diuretic agents given in the hospital; home
HCTZ discontinued as above. Diabetes insipidus felt to be less
likely as no increased thirst. Urinary frequency felt to
therefore be most likely due to IVF given upon admission.
#Loose stool: occurring prior to hospital course but not seen
while admitted. Home stool softeners and laxatives held given
loose stool. Norovirus and Cdiff ordered but not sent due to no
diarrhea this admission.
# HTN:
Patient takes lisinopril daily at home and PRN HCTZ when SBP is
greater than 160. She reported her BP at home was quite variable
but she does occasionally take HCTZ. HCTZ was discontinued since
patient had positive orthostatics and diuretics may have been
contributing.
CHRONIC ISSUES
==============
# Constipation: Home bowel regimen was held on admission while
she was having diarrhea.
# DMII
Controlled by diet at home.
TRANSITIONAL ISSUES
============================
[] please consider adjusting stool softeners, balancing h/o
constipation with diarrhea, which may be what prompted current
admission.
[] HCTZ held on discharge since patient had positive
orthostatics while admitted.
[] DNR/DNI
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO QPM
2. Hydrochlorothiazide 12.5 mg PO DAILY:PRN SBP > 160
3. Felodipine 10 mg PO QAM
4. Levothyroxine Sodium 100 mcg PO DAILY
5. ofloxacin 0.3 % ophthalmic (eye) BID
6. melatonin 3 mg oral QHS
7. Simethicone 80 mg PO QID:PRN gas
8. Docusate Sodium 100 mg PO TID:PRN constipation
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Felodipine 10 mg PO QAM
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 40 mg PO QPM
5. melatonin 3 mg oral QHS
6. ofloxacin 0.3 % ophthalmic (eye) BID
7. Simethicone 80 mg PO QID:PRN gas
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Vasovagal syncope
Orthostatic hypotension
Urinary frequency without dysuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You were admitted after you had an unresponsive episode in
front of your daughter.
What was done for me while I was here?
- Your heart rate was monitored and there was no concerning
arrhythmias.
- You worked with the physical therapists who determined you
were safe to go home.
- Your hydrochlorothiazide was stopped to avoid your blood
pressure from dropping too low.
What should I do when I go home?
- You should take all of your medications as prescribed.
- You should attend all of your follow-up appointments.
We wish you the best in the future.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10566967-DS-11 | 10,566,967 | 25,287,568 | DS | 11 | 2127-06-15 00:00:00 | 2127-06-16 08:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
C5/6 ACDF ___ ___
History of Present Illness:
Mr. ___ is a ___ y/o M with no PMH presenting with L arm, leg
and neck pain s/p fall. Patient slipped on deck around 3 ___ this
afternoon and fell from standing on to his left side. There was
no head strike or LOC at this time. He got up and went back
inside was speaking to his wife while standing at the top of the
stairs and stopped mid-sentence and fell down 12 stairs. He does
not remember falling and immediately regained consciousness at
the bottom of the stairs. He hit his head and again landed on
his left side. In between the 2 falls he reports feeling faint
and nauseous but denies any palpitations, shortness of breath,
headache or chest pain. He currently endorses neck pain, L
upper arm and shoulder pain (___) and L thigh/gluteal pain
___. He denies any weakness, paresthesias, or changes in
sensation.
Past Medical History:
Past Medical History: insomnia
Past Surgical History:
-childhood tonsillectomy
-inguinal hernia repair ___ years ago
Social History:
___
Family History:
early MI in maternal and paternal side of family
Physical Exam:
ON ADMISSION:
PHYSICAL EXAM:
O: T:96.9 BP: 158/77 HR:72 R:17 O2Sats:100%
RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2 mm bilaterally EOMs intact
Neck: Point tenderness to lower c-spine
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L D D D 5 5 5 5 5 5 5 5
LUE motor exam Deferred ___ L proximal humerus FX
Sensation: Intact to light touch
Propioception intact
Negative clonus or ___
ON DISCHARGE: ***
Pertinent Results:
IMAGING:
___: CT C-SPINE
1. Minimally displaced and mildly comminuted fracture involving
the right C6 superior articular facet with mild prevertebral
soft tissue swelling at C5-C6. No malalignment or other
fracture.
2. Mild-to-moderate multilevel cervical spondylosis as described
in the
findings.
___: CT HEAD
1. Soft tissue laceration overlying the left lateral orbital rim
with
associated subcutaneous emphysema. No underlying fracture or
intracranial
hemorrhage.
2. Chronic lacunar infarct of the right midbrain.
3. Chronic microangiopathy.
___: L SHOULDER
Acute fracture left humeral neck. Acute displaced fracture of
the left humeral neck. Humeral head seated well in the
glenohumeral joint.
___: L SHOULDER AND ELBOW
Acute displaced fracture of the left humeral neck.
___: MRI C-SPINE
1. Widening and edema of the anterior C5-C6 intervertebral disc
space with
apparent injury to the anterior and posterior longitudinal
ligament,
ligamentum flavum, fluid in the right C4-C5 and C5-C6 facets,
and fracture of the C6 superior articular facet better seen on
prior CT. These findings raise concern for an unstable injury.
2. There is lack of flow related signal of the right vertebral
artery,
chronicity uncertain. While this may be chronic in nature,
given
calcifications seen on CT examination, in the setting of trauma,
further
evaluation with MRA dissection protocol is recommended.
3. Extensive posterior paraspinal soft tissue edema.
4. No evidence of cord compression, cord edema, or hemorrhage.
5. Mild-to-moderate cervical spondylosis.
___: MRA C-SPINE
1. Focal severe stenosis with abrupt termination of contrast
enhancement
immediately distal to the origin of the right vertebral artery,
extending to C5 level, with reconstitution of flow to a distal
hypoplastic right vertebral artery. Constellation of findings
may be related an underlying occlusive process, possibly from
atherosclerosis or chronic dissection. No evidence of abnormal
pre T1 signal to suggest acute dissection.
2. Otherwise, patency of the cervical vasculature.
___: L HIP AND FEMUR
No acute fractures or dislocations are seen. There are mild
degenerative
changes of the hip joints with acetabular and femoral spurring
bilaterally. The left femur appears intact without displaced
fractures. Vascular calcifications are seen. There are mild
degenerative changes of the patellofemoral compartment.Moderate
to severe degenerative changes of the lower lumbar spine are
present. There are also degenerative changes of the inferior
sacroiliac joints. Hernia repair clips are seen in the right
hemipelvis.
Brief Hospital Course:
Following initial evaluation and CT imaging in the ED, the
patient was found to have a C6 Superior Facet Fracture and a
Displaced Proximal Left Humerus fracture. He was evaluated by
the Orthopedic team in the ED and his left humerus fracture was
deemed non-operative. He will follow up closely with the
Orthopedic team as an outpatient.
The patient was placed in a hard collar per the Neurosurgery
team and admitted to the Acute Care Surgery service. An MRI was
performed for concern for an unstable C6 fracture and he was
found to have associated Ligamentous injury. Additionally, an
MRA Neck was performed which demonstrated an occluded Right
Vertebral Artery which is likely chronic in nature
(atherosclerotic vs. chronic dissection) and unlikely to be
related to his recent traumatic injuries.
While on the floor, he exhibited some non-specific complaints of
radicular pain in his left buttock to his left distal hamstring.
He was able to ambulate and was non-TTP; XRays were performed
when the pain persisted which were negative for acute fractures
in his left hip and femur. We next worked to control his pain
with PO medications. His mild hypertension was controlled.
Notably, the patient was also found to have a substantial drop
in his hematocrit; 35 on admission to 25 on HD#4. This
ultimately stabilized on HD#5.
___ was consulted while on the ACS service for syncope workup
as well as pre-operative clearance.
The Neurosurgery team planned to take the patient for an
Anterior Cervical Discectomy and Fusion and he was transferred
from ACS to Neurosurgery on ___.
Neurosurgery Transfer:
# C6 fracture: Patient transferred to the Neurosurgery Service
for pre-op care. Please refer to Dr. ___ report
for details. Patient was extubated in the OR and brought to the
PACU for continued care. On POD 1 the patient continued to do
well. His pain was improved and he worked well with ___ who
recommended rehab placement. He was discharged to rehab on
___ with instructions for follow-up with respective services.
Medications on Admission:
-50 mg trazodone
-melatonin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Use this for baseline pain control and add Oxycodone as needed.
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*80 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
You may discontinue when no longer taking Oxycodone.
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth twice
daily Disp #*80 Capsule Refills:*1
3. Gabapentin 200 mg PO TID
Don't take more than directed.
RX *gabapentin 100 mg 2 capsule(s) by mouth three times daily
Disp #*90 Capsule Refills:*1
4. Lidocaine 5% Patch 1 PTCH TD QAM
Apply to left shoulder daily as needed. Discontinue when no
longer needed.
RX *lidocaine 5 % apply 1 patch to left shoulder daily as needed
Disp #*30 Patch Refills:*1
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Don't take before driving, operating machinery, or with alcohol.
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4 hours
as needed Disp #*50 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
You may discontinue when no longer taking Oxycodone.
RX *sennosides 8.6 mg 2 by mouth every evening Disp #*40 Tablet
Refills:*1
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. TraZODone 25 mg PO QHS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C6 Superior Facet Fracture with Associated Ligamentous Injury
Proximal Left Humerus 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:
Mr. ___,
You were admitted to the Acute Care Surgery service at the ___
for management of the injuries you sustained from a fall down
stairs. Your injuries include a C6 vertebral fracture with
associated ligamentum injuries and a displaced left humerus
fracture. Your left humerus fracture was deemed non-operative by
the Orthopedic team and you will follow up closely with them as
an outpatient.
DISCHARGE INSTRUCTIONS FOR ___:
Surgery
· Your dressing may come off on the second day after
surgery.
· Your incision is closed with dissolvable sutures
underneath the skin and steri strips. You do not need suture
removal. Do not remove your steri strips, let them fall off.
· Please keep your incision dry for 72 hours after surgery.
· Please avoid swimming for two weeks.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· *** You must wear your hard cervical collar at all times.
You may remove it briefly for skin care and showering.
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· No contact sports until cleared by your neurosurgeon.
· Do NOT smoke. Smoking can affect your healing and fusion.
Medications
· ***Please do NOT take any blood thinning medication
(Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the
neurosurgeon.
· Do not take any anti-inflammatory medications such as
Motrin, Advil, Aspirin, and Ibuprofen etc
for 2 weeks.
· 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:
___
|
10567046-DS-2 | 10,567,046 | 27,037,572 | DS | 2 | 2185-07-10 00:00:00 | 2185-07-10 19:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac Cath ___
Hemodialysis via Right CVL, subsequently discontinued
History of Present Illness:
___ w/ h/o diabetes, CHF, CAD s/p CABG in ___, spinal stenosis
and hypertension presents emergency today for evaluation of
shortness of breath. Prior to call-in it appears that her son
had called the ___ on-call physician to report that the
patient had 3 days of shortness of breath and unable to ambulate
up to 6 feet to the bathroom without complaint of shortness of
breath. Her current Lasix regimen is 20 mg on ___
and ___. ___ w/ h/o diabetes, CHF, CAD s/p CABG in ___,
spinal stenosis and hypertension presents emergency today for
evaluation of shortness of breath. Prior to call-in it appears
that her son had called the ___ on-call physician to report
that the patient had 3 days of shortness of breath and unable to
ambulate up to 6 feet to the bathroom without complaint of
shortness of breath. Her current Lasix regimen is 20 mg on
___ and ___. During the time of initial
evaluation the patient appears to be significantly dyspneic.
Past Medical History:
CHF ___ LVEF 45%.
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications
Hypercholesterolemia
Coronary artery disease
Hypertension, essential
Screening for colon cancer
CKD (chronic kidney disease) stage 4, GFR ___ ml/min
Obesity
Spinal stenosis, lumbar
Vitamin D deficiency
Proliferative diabetic retinopathy
Gout, unspecified
Atrial fibrillation
Neovascular glaucoma
S/P CABG x 3 (Known CAD. Status post CABG x 3 in ___ at ___)
Decreased hearing of both ears
Diabetic neuropathy
Cognitive decline
Social History:
___
Family History:
Maternal Aunt ___ - Type II
Maternal Uncle ___ - Type II
Paternal Aunt ___ - Type II
Paternal Grandmother ___ - Type II
Paternal Uncle ___ - Type II
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles in bilateral lung bases
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: 1+ pitting edema below the knees
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD, sitting comfortably in chair
NECK: JVP within normal limits
CV: RRR. s1/s2, no mgr
RESP: CTAB
___: soft, NDNT, no rebound/guarding
EXTREMITIES: no ___ edema b/l, WWP
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS:
___ 03:56PM POTASSIUM-5.2*
___ 02:23PM GLUCOSE-327* UREA N-38* CREAT-1.6*
SODIUM-134* POTASSIUM-6.9* CHLORIDE-96 TOTAL CO2-26 ANION GAP-12
___ 02:23PM CK-MB-5 cTropnT-0.01
___ 02:23PM CALCIUM-8.5 PHOSPHATE-4.6* MAGNESIUM-2.5
___ 12:02PM ___ PO2-29* PCO2-55* PH-7.27* CO2-26
BASE XS--3
___ 08:23AM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 08:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100*
GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 08:23AM URINE RBC-1 WBC-14* BACTERIA-MANY* YEAST-NONE
EPI-<1
___:04AM ___ PO2-46* PCO2-68* PH-7.25* CO2-31*
BASE XS-0
___ 07:04AM LACTATE-0.9
___ 06:53AM GLUCOSE-253* UREA N-35* CREAT-1.4* SODIUM-141
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
___ 06:53AM cTropnT-0.03*
___ 06:53AM proBNP-1351*
___ 06:53AM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.2
___ 06:53AM WBC-9.3 RBC-4.47 HGB-13.2 HCT-41.7 MCV-93
MCH-29.5 MCHC-31.7* RDW-14.4 RDWSD-49.5*
___ 06:53AM NEUTS-69.0 ___ MONOS-9.3 EOS-1.2
BASOS-0.4 IM ___ AbsNeut-6.42* AbsLymp-1.83 AbsMono-0.87*
AbsEos-0.11 AbsBaso-0.04
___ 06:53AM PLT COUNT-161
DISCHARGE LABS:
___ 07:44AM BLOOD WBC-10.6* RBC-3.39* Hgb-9.7* Hct-30.2*
MCV-89 MCH-28.6 MCHC-32.1 RDW-14.8 RDWSD-47.4* Plt ___
___ 07:44AM BLOOD ___ PTT-31.7 ___
___ 07:44AM BLOOD Glucose-201* UreaN-33* Creat-2.6* Na-133*
K-4.7 Cl-94* HCO3-25 AnGap-14
___ 07:44AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1
REPORTS:
TTE ___
The left atrium is mildly elongated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
apical third of the ventricle.The remaining segments contract
normally (LVEF = 40 %). No intraventricular thrombi are seen.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with mild regional systolic dysfunction most
suggestive of CAD (distal LAD distribution). Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Increased PCWP.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
PHARM STRESS ___:
1. Reversible, large, moderate severity perfusion defect
involving the LAD
territory.
2. Normal left ventricular cavity size. Mild systolic
dysfunction with
hypokinesis of the apex and distal inferior wall.
C. CATH ___:
Impressions:
1. Severe native three vessel CAD
2. The LIMA graft to the LAD had a severe 95% stenosis at the
point of touch down/anastamosis to the
LAD and was the likely culprit, successfully Rxed with a 2.5 x
15 Onyx DES
3. The Vein grafts to the R-PDA and OM were widely patent
4. Near normal biventricular filling pressures
5. Mildly reduced cardiac output and index
Recommendations
1. Loaded with Clopidogrel 600mg in the lab prior to PCI
2. Continue Dual anti plt RX with ASA and Plavix for a min of ___
year, then ASA indefinitely
3. Gentle post procedure hydration
4. CHF mgt as per primary inpatient Cardiology Service
PELVIC US ___:
1. Limited evaluation as patient could not tolerate transvaginal
exam.
2. Endometrium is not well seen but appears thickened, measuring
at least 15 mm. Consider endometrial biopsy for further
evaluation.
CT HEAD ___:
No acute intracranial hemorrhage. Extensive small vessel
ischemic disease.
CT ABD/P ___:
1. No acute abnormality in the abdomen and pelvis. In
particular, there is no hydronephrosis. Retained contrast
material within both renal cortices is in keeping with provided
history of renal failure.
2. Apparent thickening of the endometrium which was also
suggested on the most recent pelvic ultrasound. Consider
endometrial biopsy for further evaluation.
3. Limited assessment of the lower lobes is suggestive of mild
interstitial pulmonary edema.
4. Cholelithiasis.
TTE ___:
LV systolic function appears mildly-to-moderately depressed
(LVEF = 40%) secondary to hypokinesis of the septum, anterior
free wall, and apex. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
there is no obvious change but the technically suboptimal nature
of both studies precludes definitive comparison.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with (LVEF 55-60% in ___,
diabetes mellitus, complicated by nephropathy (CKD IV),
peripheral neuropathy and retinopathy, HTN, HLD, admitted for
CHF and now s/p LAD-LIMA stent placement. Hospital course c/b
___ and ___ pulmonary edema.
# Hypoxic respiratory failure
# Acute on chronic HFpEF (LVEF 55-60% in ___
# NSTEMI
# CAD s/p CABG -> s/p DES to LAD
The patient presented with subacute dyspnea and heart failure
exacerbation. She was also found to have troponinemia peaking at
0.27 concerning for NSTEMI without symptoms or EKG changes. She
was diuresed with IV Lasix and improved from a respiratory
status. Her echocardiogram was without significant change. She
underwent stress test showing a large reversible deficit in the
LAD territory. She underwent cardiac catheterization and
received DES to ___/LAD ___. Her post-procedural course
was complicated by flash pulmonary edema and ___ requiring
admission to the ICU with temporary hemodialysis, now improving
spontaneously. Discharged on aspirin/Plavix. Follow-up with
cardiology. Discharged without diuresis, monitor volume status
and daily weights. Switched from amlodipine to Imdur/hydralazine
given heart failure. Monitor outpatient BPs.
# ___ on CKD: The patient has stage 4 CKD from diabetic
nephropathy at her baseline. She developed ___ post-procedurally
from her catheterization, due to flash pulmonary edema and
possibly contrast nephropathy. She was started on hemodialysis
on ___. At the time of discharge, her renal function was
spontaneously improving and she was no longer requiring
hemodialysis. Follow-up electrolytes within 1 week of discharge
to trend renal function. Follow-up with nephrology for CKD and
recovery of acute renal failure. Discharge Cr 2.6.
#Urinary tract infection:
The patient was found to have a Klebsiella UTI. Given concern
for trigger for heart failure exacerbation, she was treated with
a course of fosfomycin in-house.
#Vaginal Bleeding:
Following initiation of Plavix after cardiac catheterization,
the patient was found to have trickling blood from the vagina.
OB/GYN was consulted. Pelvic ultrasound was performed revealing
a thickened endometrium. The patient remained hemodynamically
stable with improved bleeding. Recommend outpatient OB/GYN
follow-up with endometrial biopsy for bleeding.
#HTN
In the setting of coronary artery disease and heart failure, the
patient was switched from amlodipine to Imdur/hydralazine. ACEi
was deferred as she did not tolerate this in the past. Atenolol
was changed to metoprolol.
# Type II diabetes mellitus
# Diabetic nephropathy, retinopathy, neuropathy
The patient was initially placed on home glargine, but had
periodic morning hypoglycemia and therefore was discharged on
glargine 15 BID. Monitor outpatient blood glucose.
# HLD: Continued atorvastatin 40mg daily
# Gout: Continued home allopurinol ___ daily
# Constipation: Continued home Miralax as needed
TRANSITION ISSUES:
-Received DES to LAD ___. Discharged on Aspirin/Plavix.
Follow-up with cardiology.
-Switched from amlodipine to Imdur/hydralazine given heart
failure.
-Discharged without diuresis, monitor volume status and daily
weights.
-Monitor outpatient BPs with adjustment of regimen as
appropriate.
-Recommend outpatient electrolytes within 4 days of discharge to
trend renal function.
-Follow-up with nephrology for CKD and recovery of acute renal
failure. Discharge Cr 2.6.
-ACEi was deferred as she did not tolerate this in the past (and
due to recovering ___
-Atenolol was changed to metoprolol
-Monitor blood glucose and A1C with adjustment of regimen as
appropriate. Discharged on glargine 15 BID.
-Recommend outpatient OB/GYN follow-up with endometrial biopsy
for bleeding
-Recommend outpatient CBC to follow-up bleeding (within 4 days
of discharge)
-Imaging was suggestive of possible hemidiaphragmatic paralysis,
follow-up with pulmonary as appropriate
-Discharged with foley for urinary retention, follow-up with
urology
-Pending blood cultures should be followed up in clinic
-Discharge weight: 75.5 KG
#CODE: DNR/DNI
#CONTACT: HCP: ___ (son) ___
>30 minutes spent coordinating discharge to rehab
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Glargine 38 Units Breakfast
Glargine 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. HydrALAZINE 25 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Atorvastatin 80 mg PO QPM
9. Glargine 15 Units Breakfast
Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Allopurinol ___ mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Hypoxic respiratory failure
# Acute on chronic HFpEF
# CAD status post CABG
# NSTEMI
# Urinary tract infection
# 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:
Ms. ___,
You were admitted to ___ for
shortness of breath.
While you were here:
-We found that your heart was not working as hard as normal, and
you had some extra fluid in your body
-We gave you the IV water pill to help take some of the fluid
off and you started to feel better
-We put a stent in your heart to improve blood flow
-You had some vaginal bleeding which should be followed up as an
outpatient
When you go home:
-Please continue all medications as directed
-Please follow-up with the below doctors
-___ weigh yourself each morning, call your doctor if your
weight varies more than 3 pounds
-You will need an "endometrial biopsy" as an outpatient with
your OB/GYN doctor
___ wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10567046-DS-3 | 10,567,046 | 21,890,812 | DS | 3 | 2185-11-05 00:00:00 | 2185-11-07 07:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None performed
History of Present Illness:
___ w/ h/o ICM, HFrEF (EF 40%), IDDM, CAD s/p CABG in ___ and
stent in ___, spinal stenosis, and CKD stage 4, and shortness
of breath with frequent CHF exacerbations presenting with
worsening shortness of breath over last day.
Patient was in her usual state of health until last night about
7pm when she began to feel short of breath. She relates an hour
prior to onset of symptoms she was in a heated and emotional
family meeting and endorses feeling extremely overwhelmed and
stressed after the meeting. She relates she proceeded to go to
bed at her usual time, but could not lay down flat as she felt
short of breath. She attempted to sleep with several pillows,
which brought some relief. She reports around 1am she was still
persistently short of breath and called EMS. Of note, she also
endorses bilateral lower extremity swelling with pain worse on L
than R over the past few days - no precipitating trauma or
static
activity. She relates the pain is somewhat consistent with her
chronic neuropathic pain.
Past Medical History:
CHF ___ LVEF 45%.
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications
Hypercholesterolemia
Coronary artery disease
Hypertension, essential
Screening for colon cancer
CKD (chronic kidney disease) stage 4, GFR ___ ml/min
Obesity
Spinal stenosis, lumbar
Vitamin D deficiency
Proliferative diabetic retinopathy
Gout, unspecified
Atrial fibrillation
Neovascular glaucoma
S/P CABG x 3 (Known CAD. Status post CABG x 3 in ___ at ___)
Decreased hearing of both ears
Diabetic neuropathy
Cognitive decline
Social History:
___
Family History:
Maternal Aunt ___ - Type II
Maternal Uncle ___ - Type II
Paternal Aunt ___ - Type II
Paternal Grandmother ___ - Type II
Paternal Uncle ___ - Type II
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Temp: 98, BP: 160/66, HR: 82, RR:20, SP02: 100% 1L NC
GENERAL: Elderly lady sitting upright in chair, NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP 11cm, augments 1-2 cm with
hepatojugular reflex.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Bibasilar crackles, moderately decreased breath sounds on
R side, no rhonchi or wheeze. Breathing comfortably without use
of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, or clubbing, 1+ pitting edema on BLE,
tenderness to BLE, L>R, negative ___ Sign
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, chronic venous stasis changes noted on skin of BLE, but
no erythema or ecchymosis
DISCHARGE PHYSICAL EXAM
VITALS: ___ 0745 Temp: 98.2 PO BP: 147/64 L Sitting HR: 72
RR: 20 O2 sat: 100% O2 delivery: RA FSBG: 70
GENERAL: Elderly woman sitting comfortably in chair in NAD.
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP 8 cm
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB. Breathing comfortably without use of accessory
muscles
ABDOMEN: Soft, non-tender, non-distended. +Bowel Sounds
EXTREMITIES: no cyanosis, clubbing, 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, chronic venous stasis changes noted on skin of BLE
Pertinent Results:
DISCHARGE LABS
___ 06:40AM BLOOD WBC-6.9 RBC-3.90 Hgb-11.0* Hct-35.8
MCV-92 MCH-28.2 MCHC-30.7* RDW-16.2* RDWSD-54.4* Plt ___
___ 06:40AM BLOOD Glucose-76 UreaN-66* Creat-1.8* Na-145
K-4.9 Cl-103 HCO3-29 AnGap-13
___ 06:40AM BLOOD ALT-111* AST-55* AlkPhos-330* TotBili-0.3
___ 06:40AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.3
ADMISSION LABS:
___ 03:33PM BLOOD K-5.3
___ 07:28AM BLOOD Glucose-152* UreaN-56* Creat-1.6* Na-146
K-5.9* Cl-107 HCO3-29 AnGap-10
___ 02:26AM BLOOD Glucose-212* UreaN-57* Creat-1.5*# Na-144
K-5.9* Cl-106 HCO3-25 AnGap-13
___ 02:26AM BLOOD ALT-185* AST-152* AlkPhos-398*
TotBili-0.2
___ 03:33PM BLOOD CK-MB-5 cTropnT-0.04*
___ 07:28AM BLOOD cTropnT-0.04*
___ 02:26AM BLOOD cTropnT-0.04*
___ 02:26AM BLOOD proBNP-1358*
___ 02:26AM BLOOD Albumin-4.2 Calcium-9.3 Phos-4.3 Mg-2.6
___ 03:45PM BLOOD pO2-216* pCO2-46* pH-7.40 calTCO2-30 Base
XS-3 Comment-GREEN TOP
___ 07:36AM BLOOD ___ pO2-33* pCO2-62* pH-7.31*
calTCO2-33* Base XS-2
___ 02:39AM BLOOD ___ pO2-35* pCO2-69* pH-7.26*
calTCO2-32* Base XS-1
___ 02:39AM BLOOD K-5.6*
___ 02:39AM BLOOD O2 Sat-61
* CXR: Improved pulmonary vascular congestion and pulmonary
edema compared to the
previous exam.
Brief Hospital Course:
This is a ___ with a past medical history significant for HFrEF
(EF 40%) with frequent exacerbations, DM, CAD s/p CABG x 3 in
___ and stent in ___, spinal stenosis, CKD stage 4, who was
brought in by EMS with worsening dyspnea x 1 day in the setting
of hypertensive emergency with systolic BPs in the 200s.
#Hypercarbic hypoxemic respiratory failure
#Acute respiratory acidosis
#Flash pulmonary edema
#Hypertensive emergency
The patient presented with complaints of dyspnea in the setting
of acute stress following a heated family discussion on the
evening prior to presentation. The patient's initially blood
pressures on presentations were 196/79 in the ED with concerns
for hypertensive emergency. Her CXR showed flash pulmonary edema
and her VBG showed a pCO2 high ___ and a pH 7.26. She was
started on a nitroglycerin drip and her home anti-hypertensive
medications were restarted with subsequent improvement in her
home anti-hypertensive medications. In addition, the patient was
given IV diuresis. Imdur was added to the patient's medication
regimen and titrated up to 90mg by the time of discharge. On the
day of discharge, the patient's Metoprolol succinate 100mg daily
was discontinued in favor of Carvedilol 6.25mg PO BID for more
blood pressure effect.
___ on CKD
#Hyperkalemia
The patient's Cr increased was noted to be elevated to 2.0 from
a baseline of 1.5 in the setting of hypertensive emergency as
noted above. The patient was also noted to be hyperkalemic to
5.8 (also has some chronic hyperkalemia as an outpatient)
without concerning changes on EKG. She received two doses of IV
Lasix as detailed below. She was given kayexylate x1 while
inpatient with subsequent normalization of her potassium.
Creatinine improved to 1.8 by day of discharge.
#HFrEF
The patient has a known history HFrEF with her last echo in
___ showing an EF of 40%. She had no evidence of acute
exacerbation currently and appeared euvolemic euvolemic on exam.
Her pulmonary edema was thought to be due likely secondary to
flash pulmonary edema due to hypertension and resolved by the
time of discharge. Of note proBNP 1358 on admission, which was
elevated from the 200s 5 days prior to admission. Given the
pulmonary edema as above she was diuresed with 2 doses of IV
Lasix 40mg and the restarted on her home Lasix 20mg daily. For
afterload she was continue hydralazine 25 BID and started on
Imdur which was titrated to 90mg daily upon d/c. Of note, she is
not on an ACEi ___ allergy, unclear if trial ___ previously
(however her Hyperkalemia may be limiting). For her hormonal
blockade, her Metoprolol succinate 100mg daily was switched to
Carvedilol 6.25mg PO QD.
#Abnormal LFTs
The patient presented with transaminitis (ALT/AST 185/152), and
elevated Alk Phos but with normal T.bili and Lipase. Patient
denies any abdominal pain, toxic ingestion, or risk factors for
hepatitis. Her lab abnormalities were thought to be possibly
congestive hepatopathy and trended down throughout her
hospitalization. Her statin was held during admission given her
transaminitis. Her LFTs should be re-checked and if normal (or
continuing to down trend), her statin should be re-started.
#Type 2 NSTEMI
#CAD s/p CABG and stent
The patient presented with an elevated but flat troponin (0.04 x
3) in the setting of an unchanged ECG from prior on ___. Her
tropnemia was thought to be secondary to a Type 2 NSTEMI in the
setting of increased myocardial demand from acute illness and
pulmonary edema. Her hypertension was management as above. Here
HFrEF was managed as above. She was continued on her home
ASA/Plavix.
#Leg Pain and Swelling
The patient had complaints of chronic pitting edema upon
presentation, but did states that she had increased pain and
swelling in her left>right leg. She had a LLE US which showed no
DVT.
TRANSITIONAL ISSUES:
[] Patient's Metoprolol changed to carvedilol and Imdur added to
regimen for better BP control; will need BP check and lab follow
up on ___.
[] Patient has known hx of hyperkalemia: Would check
electrolytes (Chem-10) on ___ and if continued to be
hyperkalemic would consider adding Kayexylate to medication
regimen
[] For afterload, patient not on ACEi b/c of allergy, but does
not appear ___ has been tried; may consider in future although
patient's issues w/HyperK may be prohibitive.
[] Had transaminitis on presentation, trending down on d/c--
would follow up as outpatient by checking liver function studies
(AST/ALT/ALK Phos/Bilirubin) on ___. Her statin was held during
admission given her transaminitis. Her LFTs should be re-checked
and if normal (or continuing to down trend), her statin should
be re-started.
[] Discharge weight: 74.2 kg (163.58 lb)
[] Discharge Cr: 1.8
[] Code Status: Full
[] Contact: ___/ Relationship: Son/ Phone number:
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. HydrALAZINE 25 mg PO BID
3. Glargine 46 Units Breakfast
Glargine 15 Units Bedtime
4. Furosemide 20 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY:PRN constipation
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
10. Allopurinol ___ mg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Ferrous Sulfate Dose is Unknown PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
4. Glargine 46 Units Breakfast
Glargine 15 Units Bedtime
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY:PRN constipation
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. HydrALAZINE 25 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until your liver tests improve
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on Chronic Heart failure
Hypertensive Emergency
Pulmonary Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
trouble breathing for the day prior to coming into the hospital.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you were found to have fluid
in your lungs. This was likely a result of your high blood
pressure.
- You were given medications to lower your blood pressure.
- You were given medications to help remove the fluid from your
lungs.
- Your breathing and other symptoms improved and you were
discharge to help better control your blood pressure and prevent
this from happening again.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. Please see the sections below outlining all of
your medications and upcoming appointments.
- Please come to the hospital or call your cardiologist or PCP
if you are having any trouble breathing.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs
We wish you the best!
Sincerely,
Your ___ Team
.
Followup Instructions:
___
|
10567046-DS-5 | 10,567,046 | 20,586,078 | DS | 5 | 2186-11-20 00:00:00 | 2186-11-20 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ with PMHx T2DM, CKD stage IV, atrial
fibrillation, HTN, HFrEF with recovered EF (most recently 50% on
___, and CAD s/p DES and CABG who presents with a chief
complaint of shortness of breath that has been ongoing for 2
days
prior to arrival.
Per Pt and sons ___ and ___, Pt was doing generally
well until about ___ afternoon when she began having
intermittent shortness of breath. It went away on ___.
___ morning, ___ came by his mother's ___ in the
morning
to check on her before church; he notes that she was shaky,
sweaty, and had a blood sugar in the 90's. Thinking she had low
blood sugar, he gave her some sweets with improvement in her
blood sugar and overall appearance. In the afternoon, however,
she reported feeling more shortness of breath to her son ___
- which was not getting better. So they brought her to the
hospital for further evaluation.
Past Medical History:
CHF ___ LVEF 45%.
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications
Hypercholesterolemia
Coronary artery disease
Hypertension, essential
Screening for colon cancer
CKD (chronic kidney disease) stage 4, GFR ___ ml/min
Obesity
Spinal stenosis, lumbar
Vitamin D deficiency
Proliferative diabetic retinopathy
Gout, unspecified
Atrial fibrillation
Neovascular glaucoma
S/P CABG x 3 (Known CAD. Status post CABG x 3 in ___ at ___)
Decreased hearing of both ears
Diabetic neuropathy
Cognitive decline
Social History:
___
Family History:
Maternal Aunt ___ - Type II
Maternal Uncle ___ - Type II
Paternal Aunt ___ - Type II
Paternal Grandmother ___ - Type II
Paternal Uncle ___ - Type II
Brother - MI older than ___ y/o at time of onset.
Otherwise no family history of early malignancy or heart
disease.
Physical Exam:
ADMISSION PHYSICAL:
===================
VITALS: T 96.5 BP 170/54 HR 67 RR 29 SaO2 100% on RA
GENERAL: WDWN elderly woman, sitting up in bed eating soup, in
NAD. Oriented x3.
HEENT: Sclerae anicteric, MMM.
NECK: Supple with JVP estimated at 10cm H2O while sitting
upright.
CARDIAC: Irregularly irregular, borderline bradycardic, normal
S1, S2. No murmurs/rubs/gallops.
LUNGS: Lungs clear to auscultation bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: There is +2 lower extremity pitting edema to the
thighs bilaterally. Legs are warm and well perfused.
PULSES: +2 dorsalis pedis pulses bilaterally.
DISCHARGE PHYSICAL:
===================
VITALS: T 98.5; BP 145/68; HR 73; RR 20; SaO2 95% RA
GENERAL: Older appearing woman sitting in no acute distress.
Soft spoken. Sitting comfortably in chair.
NECK: JVP approximately 12 cm H2O while sitting upright.
LUNGS: CTAB. Soft breath sounds throughout. No rales, wheezes,
or ronchi.
CV: III/VI holosystolic murmur loudest at left ___ intercostal
space. S1 and S2 appreciated. Regular rate and rhythm.
ABD: Normoactive bowel sounds. Soft, distended, non tender to
deep palpation.
EXT: No edema in lower extremities. No cyanosis. DP and radial
pulses 2+ bilaterally. Legs warm, well perfused.
NEURO: AAOx3. Moving all limbs spontaneously.
IMAGING:
========
Transthoracic Echo (___):
LVEF 42%
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild
regional systolic dysfunction most consistent with single vessel
coronary artery disease (mid-LAD distribution). At least
moderate
mitral regurgitation. Mild pulmonary artery systolic
hypertension.
Compared with the prior TTE (images reviewed) of ___, the
severity of mitral regurgitation is now increased and mild
pulmonary artery systolic hypertension is now present.
LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA size. IVC not visualized.
LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity
size. Mild focal systolic dysfunction (see schematic). No LV
aneurysm. No LV thrombus/mass. Intrinsic LVEF likely lower due
to
severity of mitral regurgitation. Normal cardiac index (>2.5
L/min/m2). No resting outflow tract gradient. Tissue Doppler
suggests elevated PCWP.
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTA: Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch diameter. Normal descending
aorta.
AORTIC VALVE (AV): Mildly thickened (?#) leaflets. No stenosis.
Trace regurgitation.
MITRAL VALVE (MV): Mildly thickened leaflets. No systolic
prolapse. Moderate MAC. Papillary muscle
fibrosis/calcification. Moderate [2+] regurgitation.
Regurgitation severity could be UNDERestimated due to acoustic
shadowing.
PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Mild-moderate [___]
regurgitation. Mild pulmonary artery systolic hypertension.
PERICARDIUM: No effusion.
ADDITIONAL FINDINGS: Poor subcostal and suprasternal image
quality.
Chest X-ray, ___:
No pneumonia or acute cardiopulmonary process.
ECG, ___, with similar findings on ___ and ___:
Sinus rhythm with 1st degree AV delay
Left anterior hemiblock/fascicular block
Left ventricular hypertrophy with repolarization abnormality
Pertinent Results:
ADMISSION LABS:
===============
___ 03:35PM ___-7.4 RBC-2.86* HGB-8.3* HCT-28.2* MCV-99*
MCH-29.0 MCHC-29.4* RDW-17.7* RDWSD-63.8*
___ 03:35PM PLT COUNT-204
___ 03:35PM NEUTS-70.0 ___ MONOS-6.6 EOS-2.2
BASOS-0.3 IM ___ AbsNeut-5.20 AbsLymp-1.53 AbsMono-0.49
AbsEos-0.16 AbsBaso-0.02
___ 03:35PM CALCIUM-9.3 PHOSPHATE-4.2 MAGNESIUM-2.4
___ 03:35PM cTropnT-0.05* proBNP-825*
___ 03:35PM GLUCOSE-142* UREA N-52* CREAT-1.8* SODIUM-139
POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-25 ANION GAP-11
___ 03:43PM O2 SAT-65
___ 03:43PM LACTATE-0.6
___ 03:43PM ___ PO2-42* PCO2-65* PH-7.26* TOTAL
CO2-31* BASE XS-0
___ 06:03PM LACTATE-2.2*
___ 07:30PM cTropnT-0.05*
___ 03:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:59PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:59PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:59PM URINE HYALINE-1*
LABS DURING STAY:
=================
___ 07:34AM BLOOD ___ pO2-48* pCO2-58* pH-7.34*
calTCO2-33* Base XS-3 Comment-GREEN TOP
___ 02:50PM BLOOD Lactate-1.4
___ 09:45PM BLOOD CK-MB-6 cTropnT-0.05*
___ 09:57PM BLOOD ___ pO2-60* pCO2-62* pH-7.29*
calTCO2-31* Base XS-1 Comment-GREEN TOP
DISCHARGE LABS:
===============
___ 06:52AM BLOOD WBC-6.7 RBC-2.53* Hgb-7.2* Hct-24.9*
MCV-98 MCH-28.5 MCHC-28.9* RDW-18.0* RDWSD-64.5* Plt ___
___ 06:52AM BLOOD Glucose-105* UreaN-78* Creat-2.7* Na-143
K-5.0 Cl-99 HCO3-28 AnGap-16
___ 06:52AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.4
Brief Hospital Course:
SUMMARY
=======
Ms. ___ is an ___ woman with PMHx of HFrEF with
recovered EF (LVEF 42% ___, CAD s/p 3 vessel CABG in ___
and s/p DES in LIMA/LAD in ___, post-CABG atrial fibrillation,
T2DM, CKD stage IV, HTN, and HLD who presents with 2 days of
acute shortness of breath following one month of progressively
worsening dyspnea on exertion that has improved with diuresis.
ACUTE ISSUES
============
# DYSPNEA ON EXERTION and
# LOWER EXTREMITY EDEMA due to
# ACUTE-ON-CHRONIC SYSTOLIC AND DIASTOLIC HF EXACERBATION:
The patient's dyspnea on exertion and lower extremity edema were
attributed to HF exacerbation based on elevated BNP, JVP, and
symptomatic improvement after diuresis. CXR on admission also
showed signs of volume overload. After IV diuretics, the patient
has shown clinical and lab evidence of significant improvement
in her volume status. She has been transitioned to PO Torsemide
20 mg daily. Torsemide should be held until ___ and restarted at
that time if Cr is stable or improving. Additionally, the
patient's carvedilol has been increased to 12.5 mg BID, and she
should continue on this dose. She should also continue taking
home isosodium mononitrate 30 mg daily. The addition of
hydralazine for increased afterload control should be considered
in the outpatient setting. Discharge weight: 153.88 lbs
# CKD:
Upon admission, the patient's creatinine was 1.8. Her creatinine
is now 2.7 at discharge, and this change is attributed to her
diuresis. Hold torsemide for 2 days (until ___, and then
recheck labs in 2 days for ongoing evaluation of her kidney
function to ensure Cr is returning to baseline. Consider
restarting torsemide at that time based on Cr. Scheduled follow
up appointment with patient's outpatient nephrologist.
# MITRAL REGURGITATION:
Compared with the patient's prior TTE (___), the severity
of mitral regurgitation is now increased. Wall motion
abnormalities in anterior-septal, anterior, and inferior septal
regions could be contributing to MR. ___ overload status
could also be responsible for worsening MR compared to prior
study.
# ANEMIA, NORMOCYTIC:
HgB was stable at 8 from baseline in the ___ range throughout
this admission, but has declined to 7.2 at discharge. No
evidence of acute or chronic bleeding was appreciated. Repeat
CBC in 1 week to follow-up.
# HYPERKALEMIA, BORDERLINE:
Continued home sodium polystyrene. Deferred initiation of ACE
inbibitor given chronic hyperkalemia.
# VASOVAGAL EPISODE, NOW RESOLVED:
The patient had a vasovagal episode during this admission, with
some accompanying nausea, vomiting, and diuresis. After
approximately 15 minutes, she had fully returned to her normal
state, and there were no further episodes.
CHRONIC ISSUES
==============
# HISTORY OF INSULIN-DEPENDENT DIABETES:
The patient received her home lantus and Humalog and was put on
an insulin sliding scale.
# HISTORY OF CORONARY ARTERY DISEASE S/P CABG:
The patient continued taking her home aspirin, clopidogrel, and
atorvastatin.
# HISTORY OF CHRONIC KIDNEY DISEASE:
Medications were renally dosed.
#CONSTIPATION:
Had recent hospitalization for severe constipation. Continued on
aggressive bowel regimen.
#CODE STATUS: DNR/DNI, ok for BiPAP
#CONTACT: ___ and HCP (___)
___ and caretaker (___)
TRANSITIONAL ISSUES
===================
[] Carvediolol dose was increased to 12.5 mg BID, and the
patient should continue on this dose.
[] Repeat BMP and electrolytes 2 days after discharge (___) to
monitor renal function and potassium Discharge Cr 2.7.
[] Home diuretics changed to Torsemide 20 mg daily PO. Currently
held until ___ pending improvement in Cr. Please repeat assess
whether torsemide should be restarted at that time based on lab
results.
[] Once torsemide has been restarted, please assess volume
status and titrate dose if needed in the outpatient setting.
[] Repeat CBC 1 week after discharge to monitor hemoglobin.
Discharge HgB: 7.2.
[] Addition of hydralazine for increased afterload control
should be considered in the outpatient setting.
[] The patient is still on Plavix following a PCI + DESx1 in
___. Please re-evaluate to determine whether further
treatment with Plavix is indicated.
[] Monitor bowel movements, continue on aggressive bowel
regimen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Carvedilol 6.25 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Glargine 46 Units Breakfast
Glargine 12 Units Dinner
15. Sodium Polystyrene Sulfonate 15 gm PO EVERY OTHER DAY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. CARVedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY:PRN constipation
10. Ferrous Sulfate 325 mg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Glargine 46 Units Breakfast
Glargine 12 Units Dinner
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Sodium Polystyrene Sulfonate 15 gm PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
- Acute on chronic systolic and diastolic heart failure
exacerbation
SECONDARY DIAGNOSES:
====================
- Coronary artery disease
- Type 2 diabetes mellitus
- Chronic kidney disease
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having some
difficulty breathing while walking around for the last month,
which had gotten worse over the past couple of days.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were diagnosed with an acute heart failure exacerbation.
To treat this, you were given IV diuretics that help you
eliminate the excessive amount of fluids in your body.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge creatinine: 2.7. This is a measure of your
kidney function. You should share this with your medical
providers.
- Your discharge weight: 153.88 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10567046-DS-6 | 10,567,046 | 27,144,337 | DS | 6 | 2187-05-14 00:00:00 | 2187-05-14 21:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Major Surgical or Invasive Procedure:
Right heart catheterization via right femoral vein access
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 06:35AM BLOOD WBC-7.6 RBC-3.73* Hgb-10.6* Hct-35.0
MCV-94 MCH-28.4 MCHC-30.3* RDW-17.9* RDWSD-61.7* Plt ___
___ 06:35AM BLOOD Neuts-67.1 ___ Monos-9.7 Eos-2.6
Baso-0.5 NRBC-0.3* Im ___ AbsNeut-5.07 AbsLymp-1.48
AbsMono-0.73 AbsEos-0.20 AbsBaso-0.04
___ 06:35AM BLOOD Plt ___
___ 07:09AM BLOOD ___ PTT-32.3 ___
___ 06:35AM BLOOD Glucose-391* UreaN-61* Creat-1.9* Na-141
K-5.3 Cl-105 HCO3-23 AnGap-13
___ 06:35AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.3
___ 07:40AM BLOOD ___ pO2-93 pCO2-46* pH-7.35
calTCO2-26 Base XS-0 Comment-GREEN TOP
PERTINENT LABS:
===============
___ 06:35AM BLOOD cTropnT-0.05* proBNP-1249*
___ 03:08PM BLOOD CK-MB-7 cTropnT-0.07*
___ 08:22PM BLOOD CK-MB-8 cTropnT-0.07*
___ 07:05AM BLOOD proBNP-1544*
___ 07:00AM BLOOD calTIBC-294 Ferritn-58 TRF-226
___ 07:00AM BLOOD TSH-2.6
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-7.1 RBC-3.64* Hgb-10.4* Hct-34.6
MCV-95 MCH-28.6 MCHC-30.1* RDW-17.5* RDWSD-61.5* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-315* UreaN-88* Creat-2.3* Na-135
K-5.3 Cl-99 HCO3-22 AnGap-14
___ 08:00AM BLOOD Phos-4.2 Mg-2.3
IMAGING AND PROCEDURES:
=======================
CXR: ___
IMPRESSION:
1. Retrocardiac opacities with slight obscuration of the
hemidiaphragm could merely represent small left pleural effusion
with associated atelectasis, however aspiration or pneumonia is
difficult to exclude in the appropriate clinical setting. A
lateral radiograph may help further characterize this area, if
needed.
2. Mild cardiomegaly with mild pulmonary vascular congestion.
CXR: ___
IMPRESSION:
Comparison to ___. Improved ventilation at the left
lung bases. Stable elevation of the right hemidiaphragm. No
pulmonary edema. No pleural effusions. No pneumonia. No
pneumothorax. Stable correct alignment of the sternal wires.
TTE: ___
Quantitative biplane left ventricular ejection fraction is 33 %
(normal
54-73%).
IMPRESSION: Suboptimal image quality. Inferior, posterior, and
apical hypokinesis. Compared with the prior TTE (images
reviewed) of ___, the inferior septum and inferior free
wall are now hypokinetic.
RIGHT HEART CATHETERIZATION: ___
Findings
Normal left and right heart filling pressures.
NUCLEAR PERFUSION WITH PHARMACOLOGIC STRESS: ___
FINDINGS: Left ventricular cavity size is 116-130 cc.
Rest and stress perfusion images reveal anteroseptal defect
extending into the apex. The apical portion appears fixed, and
the anteroseptal defect appears reversible. These findings are
concerning for ischemia in the LAD territory. Gated images
reveal diffuse abnormalities, consistent with multiple vessel
disease. The calculated left ventricular ejection fraction is
32-40%. The ejection fraction is lower during stress, which
suggests multiple vessel disease.
IMPRESSION: 1. Anteroseptal defect extending into the apex.
Apical portion appears fixed, and the anteroseptal defect
appears reversible. These findings are concerning for ischemia
in the LAD territory.
2. Decreased left ventricular ejection fraction (32-40%).
Brief Hospital Course:
SUMMARY STATEMENT:
Ms. ___ is an ___ year old female with a past medical history
of HFrEF, CAD s/p CABG x3, HTN, HLD and T2DM on insulin who
presented with progressive dyspnea, with proBNP elevation and
mild
pulmonary edema on CXR concerning HFrEF exacerbation, admitted
for IV diuresis and further management of HFrEF exacerbation.
Found to have depressed LVEF on TTE with nuclear stress
concerning for ischemia in the LAD territory. The patient
improved with IV diuresis with transition to PO torsemide 10mg
daily for maintannce. Further ischemic workup deferred pending
creatinine stabilization.
CORONARIES: CAD s/p CABG with SVG to the R-PDA and OM, and LIMA
to the LAD. S/p PCI (___) with DES in LIMA graft to the LAD;
SVG
to the R-PDA and OM were widely patent.
PUMP: LVEF 33% with inferior, posterior and apical hypokinesis
RHYTHM: Sinus
#CODE: Full Code
#CONTACT: HCP: ___, Phone: ___
DISCHARGE PARAMETERS:
[] Dry weight (confirmed with RH cath): 157.41 lb (71.4 kg)
[] Discharge creatinine: 2.3
[] Discharge Hgb/Hct: 10.4/34.6
[] Diuretic at discharge: Torsemide 10mg daily. Please assess
need for dose titration at follow-up.
TRANSITIONAL ISSUES:
[] Please weigh patient daily. Call doctor if weight changes by
more than 3 pounds in 1 day or 5 pounds in 1 week.
[] Monitor patient for dizziness or lightheadedness. Please
measure blood pressure and call doctor for systolic blood
pressure <100 or diastolic blood pressure <50.
[] Please check Chem-7 at 1-week follow-up to monitor
electrolytes and creatinine on torsemide.
[] Please provide ongoing nursing education for diabetes care at
home. The patient's diabetes regimen was adjusted at discharge:
LANTUS (Glargine): give 40 units at breakfast and 5 units at
bedtime. HUMALOG: Give 5 units at each meal.
[] Consider need for home physical therapy for patient's
benefit.
[] Nuclear stress revealed reversible anteroseptal defect
concerning for ischemia in LAD territory. Recommend coronary
angiography to be scheduled as an outpatient when renal function
stabilizes.
[] Carvedilol dose increased to 6.25mg BID, please monitor and
adjust dose as necessary.
[] TTE with LVEF reduced to 33% from 42%, please consider
addition of lisinopril, spironolactone and/ or Entresto for
guideline directed management of HFrEF.
[] Continued PO iron at discharge with every other day dosing to
prevent constipation.
[] Completed 5-day course of cefpodoxime for UTI (___).
ACTIVE ISSUES:
==============
# HFrEF exacerbation:
The patient prsented with progressive dyspnea on exertion and
weight gain with proBNP elevation and CXR revealing mild
pulmonary vascular congestion, c/w HFrEf exacerbation. The
patient initially required supplemental O2 with significant
improvement in respiratory effort with IV diuresis. TSH was
normal at 2.6 and iron panel revealed iron deficiency c/w prior.
No arrhythmia was noted. The patient continued to improve with
IV diuresis, although progress was limited due to ___ as below.
The patient underwent right heart catheterization on ___
revealed normal filling pressures. TTE from ___ revealed
depressed EF to 33% withnew hypokinesis in the inferior,
posterior and apical walls. Considering TTE concerning for
ischemic cardiomyopathy with new EF depression, nuclear stress
was done which revealed: anteroseptal defect extending into the
apex, apical portion appears fixed, and the anteroseptal defect
appears reversible; these findings are concerning for ischemia
in the LAD territory. After discussing with Interventional
Cardiology, the decision was made to defer further workup,
including coronary angiography, pending stabilization of
creatinine.
- Preload: Torsemide 10mg daily
- Afterload: Hydralazine 25mg TID, Imdur 30mg daily
- NHBK: Carvedilol 3.125 mg BID
# ___ on CKD:
CKD likely related to diabetes. Baseline creatinine 1.8-2.0.
Prior to discharge creatinine improved to 2.3 from a peak of
3.2. Creatinine elevation was most likely due to intravascular
volume depletion in the setting of aggressive diuresis for heart
failure exacerbation.
# CAD s/p CABG x3:
Last cath from ___. Patient has remained free from chest
pain throughout admission, however TTE from ___ showed LVEF
reduced to 33% (from prior LVEF 42% in ___. Nuclear stress
from ___ revealed reversible anteroseptal defect concerning
for ischemia in the LAD territory. Recommend further workup with
coronary angiography when creatinine stabilizes, as above.
- Continued ASA, Plavix and atorvastatin
# Urinary tract infection:
Urinalysis on admission was concerning for UTI. Urine culture
grew E. Coli. Completed 5-day course of cefpodoxime for UTI
(___). Patient remained asymptomatic although occasional
incontinent of urine. No signs of sepsis, WBC and lactic
acid were within normal limits.
================
CHRONIC ISSUES:
================
# Anemia
Hgb on admission 10.6 (at baseline). Appears to be chronic.
Transferrin saturation 7%.
- Continued PO iron with every other day dosing to prevent
constipation.
# T2DM
Hyperglycemic on presentation with recent history of
hyperglycemia iso running-out of Humalog.
- Hgb A1c from ___ was 12% from Atrius records
- Continue home Lantus
- Insulin sliding scale
RESOVLED ISSUES:
================
# Hypertensive urgency (resolved)
# Troponemia
HTN elevated on arrival to the ED, requiring nitro gtt. Upon
arrival to the floor the patient's blood pressure remained
significantly elevated to the 190s systolic. BP improved on
nitro
gtt. No signs of end organ damage, the patient continued to make
urine and creatinine was down-trending, approaching baseline
prior to discharge. Underlying HTN
likely related to CKD iso diabetes, however may consider need
for
additional workup of secondary hypertension if hypertensive
urgency persists following discharge.
- Imdur continued
- Increased hydralazine to 25mg TID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. Glargine 46 Units Breakfast
Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Allopurinol ___ mg PO DAILY:PRN gout
6. Atorvastatin 80 mg PO QPM
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
8. CARVedilol 3.125 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. Furosemide 20 mg PO BID
11. HydrALAZINE 25 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
3. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Glargine 40 Units Breakfast
Glargine 5 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Allopurinol ___ mg PO DAILY:PRN gout
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
9. CARVedilol 3.125 mg PO BID
10. Clopidogrel 75 mg PO DAILY
11. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Heart failure with reduced ejection fraction exacerbation
SECONDARY DIAGNOSIS:
Acute on chronic kidney disease
Urinary tract infection
Hypertension
Type 2 diabetes mellitus
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were having shortness of breath.
WHAT WAS DONE IN THE HOSPITAL?
- The function of your heart and lungs was monitored.
- You were given intravenous medication (called Lasix) to get
rid of excess fluid and your breathing improved.
- You had an echocardiogram (ultrasound of the heart), which
showed that the pump function of your heart had decreased.
- You had a procedure called a right heart catheterization,
which showed that the pressures in your heart were normal.
- You had a stress test, which showed that your heart had
suffered damage from a blocked artery. You should follow-up
closely with your Cardiologist and will need to have a procedure
called a cardiac catherization at a later date.
- Your breathing improved, you were free from chest pain and
your medical team felt it was safe for you to be discharged
home.
WHAT SHOULD I DO WHEN I GET HOME FROM THE HOSPITAL?
- Continue to take all of your medications as prescribed.
- Please call your Cardiologist and Primary Care Doctor to
schedule follow-up appointments.
- Have a family member or your visiting nurse weigh you every
day. Call your doctor if your weight changes by 3 pounds in 1
day or 5 pounds in 1 week.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10567123-DS-2 | 10,567,123 | 20,399,516 | DS | 2 | 2150-11-14 00:00:00 | 2150-11-14 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
meperidine / morphine / Hydromorphone
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
ORIF right tibial plateau
History of Present Illness:
___ s/p bicycle accident. Patient was riding her bike when a
short bus hit her. She fell off the bike and injured her R knee.
Patient was unable to ambulate after fall. Patient denies head
strike or LOC.
Past Medical History:
HLD
Social History:
___
Family History:
NC
Physical Exam:
Right lower extremity:
Incisions clean, dry, intact, no excessive erythema, induration,
drainage
SILT in DP/SP/S/S/T distributions
___
Toes WWP, 2+ DP pulse
Pertinent Results:
___ 06:10AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.5* Hct-28.4*
MCV-95 MCH-31.5 MCHC-33.3 RDW-12.8 Plt ___
___ 03:50PM BLOOD ___ PTT-27.6 ___
___ 06:30AM BLOOD Glucose-162* UreaN-10 Creat-0.8 Na-134
K-3.7 Cl-98 HCO3-24 AnGap-16
___ Right knee films: The lateral tibial plateau is
fractured with minimal depression of the major fracture fragment
which demonstrates approximately 6 mm of displacement
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction, internal fixation
of the right tibial plateau fracture and repair of the meniscus,
which was found intra-operatively. The patient tolerated the
procedure well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after 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
perioperative antibiotics and anticoagulation per routine. The
patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
right lower extremity with ___ brace (unlocked). She will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
Calcium
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
5. Multivitamins 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
7. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right tibial plateau 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:
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.
ACTIVITY AND WEIGHT BEARING:
- Right lower extremity: touch down weight bearing, ___
unlocked
Physical Therapy:
Right lower extremity: touch down weight bearing, ___
unlocked, AROM/PROM as tolerated
Treatments Frequency:
Wound: Surgical incision
Location: Right knee
Dressing: Please inspect surgical wound daily and changed
dressing daily with dry gauze. If non-draining, can leave open
to air.
Followup Instructions:
___
|
10567255-DS-6 | 10,567,255 | 29,625,784 | DS | 6 | 2130-11-12 00:00:00 | 2130-11-13 21:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
S/p MVA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a a ___ M with PMH significant for HTN, HLD, and
COPD, who presented to ___ after MVA, with body CT
revealing new lesions in lung, pancreas, and liver.
The patient was involved in a car accident yesterday in which he
was traveling 25 miles an hour in the front of his car hit the
side of another car. Airbags did deploy and he feels that his
face hit these airbags, but his head did not strike any other
solid surface. He denies any loss of consciousness. Since that
time he reports some lumbar back pain, but otherwise is feeling
okay.He denies any current headache, visual changes, weakness,
loss of sensation, chest pain, dyspnea, abdominal pain, N/V.
At ___, he had a CT that revealed a small cerebellar
lesion, as well as new lesions in his lung, pancreas, and liver.
He was then referred to ___ for further workup.
At ___, he had an MRI which was recommended by Neurology and
Neurosurgery. The MRI did not reveal any acute infarcts without
any other definitive pathology. He does still have lesions that
were not known about previously: a 3 cm speculated lung mass
that
is suspicious for TB (per radiology), a hypodense pancreatic
lesion, and a liver lesion. MRCP was recommended for further
characterization.
In the ED, initial vitals: 75 119/72 20 93% RA
- Labs notable for: Normal CBC, Chemistries
- Imaging notable for:
CT Abdomen/Pelvis:
1. There is an approximately 3 cm spiculated mass in the left
upper lobe concerning for malignancy. Oncologic referral is
recommended.
2. No evidence of solid organ or osseous traumatic injury. No
free fluid in the abdomen or pelvis.
3. Hypodense pancreatic mass in the uncinate process measuring
2.3 cm.
Further evaluation with MRCP is recommended.
4. 2 cm rounded hyperenhancing focus in the left hepatic lobe is
indeterminate and should be characterized at the time of MRCP.
MRI Head:
The 9 mm hyperdense lesion in the left cerebellum seen on the
prior CT demonstrates blooming artifact on the GRE sequence
compatible with blood products or mineralization. There is no
definite enhancement on post-contrast sequences although
evaluation is somewhat limited secondary to patient motion.
There
is no associated FLAIR signal abnormality. There are scattered
T2/FLAIR hyperintensities within the brain parenchyma which are
nonspecific. No other
lesions are identified. No evidence of acute infarction or
midline shift. The major T2 flow voids appear well preserved.
REVIEW OF SYSTEMS:
10 point ROS is negative accept per HPI.
Past Medical History:
# HTN
# HLD
# COPD
# Hx of smoking
# Hx of heavy EtOH use ___ drinks/day)
Social History:
___
Family History:
None relevant to presenting complaint
Physical Exam:
Admission exam:
General: Alert, NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL
NECK: No elevation in JVP, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, but decreased on left
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: WWP, no edema
Skin: No rashes or lesions.
Neuro: AOx3, CNII-XII intact, ___ strength upper/lower
extremities.
Discharge exam
24 HR Data (last updated ___ @ 1204)
Temp: 98.3 (Tm 98.3), BP: 127/68 (117-130/66-75), HR: 64
(56-64), RR: 16 (___), O2 sat: 96% (94-96), O2 delivery: RA
General: Laying in bed, feels well
HEENT: Sclerae anicteric, MMM
NECK: supple, no nodules
CV: normal s1, s2 no MGR
Lungs: CTAB with good breath sounds, no increased work of
breathing
Abdomen: soft, nondistended, nontender to deep palpation
throughout -improved .
Ext: WWP, no edema
Skin: No rashes or lesions.
Neuro: moving all extremities with purpose
Pertinent Results:
Admission labs:
=============
___ 08:37PM BLOOD WBC-6.2 RBC-4.34* Hgb-13.6* Hct-39.7*
MCV-92 MCH-31.3 MCHC-34.3 RDW-13.0 RDWSD-43.8 Plt ___
___ 08:37PM BLOOD Neuts-68.5 ___ Monos-7.6 Eos-2.3
Baso-0.6 Im ___ AbsNeut-4.26 AbsLymp-1.27 AbsMono-0.47
AbsEos-0.14 AbsBaso-0.04
___ 08:37PM BLOOD Plt ___
___ 08:37PM BLOOD ___ PTT-27.2 ___
___ 08:37PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-143
K-4.0 Cl-107 HCO3-25 AnGap-11
___ 08:37PM BLOOD ALT-12 AST-17 CK(CPK)-73 AlkPhos-58
TotBili-0.6
___ 08:37PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:37PM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.1 Mg-2.2
___ 08:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Discharge labs:
============
___ 06:20AM BLOOD WBC-4.9 RBC-4.41* Hgb-13.8 Hct-40.1
MCV-91 MCH-31.3 MCHC-34.4 RDW-13.0 RDWSD-43.0 Plt ___
___ 06:20AM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-145
K-4.0 Cl-109* HCO3-23 AnGap-13
___ 06:20AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.4
Micro:
====
None
Imaging :
======
MRCP
*** UNAPPROVED (PRELIMINARY) REPORT ***
EXAMINATION: MRCP
INDICATION: ___ year old man with newly found pancreatic and
hepatic lesions
on CT. Further evaluation with MRCP was recommended.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen
were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was
administered
for oral contrast.
COMPARISON: CT torso performed ___.
FINDINGS:
Lower Thorax: No pleural effusion. Known lung masses are better
evaluated on
prior CT torso.
Liver: The liver demonstrates normal signal intensity. Multiple
T2
hyperintense nonenhancing lesions are most compatible with
simple hepatic
cysts or biliary hamartomas, the largest measuring up to 4.0 x
3.5 cm in the
left hepatic lobe. A 1.1 x 1.1 cm lesion in segment 2
demonstrates nodular
rim enhancement on arterial phase, which persist on delayed
phase imaging.
Findings are most likely in keeping with a hemangioma
(___). No other
concerning liver lesions are identified.
Biliary: No evidence of intrahepatic or extrahepatic biliary
ductal
dilatation. The gallbladder is unremarkable.
Pancreas: A cluster of cysts are demonstrated in the pancreatic
head and
uncinate process, the dominant cyst measuring up to 1.4 cm
(08:23). Findings
are most suggestive of side branch IPMNs. There is no evidence
of pancreatic
ductal dilatation.
Spleen: Spleen demonstrates normal size and signal intensity
without evidence
of focal splenic lesions.
Adrenal Glands: A 1.0 cm T2 hypointense and rim enhancing right
adrenal nodule
is not well evaluated on in and out of phase imaging secondary
to poor breath
hold and may represent an adrenal adenoma (08:12). Attention on
follow-up is
recommended.
Kidneys: Bilateral renal cortical T2 hyperintensities do not
demonstrate
postcontrast enhancement and measure up to 1.8 cm in the right
lower pole
kidney (08:26). These findings are most in keeping with simple
renal cyst.
No hydronephrosis.
Gastrointestinal Tract: Visualized small and large bowel loops
are
unremarkable. No evidence of bowel obstruction. No evidence of
ascites.
Lymph Nodes: No abdominal lymphadenopathy
Vasculature: No abdominal aortic aneurysm. Portal veins and
hepatic veins are
patent.
Osseous and Soft Tissue Structures: Small hemangiomas
demonstrated in the L4
vertebral body. There is mild levoconvex curvature of the
thoracolumbar
spine. No suspicious osseous or soft tissue lesions are
identified.
IMPRESSION:
1. A cluster of cysts are demonstrated in the pancreatic head
and uncinate
process, likely representing side-branch IPMNs. Follow-up
recommendations are described below.
2. 1.1 cm segment II lesion is most in keeping with a hepatic
hemangioma.
3. 1.0 cm T2 hypointense rim enhancing right adrenal nodule may
represent an
adrenal adenoma. Close attention on follow-up imaging is
recommended.
RECOMMENDATION(S): For management of pancreatic cyst(s) between
6-15 mm in patients between ___- ___ years at presentation,
recommend non-contrast MRCP follow-up every other year up to a
total of ___ years.
For cysts measuring up to 1.5 cm:
(a) These guidelines apply only to incidental findings, and not
to patients
who are symptomatic, have abnormal blood tests, or have history
of pancreas
neoplasm resection.
(b) Clinical decisions should be made on a case-by-case basis
taking into
account patient's comorbidities, family history, willingness to
undergo
treatment, and risk tolerance.
MRI head
IMPRESSION:
1. Left cerebellar developmental venous anomaly with an
associated lesion is
most consistent with a cavernoma which corresponds to
hyperdensity on seen on
prior CT. No evidence of surrounding edema to suggest acute
bleeding.
2. No evidence of acute infarction or acute intracranial
hemorrhage.
3. Mild parenchymal volume loss and chronic small vessel
ischemic disease.
CT chest/abdomen / pelvis
IMPRESSION:
1. There is an approximately 3 cm spiculated mass in the left
upper lobe
concerning for malignancy. a a second 7 mm spiculated mass, also
in the left
upper lobe, is also concerning for another satellite lesion.
Oncologic
referral and additional evaluation for the same is recommended,
if not already
known.
2. No evidence of solid organ or osseous traumatic injury. No
free fluid in
the abdomen or pelvis.
3. Hypodense pancreatic mass in the uncinate process measuring
2.3 cm.
Further evaluation with MRCP with contrast is recommended.
4. 2 cm rounded hyperenhancing focus in the left hepatic lobe is
indeterminate
and should be characterized at the time of MRCP.
RECOMMENDATION(S):
1. Oncologic referral for additional workup (possibly a PET-CT
and/or biopsy)
for the left upper lobe spiculated mass-if this is not already
known.
2. MRCP with contrast for further characterization of pancreatic
head mass as
well as a hyperenhancing lesion in the left hepatic lobe.
MRI Abd:
1. An ovoid cluster of microcysts measuring approximately 5.1 cm
in the
craniocaudal axis, localized within the posterior aspect of the
uncinate
process of the pancreas without demonstrate well communication
to the main
pancreatic duct. On the CT dated ___, there are
foci of punctate
calcification within this lesion. This lesion is favored to
represent a
microcystic adenoma over side-branch IPMNs.
2. 1.1 cm segment II lesion is most in keeping with a hepatic
hemangioma.
3. 1.0 cm T2 hypointense rim enhancing right adrenal nodule may
represent an
adrenal adenoma. Close attention on follow-up imaging is
recommended.
4. A fairly large diverticulum is seen arising in the
periampullary region of
the second portion of the duodenum.
Brief Hospital Course:
Mr ___ is a a ___ M with PMH significant for HTN, HLD, smoking
and
COPD, who presented to ___ after MVA, with body CT
incidentally revealing new lesions in lung, pancreas, and liver.
Patient transferred here for further workup; however, without
complications from the lesions, the patient elected to complete
the remainder of the workup in the outpatient setting. Prior to
discharge, patient had an MRCP done to better characterize the
liver and pancreatic lesion.
# Lung Mass
3 cm spiculated mass in the left upper lobe concerning for
malignancy. Second 7 mm spiculated mass, also in the left upper
lobe, is also concerning for another satellite lesion.
Patient will need a biopsy of this mass to rule out malignancy.
Quant gold was ordered, but the test was not performed due to
inadequate sample. We discussed the radiology findings and the
possible etiologies with the patient and family, and he elected
to follow up with his PCP for outpatient referral to ___ vs IP
for biopsy.
# Pancreatic Mass
# Liver Mass
Pancreatic mass on CT: Hypodense pancreatic mass in the uncinate
process measuring 2.3 cm.
Liver mass: 2 cm rounded hyperenhancing focus in the left
hepatic lobe is indeterminate.
MRCP:
1. An ovoid cluster of microcysts measuring approximately 5.1 cm
in the
craniocaudal axis, localized within the posterior aspect of the
uncinate
process of the pancreas without demonstrate well communication
to the main
pancreatic duct. On the CT dated ___, there are
foci of punctate
calcification within this lesion. This lesion is favored to
represent a
microcystic adenoma over side-branch IPMNs.
2. 1.1 cm segment II lesion is most in keeping with a hepatic
hemangioma.
3. 1.0 cm T2 hypointense rim enhancing right adrenal nodule may
represent an
adrenal adenoma. Close attention on follow-up imaging is
recommended.
4. A fairly large diverticulum is seen arising in the
periampullary region of
the second portion of the duodenum.
Patient elected to follow up with his PCP for further workup as
above
# Cerebellar Lesion
MRI of Head:
1. Left cerebellar developmental venous anomaly with an
associated lesion is most consistent with a cavernoma which
corresponds to hyperdensity on seen on prior CT. No evidence of
surrounding edema to suggest acute bleeding.
2. No evidence of acute infarction or acute intracranial
hemorrhage.
3. Mild parenchymal volume loss and chronic small vessel
ischemic disease.
Evaluated by neurology and neurosurgery who believe that lesion
seen on CT represents benign vascular lesion (ie incidental
cavernous malformation). MRI obtained while in ED, which
demonstrated findings consistent with this, and no evidence of
acute infarct.
# MVA
No signs of sequella of trauma on whole body CT, which is
reassuring.
- Acetaminophen q6hr prn + lidocaine patch for lumbar back pain
# Hx of EtOH Use
Patient reports ___ drinks per night and >6 on the weekends. No
history of withdrawal or seizures related to EtOH. Did not have
any withdrawals while in patent.
CHRONIC ISSUES:
===============
# HTN
- Continue home 10 mg amlodipine qD
# HLD
- Continue home 20 mg simvastatin qPM
# Anx/Depression
- Continue home 150 mg buproprion
# COPD
- Continue home Spiriva qD
- Continue home albuterol prn
Transitional issues:
- Please follow up with interventional radiology. A referral
needs to be made by patients PCP. A PET CT may be required or
the patient go directly for a biopsy pending MRCP results.
- Continue smoking and alcohol cessation counseling.
- Pancreatic mass on CT: Hypodense pancreatic mass in the
uncinate process measuring 2.3 cm. MRI: An ovoid cluster of
microcysts measuring approximately 5.1 cm in the craniocaudal
axis, localized within the posterior aspect of the uncinate
process of the pancreas without demonstrate well communication
to the main pancreatic duct This lesion is favored to represent
a
microcystic adenoma over side-branch IPMNs.
- Liver mass: 2 cm rounded hyperenhancing focus in the left
hepatic lobe is indeterminate. MRI: 1.1 cm segment II lesion is
most in keeping with a hepatic hemangioma.
- Lung mass: 3 cm spiculated mass in the left upper lobe
concerning for malignancy. Second 7 mm spiculated mass, also in
the left upper lobe, is also concerning for another satellite
lesion. ** needs further investigation
- MRI OF HEAD ** per neurosurgery, benign lesion, does not need
further investigation:
1. Left cerebellar developmental venous anomaly with an
associated lesion is most consistent with a cavernoma which
corresponds to hyperdensity on seen on prior CT. No evidence of
surrounding edema to suggest acute bleeding.
2. No evidence of acute infarction or acute intracranial
hemorrhage.
3. Mild parenchymal volume loss and chronic small vessel
ischemic disease.
#CODE: Full Code (presumed)
#CONTACT: ___ ___ (granddaughter)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
5. Sildenafil 50 mg PO DAILY:PRN ED
6. Simvastatin 20 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
9. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth every day Disp #*60
Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % 1 patch every day Disp
#*30 Patch Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
4. Thiamine 200 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 2 tablet(s) by mouth every
day Disp #*60 Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. amLODIPine 10 mg PO DAILY
8. BuPROPion XL (Once Daily) 150 mg PO DAILY
9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
10. Sildenafil 50 mg PO DAILY:PRN ED
11. Simvastatin 20 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
==================
Pulmonary nodule
Pancreatic mass
Liver mass
Concern for cancer
Motor vehicle accident
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 here at ___.
You presented to the hospital after a motor vehicle accident. A
CT scan was done of your body to ensure you had no broken bones
or bleeding. The CT scan did not show any fractures or bleeding
but it did show suspicious lesions concerning for cancer in your
lung, liver and pancreas. MRI of your head showed a lesion, it
was evaluated by neurosurgery and determined to be benign. We
ran a tuberculosis test on you which is pending at discharge. We
also got an MRI which is a better quality image of your abdomen
to better characterize these lesions.
It is very important you follow up with your primary care
doctor. He will refer you to interventional radiology for
biopsies of your lesions if the MRCP looks concerning. You will
need a biopsy of your lung nodule.
It is important that you stop smoking. Smoking increases your
risk for cancer and it causes damage to your lungs.
We are happy to see you feeling better.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10567612-DS-14 | 10,567,612 | 20,877,538 | DS | 14 | 2175-05-18 00:00:00 | 2175-05-19 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
___ drainage of R psoas abscess
___ drainage of R abdominal abscess
History of Present Illness:
___ with recent history of IV drug use who presents with psoas
abscess ___ right flank. Stated felt as if he had pulled a muscle
___ his lower back at work 5 days ago. The pain then worsened and
began to radiate from his right flank to RLQ. He had fevers at
home and so he went to an OSH where he was found to have this
right psoas abscess and so was sent to ___.
He last used heroin ___ days ago. He has been moving his bowels
and passing flatus.
Past Medical History:
Past Medical History:
hepatitis C, colitis
Past Surgical History:
reconstruction surgery left hand
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals:
100.0 HR 120 BP 112/66 22 94% RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: tender and erythematous along right flank and RLQ
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.3, HR 71, BP 125/81, RR 20, O2 97% RA
Drain output: ___
GENERAL: Pleasant young man, NAD
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: RRR, normal S1/S2, no m/r/g
ABDOMEN: NABS, soft, non-tender, nondistended. RLQ with drain ___
place covered ___ clean bandage. Drain with cloudy
sero-sanguineous fluid.
EXTREMITIES: WWP, no ___ edema.
SKIN: No rashes noted on face, lower arms or lower legs
NEURO: Awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
===============
___ 09:38PM BLOOD WBC-20.2* RBC-4.59* Hgb-14.3 Hct-39.2*
MCV-85 MCH-31.2 MCHC-36.5 RDW-12.1 RDWSD-37.6 Plt ___
___ 09:38PM BLOOD Neuts-88* Bands-3 Lymphs-1* Monos-7 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-18.38* AbsLymp-0.20*
AbsMono-1.41* AbsEos-0.20 AbsBaso-0.00*
___ 09:38PM BLOOD ___ PTT-29.5 ___
___ 09:38PM BLOOD Glucose-130* UreaN-16 Creat-0.9 Na-132*
K-3.6 Cl-94* HCO3-22 AnGap-20
DISCHARGE LABS:
===============
___ 09:00AM BLOOD WBC-10.5* RBC-4.63 Hgb-13.9 Hct-41.5
MCV-90 MCH-30.0 MCHC-33.5 RDW-13.1 RDWSD-42.2 Plt ___
___ 09:00AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-142 K-4.8
Cl-105 HCO3-26 AnGap-16
MICROBIOLOGY:
=============
___ 11:41 am ABSCESS Source: rt psoas.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Daptomycin & LINEZOLID Sensitivity testing per ___.
___ (___)
___.
Daptomycin MIC 0.25 MCG/ML = SUSCEPTIBLE Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
-------
___ 9:24 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ (___) AT 9:04 AM
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
-------
___ 10:49 am ABSCESS Source: Abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
-------
IMAGING/STUDIES:
=================
TTE ___:
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen. Normal global and regional biventricular
systolic function.
MRI PELVIS ___:
Interval increase ___ the size of the right psoas fluid
collection with
enhancing rim measuring 4.1 x 1.9 cm ___ the axial dimension with
ill-defined inflammatory change and additional areas of
loculation extending over a span of 13.8 cm. Findings
compatible with multilocular abscess.
New multiloculated fluid collection with enhancing rim measuring
at least 11.4 x 5.2 cm ___ the axial dimension and spanning
nearly the entire length of the abdomen ___ the craniocaudal
dimension with extensive loculation. Both of these collections
are amenable to percutaneous drainage. Findings compatible
multilocular abscess.
Extensive edema ___ the bilateral psoas and iliacus musculature
places the
patient at risk for osteomyelitis, although there is no evidence
of
osteomyelitis on today's exam.
Brief Hospital Course:
___ year old man with history of IVDU who presented initially to
an OSH with complaints of fever, sweats and chills as well as
right hip and back pain, and was found to have multiple R
abdominal abscesses. He is now s/p ___ drainage ___
w/ cultures growing MRSA, discharged home to complete outpatient
abx as below with RLQ drain ___ place
# ABSCESSES: S/p drainage by ___ x2, Cx growing MRSA. He remains
afebrile since admission to ___. TTE has been obtained and was
unremarkable; TEE has been deferred for now given his negative
blood cultures to date at ___, and stable clinical course.
Treated with vancomycin while inpatient and transitioned to
dalbavancin q2week on discharge for likely 4 week course
followed by interval imaging with follow-up with ___
infectious disease. Discharged with RLQ drain ___ place given
output still 60-200cc daily with ___ to monitor until drain
output <10cc/day for 2 days, see page 1 for detailed drain
instructions.
# C DIFFICILE DIARRHEA: Started on metronidazole ___, having
solid stools at discharge. Transitioned to vancomycin tablets at
discharge 125mg q6h to complete course through end of MRSA
antibiotics as above
# HEPATITIS C: Known prior hepatitis C. Inquired about treatment
with Harvoni and discussed that once sober he could be a
candidate for treatment
# SUBSTANCE ABUSE: IVDU and cigarette smoking. 24+ hours off
narcotics on ___. Amenable to starting suboxone maintenance
therapy, no active withdrawal inpatient. Outpatient appointment
arranged ___ to for suboxone therapy. Decision was made to have
the patient wait until the ___ appointment for suboxone given
the fact that he is not withdrawing. SW saw while inpatient and
provided help with community resources.
TRANSITIONAL ISSUES:
[] Will complete dalbavancin q2w for at least 4 weeks with
interval imaging and f/u with ___ infectious disease- they
will make the appointment and contact the patient.
[] Will need Weekly CBC with differential, chemistry, LFT's, ESR
and CRP
[] Discharged on PO vancomycin 125mg q6h through end of MRSA abx
course and possibly 2 weeks beyond the antibiotic course- to be
determined by ID
[] Has RLQ JP drain ___ place, with ___ to manage until drain
output >10cc/day for 2 days, see page 1 for full drain
instructions
[] Known chronic hepatitis C. Please consider therapy
[] Hepatitis B non-immune, please provide vaccine series.
*) CODE STATUS: Full
*) CONTACT: Mother ___ ___
>30 minutes spent coordinating discharge to home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. dalbavancin 1500 mg injection Q 2 WEEK
RX *dalbavancin [___] 500 mg 3 vials IV q 2 weeks Disp #*9
Vial Refills:*0
2. vancomycin 125 mg oral Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*120 Capsule Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MRSA psoas abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you here at ___.
WHY WERE YOU ADMITTED:
-You had a R sided abdominal abscess
WHAT HAPPENED ___ THE HOSPITAL:
-You had drainage of your abscess two times with interventional
radiology
-Cultures from the abscess grew MRSA, a bacteria frequently
associated with IV drug use that can cause serious infections of
your heart or brain.
-You were treated with broad spectrum antibiotics
-An echocardiogram did not show signs of infection ___ your heart
-You developed diarrhea from the antibiotics, due to a bacteria
called c. difficile.
WHAT YOU SHOULD DO AT HOME:
-Please follow-up with your doctors as listed below
-___ keep your appointment next week with your suboxone
provider
-___ taking vancomycin tablets 4x/day until 2 weeks after
your last antibiotic dose or until the ID doctors ___ to
stop it.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10568267-DS-16 | 10,568,267 | 24,450,741 | DS | 16 | 2159-07-31 00:00:00 | 2159-07-31 18:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Brain tumor
Major Surgical or Invasive Procedure:
___ Right Craniotomy for tumor resection
History of Present Illness:
Mr. ___ is a ___ right-handed young man with no
medical issues who was admitted for management of a right
frontal-parietal heterogeneously enhancing mass lesion
discovered
during work-up for left hemiparesis over one week. He has been
mildly
symptomatic with left hemiparesis. The lesion is suspicious for
a cystic glioblastoma. Systemic surveillance imaging did not
demonstrate malignancy. He was scheduled for resection by Dr.
___.
Past Medical History:
Varicose vein repair in bilateral lower extremities
Social History:
___
Family History:
NC
Physical Exam:
Upon discharge:
A+Ox3. Pupils 3.5-3mm, EOM intact, Left facial, Tongue midline,
+Left drift, Left sided neglect and delayed motor response. L
side 4+/5 (stronger when patient focuses on side). Right sided
strength ___
Pertinent Results:
___ Gadolinium-enhanced brain MRI:
1. 3.7 cm x 2.8 cm x 3.6 cm centrally cystic or necrotic
enhancing mass at the posterior right frontal cortex with
adjacent edema versus nonenhancing disease causing mild mass
effect which is relatively unchanged. There is elevated ASL
perfusion which is most pronounced at the posterior medial
aspect of the mass corresponding to the most solid component.
There is displacement of the corticospinal fibers within the
centrum semiovale and corona radiata and inferior and lateral
displacement of the superior longitudinal fasciculus.
2. During movement of the left foot, there is BOLD activity
within the left parafalcine frontal cortex, just anterior to the
precentral gyrus which may represent compensatory left
lateralization of the left foot movements secondary to the
tumor. There is curvilinear activity marginating the anterior
and anterior medial aspect of the tumor at the posterior
parafalcine right frontal cortex, which may represent venous
contamination or supplementary motor activation. No definite
activity within the right frontal precentral gyrus.
3. During movement of the left hand, the BOLD activation area
demonstrates the primary motor cortex at the mid right
precentral gyrus, approximately 7 mm lateral to the enhancing
tumor margin.
4. Language paradigms demonstrates propagation of activity in
the convexity with activity in the left frontal middle gyrus and
bilateral activity in the frontal operculi, right greater than
left, which may represent language codominant.
___ CT Torso:
1. No evidence of malignancy within the abdomen and pelvis.
___ CTA head
1. Large right frontal-parietal mass, without evidence of a
large feeding
vessel.
2. Patent anterior and posterior arterial vessels without
evidence of
critical stenosis or aneurysm.
___ CT chest
1. No evidence of solid nodule or mass within the chest.
2. Small wedge-shaped focus at the left lung base probably
represents
atelectasis. Recommend follow-up in 3 months to ensure
clearance.
___ CT head
Expected post-surgical changes after right frontal lobe mass
resection, with moderate pneumocephalus and a small amount of
hemorrhage along the resection tract.
___ MRI head
Post-surgical blood products in the right frontal resection bed
with
persistent surrounding FLAIR signal abnormality. Small foci of
restricted
diffusion is likely post-operative change. No evidence of
abnormal
enhancement.
Brief Hospital Course:
Mr. ___ is a ___ year old previously healthy male who
presented to his PCP with ___ hand numbness and weakness, and left
leg tingling and weakness. An MRI revealed a right
frontal-parietal brain mass and he was sent to the ___ ED for
further evaluation where he was given Decadron. He was admitted
to the neurosurgical service. He was started on Keppra for
seizure prophylaxis. Patient underwent a functional MRI, CTA and
CT of the Torso for pre-operative workup.
On ___ Patient was neurologically stable. Family meeting was
held and it was decided to go forward with surgery.
On ___ Patient underwent Craniotomy for tumor resection. NCHCT
stable post operatively. On post operative examination left
sided weakness/neglect was appreciated. Discussed with Dr.
___. L weakness/neglect is secondary to supplementary motor
area syndrome per Dr. ___ and is expected.
ON ___ Patient was neurologically stable. He was started on a
dexamethasone taper. He was transferred to the floor. ___
consults ordered. MRI
On ___, the patient continues with symptoms of supplementary
motor area which are expected to improve. His MRI head shows
some post-operative blood products in the surgical bed and post
operative changes. His neurologic exam remains stable. Bowel
meds were ordered for constipation. Neuro-oncology has requested
labs to rule out germ cell tumor including AFP, beta hcg, LDH,
CEA. These labs have been ordered. Physical and occupational
therapy evaluated the patient and cleared him to discharge to
home. He will be discharged with instructions to follow-up for
suture removal and a neuro-oncology appointment.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain
Do not exceed greater than 4GM of acetaminophen in 24 hours.
2. Dexamethasone 4 mg PO Q6H Duration: 8 Doses
This is dose # 1 of 4 tapered doses
RX *dexamethasone 2 mg See taper tablet(s) by mouth See taper
instructions Disp #*60 Tablet Refills:*0
3. Dexamethasone 4 mg PO Q8H Duration: 6 Doses
This is dose # 2 of 4 tapered doses
4. Dexamethasone 4 mg PO Q12H Duration: 4 Doses
This is dose # 3 of 4 tapered doses
5. Dexamethasone 3 mg PO Q12H Duration: 4 Doses
This is dose # 4 of 4 tapered doses
6. Dexamethasone 2 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
7. Docusate Sodium 100 mg PO BID
8. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Outpatient Occupational Therapy
Evaluate for: ADL retraining, Mobility Retraining, UE ther-ex,
Patient/Caregiver ___: ___ x/week for 1 week
Discharge Disposition:
Home
Discharge Diagnosis:
fronto-parietal brain lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry until
sutures are removed. Do not soak incision.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
You will be discharged on Decadron. Please follow taper
instructions on your prescription. Your maintenance dose is 2mg
BID. Any changes regarding this medication will be addressed at
your brain tumor clinic follow up appointment.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is 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.
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:
___
|
10568382-DS-5 | 10,568,382 | 26,615,806 | DS | 5 | 2165-12-20 00:00:00 | 2165-12-20 19:27:00 |
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 ___ male with a history of sickle
cell disease, aortic insufficiency with severe aortic stenosis,
allergies, who is presenting with 1 week of increasing shortness
of breath. Patient states that he has been feeling more wheezy,
with associated cough. He feels that he has an allergy, for
which he has been taking higher doses of montelukast. He took it
three
times today before presenting to the ED, without any improvement
in his symptoms. He states that he has not had any chest pain or
abdominal pain, no palpitations, and is otherwise feeling well.
In the ED, initial VS were: T 98.3, HR 104, BP 133/88, RR 24,
86% RA
Exam notable for:
Speaking in short sentences, diffuse wheezes, soft abdomen,
scleral icterus, no pedal edema or appreciable JVD.
Labs showed:
- CBC: WBC 15.8, Hgb 9.0, Plt 308
- Lytes:
145 / 106 / 9
---------------- 139
4.2 \ 24 \ 1.0
Trop-T: <0.01
Abs-Ret: 0.45
- LFTs - AST 55, ALT: 32, AP: 142, Tbili: 14.7, Dbili 1.5, Alb:
4.1
FluAPCR: Negative
FluBPCR: Negative
Imaging showed: CXR pa and lat with
1. Increased bilateral interstitial opacities with peribronchial
cuffing suggests inflammatory/viral small airway disease.
Additionally there is increased opacity in the posterior left
lower lobe which raises the concern for pneumonia.
Patient received:
___ 19:00 IH Albuterol 0.083% Neb Soln 1 NEB
___ 19:00 IH Ipratropium Bromide Neb 1 NEB
___ 19:01 IH Albuterol 0.083% Neb Soln 1 NEB
___ 19:01 IH Ipratropium Bromide Neb 1 NEB
___ 19:10 IVF NS ___ Started
___ 19:22 IV MethylPREDNISolone Sodium Succ 125 mg
___ 19:22 IV Magnesium Sulfate 2gm
___ 20:37 IVF NS 1000 mL
___ 21:49 IV Levofloxacin 750 mg ordered
___ 21:49 IH Albuterol 0.083% Neb Soln 1 NEB
___ 21:49 IH Ipratropium Bromide Neb 1 NEB
Transfer VS were: T 100.0, HR 99, 133/72, RR 18, 99% 2L NC
On arrival to the floor, patient reports that his breathing is
much improved, and that he has no chest pain.
Past Medical History:
PMH:
-Sickle cell disease
-AI/Subaortic stenosis
-DVTs and Osteomyelitis LLE (___)
-Depression
PSH:
-LLE wound debridement (___)
Social History:
___
Family History:
-Father with DM, HTN
-sickle cell, disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
VS: T 98.4, HR 106, BP 143/74, RR 26, 94% 2l
GENERAL: lying in bed talking on cell phone, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: tachycardic, ___ holosystolic blowing murmur across
entire chest
LUNGS: poor air movement with shallow breathing. No wheezes or
rhonchi appreciated
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
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 934)
Temp: 98.7 (Tm 98.7), BP: 118/59 (118-146/59-74), HR: 77
(77-94), RR: 20 (___), O2 sat: 95% (91-96), O2 delivery: RA
GENERAL: NAD, lying in bed, awake and alert
HEENT: NC/AT, icteric sclerae, PERRL, EOMI, oral mucosa yellow,
MMM
NECK: no palpable masses
CV: regular rate and rhythm, blowing holosystolic murmur heard
across all chest
RESP: breathing comfortably in ra, mild expiratory wheezing
worse on the left side
GI: nondistended, nontender, no hepatosplenomegaly
GU: no suprapubic tenderness
MSK: mild tenderness to palpation of upper paraspinal muscles
SKIN: extremities warm and well perfused, no edema, erythema or
tenderness, palpable DP
and TP, no rash or lesions
NEURO: A&Ox3, CNII-XII grossly intact, spontaneously moving all
limbs against gravity
Pertinent Results:
ADMISSION LABS
===============
___ 07:05PM BLOOD WBC-15.8* RBC-3.02* Hgb-9.0* Hct-26.3*
MCV-87 MCH-29.8 MCHC-34.2 RDW-25.8* RDWSD-72.6* Plt ___
___ 07:05PM BLOOD Neuts-71 Bands-1 Lymphs-13* Monos-6
Eos-9* Baso-0 ___ Myelos-0 NRBC-38* AbsNeut-11.38*
AbsLymp-2.05 AbsMono-0.95* AbsEos-1.42* AbsBaso-0.00*
___ 07:05PM BLOOD Ret Man-14.9* Abs Ret-0.45*
___ 07:05PM BLOOD Glucose-139* UreaN-9 Creat-1.0 Na-145
K-4.2 Cl-106 HCO3-24 AnGap-15
___ 07:05PM BLOOD ALT-32 AST-55* LD(___)-625* AlkPhos-142*
TotBili-14.7* DirBili-1.5* IndBili-13.2
___ 07:05PM BLOOD proBNP-240*
___ 07:23PM BLOOD ___ pO2-56* pCO2-46* pH-7.34*
calTCO2-26 Base XS--1
___ 07:23PM BLOOD Lactate-1.5
INTERVAL LABS
==============
___ 05:00AM BLOOD WBC-11.7* RBC-2.76* Hgb-8.3* Hct-24.1*
MCV-87 MCH-30.1 MCHC-34.4 RDW-25.3* RDWSD-73.0* Plt ___
___ 05:00AM BLOOD ALT-25 AST-37 LD(___)-516* AlkPhos-116
TotBili-8.2*
DISCHARGE LABS
=============
___ 05:20AM BLOOD WBC-11.4* RBC-3.24* Hgb-9.6* Hct-28.4*
MCV-88 MCH-29.6 MCHC-33.8 RDW-23.2* RDWSD-68.5* Plt ___
___ 05:20AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-144 K-5.1
Cl-106 HCO3-26 AnGap-12
___ 05:20AM BLOOD ALT-22 AST-42* LD(___)-589* AlkPhos-100
TotBili-5.7*
___ 05:20AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
IMAGING
-===============
CHEST XRAY
PA and lateral views the chest provided. Previously noted
rounded density in the medial right lung base has resolved,
therefore representing summation of shadows on prior imaging.
The lungs appear clear without focal consolidation, large
effusion a subtle retrocardiac opacity could represent a very
early pneumonia in the correct clinical setting. Otherwise
lungs are clear. No large effusion or pneumothorax.
Cardiomediastinal silhouette appears stable. Sclerotic
appearance of the bony structures reflects sickle-cell
osteopathy.
Brief Hospital Course:
___ male with a history of sickle cell disease
(complicated avascular necrosis of left hip and osteomyelitis),
aortic insufficiency with subvalvular aortic stenosis who
presented with 1 week of shortness of breath with CXR increased
opacity in posterior left lower lobe concerning for lobar
pneumonia and/or acute chest syndrome, with symptoms improving
after treatment with antibiotics, oxygen, fluids and blood
transfusion.
ACTIVE PROBLEMS:
==========================
#Acute chest syndrome, moderate
#Community acquired pneumonia
#Sickle cell disease. Meets criteria for ACS of moderate
severity. Labs with evidence of hemolysis with rise in bili to
14.7, increased LDH and decreased Hb. Received 1pRBC with good
response. Was treated with IVF, duonebs, and oxygen therapy and
symptoms were resolved at the time of discharge. He had no other
signs/symptoms to suggest an acute pain/vaso-occlusive crisis.
He was treated with levofloxacin for CAP for coverage for
possible atypical PNA and encapsulated organisms given
functional asplenia. Discharged on neb taper.
#Aortic insufficiency
#Subvalvular aortic stenosis. Currently asymptomatic and patient
is clinically euvolemic. PCP had referred to cardiology but no
appointment has been scheduled yet. He was care connected at
discharge to see cardiology.
CHRONIC ISSUES
===========================
#Sickle cell. Continued on his home hydroxyurea and folic acid.
TRANSITIONAL ISSUES
========================
[]Levofloxacin treatment for pneumonia to complete on ___.
[]Patient should see cardiology for further workup of his aortic
insufficiency and subvalvular aortic stenosis.
[]Would refer to hematology as well for further care of his
sickle cell disease.
[]Sent with incentive spirometer. Please encourage patient to
use if still having symptoms.
#CODE: Full (presumed)
#CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydroxyurea 1500 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
7. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
ampule via nebulizer four times a day Disp #*10 Ampule
Refills:*0
2. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 250 mg 3 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Aspirin 81 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Hydroxyurea 1500 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
10.Medical Supplies
ICD10 J45 Asthma
Nebulizer with supplies
Length of Use: 99 months
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
===================
Acute chest syndrome
Community acquired pneumonia
Secondary diagnoses
================
Aortic insufficiency
Subvalvular aortic stenosis
Sickle cell disease
Reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were having trouble breathing and your oxygen levels were
low.
WHAT HAPPENED WHILE YOU WERE HERE?
-We treated you with antibiotics for a pneumonia.
-You had a sickle cell crisis, called "Acute Chest Syndrome" and
were treated with fluids through the IV, nebulizer treatments,
oxygen, and a blood transfusion.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Complete the rest of your antibitoics to treat your pneumonia.
-Continue using the nebulizer treatments over the next few days.
The nebulizer will be delivered to your house.
-On ___, use the breathing treatments four times a day.
-On ___, use the breathing treatments three times a day.
-On ___, use the breathing treatments twice a day.
-On ___, use the breathing treatments once a day. If you
are feeling better at this point then you should stop using the
breathing treatments. If your breathing is not better then call
your primary care doctor.
-___ to use the incentive spirometer for the next 5 days.
You should try to use it ten times every hour.
-Follow up with your primary care doctor. We also made you an
appointment to see a cardiologist.
It was a pleasure taking care of you,
Your ___ Medicine Team
Followup Instructions:
___
|
10568382-DS-6 | 10,568,382 | 26,143,957 | DS | 6 | 2167-08-21 00:00:00 | 2167-08-21 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
Admission Labs:
===============
___ 12:00PM BLOOD WBC-10.7* RBC-3.41* Hgb-9.6* Hct-28.0*
MCV-82 MCH-28.2 MCHC-34.3 RDW-22.9* RDWSD-66.0* Plt ___
___ 12:00PM BLOOD Neuts-60.6 ___ Monos-15.4*
Eos-1.6 Baso-0.9 NRBC-8.0* Im ___ AbsNeut-6.50*
AbsLymp-2.21 AbsMono-1.65* AbsEos-0.17 AbsBaso-0.10*
___ 12:00PM BLOOD ___ PTT-30.0 ___
___ 12:00PM BLOOD Ret Aut-8.5* Abs Ret-0.25*
___ 12:00PM BLOOD Glucose-113* UreaN-7 Creat-0.8 Na-142
K-4.1 Cl-109* HCO3-22 AnGap-11
___ 12:00PM BLOOD ALT-22 AST-35 LD(LDH)-500* AlkPhos-96
TotBili-6.8* DirBili-0.5* IndBili-6.3
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.6* Mg-1.9
___ 12:00PM BLOOD Hapto-<10*
Imaging:
========
CXR:
Cardiomediastinal silhouette is within normal limits. Increased
bilateral
interstitial opacities with peribronchial thickening and subtle
retrocardiac opacities which may represent pneumonia in
appropriate clinical setting.
There are no pneumothoraces. Sclerosis within the bilateral
humeral heads, may be seen with sickle cell arthropathy.
Discharge Labs:
===============
___ 05:45AM BLOOD WBC-13.5* RBC-3.14* Hgb-8.8* Hct-26.3*
MCV-84 MCH-28.0 MCHC-33.5 RDW-21.6* RDWSD-63.6* Plt ___
___ 05:45AM BLOOD Ret Aut-7.1* Abs Ret-0.25*
___ 05:45AM BLOOD Glucose-95 UreaN-4* Creat-0.8 Na-140
K-4.1 Cl-107 HCO3-22 AnGap-11
___ 05:45AM BLOOD ALT-14 AST-22 AlkPhos-108 TotBili-6.0*
___ 05:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7
___ 05:45AM BLOOD Hapto-11*
Brief Hospital Course:
Mr. ___ is a ___ male with a past medical history
notable for severe AS and sickle cell disease who presented with
an acute pain crisis in setting of possible community acquired
pneumonia.
ACUTE/ACTIVE PROBLEMS:
# Acute sickle cell pain crisis:
# Chronic anemia:
# Indirect hyperbilirubinemia:
Presented with total body pain, particularly in lower back. His
symptoms were overall consistent with prior pain crises.
Precipitant was thought to be possible pneumonia (seen on CXR)
although he denied fever, chills, cough, sputum, URI symptoms,
etc). He is unsure why pain came about. He had no evidence of
acute chest syndrome.
He was treated with continuous IV fluids as well as standing
Tylenol and prn oxycodone for pain. He was seen by hematology.
Home hydroxyurea, aspirin, and folate were continued.
He had evidence of hemolysis on initial labs with indirect
hyperbilirubinemia and undetectable haptoglobin. At time of
discharge his pain had mostly resolved and his markers of
hemolysis were improving (downtrending bilirubin, haptoglobin
low but detectable).
He did not require any transfusions while hospitalized.
# Community acquired pneumonia:
Found to have retrocardiac opacity seen on CXR. He also had a
brief transient oxygen requirement in the ED which quickly
resolved. Hematology did not feel that there was any concern for
acute chest syndrome. He was started on ceftriaxone and
azithromycin and transitioned to cefpodoxime/azithromycin at
discharge to complete a 5 day course for CAP (day 5 = ___.
CHRONIC/STABLE PROBLEMS:
# Aortic stenosis, MR, subaortic membrane: he will follow up as
an outpatient
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- discharged on cefpodoxime/azithromycin to complete a 5 day
course (day 5 = ___.
- hematology follow up scheduled for ___
- should have CBC and hemolysis labs rechecked at PCP follow up
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydroxyurea 1500 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 2 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Hydroxyurea 1500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Sickle cell pain crisis
Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came in with pain in your back and ribs. We found that you
were having a pain crisis from sickle cell. We treated you with
IV fluids and pain medication.
At home please make sure to stay well hydrated. You can take
Tylenol for pain. If your pain is not relieved by Tylenol you
can take oxycodone as needed. Please do not drive after taking
oxycodone, as this medication can make you drowsy.
We also found that had a pneumonia. We treated you with
antibiotics. You will need to take antibiotics for two more days
after leaving the hospital (last day ___.
Please see below for your follow up appointments.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10569095-DS-14 | 10,569,095 | 26,151,200 | DS | 14 | 2135-07-09 00:00:00 | 2135-07-09 23:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
alogliptin / Augmentin / Penicillins / Sulfa (Sulfonamide
Antibiotics) / vancomycin / Tradjenta / linagliptin
Attending: ___.
Chief Complaint:
Worsening cellulitis and gangrene of the left foot.
Major Surgical or Invasive Procedure:
___: Left lower extremity angiogram.
History of Present Illness:
Patient is a ___ year old female with a history of IDDM, CAD,
CHF, A fib on Eliquis, CKD 3, 2nd degree AV block s/p PPM, L
carotid stenosis s/p CEA ___ ago, OSH) & CAS ___,
___, and PAD s/p bilateral CIA/EIA stents ___,
CHA). She has known chronic left foot ulcers and is currently
scheduled for a left lower extremity angiogram with Dr.
___ anterograde and possible retrograde pedal
access on ___. However, she now presents with
worsening left lower extremity ulcers and erythema, concerning
for cellulitis. Vascular surgery is consulted for evaluation.
.
The patient has 2 dominant ulcers: one of the left heel that is
chronic, dry, and has been stable since ___ and another on
the left ___ digit which first appeared 2 days prior to
presentation with associated erythema. Her visiting nurse called
the vascular surgery office due to concern for possible
infection. The patient was advised to watch it and to report to
the ED if it progressed. Today, she noticed that the left ___
toe ulcer in particular was getting worse and presented to the
ED as instructed. The top of the toe blistered and left behind a
wound that began to darken in color. There was been a moderate
amount of serosanguineous drainage into her sock.
.
Currently, the patient is afebrile and hemodynamically stable.
She denies any pain in her left foot but does report
claudication with ambulation. She has stable sensory loss to the
left foot secondary to diabetic neuropathy. She denies any motor
dysfunction. Patient also reports worsening bilateral lower
extremity edema. She denies any fevers, chills, chest pain,
shortness of breath.
.
Past Medical History:
Past medical history:
PAD
CAD c/b MI
type 2 diabetes mellitus complicated by neuropathy and
retinopathy
atrial fibrillation
2nd degree AV block s/p dual-chamber pacemaker
hypertension
psoriasis
osteopenia
nephrotic syndrome
colon polyp
Vascular surgery history:
L carotid endarterectomy ___ years ago)
Bilateral angioplasty of CIA and EIA (___)
Left carotid artery stent (___)
Social History:
___
Family History:
Her father's siblings all had coronary artery disease. Diabetes
in her brother and sister. Her sister also had breast and lung
cancer.
Physical Exam:
Physical Exam:
Vitals: Temp 97.6 HR 80 BP 93/59 RR 18 SpO298% RA
Gen: AAOx3, no acute distress
HEENT: trachea midline
Cardio: RRR
Pulm: CTAB
GI: abdomen soft, non-distended, non-tender
Extremities: bilateral 2+ edema present to level of the knee.
LLE: Edema also noted to left foot with erythema surrounding two
superficial ulcerations, improved since admission. Ulceration to
left heel and dorsal ___ digit. Both wounds exhibit stable
eschar. No crepitus, no fluctuance, no proximal streaking.
Patient able to actively move all digits. Protective sensation
diminished to plantar foot.
Pulses: R: p/d/d/d L: p/d/d/d
Pertinent Results:
DISCHARGE LABS:
___ 07:47AM BLOOD WBC-8.1 RBC-2.21* Hgb-7.3* Hct-23.0*
MCV-104* MCH-33.0* MCHC-31.7* RDW-15.2 RDWSD-57.6* Plt ___
___ 07:47AM BLOOD Plt ___
___ 07:47AM BLOOD Glucose-171* UreaN-23* Creat-1.7* Na-137
K-3.5 Cl-96 HCO3-26 AnGap-15
___ 07:47AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.7
___ 08:25PM BLOOD CRP-12.2*
___ Foot XR:
No acute fractures or dislocation are seen. Deformity deformity
at the distal aspect of the proximal phalanx of the left small
digit may be from prior healed fracture. Hyperdense 2.5 mm
structure medial to the head of the proximal phalanx of the
fourth toe may represent vascular calcification or, dystrophic
calcification or foreign body. There are no significant
degenerative changes. Bone demineralization. There are no
erosions. No acute fractures or radiological signs of
osteomyelitis
___ ___ PVR/ABIs:
Left: Absent DP pulse. Doppler waveforms and pulse volume
recordings suggest significant arterial obstructive disease,
multilevel, and most severe infrapopliteal.
Right: Abnormal ABI at rest with pulse volume recordings
suggesting multilevel obstructive arterial disease, most
significant infrapopliteal.
Significant calcification atherosclerosis of the left lower
extremity arteries with no flow identified in the superficial
femoral artery, with question of possible subtotal occlusion of
the common femoral artery on color Doppler, however normal
velocities in the deep femoral artery.
Likely collateral flow to the popliteal and infrapopliteal
vessels with low flow and minimal pulsatility.
___ Angiogram:
ANGIOGRAM FINDINGS:
1. Infrarenal abdominal aorta seen without ectasia or stenosis
or aneurysm.
2. Bilateral patent common iliac arteries as well as external
iliac arteries.
3. Patent left common femoral artery.
4. Patent profunda without stenosis.
5. Occlusion of the SFA after approximately 10 cm without
reconstitution.
6. Eventual reconstitution of a popliteal artery at the level
of the knee.
7. Anterior tibial artery, patent as one-vessel runoff to the
foot with moderate disease distally into the dorsalis pedis.
8. Posterior tibial artery and peroneal artery not well
visualized on this angiogram.
Brief Hospital Course:
Ms. ___ is a ___ female past medical history of
diabetes, diabetic neuropathy and retinopathy, atrial
fibrillation, dual-chamber pacemaker, hypertension, peripheral
artery disease, myocardial infarction, and coronary artery
disease who presented to the emergency room with worsening left
foot swelling. In the ED, she had foot x-rays which
demonstrated no signs of osteomyelitis or acute fractures. She
was admitted to the vascular surgery service and started on IV
antibiotics (clindamycin and ciprofloxacin secondary to her drug
allergies). She is continued on aspirin and Plavix. Heparin
drip was started and her Eliquis was held. She is n.p.o. at
midnight for anticipation of angiogram on ___.
.
On ___, she underwent ABI/PVR's which suggested significant
arterial obstructive disease at multiple levels with the most
severe disease being infra popliteal.
She then underwent LLE angiogram which demonstrated occlusion of
the L SFA with reconstitution of the popliteal artery at the
level of the knee. She had single vessel runoff via the
anterior tibial artery. Attempt to cross her SFA occlusion was
unsuccessful. The decision was made to defer further management
until further discussion with Dr. ___ had
originally planned to do her angiogram.
.
On ___, she was voiding without issue and tolerating a regular
diet. Her home medications were started and she was
transitioned to oral clindamycin and ciprofloxacin. Her heparin
drip was stopped and she was started on her home dose of
apixaban. Her antibiotics will continue until she follows up
with Dr. ___ with a planned appointment to be made on
___. The patient understands this plan is and is in
agreement with it. She understands that if her foot worsens in
color, sensation,or pain to give the office a call as soon as
possible and go to the emergency room.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Budesonide 3 mg PO DAILY
3. Carvedilol 3.125 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Torsemide 20 mg PO BID
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
9. Apixaban 2.5 mg PO BID
10. Collagenase Ointment 1 Appl TP DAILY
11. Ferrous GLUCONATE 324 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
14. Ondansetron 4 mg PO BID:PRN nausea
15. Vitamin D 1000 UNIT PO DAILY
16. Vitamin E 400 UNIT PO DAILY
17. Pantoprazole 20 mg PO Q24H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg q tablet(s) by mouth every twelve
(12) hours Disp #*14 Tablet Refills:*0
2. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*28 Capsule Refills:*0
3. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Pantoprazole 40 mg PO Q24H
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Budesonide 3 mg PO DAILY
9. Carvedilol 3.125 mg PO BID
10. Clopidogrel 75 mg PO DAILY
11. Collagenase Ointment 1 Appl TP DAILY
12. Ferrous GLUCONATE 324 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. Lisinopril 5 mg PO DAILY
15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
16. Ondansetron 4 mg PO BID:PRN nausea
17. Rosuvastatin Calcium 40 mg PO QPM
18. Torsemide 20 mg PO BID
19. Vitamin D 1000 UNIT PO DAILY
20. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
CELLULITIS
Right foot gangrene
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:
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 81mg(enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10569159-DS-16 | 10,569,159 | 20,799,154 | DS | 16 | 2114-12-18 00:00:00 | 2114-12-19 02:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with medical history notable for prostate CA
recently started on brachytherapy who presents as transfer from
___ after syncopal event and CTA-PE showing large saddle
PE bilaterally. He has been well recently with no dyspnea, leg
edema, fevers, or cough, recently returned from a vacation,
until 1 day prior to presentation when he noted exertional
dyspnea with climbing 3 flights of stairs. He experienced the
same exertional dyspnea on day of presentation with additional
lightheadedness but no chest pain. He was visiting his eye
doctor with his wife when he felt extremely lightheaded, and
syncopized without a head strike.
He went to ___ where he had an elevated D-Dimer,
proBNP, as well as a CXR which showed no active CP process and a
CT-A PE study which revealed large saddle PE occupying L and R
main pulmonary arteries extending to ascending and descending
segmental and subsegmental branches. He was given ASA 325 and
received heparin gtt at ___ prior to transfer to ___ ___.
In the ___ initial vitals were: T 95.8 HR 104 BP 118/75 RR 22
SAO2 98%RA
EKG: sinus tachy @ 100, R axis, RBBB, LAFB, S1Q3T3 evolving, all
consistent with R heart strain; no prior for comparison
Labs/studies notable for:
- WBC 10.2, normal plt count, proBNP 261, TropT 0.23, Cr 1.0, UA
showing spec gravity 1.035, 11 RBC, negative ___, nitrites.
- While on heparin gtt without any other form of pharmacologic
anticoagulation, patient's coagulation studies notable for PTT
___.7, INR 5.2
- ___ performed in the ___ was negative
- Radiology comment on OSH CT-PE: flattening of IV septum,
bowing leftward, some contrast into IVC, RV>LV; overall, concern
for RV strain
In the ___ received: Heparin gtt was continued
Vitals on transfer: HR 94 BP 110/70 RR 20 SAO2 95%RA
On arrival to the CCU: The patient was alert and answering
questions. He did not complain of any shortness of breath, but
felt a mild chest pressure that was improved from earlier in the
day. He had no headache, outright chest pain, cough,
nausea/vomiting, diarrhea or constipation, or swelling in his
extremities.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. 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.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes - none
- Hypertension - none
- Dyslipidemia- none
2. CARDIAC HISTORY
- no history of CAD
- no prior Echo, no history of CHF
- sinus tachy @ 100 on presentation, no history of AFib
3. OTHER PAST MEDICAL HISTORY
- Prostate CA s/p brachytherapy (___)
- S/p pilonidal cyst resection (remote)
- Bell's palsy
- Hepatitis A
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; sister had PE previously, mother had HTN,
father had CAD > ___ y/o
Physical Exam:
ADMISSION EXAM:
VS: T - BP 133/95 HR 97 RR 16 O2SAT 96%RA
GENERAL: NAD, resting comfortably in bed
HEENT: NT/AC, anicteric sclera, PERRL, EOMI; MMM
NECK: Supple, no JVD
CARDIAC: RRR, S2>S1 no M/R/G
LUNGS: CTAB
ABDOMEN: S/NT/ND, no organomegaly
EXTREMITIES: WWW, non-edematous
SKIN: No significant skin lesions or rashes
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
VS: 98.2, 125/68, 81, 18, 100% RA
GENERAL: NAD, resting comfortably in bed
HEENT: NT/AC, anicteric sclera, PERRL, EOMI; MMM
NECK: Supple, no JVD
CARDIAC: RRR, S2>S1 no M/R/G
LUNGS: CTAB
ABDOMEN: S/NT/ND, no organomegaly
EXTREMITIES: WWW, non-edematous
SKIN: No significant skin lesions or rashes
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD WBC-10.2* RBC-4.95 Hgb-14.6 Hct-45.3
MCV-92 MCH-29.5 MCHC-32.2 RDW-13.1 RDWSD-43.5 Plt ___
___ 09:00PM BLOOD Neuts-74.2* Lymphs-17.7* Monos-6.6
Eos-0.7* Baso-0.4 Im ___ AbsNeut-7.55* AbsLymp-1.80
AbsMono-0.67 AbsEos-0.07 AbsBaso-0.04
___ 09:00PM BLOOD ___ PTT-150* ___
___ 09:00PM BLOOD Glucose-115* UreaN-14 Creat-1.0 Na-137
K-3.8 Cl-102 HCO3-23 AnGap-16
___ 02:51AM BLOOD ALT-18 AST-21 LD(LDH)-267* AlkPhos-64
TotBili-0.9
___ 09:00PM BLOOD proBNP-261*
___ 09:00PM BLOOD cTropnT-0.23*
___ 09:00PM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1
INTERVAL LABS:
___ 02:00AM BLOOD WBC-6.6 RBC-4.38* Hgb-13.2* Hct-39.6*
MCV-90 MCH-30.1 MCHC-33.3 RDW-13.2 RDWSD-43.9 Plt ___
___ 02:00AM BLOOD ___ PTT-87.2* ___
___ 02:00AM BLOOD Glucose-110* UreaN-15 Creat-0.9 Na-138
K-3.6 Cl-102 HCO3-24 AnGap-16
___ 02:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3
IMAGING STUDIES:
___ CTA CHEST: Done at OSH
___ ___: IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins. Slow flow is noted in the left common
femoral vein.
2. Limited evaluation of the right peroneal veins.
___ TTE: IMPRESSION: Suboptimal image quality. Mild right
ventricular cavity dilatation with moderate systolic
dysfunction. Abnormal interventricular septal motion c/w
pressure/volume overload. Normal left ventricular wall
thickness, cavity size and regional/global systolic function. At
least moderate pulmonary hypertension.
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-6.3 RBC-4.40* Hgb-13.0* Hct-40.6
MCV-92 MCH-29.5 MCHC-32.0 RDW-13.2 RDWSD-45.2 Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD ___ PTT-91.1* ___
___ 05:30AM BLOOD Glucose-109* UreaN-16 Creat-1.0 Na-138
K-4.4 Cl-104 HCO3-26 AnGap-12
___ 05:30AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ year old man with a medical history notable
for recent initiation of brachytherapy for Stage T1c prostate
cancer under the care of Dr. ___ and a sister
with massive PE who presented after several days of exertional
dyspnea and a syncopal episode who was found to have an
unprovoked PE by CTA. At the OSH where he was initially
diagnosed he was initated on heparin gtt, which was continued
through his transfer to the ___ ___ and CCU. Though there was
initially concern for RV strain, TTE and trending SAO2 challenge
by walking reinforced no indication for systemic TPA or EKOS.
The patient was de-escalated from the CCU to the floor and
initiated on Warfarin/Lovenox/Rivaroxaban and instructed to
follow up with his providers for continued monitoring and care
on lifelong anticoagulation for unprovoked PE.
ACTIVE ISSUES:
# Hemodynamically stable PE: Patient with remote travel (___)
as well as initiation of brachytherapy for prostate CA and
family history in sister of PE who presented with extertional
dyspnea and syncopal event to OSH and was found to have massive
PE by CTA. Patient got full ASA at OSH, and was started on
heparin gtt, which was continued at ___ in ___ showed no
___ thrombosis. Radiology commented on OSH CT with concern for RV
strain, and bedside echo showed mildly enlarged RV. Formal TTE
showed minimal RV strain and patient tolerated ambulation
without decrease in oxygen saturation. Heme/Onc was consulted
regarding best anticoagulation for unprovoked PE in patient with
malignancy, and patient was ultimately initiated on
anticoagulation with Rivaroxaban and instructed to follow up
with both his urologist and PCP after discharge.
# Exertional dyspnea: Presently resolved, likely due to massive
PE. Patient was walked with oxygen monitoring and did not
desaturate.
# Syncope: One episode without prodrome, no reported
palpitations. Other etiologies such as vasovagal vs. orthostatic
syncope unlikely given history.
CHRONIC ISSUES:
# Prostate CA s/p brachytherapy: Per patient's urologist, stage
T1c, had brachytherapy implanted ___ and has not had issues.
Finished ___ meloxicam and continued tamsulosin
during admission.
TRANSITIONAL ISSUES:
- consider CT venogram of the pelvis
- new anticoagulation indefinitely with
Warfarin/Lovenox/Rivaroxaban
- follow up with PCP (Dr. ___ and Urology (Dr. ___
NEW MEDICATIONS:
- Rivaroxaban
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.8 mg PO QHS
2. meloxicam 7.5 mg oral Q24H
Discharge Medications:
1. Rivaroxaban 15 mg PO BID Duration: 21 Days
with food. Please take 15mg PO twice a day x21 days, then take
20mg PO once a day after that.
RX *rivaroxaban [Xarelto] 15 mg (42)- 20 mg (9) As directed
tablets(s) by mouth As directed by dose pack Disp #*1 Dose Pack
Refills:*0
2. Tamsulosin 0.8 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Submassive pulmonary embolism
Secondary diagnosis:
- Prostate cancer status post brachytherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ you for allowing us to participate in your care while at
___.
Why did I come to the hospital?
- You were experiencing shortness of breath with activity and
had lightheadedness and dizziness which resulted in an episode
where you fainted.
- You were found to have blood clots in your lungs which were
thought to have brought on the above symptoms.
What was done for me while in the hospital?
- You were given intravenous medication that thinned your blood
to prevent further clots from forming.
- Your lungs and heart were examined by imaging to determine the
extent of clot in your lungs and to determine whether your heart
was under stress as a result of those clots.
- You were transitioned to an oral/injectable blood thinning
medication and instructed to continue to take this indefinitely
after your discharge.
What should I do when I go home?
- Take your new blood thinning medication as instructed: Please
take rivaroxaban 15 mg two times a day for the first 3 weeks,
then switch to 20mg daily thereafter.
- Follow up with your primary doctor and urologist to inform
them of why you were cared for in the hospital and what
treatment you are currently receiving.
- Please attend your new Cardiology appointment, which we
scheduled for you.
- Please also call to schedule an appointment with
Hematology/Oncology as instructed below
It was a pleasure taking care of you while you were at ___!
Best regards,
Your ___ Care Team
Followup Instructions:
___
|
10569231-DS-22 | 10,569,231 | 27,531,737 | DS | 22 | 2149-02-28 00:00:00 | 2149-02-28 11:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
tomatoe / latex
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ woman with a history of refractory
epilepsy (followed by Dr. ___, non-epileptic seizures,
congenital toxoplasmosis with resultant blindness, diabetes,
migraine, anxiety, and depression who presented to the emergency
room on the morning of ___ with nausea, vomiting, and diarrhea
and subsequently had 2 witnessed seizures while in the emergency
room.
History is limited as the patient was postictal at the time of
my
examination.
Per review of prior provider notes, she initially developed
symptoms 48 hours prior to presentation in the ED. These
symptoms included nausea, vomiting, diarrhea. She endorsed 8
episodes of vomiting, including with some blood in the emesis.
She also had multiple episodes of diarrhea without hematochezia.
She denied melena.
At the time of initial presentation, she endorsed pain in her
stomach which she described as sharp constant, and epigastric
radiating to the right lower quadrant. She denied any recent
travel, fevers, chills. She had also endorsed chest pain which
she described as sharp, nonpleuritic, nonexertional.
Initial plan was for the patient to be admitted to the
observation unit in the emergency room. However, during CT scan
of her abdomen and pelvis, the patient had a witnessed seizure
event. The details of this event are not clear per ED notes or
my
discussion with available ED personnel. Patient received 1 mg IV
Ativan and subsequently returned to baseline.
She was alert enough to take her lamotrigine 400 mg and
zonisamide 300 mg both PO. This was at 19:38. However, patient
had then another seizure while in the ED (again, details
unclear)
which prompted neurology consultation.
ROS unable to be obtained due to the patient's mental status.
Past Medical History:
PAST MEDICAL HISTORY:
=====================
EPILEPSY: Per Dr. ___ note from ___, seizure
types include:
1. Secondarily generalized tonic-clonic: Severe headache, and
loss of consciousness, upward eye deviation, shaking of arms and
legs, lasting ___ minutes, postictal confusion. Approximately
every ___ years.
2. Complex partial, left temporal: Headaches, then behavioral
arrest, lip smacking, confusion, lasting ___ seconds,
postictal
confusion. One every ___ months in past, maximal frequency ___
per month, current less than one per month.
3. Nonepileptic events: Flailing movements of legs with
unresponsiveness, unclear frequency.
4. Probable nonepileptic events: Diaphoresis, sensation of
impending loss of consciousness, then loss of awareness, mild
postictal confusion. Unclear duration. Unclear frequency.
NONEPILEPTIC EVENTS
CONGENITAL TOXOPLASMOSIS: Blind right eye, status post
prosthesis. Low vision left eye. Intellectual disability.
Seizures.
ASTHMA
HYPERLIPIDEMIA
SLEEP APNEA ON CPAP
MORBID OBESITY
INTELLECTUAL DISABILITY
MIGRAINE HEADACHES: Begin at the back of the head or
bilaterally, stabbing or throbbing pain, ___ in intensity.
Photophobia and some phonophobia. Some nausea and vomiting.
Headaches last ___ days. She has been treated in the past with
Zomig and ibuprofen. Verapamil SR 180 mg daily for prophylaxis
Now on sumatriptan.
DEPRESSION
ANXIETY
OSTEOARTHRITIS: Right knee
BLINDNESS: Right eye prosthesis
DIABETES TYPE II: Diagnosed ___
Social History:
___
Family History:
Unable to obtain at present. Per prior notes, no FH of seizures
or epilepsy. She reports that both her grandmothers had colon
cancer. There is extensive history of HTN and diabetes in the
family.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
Vitals: HR 81, BP 129/74, RR 17, Sa 95% RA
General: Sleeping, difficult to rouse. Morbidly obese.
Neck: Supple, no nuchal rigidity
Pulmonary: breathing heavily though maintaining good O2
saturation
Cardiac: warm and well perfused
Abdomen: soft, obese, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Eyes closed. Breathing heavily on RA. Does not
open eyes to voice. Groans incoherently to trap squeeze. Able to
open eyes when asked repeatedly. Able to reliably show 2 fingers
on right hand though drifts back to sleep immediately after
completing 1 step tasks. Able to select hospital from list of
available locations but cannot say the word hospital. Speech is
incomprehensible.
-Cranial Nerves:
II: Right pupil 4 mm and fixed. Left pupil 6 mm and briskly
reactive to light.
III, IV, VI: Left EOMI without nystagmus though full exam
limited
by mental status.
VII: No facial droop, facial musculature symmetric.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted. Able to lift all 4
extremities anti-gravity with encouragement. Formal
confrontation
testing limited due to mental status.
-Sensory: Unable to assess
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
-Coordination: Unable to assess
-Gait/Station: Unable to assess
DISCHARGE PHYSICAL EXAM
================================================
PHYSICAL EXAM:
General: awake, using smartphone
Neck: Supple
Pulmonary: normal WOB, normal O2 sat on RA
Cardiac: warm and well perfused
Abdomen: soft, obese, NT
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Eyes open, interactive, Able to say ___
backwards. No dysarthria.Can follow all commands wtih
encouragement.
-Cranial Nerves:
II: Right pupil 4 mm and fixed. Left pupil 6 mm and briskly
reactive to light.
III, IV, VI: Left EOMI without nystagmus though exam limited by
cooperation
VII: No facial droop, facial musculature symmetric.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. Able to lift all 4
extremities anti-gravity with encouragement. delts ___
bilaterally, dorsi/plantarflexion ___ on R, on L limited due to
pain/cooperation but can wiggle toes. rest of exam
limited by cooperation.
-Sensory: deferred
-DTRs:
deferred
___: reaching for objects without dysmetria
Gait: deferred
Pertinent Results:
LABORATORY DATA:
___ 08:30AM BLOOD WBC: 10.5* RBC: 4.92 Hgb: 14.2 Hct: 45.7*
MCV: 93 MCH: 28.9 MCHC: 31.1* RDW: 13.3 RDWSD: 45.___
___ 08:30AM BLOOD ___: 11.3 PTT: 28.7 ___: 1.0
___ 08:30AM BLOOD Glucose: 227* UreaN: 12 Creat: 0.8 Na:
143
K: 4.3 Cl: 105 HCO3: 18* AnGap: 20*
___ 08:30AM BLOOD ALT: 15 AST: 30 AlkPhos: 44 TotBili: 0.3
___ 08:30AM BLOOD Albumin: 4.1 Calcium: 9.2 Phos: 3.4 Mg:
1.2*
___ 08:30AM BLOOD Lipase: 65*
___ 08:30AM BLOOD HCG: <5
___ 06:25AM BLOOD WBC-5.1 RBC-4.31 Hgb-12.4 Hct-40.3 MCV-94
MCH-28.8 MCHC-30.8* RDW-13.3 RDWSD-45.9 Plt ___
___ 06:25AM BLOOD ___ PTT-28.9 ___
___ 06:25AM BLOOD Glucose-140* UreaN-6 Creat-0.6 Na-143
K-4.2 Cl-105 HCO3-22 AnGap-16
___ 06:25AM BLOOD Lipase-35
___ 06:25AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
IMAGING DATA:
Liver U/S:
1. Evaluation of the liver is markedly limited due to poor
sonographic penetration. Within these limitations, there is an
echogenic liver consistent with steatosis. Other forms of liver
disease including steatohepatitis, hepatic fibrosis, or
cirrhosis
cannot be excluded on the basis of this examination.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Spleen is top-normal in size.
CT A/P:
1. No acute intra-abdominal or intrapelvic pathology to explain
the patient's pain.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Hepatic steatosis.
Brief Hospital Course:
This is a ___ woman with a history of refractory
epilepsy, non-epileptic seizures, congenital toxoplasmosis with
resultant blindness, diabetes, migraine, anxiety, and depression
who presented to the emergency room on the morning of ___ with
nausea, vomiting, and diarrhea and subsequently had 2 witnessed
events with AMS, details of events unclear to determine if
seizure or PNES event. Could have been breakthrough seizures
from
sub-therapeutic AED levels as missed meds x2 days in setting of
likely viral gastroenteritis. Altered afterwards for prolonged
period (more consistent with her epileptic seizures), presumed
postictal, admitted for further monitoring to epilepsy.
Hospital course:
Her vomiting improved, able to tolerate food prior to discharge
as well as AEDs. Her mental status also significantly improved,
alertness appeared to have significant volitional or functional
overlay. EEG with no seizures. ___ evaluated and thought would
benefit from rehab so discharged to rehab.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Zonisamide 200 mg PO QAM
2. Zonisamide 300 mg PO QPM
3. Verapamil SR 180 mg PO DAILY
4. Sertraline 150 mg PO DAILY
5. Montelukast 10 mg PO DAILY
6. Mirtazapine 30 mg PO QHS
7. MetFORMIN (Glucophage) 500 mg PO BID
8. LamoTRIgine 400 mg PO BID
9. HydrOXYzine 50 mg PO QHS
10. ClonazePAM 1 mg PO BID
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
12. Velivet Triphasic Regimen (28) (desogestrel-ethinyl
estradiol) ___ mg-mcg oral DAILY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN respiratory distress
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN respiratory distress
2. ClonazePAM 1 mg PO BID
3. HydrOXYzine 50 mg PO QHS
4. LamoTRIgine 400 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Mirtazapine 30 mg PO QHS
7. Montelukast 10 mg PO DAILY
8. Sertraline 150 mg PO DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Velivet Triphasic Regimen (28) (desogestrel-ethinyl
estradiol) ___ mg-mcg oral DAILY
11. Verapamil SR 180 mg PO DAILY
12. Zonisamide 300 mg PO QPM
13. Zonisamide 200 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Seizure
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to neurology after you had likely 2 seizures
as you were not able to take your anti-seizure medications due
to vomiting likely due to a stomach bug. You were placed on EEG
which showed no seizures. You were able to tolerate food by the
time of discharge as well as your anti-seizure medications, and
you were much more awake during your hospitalization after the
first day.
Followup Instructions:
___
|
10569306-DS-38 | 10,569,306 | 25,039,540 | DS | 38 | 2156-06-11 00:00:00 | 2156-06-11 22:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Vancomycin
Analogues / Tape ___ / Lisinopril / Bactrim / Pentamidine
Isethionate
Attending: ___
Chief Complaint:
Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a-fib, PCKD s/p renal
transplant in ___, with recent 2 week admission requiring
MICU for flash pulmonary edema, hypotension and iatrogenic
pancytopenia, presenting today for nausea and vomiting in past
24 hours.
.
Pt noticed nausea and NBNB emesis after eating dinner last
night. She denies CP, SOB, abdominal or diarrhea. Of note, pt
was sick from a URI a week ago, with sneezing, congestion and
productive cough. She did not have fever or chill. And her
symptom reportedly is improving. Her grandchildren as well as
son-in-law. None of them had high grade fever or GI symptoms.
Since discharge from last admission, pt had been c/o feeling
dizzy at times. She could not tolerate ultrafiltration during
the last dialysis session.
.
Of note, pt's post-transplant course has been complicated by
urinary obstruction, s/p nephrostomy tube, CMV viremia, BK
viremia, multiple urinary tract infections, most recently
enterococcus s/p linezolid (vanco allergy) and linezolid induced
pancytopenia. Pt's graft however failed and was restarted on
dialysis in ___.
.
In the ED, initial VS: 97.2 100 124/87 16 98% 3L Nasal Cannula.
She received a total of 250 cc of normal saline. She also
received ondansetron 4 mg x2, metoclopramide, ceftriaxone, and
lorazepam. Labs significant for an INR of 3.8, lactate of 1.2,
and WBC of 7.6.
.
Currently, admission to the floor, her VS are 97.6, 100, 128/84,
20, 94-98% on RA.
Past Medical History:
-PKD s/p b/l nephrectomy ___, ECD kidney transplant ___
-HTN
-Endometrial ca s/p TAH/BSO
-Afib/flutter on amiodarone and coumadin s/p cardioversion
___
-Primary hyperparathyroidism
-C.difficile colitis
-Hypothyroidism
-Mitral and tricuspid regurgitation
-Systolic dysfunction with EF 40-45% (TTE ___
PSH:
-___ - ECD kidney transplant and VHR with mesh
-___ - RUE AV fistulogram, balloon angioplasty
-___ - b/l nephrectomies for PKD
-___ - RUE brachiocephalic AV fistula
-___ - appendectomy and incisional hernia repair with mesh
-___ - TAH/BSO for endometrial ca
-___ - hysteroscopy
-___ - hemorrhoidectomy and drainage of perirectal
hematoma
-___ - R hemithyroidectomy and excision of R parathyroid
adenoma, neck exploration
Social History:
___
Family History:
Father and daughter both with PKD. No FH of ovarian, colon,
breast, or endometrial CA. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION EXAM
VS - 97.6, 100, 128/84, 20, 94-98% on RA.
GENERAL - well-appearing in NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, tender over RLL, no masses or HSM,
nephostomy site clean, intact
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
VSS
GEN: A&OX3, NAD
HEENT: PEERL, MMM, OP Clear
HEART: irregularly irregular rhythm, no m/r/g
LUNG: CTA bl
ABD: soft, ND, tender over RLL (close to nephrostomy site)
EXT: no pitting edema
Pertinent Results:
ADMISSION LABS
___ 01:00AM BLOOD WBC-7.6 RBC-3.15* Hgb-9.6* Hct-31.4*
MCV-100* MCH-30.4 MCHC-30.6* RDW-19.8* Plt ___
___ 01:00AM BLOOD Neuts-82.0* Lymphs-14.5* Monos-1.7*
Eos-1.6 Baso-0.2
___ 01:00AM BLOOD ___ PTT-33.2 ___
___ 01:00AM BLOOD Glucose-145* UreaN-24* Creat-2.7* Na-135
K-4.6 Cl-97 HCO3-27 AnGap-16
___ 02:30AM BLOOD ALT-12 AST-20 AlkPhos-93 TotBili-0.5
___ 08:45AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.7 Iron-42
.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-7.4 RBC-2.95* Hgb-9.4* Hct-30.2*
MCV-102* MCH-31.7 MCHC-31.0 RDW-20.1* Plt ___
___ 07:00AM BLOOD ___ PTT-33.4 ___
___ 07:00AM BLOOD Glucose-135* UreaN-18 Creat-2.4* Na-136
K-3.7 Cl-101 HCO3-28 AnGap-11
___ 07:00AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.8
.
PERTINENT LABS
___ 02:30AM BLOOD Lipase-33
___ 02:30AM BLOOD cTropnT-0.01
___ 08:45AM BLOOD ALT-11 AST-17 LD(LDH)-211 AlkPhos-90
Amylase-50 TotBili-0.4
___ 08:45AM BLOOD calTIBC-183* Ferritn-1164* TRF-141*
___ 08:45AM BLOOD PTH-438*
___ 07:00AM BLOOD tacroFK-4.1*
___ 06:35AM BLOOD tacroFK-2.7*
___ 08:45AM BLOOD tacroFK-2.9*
___ 02:57AM BLOOD Lactate-1.2
.
PERTINENT STUDIES
CXR ___
Mild linear opacities in the lung bases likely represent stable
mild bronchial wall thickening. Otherwise, the lungs are clear
without focal consolidation. There is no pneumothorax. No
vascular congestion, pulmonary edema, or pleural effusions are
identified. Cardiomediastinal and hilar contours are within
normal limits. Interval removal of a right-sided central venous
catheter is noted.
IMPRESSION: No acute cardiopulmonary process
Brief Hospital Course:
Ms. ___ is a ___ year old woman with polycystic kidney
disease, s/p renal transplant on immunosuppresive treatment, and
recent reinitiation of dialysis in the setting of graft failure,
presenting with dizziness, nausea, vomiting
.
ACTIVE ISSUES
# Gastroenteritis: The most like cause for her nausea, vomiting
and dizziness is viral gastroenteritis. The presentation is
rather GI focused symptoms over URI. Pt remained afebrile with
no leukocytosis. Her immunosuppressed state and recent
extensive sick exposure are concerning for atypical presentation
of more serious infections. At the time of discharge, her flu
direct antigen was negative. Other culture and viral serology
were still pending.
.
# Complicated UTI: Pt presented with UA concerning for
infection. Urine culture grew pansensitive enterococcus. Given
her prior allergy history, she was treated with Vancomycin
through HD sessions for a total of 14 days.
.
# URI: Pt presented with productive cough, status post URI
symptoms one week ago. Her flu screening was negative. We
treated her symptomatically with guaifenesin.
.
# Hypotension: Pt has tenuous BP, likely secondary to atrial
fibrillation. We discontinued her furosemide
.
CHRONIC ISSUES
# s/p renal transplant: Her recent graft biopsy showed chronic
allograft nephropathy. We continued her myfortic and tacrolimus.
Daily drug level was checked. At the time of discharge, it was
still undetermined whether pt would need surgery for removal of
graft.
.
# Atrial fibrillation/flutter: Pt was in sinus rhythm. She had
recent hx of flash pulmonary edema in the setting of a-fib/RVR.
We continued her amiodarone and metoprolol. We held her
warfarin given elevated INR.
.
# Hyperlipidemia: We continued Pravastatin 20 mg qd
.
# Hypothyroidism: We continued levothyroxine 75 mcg qd
.
TRANSITIONAL ISSUES
# CODE STATUS: Full
# MEDICATION CHANGES:
- STOPPED furosemide
- STARTED Guaifenesin 10 cc qid
- STARTED Vancomycin sliding scale through hemodialysis
- HELD warfarin given supratherapeutical INR
# STUDIES PENDING AT DISCHARGE:
- EBV PCR
- BK virus PCR
- CMV viral load
- Blood culture ___
# FOLLOW UP PLAN:
- Appointment with Dr. ___ on ___
- Follow up with ___ on ___, await decision
from transplant regarding graft removal
Medications on Admission:
Amiodarone 200 mg a day
Nephrocaps
dapsone 100 mg a day
furosemide 80 mg on nondialysis days
levothyroxine 75 mcg
metoprolol tartrate 25 mg twice a day except for before dialysis
Myfortic 180 mg twice a day
pravastatin 20 mg a day
tacrolimus 1.5 mg twice a day,
Valcyte 450 mg every other day
warfarin
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): do not take prior to dialysis.
7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
9. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
10. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough for 14 days.
Disp:*qs * Refills:*2*
11. Outpatient Lab Work
please check INR on ___ and forward to Dr.
___ at ___ ___
12. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
qHD for 5 doses: please infuse slowly over 2 hours with HD for 5
doses.
Disp:*5 doses* Refills:*0*
13. Outpatient Lab Work
please check weekly vancomycin troughs while receiving treatment
at ___ and forward to Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- gastroenteritis
- urinary tract infection
Secondary diagnosis
- end stage renal disease on hemodialysis
- atrial fibrillation
- hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to our hospital for nausea and vomiting. You likely
had a gastroenteritis, also known as "stomach flu". We also
find that you have a urinary tract infection caused by
enterococcus, which you had several times in the past. You have
been treated with Vancomycin during hemodialysis. So far, you
tolerated the treatment very well with no evidence of allergy.
.
Please note that the following medication has been changed:
- Please STOP taking furosemide
- Please START to take Guaifenesin 10 mL syrup by mouth as
needed for cough and phlegm up to 4 times a day.
- Please START to get Vancomycin through dialysis five
additional sessions. Your kidney doctor ___ arrange that for
you.
- Please STOP warfarin until you have your INR checked on
___, ask Dr. ___ restarting
- Please continue to take the rest of the medication as
prescribed by your physician.
.
Please continue to follow with your PCP and transplant
specialist as previously scheduled. It has been a pleasure
taking care of you here at ___. We wish you a speedy
recovery.
Followup Instructions:
___
|
10569306-DS-42 | 10,569,306 | 23,236,986 | DS | 42 | 2156-08-25 00:00:00 | 2156-08-26 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ /
Lisinopril / Bactrim / Pentamidine Isethionate
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Hemodyalisis
History of Present Illness:
___ w/ ESRD ___ PKD on dialysis, Mitral regurgitation, AFib on
coumadin p/w dyspnea. Pt states she was in her usual state of
health the day of presentation. Went to lunch with a friend and
had a meal that might have had more salt than normal. Felt
fatigued at the end of the day and took a nap. Patient awoke
very SOB. Denies CP, cough, fever, feeling unwell. Endorses
medication compliance, and no changes in daily activity.
.
ED Course Initial Vitals notable for room air saturation of 50%.
Bedside echo with no pericardial effusion. She was started on a
nitroglycerin gtt and CPAP and improved significantly. CXR
showed evidence of volume overload and request for urgent HD was
placed. Patient was admitted to the MICU.
Past Medical History:
APKD s/p failed kidney transplant on HD
Bacteremia
HTN
Endometrial ca
Afib/flutter on amiodarone and coumadin s/p cardioversion ___
Primary hyperparathyroidism
Hypothyroidism
Mitral and tricuspid regurgitation
Systolic dysfunction with EF 40-45% (TTE ___
Knee osteoarthritis
Social History:
___
Family History:
Father and 3 uncles with PKD.
Physical Exam:
On admission:
Vitals: 142/83 84 18 98% on 4l NC
General: AAO, mild respiratory distress but able to speak full
sentences
HEENT: Sclera anicteric, EOMI, PERRL
Neck: supple, JVP elevated, no LAD
CV: RRR, normal S1 + S2, no clear S3, no m/g/r- muffled HS
Lungs: Crackles at bases ___ Rt>Lt
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, graft nontender to palpation
Ext: warm, well perfused, 2+ pulse in L DP, dopplerable pulse R
DP, no clubbing, or cyanosis, 1+ pitting edema b/l ___
Access: RUE AVF with good thrill and bruits
.
On Discharge:
VS - afebrile T 98.2 BP 110/66 HR 60 RR18 , O2-sat 96% RA
GENERAL - awake, alert, appropriate. comfortable
LUNGS -bibasilar crackles. no rhonchi or wheezes, resp unlabored
HEART - RRR, no Murmurs
ABDOMEN - soft/NT/ND
EXTREMITIES - WWP, no c/c/e. R arm fistula with palpable thrill.
non-tender. 2+radial pulses
Pertinent Results:
LABS
On admission: ___ 01:29AM)
WBC-22.2*# RBC-3.50*# Hgb-10.1*# Hct-34.8*# MCV-99* MCH-28.9
MCHC-29.0* RDW-17.4* Plt ___
Neuts-61.4 ___ Monos-3.0 Eos-2.2 Baso-1.2
___ PTT-34.1 ___
Glucose-286* UreaN-39* Creat-6.2*# Na-134 K-5.3* Cl-96 HCO3-22
AnGap-21*
Calcium-8.2* Phos-5.3* Mg-2.2
Type-ART Temp-37.2 FiO2-100 pO2-157* pCO2-59* pH-7.24*
calTCO2-27 Base XS--3 AADO2-494 REQ O2-84 Intubat-NOT INTUBA
Comment-CPAP
.
On discharge: (___)
WBC-9.8 RBC-2.88* Hgb-8.4* Hct-27.1* MCV-94 MCH-29.3 MCHC-31.0
RDW-17.3* Plt ___
Glucose-111* UreaN-51* Creat-7.6*# Na-133 K-4.8 Cl-94* HCO3-29
AnGap-15
.
CMV Viral Load (Final ___: CMV DNA not detected.
.
DIAGNOSTICS
CHEST (PORTABLE AP) ___ 1:16 AM IMPRESSION:
1. Evidence of heart failure with enlarged cardiomediastinal
silhouette as
well as moderate-to-severe pulmonary edema.
2. Focal opacity in the right lower lobe may be representative
of
atelectasis, asymmetric pulmonary edema, or pneumonia.
3. Bilateral small pleural effusions.
.
CHEST (PA & LAT) ___ 2:55 ___ There is substantial interval
improvement of pulmonary edema. Right pleural effusion is small.
Associated is opacity most likely representing atelectasis,
although infectious process in this area cannot be excluded.
Small amount of left pleural effusion is redemonstrated,
unchanged.
.
ECHO (TTE) ___ IMPRESSION: Mild symmetric left
ventricular hypertrophy with normal global and regional systolic
function. Mildly dilated right ventricle with borderline
systolic function. Moderate to severe mitral regurgitation.
Moderate to severe pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
mitral regurgitation severity has increased. The other findings
are similar. EF 55%
Brief Hospital Course:
___ female with ESRD on HD, AFib on Coumadin, and CHF admitted
with dyspnea found to have volume overload.
.
# Hypoxemia: Patient presented to the ED after awaking severely
short of breath. CXR showed pulmonary edema and a right lung
opacity. Renal was consulted for urgent hemodialysis and the
patient was started on empiric vancomycin and meropenem.
Patient's breathing and oxygenation returned to baseline after
HD. Given that patient remained afebrile, without cough or
chest pain, and her dyspnea resolved after fluid was removed,
the CXR finding of the opacity was considered to be more
indicative of asymmetrical edema rather than infection.
Antibiotics were discontinued. Blood cultures had no growth, yet
were pending at time of discharge. On HD#1 overnight patient had
a desaturation to 88% on RA. Patient was put on 2L NC and
oxygenation normalized. It is possible patient could have an
element of sleep apnea, and the recommendation was made for
outpatient sleep study to further assess this matter. Patient
had 2 more sessions of ultrafiltration while in hospital to
better establish her at her dry weight.
.
# CHF/VALVULAR DISEASE: The patient did not have a history of
CHF. However CXR pulmonary edema and clinical exam supported
evidence of volume overload and clinical exam. Patient was
continued on home beta-blocker. Patient stated she had not
tolerated lisinopril due to cough. Considered starting patient
on an ___, however it was considered this might not benefit the
patient due to blood pressure changes in HD. An ECHO was
obtained which showed worsening of mitral regurgitation, now
classified as moderate to severe, as well as significant
pulmonary hypertension. Patient will follow up with her
cardiologist within 1 week.
.
#END STAGE RENAL DISEASE (PCKD, s/p failed kidney transplant):
Patient was continued on tacrolimus, midodrine and sevelamer per
renal recommendations. Patient will continue HD per ___
schedule.
.
#ATRIAL FIBRILLATION: Patient was in sinus rhythm during most of
her admission. Patient was continued on metoprolol and
amiodarone for rate/rhythm control and continued anticoagulation
with Coumadin with INR remaining within therapeutic range. On
the last session of ultrafiltration in hospital patient had an
episode of atrial fibrillation, but returned to ___ without any
hemodynamic compromise or symptoms.
.
#PANCREATIC CYST: Pancreatic cyst of unclear etiology was seen
on EUS. Recommend repeat EUS or MRCP in 6 months.
TRANSITIONAL ISSUES:
Follow up blood cultures
INR to be followed by Dialysis Center
Repeat imaging of pancreatic cyst in 6 months.
Medications on Admission:
1. warfarin 3 mg Daily at 4 ___.
2. amiodarone 200 mg Daily
3. metoprolol tartrate 12.5 mg BID hold on mornings of dialysis.
4. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H PRN Pain
5. B complex-vitamin C-folic acid 1 mg DAILY
6. tacrolimus 0.5 mg PO Q12H
7. docusate sodium 100 mg BID
8. sevelamer carbonate 800 mg TID
9. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
10. midodrine 5 mg Tablet Sig: One (1) Tablet PO HD PROTOCOL (HD
Protochol): please give 1 hour prior to dialysis.
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
12. levothyroxine 75 mcg PO DAILY
13. ceftazidime 2 gram Recon Soln Sig: One (1) Intravenous
three times a week: To be given with dialysis sessions until
___.
Discharge Medications:
1. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
___.
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
9. levothyroxine 50 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
10. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. midodrine 5 mg Tablet Sig: One (1) Tablet PO QHD (each
hemodialysis).
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: CHF exacerbation
Secondary diagnosis:
polycystic kidney disease
ESRD on HD
CHF
Afib
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were evaluated for your shortness of breath and were found
to have fluid overload. ___ required emergent hemodyalisis, and
your breathing improved. Overnight your oxygen saturation was
lower at 88% which might be a chronic issue for ___ and ___
might benefit from a sleep study. ___ had more fluid removed to
try to reach your dry weight. ___ also had a repeat ECHO (an
ultrasound of your heart). This showed one of your heart valves
(mitral valve) was more leaky than before. Nothing acute to do
at this time, but will need to follow up with your cardiologist
for close follow up.
The following changes were made to your medications:
#CHANGES: hold warfarin today and take 2mg tomorrow then
continue based on your outpatient team recommendations.
Followup Instructions:
___
|
10569306-DS-45 | 10,569,306 | 27,700,716 | DS | 45 | 2156-11-22 00:00:00 | 2156-11-22 14:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ /
Lisinopril / Bactrim / Pentamidine Isethionate
Attending: ___.
Chief Complaint:
Anemia, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PMH dCHF, HTN, Polycystic kidney disease
s/p ___ nephrectomy s/p renal transplant is referred from
dialysis after pre-HD HGB showed 6.6 (baseline around 7). She
notes fatugue over last ___ days with dyspnea, denies chest
pain, melena hematochezia or hemetemesis. She reports no change
in bowel habits, noting some BRBPR one month ago on the toilet
paper after straining to have BM, now resolved.
Of note, she was seen in the ED ___ for anemia with HCT
24.7, she was asymptomatic and dishcarged home. She was also
admitted to medicine ___ to ___ for fever with an
extensive workup that failed to reveal a source, fever was
attributed to the transplanted kidney which had been embolized
___ she was discharged home with follow up in ___
clinic.
In the ED, initial vitals were: 98.2 122 145/78 15 100%, Labs
were remarkable for HGB 7.7, HCT 27.9 (baseline HGB/HCT: ___
INR: 1.2, K 3.3. She was GUIAC negative. CXR was negative for
infiltrate or effusion. Renal fellow ___ recommended
transfusion slowly with one unit overnight given progressive
dyspnea and fatigue.
Vitals on transfer 99.9po 110 16 126/80 96% 2L nc (92% ra).
On the floor, she reported breathing was comfortable denied
dyspnea at rest. She complained of continued itching on her back
which has been going on for months. She was otherwise without
complaints.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria. The ten point review
of systems is otherwise negative.
Past Medical History:
PCKD s/p bil. nephrectomies in ___
ESRD s/p failed ECD renal transplant in ___ on HD
- s/p coil embolization of graft artery on ___
- multiple episodes of CMV viremia
- recently weaned off transplant meds
HTN
Endometrial cancer
PAfib/flutter s/p cardioversion in ___
Primary Hyperparathyroidism
H/o C.diff colitis
Hypothyroidism
MR/TR on Echo
h/o tachycardiomyopathy - last EF > 55% in ___
___
E.coli bacteremia ___
Knee OA
VRE
Enterococcus UTI
s/p tonsillectomy
.
Past Surgical History:
-___ - coil embolization tpx renal artery
-___ - ECD kidney transplant and VHR with mesh
-___ - RUE AV fistulogram, balloon angioplasty
-___ - b/l nephrectomies for PKD
-___ - RUE brachiocephalic AV fistula
-___ - appendectomy and incisional hernia repair with mesh
-___ - TAH/BSO for endometrial ca
-___ - hysteroscopy
-___ - R hemithyroidectomy and excision of R parathyroid
adenoma, neck exploration
-___ - hemorrhoidectomy and drainage of perirectal hematoma
Social History:
___
Family History:
Father & daughter w/ PKD. No other history of cancer or CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.9 BP 128/78 ___ RR 16 SaO2 98% RA
GENERAL: Well-appearing elderly female in NAD, comfortable,
appropriate. Appearing pale.
HEENT: Mucous membs moist,
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND. transplant kideny in RLQ non tender.
EXTREMITIES: right sided fistula with + bruit, 2+ peripheral
pulses.
SKIN: A fine scaling overlies the shoulders with excoriations
and without erythememia.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
DISCHARGE PHYSICAL EXAM:
VS: 99.5 130/70 98 18 97%RA
GENERAL: Well-appearing elderly female in NAD, comfortable,
appropriate. Pale.
HEART: ___, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: NABS SNTND nHSM
EXTREMITIES: right sided fistula with + bruit, 2+ peripheral
pulses.
SKIN: A fine scaling overlies the shoulders with excoriations
and without erythema.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Pertinent Results:
___ 09:10PM BLOOD WBC-5.0 RBC-3.29* Hgb-7.7* Hct-27.9*
MCV-85 MCH-23.4* MCHC-27.5* RDW-19.0* Plt ___
___ 08:28AM BLOOD WBC-5.2 RBC-3.66* Hgb-8.7* Hct-31.2*
MCV-85 MCH-23.8* MCHC-27.9* RDW-18.5* Plt ___
___ 09:10PM BLOOD Neuts-78.8* Lymphs-14.7* Monos-3.6
Eos-2.6 Baso-0.4
___ 09:31PM BLOOD ___ PTT-28.7 ___
___ 09:10PM BLOOD Glucose-141* UreaN-18 Creat-3.2* Na-142
K-3.3 Cl-97 HCO3-33* AnGap-15
___ 08:28AM BLOOD Glucose-90 UreaN-27* Creat-4.2* Na-142
K-4.1 Cl-98 HCO3-34* AnGap-14
___ 08:28AM BLOOD Phos-3.8 Mg-2.1
CXR ___:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ year old female with PMH dCHF, HTN, Polycystic kidney disease
s/p unsuccessful renal transplant presents with mildly
symptomatic anemia.
# Anemia: Hematocrit has been dwlindling around 26 since ___
and is not acutely down at the time of admission. She is mildly
symptomatic with dyspnea on exertion. Stool GUIAC is negative,
though she reported some BRBPR on the toilet paper one month
ago, this has since resolved and is most likely related to
hemorrhoidal bleeding. Etiology for this admission was secondary
to volume shifts; her referral Hgb of 6.6 was pre-HD, and her
post-HD Hgb (in the ED) was 7.7, at baseline. Regardless due to
her mild symptoms, she was provided one unit of pRBCs at a very
slow rate, which she tolerated well without any signs or
symptoms of volume overload. She was discharged with follow-up.
# Tachycardia: patient with history of atrial fibrillation
currently in afib with rates in 110 range. She is
hemodynamically stable and does not have pulmonary edema.
Discharged on home regimen of rate/rhythm control agents.
# dCHF: no volume overload signs or symptoms after transfusion.
# ESRD: Patient receives dialysis ___, she
received dialysis the day prior to admission and did not need
further on this admission.
# Rash: patient has a puritic rash over her upper back which has
been present for weeks. The cause of the rash is unclear, it
does not appear cellulitic. It is not scaly or erythematous.
Continued on clobetasol (per her derm) and hydroxyzine.
# Atrial fibrillation: rate is elevated in the setting of
anemia, will continue home regimen. She is subtherapeutic on
warfarin and has missed a dose, with CKD and age she has often
been supratherapeutic. Due to low CHADS2 score she was not
bridged. She will have an INR drawn with hemodialysis in 2 days
and have the results faxed to her coumadin provider for
management.
# Hypothyroidism: continued on synthroid
Transitional Issues:
- INR check
- should check post-HD Hgb instead of pre due to volume shifts.
Medications on Admission:
-- Amiodarone 200 mg PO/NG DAILY
-- Metoprolol Tartrate 12.5 mg BID, Hold on morning prior to
hemodialysis.
-- Midodrine 5 mg PO ASDIR Give on mornings prior to
Hemodialysis
-- Nephrocaps 1 CAP PO DAILY
-- Sevelamer CARBONATE 1600 mg PO TID W/MEALS
-- Levothyroxine Sodium 75 mcg
-- Warfarin 1 mg PO/NG DAILY16
-- Clobetasol Propionate 0.05% Cream 1 Appl TP BID apply to back
-- HydrOXYzine 25 mg PO/NG Q6H:PRN itching
-- Lorazepam 1 mg PO/NG HS:PRN insomnia
-- Docusate Sodium 100 mg PO/NG BID
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO ASDIR (AS
DIRECTED): hold AM dose prior to HD.
3. midodrine 5 mg Tablet Sig: One (1) Tablet PO ASDIR (AS
DIRECTED): 1 on mornings prior to HD.
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
8. clobetasol 0.05 % Cream Sig: One (1) Appl Topical BID (2
times a day).
9. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia
ESRD
Polycystic kidney disease s/p failed kidney transplant
Diastolic CHF
Atrial fibrillation
Hypertension
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 a low red blood cell count which was
checked before dialysis. After dialysis, it was normal for you.
We still gave you a unit of blood because you described some
mild symptoms of anemia. You tolerated the blood very well
without needing any further dialysis to remove fluid.
Please note, there are no changes to your medications. Take
everything as previously prescribed.
Followup Instructions:
___
|
10569306-DS-48 | 10,569,306 | 24,582,666 | DS | 48 | 2158-05-06 00:00:00 | 2158-05-07 19:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ /
Lisinopril / Bactrim / Pentamidine Isethionate / Levofloxacin
Attending: ___.
Chief Complaint:
Fever, Dyspnea and Hypotension
Major Surgical or Invasive Procedure:
Modified AV Ablation
History of Present Illness:
___ year old female with past medical history of refractory
atrial fibrillation, ESRD due to PCKD, s/p failed transplant on
dialysis MWF presenting with fever, dyspnea and hypotension.
Patient was recently admitted on ___ for afib with RVR and was
sent home with high heart rates given BP limitation on afib rate
control agents. Plan was to move up her scheduled AV ablation
to ___. She received dialysis on ___ and was sent home.
On ___ evening, she developed fever to 102 at home and a dry
cough. On ___ AM, she checked her BP 79/59, Hr 141. Took her
daily metoprolol 25 mg. She rechecked her BP one hour later and
it was 72/58, HR 128. She was feeling lightheaded and a little
SOB. She repeated the BP and it was 68/56, HR 150. She called
her PCP's office and was advised to come to the ED.
In the ED, initial vitals were: HR 144 BP91/76
Labs and imaging significant for CXR with ? RLL PNA.
In the ED pt received metoprolol 5mg IV with HR down to 120s,
but SBP down to the ___. She received 500cc bolus with SBP
improving to 100s and also received vanc/cefepime for PNA.
Upon arrival to the CCU, patient was alert, oriented x 3,
mentating well, tachycardic hr 140s, hypotensive SBP 80-90s.
Patient reports that her breathing has improved, but feels
palpitations.
Past Medical History:
AF: Chronic
CHF: diastolic
Tachycardic cardiomyopathy
PCKD s/p bil. nephrectomies in ___
ESRD s/p failed ECD renal transplant in ___ on HD MWF
- s/p coil embolization of graft artery on ___
- multiple episodes of CMV viremia
HTN
Endometrial cancer
Primary Hyperparathyroidism
H/o C.diff colitis
Hypothyroidism
MR/TR on Echo
h/o tachycardiomyopathy - last EF > 55% in ___
dCHF
E.coli bacteremia ___
Knee OA
VRE
Enterococcus UTI
s/p tonsillectomy
-___ - coil embolization tpx renal artery
-___ - ECD kidney transplant and VHR with mesh
-___ - RUE AV fistulogram, balloon angioplasty
-___ - b/l nephrectomies for PKD
-___ - RUE brachiocephalic AV fistula
-___ - appendectomy and incisional hernia repair with mesh
-___ - TAH/BSO for endometrial ca
-___ - hysteroscopy
-___ - R hemithyroidectomy and excision of R parathyroid
adenoma, neck exploration
-___ - hemorrhoidectomy and drainage of perirectal hematoma
Social History:
___
Family History:
Father & daughter w/ PKD. No history of CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB, decreased breath sounds on RLL
CV- Irregular irregular, tachycardic, normal S1 and S2, ___
systolic murmur heard best at the apex and radiates to axilla
Abdomen- soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right arm fistula with bruit and thrill
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB, no w/r/r, cough
CV- Irregular irregular, normal S1 and S2, ___ systolic murmur
heard best at the apex and radiates to axilla
Abdomen- soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right arm fistula with bruit and thrill
Neuro- CNs2-12 intact, motor function grossly normal
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
ADMISSION LABS:
___ 01:55PM BLOOD WBC-6.7 RBC-3.26* Hgb-9.9* Hct-32.3*
MCV-99*# MCH-30.4 MCHC-30.6* RDW-14.3 Plt ___
___ 01:55PM BLOOD Neuts-72.7* ___ Monos-7.2 Eos-1.2
Baso-0.6
___ 01:55PM BLOOD ___ PTT-34.6 ___
___ 01:55PM BLOOD Glucose-112* UreaN-44* Creat-6.7*# Na-135
K-4.4 Cl-91* HCO3-25 AnGap-23*
___ 04:30AM BLOOD Calcium-9.5 Phos-6.9* Mg-2.1
___ 02:03PM BLOOD Lactate-2.1*
.
.
IMAGING:
CXR (___): FINDINGS: AP portable upright chest radiograph
was provided. The heart ismildly enlarged. Lung volumes are
low which limits evaluation. There issubtle haziness in the
right lower lung which could represent underpenetratedtechnique,
though the possibility of a partially layering right effusion
isnot excluded. There is no pneumothorax. The left lung
appears clear. Bonystructures appear intact. Clips are noted
in the superior mediastinum,unchanged. There is a calcified
rounded structure again noted in the rightupper quadrant
compatible with hepatic lesion. IMPRESSION: Low lung volumes,
mild cardiomegaly, subtle haziness in the rightlower lung which
may represent a partially layering right effusion.
.
CXR ___ are relatively well inflated. There is a
slight reticulonodularopacity along the medial right base which
is not significantly changed but wasnot previously present in
___ and therefore could represent an acuteinfectious
atypical process or patchy atelectasis. Clinical correlation
isadvised. Left lung is clear. No pulmonary edema or
pneumothorax. Overallcardiac and mediastinal contours are
stable.
MICRO:
___ 3:16 pm BLOOD CULTURE Source: Venipuncture. Final
___ GROWTH.
___ 12:26 pm BLOOD CULTURE Source: Line-hd.Final
___ GROWTH.
___ 2:00 pm BLOOD CULTURE Final ___ GROWTH.
___ 1:45 pm BLOOD CULTURE Final ___ GROWTH.
___ 11:00 am BLOOD CULTURE Final ___ GROWTH.
___ 4:20 am BLOOD CULTURE Source: Venipuncture. Final
___ GROWTH.
DISCHARGE LABS
___ 01:20PM BLOOD WBC-8.2 RBC-2.76* Hgb-8.2* Hct-26.8*
MCV-97 MCH-29.7 MCHC-30.6* RDW-15.0 Plt ___
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
___ 01:20PM BLOOD ALT-258* AST-167* AlkPhos-86 TotBili-0.5
___ 01:20PM BLOOD Calcium-9.9 Phos-6.1*# Mg-2.3
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: ___ with past medical history of
refractory A. fib, ESRD due to PCKD, s/p failed transplant, on
dialysis MWF presenting with afib with RVR, fever and new cough.
Previously admitted and discharged on ___ (day prior to this
admission) with symptomatic tachycardia
# afib with RVR: The patient with history of difficult to rate
control afib, currently on metoprolol every other day with
dosing limited by hypotension. On coumadin for anticoagulation.
In the ED, trial IV metoprolol slowed ventricular rate to the
120s, but SBP dropped to the ___. Similar reaction to diltiazem
IV in the CCU. She is otherwise hemodyanamically stable with HR
in the 140-160s although symptomatic with palpitations. She had
previously been scheduled for ablation on ___ but given
concerns for infection (see below), as well as an elevated INR,
this was postponed until ___. Patient tolerated the modified
AV ablation well. She was started on digoxin, with an initial
dose of 0.125 mg PO on ___, to followed by 0.0625 mg PO on
a ___ and ___ schedule. Patient will need to
be followed closely while on digoxin. Her INR will also need to
continue to be monitored and her coumadin dose adjusted
accordingly.
# Fever, hypotension, cough: While at home prior to admission,
the patient had fevers reportedly to a high of 102 and an non
productive cough, with blood pressures in the mid-high ___
(recent baseline sbp 90-100s). Hypotension felt to be related to
tachycardia rather than reflective of sepsis. CXR was
significant for a partially layering right effusion and given
her cough she was started on ceftriaxone and azithromycin for
CAP (had been previously in hospital for <24hr). She was given 2
days of azithromycin and completed a 5 day course of
ceftriaxone. She was afebrile since ___ and cultures were
negative.
#Transaminitis: Patient's AST and ALT were elevated during her
admission, likely secondary to antibiotics. On discharge, her
AST was 167 and ALT 258. Patient should have follow-up as an
outpatient to ensure her LFT's have returned to normal levels.
.
CHRONIC ISSUES:
# ESRD: The patient has ESRD secondary to PCKD s/p failed
transplant now on dialysis ___. She was followed by Nephrology
Dialysis and received dialysis as inpatient. She was maintained
on her home sevalemer, sensipar, nephrocaps.
.
# Hypothyroidism: TSH 0.92. Continued home levothyroxine.
,
# Reactive airway disease: Continued home flovent, montelukast
although atrovent was held given her tachycardia.
.
.
TRANSITIONAL ISSUES:
# Patient was given digoxin 0.125 mg PO on ___. She is
being discharged on 0.0625 mg PO to be taken on a ___,
___ schedule. She will need to be followed closely while on
digoxin.
# Patient's metoprolol dose, given on non-dialysis days, was
increased from 12.5 to 25 mg PO.
# Patient will continue on coumadin and her INR will continue to
need to be monitored and coumadin doses adjusted accordingly.
# Patient's liver enzymes were elevated during her admission,
and should be re-checked, and if not resolved, further work-up
done. PCP ___ emailed about this on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Midodrine 10 mg PO MWF
2. Metoprolol Succinate XL 50 mg PO EVERY OTHER DAY
3. Ipratropium Bromide MDI 2 PUFF IH BID:PRN SOB
4. Nephrocaps 1 CAP PO DAILY
5. Renagel 2400 mg Other TID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lorazepam 2 mg PO HS:PRN insomnia
8. Montelukast Sodium 10 mg PO DAILY
9. Warfarin 3 mg PO DAILY16
10. Cinacalcet 60 mg PO DAILY
11. Fluticasone Propionate 110mcg 4 PUFF IH BID
Discharge Medications:
1. Cinacalcet 60 mg PO DAILY
2. Fluticasone Propionate 110mcg 4 PUFF IH BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Lorazepam 2 mg PO HS:PRN insomnia
5. Midodrine 10 mg PO MWF
6. Montelukast Sodium 10 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. sevelamer HYDROCHLORIDE 2400 mg OTHER TID
9. Warfarin 3 mg PO DAILY16
10. Digoxin 0.0625 mg PO 3X/WEEK (___)
11. Ipratropium Bromide MDI 2 PUFF IH BID:PRN SOB
12. Metoprolol Succinate XL 25 mg PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1.Community Acquired Pneumonia
2.Refractory atrial fibrillation with rapid ventricular response
status post modified ablation
Secondary:
1. End Stage Renal Disease on ___
hemodialysis
2. Diastolic Chronic Heart Failure
3. Transaminitis
4. Hypothyroidism
5. Reactive Airway Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
the hospital with fever, cough, low blood pressure and a rapid
irregular heart beat. You were found to have pneumonia, were
given antibiotics, and your symptoms improved. You were also
found to have a very rapid heart beat, with an irregular rhythm.
You had a procedure (a modified ablation), after which your
heart rate returned to normal. You continue to have an irregular
heart rhythm (afib), therefore you will need to stay on
coumadin. You also continued hemodialysis for your kidney
disease, and were given your home medications for your other
chronic health problems. Please take your medications, including
new medications, as prescribed, and follow-up with the medical
appointments listed below.
Please weight yourself daily and call your MD if your weight
increases by more than 3lbs.
Please also weigh yourself every morning, and call MD if weight
goes up more than 3 lbs.
Followup Instructions:
___
|
10569306-DS-50 | 10,569,306 | 20,719,223 | DS | 50 | 2158-09-14 00:00:00 | 2158-09-14 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tape ___ /
Lisinopril / Bactrim / Pentamidine Isethionate / Levofloxacin
Attending: ___.
Chief Complaint:
Elevated temperature
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with complicated PMH here from dialysis with shaking
chills. She has a long history of recurrent fevers, most
recently with hospitalization ___ for Klebsiella
bacteremia of unknown source. She reports she has not felt right
since she completed her course of cefazolin, which she received
at dialysis on ___, 10 days ago. She reports that she has been
very tired, achy, complains of SOB with DOE, and has had several
fevers to 100. She reported back pain radiating to lower
extremities, associated with lower extremity weakness. Today at
dialysis she became very cold and began having chills/rigors.
Temp 100.0. She completed dialysis, and was given acetaminophen
and either cefazolin or cefepime, then sent to the ED. Patient
denies headache, chest pain, abdominal pain, nausea, vomiting,
diarrhea, urinary symptoms. She has chronic cough which is at
baseline. Denies n/v, states she is tolerating PO. She does
report dental work 4 days prior, a ___ year old crown fell out
and she had it replaced. She reports taking unknown prophylactic
antibiotic. No longer makes urine.
In the ED intial vitals were: 4 98.6 94 146/72 18 98%
- Labs were significant for WBC 6.5, Hct 28.0, K of 4.1, Cre
3.7, Calcium 11.0, phos 3.5. INR 1.3. Lactate 1.9.
- CXR showed small bilateral pleural effusion, no focal
consolidation, pulmonary vasculature pronminant, unchanged from
prior. RUQ large rim calcified structure (c/w known liver cyst)
- Patient was given vancomycin
Vitals prior to transfer were: 98.5 91 125/66 18 98% RA
On the floor, patient is tired and feels chilly. Complains of
itchiness from eczema.
Review of Systems:
(+) as above
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia.
Past Medical History:
* Recurrent fevers
- E. coli bacteremia, ___
- s/p WBC scan ___ revealed chronic cholecystitis, s/p CCY
- Klebsiella bacteremia ___
- h/o C. diff colitis
* ESRD s/p failed ECD renal transplant in ___ on HD MWF
- c/b urinary obstruction, multiple UTIs, nephrostomy tube
- s/p coil embolization of graft artery on ___
- h/o multiple episodes of CMV viremia
- h/o BK viremia
* Chronic atrial fibrillation s/p modified AV ablation ___
- dCHF, last EF > 55% in ___
- Tachycardic cardiomyopathy
- MR/TR
* Aortic stenosis
* PCKD s/p bilateral nephrectomies in ___
* HTN
* Endometrial cancer
* Primary Hyperparathyroidism
* Hypothyroidism
* Knee Osteoarthritis
SURGICAL HISTORY
-___ - cholecystectomy
-___ - coil embolization tpx renal artery
-___ - ECD kidney transplant and VHR with mesh
-___ - RUE AV fistulogram, balloon angioplasty
-___ - b/l nephrectomies for PKD
-___ - RUE brachiocephalic AV fistula
-___ - appendectomy and incisional hernia repair with mesh
-___ - TAH/BSO for endometrial ca
-___ - hysteroscopy
-___ - R hemithyroidectomy and excision of R parathyroid
adenoma, neck exploration
-___ - hemorrhoidectomy and drainage of perirectal hematoma
-s/p tonsillectomy
Social History:
___
Family History:
Father & daughter w/ PKD. No history of CAD.
Physical Exam:
ON ADMISSION:
=============
Vitals - T: 99.6 BP: 136/75 HR: 81 RR: 20 02 sat: 99%RA
Gen: female, tired but non-toxic appearing
HEENT: MMM
CV: Irregulary irregular, ___ SEM at ___
Pulm: CTAB, no w/r/r
Abd: Soft, NTND, normoactive bowel sounds, well healed surgical
scar with palpable transplanted kidney at RLQ.
Ext: Warm, well-perfused, no edema, ? ___ cyst on Right.
Neuro: AAOx3, CN II-XII grossly intact
Skin: No concerning lesions, fistula is stable with good thrill,
not hot.
ON DISCHARGE:
==============
Vitals 99.0(tmax), 83, 132/73, 17
Gen: female, tired but non-toxic appearing, laying in bed at HD
HEENT: MMM, anicteric sclera, EOMI
Neck: supple, no LAD
CV: Irregulary irregular, ___ SEM at ___
Pulm: CTAB, no w/r/r
Abd: Soft, NTND, normoactive bowel sounds, well healed surgical
scar
MSK: no vertebral process tenderness, no CVAT
Ext: Warm, well-perfused, no edema, ? ___ cyst on Right.
Skin: No concerning lesions, fistula is stable with good thrill,
no warmth or erythma
Pertinent Results:
ON ADMISSON:
=============
___ 05:50PM BLOOD WBC-6.5 RBC-2.93* Hgb-8.3* Hct-28.0*
MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___
___ 05:50PM BLOOD Neuts-85.7* Lymphs-8.3* Monos-4.3 Eos-1.5
Baso-0.3
___ 05:50PM BLOOD ___ PTT-30.5 ___
___ 05:50PM BLOOD Glucose-115* UreaN-18 Creat-3.7* Na-140
K-4.1 Cl-98 HCO3-28 AnGap-18
___ 05:50PM BLOOD ALT-6 AST-21 AlkPhos-85 TotBili-0.4
___ 05:50PM BLOOD Calcium-11.0* Phos-3.5 Mg-2.2
___ 05:57PM BLOOD ___ FiO2-20 pO2-25* pCO2-48* pH-7.45
calTCO2-34* Base XS-6 Intubat-NOT INTUBA
___ 05:57PM BLOOD Lactate-1.9
MICRO:
======
___: BLOOD CX-PND
___: OSH BLOOD CX FROM ___ DIALYSIS IN ___
___: CMV VIRAL LOAD-PND
PERTINENT LABS:
================
___: SPEP-PND
RADIOLOGY:
===========
CXR ___:
FINDINGS: The inspiratory lung volumes are appropriate. There
is bilateral blunting of the costophrenic angles compatible with
small bilateral pleural effusions. There is improved aeration
of the right lung base in comparison to ___. No
focal consolidation concerning for pneumonia is seen. There is
no pneumothorax. The pulmonary vasculature is slightly
prominent, unchanged from the prior exam. No overt pulmonary
edema is present. The cardiomediastinal silhouette is within
normal limits and unchanged. In the right upper quadrant, there
is a large rim calcified rounded structure measuring 7.4 x 7.3
cm within the liver.
IMPRESSION:
1. Small bilateral pleural effusions and mild pulmonary
vascular congestion.
2. Improved aeration of the right lung base from ___.
DISCHARGE LABS:
===============
___ 05:50PM BLOOD WBC-6.5 RBC-2.93* Hgb-8.3* Hct-28.0*
MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___
___ 07:10AM BLOOD ___ PTT-30.9 ___
___ 07:10AM BLOOD Glucose-120* UreaN-37* Creat-6.5*# Na-138
K-4.8 Cl-97 HCO3-25 AnGap-21*
Brief Hospital Course:
___ year old female with PCKD s/p failed transplant on HD MWF,
recurrent fevers due to gram negative bacteremia of unknown
source, who presents from dialysis with rigors and temperature
to 100.0, without localizing infection.
ACTIVE MEDICAL ISSUES:
# Elevated temperature: On admission, pt did not meet SIRS
criteria and was afebrile however she had report temperature to
100.0 ___s rigors at dialysis. In the past, pt has had two
episodes of E. coli bacteremia, and most recently completed a
course on ___ of cefazolin for Klebsiella bacteremia. On
admission, she had few localizing symptoms other than a cough
which is chronic as well as back pain with standing which she
reports is also chronic. She denied abdominal pain, n/v/d. No
headaches or neck pain to suggest CNS infection. CXR did not
show evidence of pneumonia. Blood cultures from ___ at both
dialysis and BI were pending, no growth at discharge. CMV viral
load was also pending. She was empirically treated with
vancomycin (HD protocol) and cefepime. Her antibiotics were
stopped as she had no symptoms, remained afebrile with no
leukocytosis. Her elevated temperature and malaise may represent
viral process rather than overt bacterial infection. Her
antibiotics were stopped on the day prior to discharge, and she
remained stable. She had an appointment to follow up with her
PCP the day after discharge.
# HYPERCALCEMIA: Pt noted to have hypercalcemia due to
hyperparathyroidism in the past. Her calcium on admission was
11.0. An SPEP was checked (given her back pain and malaise)
which is pending at discharge. Her dialysis was also modified as
below.
CHRONIC MEDICAL ISSUES:
# ESRD on HD MWF: Pt completed scheduled dialysis on ___. She
was seen by renal dialysis and received HD on ___. Vitamin D
was held in dialysis given her hypercalcemia. Her HD was also
given in a low calcium bath. She was continued on home
sevelamer, nephrocaps, and cinicalcet. She was also continued on
midodrine on HD days.
# ATRIAL FIBRILLATION: She is s/p modified ablation procedure.
INR subtherapeutic to 1.3 on admission. She was given 4mg
coumadin and her INR was 1.6 on discharge.
Her anticoagulation is managed by PCP ___. She was also
continued on ___ digoxin and metoprolol on non-HD days.
# ANEMIA: Chronic, stable. Likely anemia of chronic disease; due
to ESRD.
# RUQ liver cyst: She was noted to have a 7cm rim-enhancing cyst
on CXR. On recent RUQ US in ___, she had been noted to have
multiple liver cysts, many of which are calcified and are of
varying sizes compatible with history of polycystic liver
disease.
# BACK PAIN: Pt c/o stable, chronic band-like pain upon
standing.
# HYPOTHYROIDISM: She was continued on home levothyroxine
# CHRONIC DIASTOLIC CHF: Pt's EF >55% on echo in ___. She
appeared to be euvolemic on exam. She received a low Na diet and
was continued on home metoprolol and digoxin.
# REACTIVE AIRWAY DISEASE: Pt was continued on home
ipratropium, advair and montelukast.
TRANSITIONAL ISSUES:
[ ] Pt with pending blood cultures from ___ (no growth in 48
hr) as well as pending CMV viral load at time of discharge
[ ] Pt noted to have hypercalcemia which in past has been
attributed to hyperparathyroid. Her SPEP was checked (given back
pain and malaise) and was pending at time of discharge.
[ ] Given pt's hypercalcemia, renal dialysis service held Vit D
in dialysis. Her HD was given in low Ca bath of 2mg. Her calcium
should be monitored as an outpatient
[ ] Pt's INR subtherapeutic on admission (1.3). She was given
warfarin 4 mg dose and her INR on discharge was 1.6. Her INR
should continued to be monitored (being managed by PCP, ___.
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cinacalcet 60 mg PO DAILY
2. Digoxin 0.0625 mg PO 3X/WEEK (___)
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Gabapentin 300 mg PO 3X/WEEK (___)
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lorazepam 1 mg PO BID:PRN anxiety
9. Metoprolol Succinate XL 25 mg PO 4X/WEEK (___)
10. Midodrine 10 mg PO MWF
11. Montelukast Sodium 10 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. sevelamer HYDROCHLORIDE 2400 mg OTHER TID
14. Warfarin 1 mg PO DAILY16
15. Cetirizine 10 mg oral daily prn allergy symptoms
16. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
17. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
18. Omeprazole 20 mg PO BID
Discharge Medications:
1. Cinacalcet 60 mg PO DAILY
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Digoxin 0.0625 mg PO 3X/WEEK (___)
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Gabapentin 300 mg PO 3X/WEEK (___)
7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Lorazepam 1 mg PO BID:PRN anxiety
11. Metoprolol Succinate XL 25 mg PO 4X/WEEK (___)
12. Midodrine 10 mg PO MWF
13. Montelukast Sodium 10 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Omeprazole 20 mg PO BID
16. sevelamer HYDROCHLORIDE 2400 mg OTHER TID
17. Warfarin 1 mg PO DAILY16
18. Cetirizine 10 mg oral daily prn allergy symptoms
Discharge Disposition:
Home
Discharge Diagnosis:
Elevated temperatures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10569425-DS-19 | 10,569,425 | 23,902,697 | DS | 19 | 2112-06-19 00:00:00 | 2112-06-19 12:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Ambien / Levaquin
Attending: ___.
Chief Complaint:
Left foot pain
Major Surgical or Invasive Procedure:
___ - Left foot I+D and Removal hardware
History of Present Illness:
___ who presented to the outpatient clinic with Left foot pain
___ s/p Left midfoot surgery. She was presumed to have
cellulitis, admitted through the ED, began IV Antibiotics, and
was admitted to the orthopaedic service in stable condition.
Past Medical History:
Past Medical History:
RA
hypothyroidism
Past Surgical History:
Includes left shoulder replacement, left hip
replacement, right hip replacement and left and right knee
replacements
Social History:
___
Family History:
n/a
Physical Exam:
NAD
AAOx3
Resp unlabored
L foot WWP in all toes, ___ fire
SILT in all toes
Dressings clean
Pertinent Results:
___ 03:00PM BLOOD ___ PTT-27.2 ___
___ 03:00PM BLOOD Neuts-81.0* Lymphs-9.9* Monos-8.3
Eos-0.1* Baso-0.3 Im ___ AbsNeut-7.44* AbsLymp-0.91*
AbsMono-0.76 AbsEos-0.01* AbsBaso-0.03
___ 09:00AM BLOOD Neuts-69.1 Lymphs-16.5* Monos-11.6
Eos-2.1 Baso-0.4 Im ___ AbsNeut-4.64 AbsLymp-1.11*
AbsMono-0.78 AbsEos-0.14 AbsBaso-0.03
___ 06:40AM BLOOD Neuts-54.2 ___ Monos-14.9*
Eos-4.0 Baso-0.6 Im ___ AbsNeut-3.54 AbsLymp-1.68
AbsMono-0.97* AbsEos-0.26 AbsBaso-0.04
___ 03:00PM BLOOD WBC-9.2 RBC-3.83* Hgb-11.1* Hct-34.5
MCV-90 MCH-29.0 MCHC-32.2 RDW-14.0 RDWSD-45.6 Plt ___
___ 06:44AM BLOOD WBC-8.3 RBC-3.46* Hgb-10.0* Hct-31.2*
MCV-90 MCH-28.9 MCHC-32.1 RDW-14.0 RDWSD-46.3 Plt ___
___ 09:00AM BLOOD WBC-6.7 RBC-3.34* Hgb-9.7* Hct-30.1*
MCV-90 MCH-29.0 MCHC-32.2 RDW-14.0 RDWSD-46.1 Plt ___
___ 06:40AM BLOOD WBC-6.5 RBC-3.04* Hgb-8.9* Hct-27.8*
MCV-91 MCH-29.3 MCHC-32.0 RDW-14.2 RDWSD-47.8* Plt ___
Brief Hospital Course:
The patient was evaluated in the ED and admitted to the
orthopaedic service on IV Vancomycin. She had fevers during day
1 but this resolved and by HD1 her symptoms appeared to
partially improve. ID was consulted and abx changed to IV
Ancef. She continued to have only slight improvement but then
plateaued in her erythema and moderate pain with ambulation
limiting her activities.
After discussion with all teams and patient, decision was made
to on ___ perform I+D Left foot and removal of most of her
hardware, a few broken screws remain given morbidity of removing
them deep in her midfoot.
A PICC Line was placed post operatively for IV antibiotics
(Ancef) and outpatient ID followup.
She otherwise did well in the hospital. Prior to d/c she was
voiding, tol PO intake, pain well controlled. She worked with
___ and was deemed safe for discharge home with services. She
will be PWB in her ACB.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium Dose is Unknown PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Pregabalin unknown PO BID
4. Fish Oil (Omega 3) Dose is Unknown PO BID
5. Multivitamins Dose is Unknown PO DAILY
Nifedipine
Doxepin
Citalopram
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Atorvastatin 10 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. Doxepin HCl 25 mg PO QHS:PRN anxiety
5. NIFEdipine CR 30 mg PO DAILY
6. 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
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Levothyroxine Sodium 200 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Pregabalin 150 mg PO TID
12. IV Ancef 2gm Q8hrs
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left foot deep infection
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:
Thank you for allowing me to assist in your care. It is a
privilege to be able to take care of you. Should you have any
questions about your post-operative care feel free to call my
office at ___ during business hours and either myself
or ___, NP will address any questions or concerns you
may have. If this is an urgent matter at night or on weekends
please call ___ and ask the page operator to page the
covering ___ call orthopaedic physician.
Prescription refills or changes cannot be addressed after normal
business hours or on weekends.
PAIN CONTROL:
-You may or may not have had a nerve block depending on the
type of surgery. This will likely wear off later in the evening
and it is normal to have increased pain when the nerve block
wears off. Please take your prescribed pain medications as
directed with food prior to the nerve block wearing off.
-Stay ahead of the pain!
-Narcotic pain medications can cause constipation. Please take
a stool softener while taking these and drink plenty of water.
-Please plan ahead! If you are running out of your medication
prior to your followup appointment please call during business
hours with a ___ day notice. Prescription refills or changes
cannot be addressed after normal business hours or on weekends.
ACTIVITY:
-You will likely have swelling after surgery. Please keep the
foot elevated on ___ pillows at all times possible. You can
apply a dry icebag on top of your dressing for 20 minutes at a
time as often as you like.
-Unless instructed otherwise you should not put any weight down
on your operated extremity until you come back for your first
postoperative visit.
CARE FOR YOUR DRESSING:
-You should not remove your dressing. I will do so when I see
you for your first post-operative visit.
-It is not unusual to have a little bloody staining through
your dressing. However please call the office for any concerns.
-Keep your dressing clean and dry. You will have to cover it
when you bath or shower. If it gets wet please call the office
immediately.
PREVENTION OF BLOOD CLOTS:
-You have been instructed to take medication in order to help
prevent blood clots after surgery. Please take an aspirin 325 mg
every day unless you have been specifically prescribed a
different medication by me. If there is some reason why you
cannot take aspirin please notify my office.
DRIVING:
-My recommendation is that you should not drive if you:
(1)are still taking narcotic pain medications
(2)have any type of immobilization on your right side
(3)are unable to fully bear weight without pain on your right
side
(the above also apply to the left side if you have a manual
transmission (stick shift)
WHEN TO CALL:
-Please call the office if you have any questions or concerns
regarding your post-operative care. We need to know if things
are not going well.
-Please make sure you call the office or page the ___ call
orthopaedic physician immediately if you are having any of the
following problems:
1.Fever greater than 101.0
2.Increasing pain not controlled on pain medications
3.Increasing bloody staining on the dressing
4.Chest pain, difficulty breathing, nausea or vomiting
5.Cold toes, toes that are not normal color (pink)
6.Any other concerning symptoms
Physical Therapy:
PWB LLE in Short ACB
Treatments Frequency:
IV Antibiotics, elevation, observation
Then ___ - I+D ___ L foot
Followup Instructions:
___
|
10569538-DS-5 | 10,569,538 | 21,874,968 | DS | 5 | 2142-09-14 00:00:00 | 2142-09-14 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:
R leg pain
Major Surgical or Invasive Procedure:
___ - R Femur Retrograde Intramedullary Nail
___ - R Tibia irrigation and debridement with placement of
intramedullary nail
History of Present Illness:
___ year-old male, healthy, who presents as mediflight transfer
from OSH after MCC traveling 30mph. Patient helmeted. Per
family/friends +HS +LOC. Patient AOx4 upon ortho eval in ED,
normal respirations, conversant. Smell of EtOH on breath,
endorses 1 beer at 9pm and two slices of pizza, last PO intake
at
9:30pm on ___. VSS and HDS upon ortho eval in ED. RLE NVI upon
initial eval with palp DP and ___ pulses to RLE, sensation intact
throughout distal foot. No signs of skin threatening, though
thigh compartments full. In C collar.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals:
___ 0246 Temp: 98.1 PO BP: 115/67 L Lying HR: 94 RR: 18 O2
sat: 94% O2 delivery: Ra
Exam:
General: resting comfortably in bed, no acute distress
Cardio: Regular rate and rhythm by palpation at the time of
examination
Pulm: breathing comfortably, no acute distress
MSK: RLE in clean, dry ace wrap. Cap refill <2sec. 2+ DP pulse
fires ___. SILT in the S/S/SP/DP/T distributions
Brief Hospital Course:
The patient presented to the emergency department early on the
morning of ___ following a motor cycle crash and was
evaluated by the orthopedic surgery team. Because of his open
fracture of the right lower extremity, he was given antibiotics
in the emergency department. The patient was found to have a R
femoral shaft fracture as well a as a R open tibial shaft
fracture. He was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for
retrograde nail of the right femur and irrigation and
debridement with placement of an intramedullary nail of the
right tibia. The patient tolerated this procedure well. There
were no complications. 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. In the postoperative period, the patient did develop
anemia for which she received a total of 2 units of packed red
blood cells. He tolerated the blood transfusions without issue.
He was initially given IV fluids and IV pain medications over
the ultimately progressed to oral pain medications and a regular
diet. He was given appropriate perioperative antibiotics as
well as prophylactic anticoagulation per routine. Patient work
with physical therapy team who determined that a discharge to
rehab was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact. Despite
multiple trials of void, the patient was unable to urinate
independently. Ultimately, a Foley catheter was placed for his
urinary retention. He will need his Foley catheter removed in
approximately 1 week's time. This is to be done at at his rehab
facility. His most recent Foley catheter was placed on
___. The patient is weightbearing as tolerated and range
of motion as tolerated in the right lower extremity, and will be
discharged on enoxaparin 40 mg daily for DVT prophylaxis. This
medication is to be continued for a total of 1 month from today
with operation. The expected end date of this medication is
___. 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
Do not take more than 4000m of acetaminophen (Tylenol) total,
daily.
2. Docusate Sodium 100 mg PO BID
Please take while you are using your opioid pain medication.
3. Enoxaparin Sodium 40 mg SC QPM
The expected end date of this medication is ___.
RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*27 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Do not drink or drive on this medication. Beware sedating effect
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*48 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R Femur fracture
R Open Tibial 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 and range of motion as tolerated in
the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take enoxaparin 40 mg daily for 4 weeks from the date
of the operation, ___. The expected end date of this
medication is ___.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10569728-DS-19 | 10,569,728 | 21,264,026 | DS | 19 | 2121-09-06 00:00:00 | 2121-09-06 14:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: <1> minutes
Time/Date the patient was last known well: 10PM ___
Pre-stroke mRS ___ social history for description): 0
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: out of window
Endovascular intervention: []Yes [x]No
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale - Total [19]
1a. Level of Consciousness -0
1b. LOC Questions -2
1c. LOC Commands -1
2. Best Gaze -1
3. Visual Fields -2
4. Facial Palsy -2
5a. Motor arm, left -0
5b. Motor arm, right -3
6a. Motor leg, left -0
6b. Motor leg, right -3
7. Limb Ataxia - -- Unable to test
8. Sensory -1
9. Language -2
10. Dysarthria -2
11. Extinction and Neglect - - Unable to test.
HPI:
___ with hx CAD s/p stent, LKW 10pm ___ found this AM by
husband with aphasia and right sided weakness, NIHSS 19,
hyperdense L MCA on NCNHCT transferred for DEFUSE3 trial for
embolectomy.
Pt reportedly had a cold with chills, violent cough, feeling
unwell 2 weeks ago. She was reportedly rapid strep negative but
had been having a lingering cough since that time.
___ days ago, she had a tooth pulled on the left and since that
procedure she had been having intermittent right arm and hand
numbness and weakness lasting for at least hours at a time not
associated with any neck or arm pain. She thought this was
related to chronic neck issues - s/p a type of neck surgery -
partner unsure of the exact nature of this problem.
She was at her baseline the evening prior and went to bed at
10PM
seen by her partner at that time. This AM, she was found by her
partner at 7AM on the ground with right sided weakness, garbled
speech, right facial droop. She was taken to ___ where
___ showed possible dense L MCA. She was transferred here for
possible participation in the DEFUSE3 trial - evaluating
embolectomy up to 16 hours from LKW.
In the ED, her NCHCT showed developing early hypodensity and
blurring of grey white differentiation in L MCA territory -
scoring ASPECTS 6. CTA showed L ICA occlusion at origin with
atherosclerotic plaque and soft plaque. CT Perfusion also
performed with large area of penumbra. Pt met inclusion criteria
for DEFUSE 3 and consent obtained from family. She was
randomized
to the medical therapy only arm of the study.
Decision was made to start Heparin gtt without bolus given
presence of soft clot in the ICA.
Past Medical History:
HTN
HLD
CAD s/p Stent
s/p Neck and lower back surgeries - unclear details.
s/p Hysterectomy
Social History:
___
Family History:
Alzheimers disease. No stroke that is known to significant
other.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals:99.6F, HR 79-91, 128-147/76-81, RR 18, 100% on RA, FSG
107
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Unintelligible speech both
dysarthric and nonsensical sounds. Followed command to
close/open
eyes only. Did not show two fingers, or grip/release hand. Could
not name correctly. Would repeat the word "name" when I asked
her
to tell me her name. Did not answer the month, year.
Focused/followed when standing to her left.
- Cranial Nerves: R facial droop. Consistently, no BTT on the
right, when standing on her right, she will cross midline
somewhat but does not completely look to the right. PERRL 3 to
2mm. Unable to answer questions regarding sensation reliably.
- Motor: Lifts left arm and leg antigravity and briskly with no
drift - confrontational testing not performed.
Right arm moving within the plane of the bed vs extensor to
noxious stim - no movement to command/request, right leg
withdrawing to noxious with antigravity effort at the IP.
- Reflexes:
Right toe is upgoing. No clonus.
- Sensory:
Mildly delayed response to noxious in the right arm and leg.
- Coordination:
Unable to test
- Gait:
Unable to test
DISCHARGE PHYSICAL EXAM
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Global aphasia- Unintelligible
speech with both dysarthric and nonsensical sounds. Does not
follow midline or appendicular commands. Would repeat the word
"name" when I asked her to tell me her name. Unable to assess
naming.
- Cranial Nerves: ___ 4>3 sluggish, L gaze preference but does
cross past midline, No BTT on the right, BTT on L. R facial
droop.
- Motor: Lifts L arm and leg antigravity and briskly with no
drift - confrontational testing unable to assess. R UE no
spontaneous movement, extensor posture to noxious. R ___ flaccid,
TF to noxious.
- Reflexes:
Right toe is upgoing. No clonus.
- Sensory:
Mildly delayed response to noxious in the right arm and leg.
- Coordination: Unable to test
- Gait: Unable to test
Pertinent Results:
LABS:
WBC 11.2 (from 11.2 ___ Hgb 12.6 Hct 36.6 Plt 318
Na 140 K 3.6 CL 101 HCO3 27 BUN 9 Cr 0.7 Gluc 117
Ca 9.6 Phos 4.9 Mg 2.0
Thrombin 18.0
Lupus anticoag PND
Beta-2-glycoprotein1 Abs IgG PND
LDL 211 Cholest 323
HbA1c 5.8%
TSH 1.2
Utox - pos cocaine, neg bnzodzp, neg barbitr, neg opiates, neg
amphetm, neg oxycodn, neg methadone
Blood cx x2 PND
Strep culture - negative
IMAGING:
___ - TEE
IMPRESSION: No cardiac source of embolus identified. Normal
biventricular systolic function. No signficant valvular disease.
___ - TTE
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF = 65%). 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 estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
___ - MR neck ___ and w/o contrast
IMPRESSION:
1. No evidence for intramural hematoma or dissection in the
cervical arteries.
2. Complete occlusion of the left internal carotid artery is
again
demonstrated.
3. 40-50% stenosis of the proximal right internal carotid
artery, better demonstrated on the ___ neck CTA.
4. Unchanged MR perfusion findings compared to ___,
with the infarct core in the left basal ganglia, left frontal
operculum, and scattered left paracentral gyri, and surrounding
ischemic penumbra in the left middle cerebral artery territory.
___ - NCHCT
IMPRESSION:
1. Expected evolution of the known left MCA distribution
infarcts. No new intracranial hemorrhage or territorial
infarcts.
2. Interval increase in density of the moderate-sized right
frontoparietal subgaleal hematoma since ___.
___ - MRI and MRA brain
IMPRESSION:
1. Late acute infarction in the distribution of the left middle
cerebral artery without intracranial hemorrhage.
2. Infarct core within the left basal ganglia, left frontal
operculum and scattered regions the left parietal lobe with
larger area of surrounding ischemic penumbra. The overall
configuration is similar to that seen on CT perfusion of 1 day
prior.
3. Redemonstration of occluded left intracranial internal
carotid artery and left middle cerebral artery with reduced
arborization of the distal left MCA branches.
___ - ___
IMPRESSION
1. Expected evolution of the known left MCA distribution
infarcts since the prior study without evidence of hemorrhagic
conversion. No evidence of new acute major infarct.
2. Interval increase in the size of a moderate-sized right
frontoparietal subgaleal hematoma since ___.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with past medical history of
coronary artery disease status-post stenting, hypertension, and
hyperlipidemia presenting with dysphagia and right sided
weakness secondary to left MCA syndrome and ICA occlusion. On
the evening prior to presentation, she went to sleep in her
usual state of health at 10pm and was found by her partner at
7am with incomprehensible speech, right-sided weakness, and
right-sided facial droop. At that time, she was taken to
___, then transferred to ___ for further
management.
Upon arrival, she underwent a CTA head and neck which
demonstrated (1) subtle foci of hypodensity in the distribution
of the left middle cerebral artery compatible with an acute
infarction, without evidence of intracranial hemorrhage, (2) a
large area of ischemic penumbra with a small infarct core within
the left basal ganglia and left frontal operculum, (3) occlusion
of the left middle cerebral artery with reduced arborization of
the distal MCA branches, and (4) occlusion of the left internal
carotid artery from its origin at the carotid bifurcation to the
intracranial segments. MRA neck and brain confirmed (1) complete
occlusion of the left internal carotid artery, (2) 40-50%
stenosis of the proximal right internal carotid artery, and (3)
infarct core in the left basal ganglia, left frontal operculum,
and scattered left paracentral gyri, and surrounding ischemic
penumbra in the left middle cerebral artery territory. She was
enrolled in the Difuse3 trial.
She had an echocardiogram performed (both TTE and TEE),
demonstrating no cardiac source of embolus, normal biventricular
systolic function, and no signficant valvular disease. A
hypercoagulable panel was sent and is pending.
Etiology of the infarct was thought to most likely be
atheroembolic, secondary to significant luminal narrowing of the
left ICA and MCA due to atherosclerotic plaque, with possible
contribution by cocaine-induced vasospasm. The patient and her
partner endorsed recreational cocaine use in the week prior
onset of aphasia and right sided weakness. She was initially on
a heparin gtt given carotid conclusion but transitioned to
apixiban 5mg BID for discharge.
- Continue atorvastatin 80mg, Apixiban 5mg BID.
- ___ of Hearts monitor to be done to monitor for occult
arrhythmic following discharge from rehabilitation.
- Follow-up results of hypercoagulable work-up (antiphospholipid
antibody, cardiolipin antibiodies, lupus anticoagulant,
beta2-glycoprotein
- Continued Neurology outpatient f/u.
- CTA H+N roughly 4 weeks following discharge to evaluate for
interval recanalization of Left ICA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO PRN Pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Apixaban 5 mg PO/NG BID
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke in left MCA distribution ___ Left carotid
Occlusion
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for difficulty speaking and
weakness of your right side, 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 you were assessed by
the Neurology Service for medical conditions that might raise
your risk of having stroke. We performed a CT of your head, MRI
of your head and neck, and imaging of the vessels in your head
and neck. We found that your left internal carotid artery, a
large vessel that feeds the brain, was completely blocked and
that your right internal carotid artery was 50% blocked. We also
performed an echocardiogram, to visualize how your heart is
working, which showed no signs of clot or infection in the
heart, and that the heart is pumping well. It is also possible
that your cocaine-use lead to a spasm of the blood vessels in
your brain, limiting the amount of blood flow that was available
to bring oxygen to your brain.
In order to prevent future strokes, we plan to modify your risk
factors. Your risk factors are:
- Elevated cholesterol (LDL = 211)
- Cocaine use
We are changing your medications as follows:
- Atorvastatin 80mg daily
- Apixiban 5mg BID
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Thank you for allowing us to participate in your care.
-Your ___ Neurology Team
Followup Instructions:
___
|
10569882-DS-17 | 10,569,882 | 23,608,636 | DS | 17 | 2193-06-03 00:00:00 | 2193-06-03 20:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / strong perfumes
Attending: ___.
Chief Complaint:
Mechanical fall, orthostatic hypotension
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy, decompressive enterotomy,
left inguinal hernia repair, extensive lysis of adhesions.
History of Present Illness:
Mr. ___ is a ___ M w/ Hypertension and Lumbar spinal stenosis
who was discharged on ___ from ___ to rehab s/p L2 to L5
laminectomy, L3 to S1 fusion and L3 to L5 instrumentation on
___ who presents after an unwitnessed mechanical fall from
his unlocked bed at rehab.
The patient was found by nursing staff at 1400 on ___ and
was concerned by facial droop and garbled speech. Per ED patient
expressed that he experienced dizziness/lightheadedness, nausea,
diaphoresis, vision changes. He endorsed some incontinence after
the fall. Denied loss of consciousness or head strike. Per
discussion on the floor, patient denied any lightheadedness or
chest pain. He walked to bathroom, felt well doing that. Then
went to sit on edge of bed and it rolled away from him. He fell
on his buttocks, and had mild muscle soreness in that area, but
denied LOC or headstrike.
ED Course:
- Initial vitals: 98.4 HR 101 124/77 19 sat 98% on 4L NC
- Subsequently O2 sat improved to 100% RA.
- orthostatic
- 1L NS
- Neurology consulted: ED concern for slurred speech and L
facial droop. He was found to have facial asymmetry (decreased
wrinkling of the left forehead, with h/o L derm surgery in that
region, and left NLF flattening) and subacute slurred speech
over the past few months with unclear etiology, no recent
worsening.
- Ortho consulted: no evidence of surgical site infection or
complications, no new neuro deficits on exam, and recommended no
spine surgery intervention at this time.
- Transfer vitals: 98.9 HR 102 151/79 25 sat 95% RA
On arrival to floor, patient denies any soreness aside from mild
pain in lower back where had his recent surgery. No chest pain
or dyspnea. No dizzinessness or lightheadedness.
ROS: Full 10 pt review of systems negative except for above. Of
note, Denies recent fever, headache, dizziness, chest pain,
shortness of breath, abdominal pain, nausea, vomiting,
constipation, diarrhea, dysuria, leg pain and leg swelling.
Past Medical History:
Hypertension
Hypercholesterolemia
GI reflux
Multifactorial gait disorder
Spinal stenosis s/p L2 to L5 laminectomy, L3 to S1 fusion and L3
to L5 instrumentation
S/P APPENDECTOMY
S/P CARPAL TUNNEL SURGERY
S/P GALLBLADDER SURGERY
INGUINAL HERNIA S/P HERNIA REPAIR
S/P RIGHT LEG VENOUS STRIPPING
S/P TONSILLECTOMY
? ANGINA PECTORIS
ALLERGIC RHINITIS
ANXIETY
ASTHMA
PROSTATE CANCER
SEASONAL ALLERGIES
DEPRESSION
BACK PAIN
LOW BACK PAIN
H/O COLON CANCER s/p partial colectomy (per patient, partial)
H/O KIDNEY STONES
H/O MULTIPLE DRUG ALLERGIES
HIATAL HERNIA
Social History:
___
Family History:
No history of sudden death, seizures, MI
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.3 148/84 HR 102 sat 94% on RA
Gen: NAD
HEENT: clear OP
CV: NR, RR, no murmur
Pulm: CTAB, nonlabored
Abd: mild distention, mild diffuse tenderness w/ deep palpation,
soft
GU: no Foley
Ext: no edema
Skin: no lesions noted
Neuro: CNs intact per my exam, tongue may deviate slightly to
patient's left, left side of face appears drooped but able to
raise eyebrows and give a symmetric smile, moves all ext against
resistance, ___
Psych: appropriate, pleasant
DISCHARGE PHYSICAL EXAM
VS: T98.3, 116-125/55-63, p84, RR18, 97RA, ___-163
General: Awake, no distress, speech soft, minimal dysarthria
HEENT: Sclera anicteric, Dobhoff attached to nare with TF
running
CV: Regular rate and rhythm; no murmurs
Lungs: some crackles in left lung
Abdomen: well-healing midline abdominal incision with staples
with small 3cm patch of mild erythema on R middle of incision
with no pus/dehiscence, non-tender, non-distended, bowel sounds
normal
Back: lower lumbar with vertical incision well healed, staples
removed, several stitches in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves all extremities. alert and oriented to person,
hospital, and date.
GU: No Flexiseal. No condom catheter in place.
Pertinent Results:
ADMISSION
___ 03:35PM BLOOD WBC-5.9 RBC-3.54* Hgb-11.4* Hct-31.5*
MCV-89 MCH-32.2* MCHC-36.2* RDW-12.6 Plt ___
___ 03:35PM BLOOD Plt ___
___ 03:35PM BLOOD ___ PTT-28.6 ___
___ 03:36PM BLOOD Creat-0.9
___ 03:35PM BLOOD UreaN-26*
___ 03:35PM BLOOD cTropnT-<0.01
___ 03:44PM BLOOD Glucose-167* Na-136 K-2.7* Cl-100
calHCO3-24
___ 01:07AM BLOOD CK-MB-2 cTropnT-<0.01
IMAGING:
CT HEAD W/O CONTRAST ___: No acute intracranial process.
CTA CHEST ___:
No filling defects are identified within the pulmonary arterial
vasculature. Note is made of hypertrophy of the interventricular
septum on the images of the heart. There is a small amount of
calcified atheromatous plaque within the aortic arch. The
aortic arch and thoracic aorta are otherwise unremarkable. The
great vessels of the aortic arch are within normal limits. There
is a common origin of the left common carotid and
brachiocephalic trunk (normal variant).
CHEST:
There are small bilateral non-hemorrhagic pleural effusions.
There is associated compressive atelectasis within both lower
lobes. A 4 mm calcified granuloma is identified within the
right upper lobe (3:65). No other pulmonary nodules or masses.
The esophagus is grossly dilated and contains oral contrast
within its lumen. No mediastinal, axillary or hilar adenopathy.
The thyroid gland is
unremarkable.
ABDOMEN AND PELVIS:
There is an indirect left inguinal hernia that contains a
portion of the distal descending colon and is causing proximal
obstruction (2b:155 and 501b:31). Proximal to this point, the
descending and transverse colon are dilated with the transverse
colon measuring up to 12 cm in diameter. The
patient is status post right hemicolectomy. There is an
enterocolic anastomosis in the midline of the upper abdomen
between the transverse colon and ileum (501b:13) and the
anastomosis is widely patent. The small bowel is grossly
distended measuring up to 4.7 cm in diameter. The stomach and
esophagus are also distended. No free air or fluid is identified
within the abdomen or pelvis. There is no evidence of bowel
ischemia.
The liver is within normal limits. The portal and hepatic veins
are patent. No intra or extrahepatic duct dilatation. The
patient is status postcholecystectomy. There are simple cysts
within the upper pole of the left kidney with the largest
measuring 1.4 cm in diameter. The kidneys are otherwise
unremarkable. No hydronephrosis. The left adrenal gland
demonstrates an indeterminate 1.2 cm nodule which is stable.
The right adrenal gland is normal. Multiple subcentimeter
calcified granulomas are noted within the spleen. The pancreas
is unremarkable. No mesenteric or retroperitoneal adenopathy.
The abdominal aorta is of normal caliber.
There is a Foley catheter within the bladder. Small pockets of
gas are identified within the bladder consistent with recent
catheterization. The patient appears to be status post
prostatectomy with surgical clips noted in the pelvis. The
seminal vesicles appear to remain in situ. No pelvic
adenopathy.
OSSEOUS STRUCTURES:
The patient is status post laminectomy at L2-L5 with an fusion
noted from L3-L5 with an spinal fusion plate and screws in situ.
Degenerative disc disease is noted throughout the thoracic and
lumbar spine and is most marked at T12-L1. The osseous
structures of the chest, abdomen and pelvis are otherwise
unremarkable.
XR ABDOMEN (portable) ___:
The AP radiograph of the abdomen demonstrates small and large
bowel dilatation, substantial raising concern for acute
enterocolitis. Toxic megacolon although not clearly seen cannot
be entirely excluded. The findings were discussed with Dr.
___ on ___, at 10:30 a.m. over the phone by Dr.
___ resident). Lung bases are clear and no
substantial pleural effusion is seen, although small amount is
most likely present especially on the left.
___ TTE
While image quality is somewhat suboptimal, regional left
ventricular wall motion appears to be normal. Left ventricular
systolic function is hyperdynamic (EF>75%). The right
ventricular cavity is dilated with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. No aortic regurgitation is
seen. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is a small free
space anterior to what appears to be a fat pad which may
represent a small, loculated pericardial effusion.
IMPRESSION: Hyperdynamic left ventricle, dilated right ventricle
with normal systolic function
___ LUE US
The left internal jugular, subclavian, axillary, cephalic,
basilic, and two brachial veins were interrogated. There is
normal color spectral Doppler waveforms within the visualized
veinsdistally. There is patency and normal caliber within all
interrogated vessels without evidence of DVT. There is normal
compression within the internal jugular, axillary, cephalic, and
basilic, with normal augmentation in the axillary, cephalic,
basilic, and two brachial veins. An arterial line is best seen
in the axillary artery.
IMPRESSION:
No evidence of DVT in the left upper extremity.
___ video swallow study
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is penetration of thin
liquids, nectar thick liquids, and puree. There is aspiration
of nectar thick liquids. There is severe residue with puree.
For additional details, please refer to the speech and swallow
division note in OMR.
IMPRESSION:
Penetration of thin liquids, nectar thick liquids, and puree.
Aspiration of nectar thick liquids.
___ bilateral ___ US
Grayscale, color and Doppler images were obtained of bilateral
common femoral, femoral, popliteal and tibial veins. There is
extensive deep vein thrombosis seen within both legs within the
common femoral, femoral, popliteal and tibial veins.
In the right leg there is minimal flow detected within the
popliteal, femoral and common femoral veins. No flow is
detected in the right calf veins.
Thrombus within the left leg appears to be occlusive within the
calf veins, popliteal and femoral veins. Note is made that
Ultrasound is unable to visualize the iliac veins to determine
extent of the thrombus.
IMPRESSION:
Extensive acute deep vein thrombosis seen throughout the veins
of both legs.
___ CXR
Interval placement of a feeding tube with the tip in the
proximal small bowel.
Clips in the right upper quadrant are seen, consistent with
cholecystectomy.
Spinal hardware is seen overlying the visualized mid-to-lower
lumbar spine.
There are two approximately 1 cm ill-defined patchy opacities in
the right
upper lung which have developed since the prior study and
therefore may
represent areas of early aspiration or infection. In a patient
with multiple comorbidities, emboli should also be considered.
Clinical correlation is advised. There is blunting of the left
costophrenic angle which may represent pleural thickening or a
small effusion. No pneumothorax is seen. Overall,
cardiac and mediastinal contours are stable. Calcification of
the aorta,
consistent with atherosclerosis.
___ MR head without contrast
1. No acute intracranial abnormality; specifically, there is no
finding to
suggest acute ischemia.
2. Moderate global atrophy with central component, but only
very mild
sequelae of chronic small vessel ischemic disease and no finding
to suggest
previous territorial infarction.
3. Fluid-opacification of scattered right mastoid air cells,
new since the
previous studies, with no evidence of discrete right
nasopharyngeal mass;
correlate clinically.
___ EMG
Abnormal study. The electrophysiologic data is consistent with
ongoing
denervation in the left L3-4 and right L5-S1 myotomes and
chronic
reinnervation in all myotomes tested. The differential diagnosis
includes
bilateral lumbosacral polyradiculopathies, or a focal disorder
of motor
neurons at the lumbosacral level; however there is no evidence
for a
generalized disorder of motor neurons or their axons as in
amyotrophic lateral sclerosis. If warranted, a repeat study can
be considered in ___ months.
___ MR cervical spine
Multilevel spondylosis most prominent at C3-C4 and C4-C5 levels,
with disc
bulges causing flattening the ventral surface of the spinal
cord, without
definite spinal cord signal abnormality.
URINE:
___ 04:41PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 02:23AM URINE Color-Amber Appear-Clear Sp ___
___ 04:41PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 02:23AM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-0.2 pH-5.5 Leuks-NEG
___ 04:41PM URINE RBC-11* WBC-15* Bacteri-MANY Yeast-MOD
Epi-<1
___ 02:23AM URINE RBC-23* WBC-10* Bacteri-FEW Yeast-NONE
Epi-1
___ 02:23AM URINE CastHy-22___ 02:23AM URINE Hours-RANDOM Creat-174 Na-LESS THAN K-27
Cl-25
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.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
blood cultures ___ to ___ no growth
DISCHARGE
___ 04:45AM BLOOD WBC-5.7 RBC-3.15* Hgb-9.2* Hct-29.7*
MCV-94 MCH-29.3 MCHC-31.1 RDW-15.0 Plt ___
___ 04:45AM BLOOD ___ PTT-72.3* ___
___ 04:45AM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-138
K-4.6 Cl-101 HCO3-28 AnGap-14
___ 05:38AM BLOOD CK(CPK)-108
___ 04:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.3
Brief Hospital Course:
This is a ___ year-old man with h/o HTN, HLD, lumbar spinal
stenosis who was discharged on ___ from ___ to rehab s/p
L2 to L5 laminectomy, L3 to S1 fusion and L3 to L5
instrumentation. On ___, he was readmitted after a
mechanical fall related to orthostasis. His hospital course was
complicated by toxic megacolon and SBO requiring exploratory
laparotomy on ___. He developed bilateral DVTs
post-operatively on ___. He also had worsening
dysphagia/dysarthria, tachypnea, and fecal and urinary
incontinence with UTI.
# Abdominal distension: The patient developed abdominal
distension with mild tenderness on ___, one week
post-operatively. An abdominal CT was obtained and showed
dilation of the small and large intestines with a L inguinal
hernia concerning for incarceration. An NG tube was placed for
decompression and the patient was resuscitated with IV fluids.
All narcotic medications were limited/stopped as tolerated. The
patient was seen by Surgery and found to have a reducible
hernia. He did transiently have an elevated lactate of 2.4; in
general the lactate did trend downward, however there was a
spuriously elevated lactate of 10.5 on ___ which was normal on
repeat draw. The patient was re-evaluated by Surgery and was
felt to have a surgical cause for his abdominal distension. He
was taken to the OR in the afternoon on ___ and underwent
exploratory laparotomy, decompressive enterotomy, left inguinal
hernia repair, and extensive lysis of adhesions. Wound remained
clean and dry. Abdominal staples will be removed on ___.
# Extensive bilateral deep venous thrombi: On ___, the
patient was found to have edema of his right lower leg. Doppler
ultrasounds revealed bilateral lower extremity DVTs. He was
started on a heparin drip and transitioned to warfarin. His INR
did not have a chance to become therapeutic. On ___,
heparin was stopped and he will be bridged using enoxaparin SC
70mg Q12H (1mg/kg/dose) and warfarin. As this was a reversible
risk factor (surgery, bedrest) and first time DVT, he will
require 3 months of anticoagulation with warfarin, with goal INR
of 2.0-3.0.
# Dysphagia/Dysarthria: Patient was admitted with mild
dysarthria, which per chart review appears to have been present
for ___ months. CT of the head on admission did not reveal any
acute intracranial abnormalities. During his hospitalization,
however, the dysarthria worsened as did his dysphagia. He was
evaluated by the speech and swallow service who felt that he was
unsafe to take PO. A Dobhoff was placed, tube feeds initiated,
and the patient made strict NPO. He was evaluated by Neurology
who suspected motor neuron disease given various upper and lower
motor neuro physical exam findings. EMG was inconclusive, but
was not definitive for ALS. MRI c-spine did not reveal cervical
stenosis to explain dysarthria and dysphagia. Patient's
dysarthria did improve near the end of his stay. Repeat swallow
evaluation on ___ revealed persistent oropharyngeal
dysphagia. Patient will be discharged to rehab with TF through
Dobhoff and will need re-assessment by swallow team.
# UTI. Patient with Foley during medical course developed UTI,
E. coli pansensitive. He was treated with ceftriaxone starting
___. This was transitioned on ___ to cefpodoxime 200mg PO BID,
ending ___, for a 7-day course for complicated UTI. Patient
was discharged without a catheter.
# Respiratory distress: While admitted to medicine, the patient
developed tachypnea and tachycardia and was found to have an O2
saturation in the low ___ ABG was urgently drawn and showed: pH
7.51 / pCO2 18 / pO2 68 / HCO3 15. He was transferred to the
MICU service but was felt to have either a primary or mixed
alkalosis without worry for fatigue. Pulmonary embolus was
considered; CTA of the chest was obtained and did not show any
evidence of PE. The patient's tachypnea and alkalosis were more
likely secondary to abdominal distension with diminished tidal
volumes and compensatory rapid respiratory rate. His tachypnea
resolved.
# Fall: Ddx included orthostatic hypotension, MI, arrhythmia,
stroke/TIA, seizure. Orthostatic hypotension most likely given
positive orthostatics in ED after fall, pre-renal picture,
recent decreased PO and loose stools (increased since spinal
surgery on ___ per patient). Anemia possibly contributing. He
was found to be profoundly orthostatic on the floor s/p IVF and
was treated with. EKG showing diffuse ST segment changes in
setting of sinus tachycardia, but MI less likely given lack of
chest pain/chest pressure, negative troponins x3, negative CK-MB
x2. Stroke unlikely given no new neurologic deficit. Head CT
negative for acute major vascular territorial infarction.
Arrhythmia possible, monitored. Seizure unlikely given no h/o
seizures, no LOC and no post-ictal symptoms.
# Fecal incontinence/loose stools: Infectious diarrhea (C. diff,
other pathogens) vs. neurologic derangement s/p spinal surgery.
Bacterial pathogens causing dysentery unlikely given lack of
fever and guaiac negative so far. Spinal involvement unlikely
given lack of other changes on neurologic exam. Ortho was
consulted in the ED and did not recommend any further surgical
interventions. C. diff toxin was negative on multiple occasions.
Rectal tube removed on ___. Patient continued to have ___
loose stools in the bed but with slowly gaining bowel movement
sensation. He was able to have normal bowel movement in bedpan
just prior to discharge.
# Anemia: Hct 31.5 on admission, normocytic, down from what
appears to be baseline in the ___. Ddx recent spinal surgery
with EBL 800cc vs. hemolysis. Anemia may have contributed to
orthostasis.
# Spinal stenosis/back pain: s/p L2 to L5 laminectomy, L3 to S1
fusion and L3 to L5 instrumentation on ___. Pain well
controlled with Tylenol and dilaudid PRN, no neurological
deficits appreciated. Back staples removed by his surgeon Dr.
___ on ___. Wound remained clean, dry, and intact.
# Hypertension. Home amlodipine was stopped given orthostasis.
# Depression and anxiety: stable. Continued home meds.
# GERD: stable. Continued home meds.
### TRANSITIONAL ISSUES ###
1) Failed swallow evaluation on ___. He will need to remain
strict NPO and have all nutrition tube feeds through his Dobhoff
tube. Frequent evaluations by Swallow in rehab will be most
helpful in advancing his diet. He will need tube feeds until
further swallow evaluation. Neurology will follow him as
outpatient and he may need repeat EMG in ___ months. We are
hopeful he will regain speech and swallow function as his
medical issues improve.
2) Bilateral DVT. Patient was initially on heparin drip and
warfarin 5mg daily. Heparin drip was stopped on ___ and he
started enoxaparin 70mg SC q12hr (1mg/kg/dose). He will need to
be on enoxaparin for 7 days until INR>2 and then warfarin for 3
months with goal INR 2.0 to 3.0.
3) Fecal incontinence. Patient developed fecal incontinence
during his hospitalization for unclear reasons, possibly related
to spinal surgery and immobility. C. diff negative on multiple
tests. He did have a FlexiSeal which was removed on ___. He
did have 4 loose small stool movements, but with decreasing
frequency and he states he is starting to gain some sensation in
his bowel movements. We are hopeful he will regain stool
continence since he was fine before he arrived.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Lorazepam 0.25 mg PO BID
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Sertraline 50 mg PO DAILY
5. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation BID
6. Acetaminophen 650 mg PO Q6H
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Calcium Carbonate 500 mg PO TID W/MEALS
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Tamsulosin 0.4 mg PO HS
13. Aspirin 81 mg PO DAILY
14. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg Oral Daily
15. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral Daily
16. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Calcium Carbonate 500 mg PO TID W/MEALS
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Lorazepam 0.25 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Omeprazole 20 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO DAILY
10. Sertraline 50 mg PO DAILY
pt has tolerated
11. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg Oral Daily
12. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral Daily
13. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation BID
14. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
Need for 7 days until your INR>2 for 24 hours. Continue warfarin
5mg with goal INR ___ for 3 months.
15. Warfarin 5 mg PO DAILY16
INR goal 2.0-3.0 x 3 months.
16. Tamsulosin 0.4 mg PO HS
17. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
18. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
19. Glucose Gel 15 g PO PRN hypoglycemia protocol
20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
21. OxycoDONE Liquid 5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg/5 mL 5 mg by mouth Q8H:PRN Disp #*100
Milliliter Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1) Mechanical fall
2) Recent spinal surgery
3) Inguinal hernia, small bowel obstruction
4) Urinary tract infection, complicated
5) Oropharyngeal dysphagia and dysarthria
6) Bilateral extensive deep venous thrombi
7) Fecal incontinence
SECONDARY DIAGNOSES:
- Hypertension
- Hypercholesterolemia
- GERD
- Multifactorial gait disorder
- Hx Prostate cancer
- Hx Colon cancer
- Anxiety
- Depression
- Hx Nephrolithiasis
- Spinal stenosis s/p L2 to L5 laminectomy, L3 to S1 fusion and
L3 to L5 instrumentation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for a
fall. You were found to have low blood pressure when standing.
You were treated with intravenous fluids and improved with this
treatment. While here, you also were found to have abdominal
distension, enlarged colon and obstruction of the small
intestine. You underwent abdominal surgery to repair the
inguinal hernia, bowel obstruction, and adhesions that developed
within your abdomen.
You also had extensive blood clots in both of your legs. This
will be treated with blood thinning medications for at least 3
months. You had a complicated urinary tract infection which was
treated with 7 days of IV antibiotic, ceftriaxone.
You also developed some difficulty with speech and swallow
functions. Neurology and Speech/Swallow teams evaluated you and
did not find any evidence of stroke or motor neuron disease. You
were started on tube feeds given the difficulty of swallowing.
You will not be able to eat or drink anything by mouth. You will
have all of your nutrition through the tube that goes through
your nose and into your stomach and small intestine. You will
need to re-evaluated at the rehab facility for swallow function.
Followup Instructions:
___
|
10569938-DS-9 | 10,569,938 | 28,789,722 | DS | 9 | 2138-04-08 00:00:00 | 2138-04-08 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Zithromax / Seroquel / Vagifem
Attending: ___.
Chief Complaint:
Right ankle fracture
Major Surgical or Invasive Procedure:
Right ankle ORIF (___)
History of Present Illness:
Is a ___ female, who fell onto her right foot. She had
immediate pain. When EMS arrived her foot was deformed in the
attempted reduction. No other injuries. Patient stating her
pain is only located over ankle. Worse with movement. No
numbness or tingling. No blood thinners. Patient at baseline
states she has poor perfusion to her lower extremities often not
been able to find a pulse.
Past Medical History:
HTN, HLD, DM, Asthma, restless leg syndrome
Social History:
___
Family History:
N/C
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
short leg splint in place
wiggles toes
Pertinent Results:
___ 05:43PM GLUCOSE-133* UREA N-23* CREAT-0.9 SODIUM-140
POTASSIUM-5.4 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16
___ 05:43PM WBC-9.3 RBC-4.21 HGB-12.4 HCT-37.4 MCV-89
MCH-29.5 MCHC-33.2 RDW-14.1 RDWSD-45.4
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R ankle ORIF, 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
non weight bearing in the right lower extremity, and will be
discharged on Aspirin 325mg daily for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
-Adult Low Dose Aspirin 81 mg tablet,delayed release 1 (One)
tablet,delayed release (___) by mouth once a day
-Centrum Silver 500 mcg-250 mcg Chewable Tab (dose uncertain)
-Cranberry 250 mg Tab (dose uncertain)
-Crestor 20 mg tablet TAKE 1 TABLET BY MOUTH EVERY DAY
-L-Threonine Crystals po once a day
-Loratadine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
-Metformin 850 mg Tab 1 (One) Tablet(s) by mouth three times a
day
-Omega-3 Fish Oil 1,000 mg-5 unit Cap 3 (Three) Capsule(s) by
mouth once a day
-ProAir HFA 90 mcg/actuation aerosol inhaler INHALE 2 PUFFS BY
MOUTH EVERY 4 HOURS AS NEEDED FOR COUGH
-Victoza 2-Pak 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous pen
injector 0.3 ml sc qAM
-citalopram 40 mg tablet TAKE 1 TABLET BY MOUTH EVERY MORNING
-codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid 2 tsp by
mouth q 4 hours as needed for cough
-dextroamphetamine ER 10 mg capsule,extended release 2 (Two)
capsule(s) by mouth twice daily
-diazepam 5 mg tablet 1 tablet(s) by mouth q 8 hours as needed
for anxiety
-glipizide ER 5 mg tablet, extended release 24 hr 1 tablet(s) by
mouth once a day
-levothyroxine 125 mcg Tab 1 Tablet(s) by mouth daily
-lisinopril 20 mg Tab 1 (One) Tablet(s) by mouth once a day
-pramipexole 1 mg tablet 3 TABLET(S) BY MOUTH AT BEDTIME AS
NEEDED FOR RESTLESS LEGS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every eight
(8) hours Disp #*30 Tablet Refills:*1
2. Aspirin 325 mg PO DAILY Duration: 30 Days
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 (One) tablet(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
5. Citalopram 40 mg PO DAILY
6. GlipiZIDE XL 5 mg PO DAILY
7. Levothyroxine Sodium 125 mcg PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing of the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone ___ mg every 4 hours as needed for
increased pain. Aim to wean off this medication in 1 week or
sooner. This is an example on how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- 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
Followup Instructions:
___
|
10570063-DS-7 | 10,570,063 | 22,881,221 | DS | 7 | 2144-01-22 00:00:00 | 2144-01-23 17:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
simvastatin / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Left chest tube insertion
History of Present Illness:
Mr. ___ is a ___ with a PMH of ___ disease who
presents with 2d of altered mental status and progressively
worsening SOB since discharge from ___ two days ago.
Six weeks ago he fell while walking up stairs and sustained
multiple left-sided rib fractures (___). He was admitted to ___
and discharged to rehab after 1 week. He had no shortness of
breath at the time and denies subsequent trauma.
About a week and a half ago he developed worsening shortness of
breath on exertion and pain with inspiration and was found to
have a hemothorax on CXR. Chest tube placement in the ED drained
2L of serosanginous fluid. He was admitted and subsequent CXR
showed improvement of the pleural effusion with improvement of
clinical symptoms. He was discharged on HOD2 (___).
Mr. ___ says he has continued to experience progressive
shortness of breath since the time of discharge. He reports no
fevers, chills, night sweats, fatigue, cough, hemoptysis,
nausea,
vomiting, or diarrhea. His PCP recommended that he come to the
ED. He reports moderate chest pressure and tenderness over the
left-chest on inspiration.
Past Medical History:
___ disease, hyperlipidemia, type II diabetes, gout,
hypertension, BPH, gallstones, mitral regurgitation
Social History:
___
Family History:
NC
Physical Exam:
Physical Exam:
T: 97.4 P:78 BP: 104/69 O2sat: 96,3L NC
General: awake, alert, in mild distress due to shortness of
breath
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: decreased breath sounds on L, normal excursion, no
respiratory distress, no crackles, rales, or rhonchi
Back: no vertebral tenderness, no CVAT
Musculoskeletal: ttp over L anterior ribs
Abdomen: soft, NT, ND, no mass, no hernia
Neuro: strength intact/symmetric, sensation intact/symmetric
Extremities: edema of b/l LEs, palpable pulses
Skin: no rashes/lesions/ulcers
Discharge Physical Exam:
VS: 98.2, 77, 128.82, 18, 98%ra
Gen: A&O x3
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: decreased breath sounds on L, normal excursion, no
respiratory distress, no crackles, rales, or rhonchi
Back: no vertebral tenderness, no CVAT
Musculoskeletal: ttp over L anterior ribs. CT site with gauze
dsg, CDI.
Abdomen: soft, NT, ND, no mass, no hernia
Neuro: strength intact/symmetric, sensation intact/symmetric
Extremities: edema of b/l LEs, palpable pulses
Skin: no rashes/lesions/ulcers
Pertinent Results:
___ 03:07PM BLOOD WBC-9.7 RBC-4.56* Hgb-13.1* Hct-39.5*
MCV-87 MCH-28.7 MCHC-33.2 RDW-13.2 RDWSD-41.1 Plt ___
___ 12:50PM BLOOD WBC-10.3* RBC-4.33* Hgb-12.5* Hct-37.5*
MCV-87 MCH-28.9 MCHC-33.3 RDW-13.2 RDWSD-41.1 Plt ___
___ 05:46AM BLOOD WBC-8.0 RBC-4.30* Hgb-12.3* Hct-36.7*
MCV-85 MCH-28.6 MCHC-33.5 RDW-13.2 RDWSD-41.1 Plt ___
___ 05:50AM BLOOD WBC-8.3 RBC-4.65 Hgb-13.3* Hct-39.1*
MCV-84 MCH-28.6 MCHC-34.0 RDW-13.2 RDWSD-40.1 Plt ___
___ 03:18PM BLOOD WBC-8.4 RBC-4.34* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.3 MCHC-33.9 RDW-13.2 RDWSD-41.6 Plt ___
___ 12:50PM BLOOD Glucose-159* UreaN-16 Creat-0.7 Na-136
K-4.9 Cl-103 HCO3-26 AnGap-12
___ 05:46AM BLOOD Glucose-195* UreaN-16 Creat-0.6 Na-136
K-3.7 Cl-102 HCO3-22 AnGap-16
___ 05:50AM BLOOD Glucose-115* UreaN-17 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-21* AnGap-18
___ 03:18PM BLOOD Glucose-138* UreaN-24* Creat-0.8 Na-133
K-4.8 Cl-100 HCO3-19* AnGap-19
___ 11:57PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:01PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:07PM BLOOD cTropnT-<0.01
___ 12:50PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
___ 05:46AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.9
___ 05:50AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9
Imaging:
___ CT Head: no acute intracranial process
___ CXR: Interval volume loss of the left lung with increased
opacity
particularly along the periphery of the left mid to lower lung.
Persistent blunting of the left costophrenic angle. Findings
concerning for pleural effusion which may be partially
loculated.
Superimposed focal consolidation the left mid lung is not
excluded
___ CTA Chest:
No evidence of pulmonary embolism to the proximal segmental
levels. Large loculated left pleural effusion with adjacent
compressive atelectasis, decreased from ___.
Heterogeneous
consolidation in the left upper lobe largely surrounds the prior
thoracostomy tract, although superimposed infection is difficult
to exclude.
___ CXR:
Over riding acute left rib fractures are responsible for local
pleural or
extrapleural hematoma along the lateral costal pleural surface,
but there has also been an increase in small areas of
consolidation in the adjacent left lung.
___ CT CHEST:
Peripheral consolidation in the left lung is grossly unchanged
Loculated left pleural effusion has decreased, of note the tip
of the pigtail catheter is anterior to the current largest area
of pleural fluid.
___ CT CHEST:
Of the chest tube removal, air inclusions in the chest wall have
decreased. The extent of the partly inter fissure oral left
pleural effusion is stable. The left lateral consolidation with
surrounding ground-glass opacities is also stable. No new lung
parenchymal abnormalities. Overall normal appearance of the
right lung.
___ CXR:
In comparison with the study ___, there is increased
blunting of the left costophrenic angle suggesting some
re-accumulation of pleural fluid.
___ CXR:
Small if any increase in the residual left pleural effusion,
since ___, largely basilar, and in the residual peripheral,
left upper lobe pulmonary abnormality. No pneumothorax. Right
lung clear. Heart size normal
**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 ___:
PROPIONIBACTERIUM ACNES. RARE GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ with ___'s disease who presents with
progressive SOB and pleuritic pain since his discharge 2d ago
after placement of thorocostomy and drainage of hemothorax. He
mentioned feeling chest pressure, but troponin levels were
<0.01. He has been intermittently tachypneic to the ___ and
requiring 3L O2 by NC. CXR and CTA Chest show locularted pleural
effusion and heterogenous lesion in the LUL. The patient was
admitted for close respiratory monitoring and further
management.
Interventional Pulmonary was consulted and a left chest tube was
placed on HD2. Subsequent imaging showed improvement in the
fluid collection and patient's breathing. On HD3 the patient had
a fall. There was no headstrike or loss of consciousness. There
were no injuries. The patient was started on a PPI and ibuprofen
for pleuritis. On HD4, the patient was having chest pain. EKG
and troponins were negative. On HD5 the chest tube came out.
Post pull chest XRays were stable but did note a small
reaccumulation of pleural fluid on left lobe. The patient
remained clinically stable, saturating well on room air and
pulling 1000 on incentive spirometer.
Physical therapy worked with the patient and recommended rehab
once medically cleared. During this hospitalization, the patient
ambulated with assist, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged to rehab services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. He had follow-up scheduled with the Trauma clinic and with
Interventional Pulmonology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Carbidopa-Levodopa (___) 3 TAB PO @8AM
6. Carbidopa-Levodopa (___) 2 TAB PO @12PM
7. Carbidopa-Levodopa (___) 3 TAB PO @4PM
8. Carbidopa-Levodopa (___) 2 TAB PO @8PM
9. Finasteride 5 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Pramipexole 0.5 mg PO QHS
13. Tamsulosin 0.4 mg PO QHS
14. Acetaminophen 650 mg PO Q4H:PRN pain
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Carbidopa-Levodopa (___) 3 TAB PO @8AM
6. Finasteride 5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Pramipexole 0.5 mg PO QHS
10. Tamsulosin 0.4 mg PO QHS
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
12. Allopurinol ___ mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Heparin 5000 UNIT SC BID
15. Ibuprofen 600 mg PO Q8H Duration: 3 Weeks
16. Omeprazole 40 mg PO DAILY
17. TraZODone ___ mg PO QHS:PRN insomnia
18. Carbidopa-Levodopa (___) 2 TAB PO @12PM
19. Carbidopa-Levodopa (___) 3 TAB PO @4PM
20. Carbidopa-Levodopa (___) 2 TAB PO @8PM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left pleural effusion likely sympathetic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were brought to ___ with increasing shortness of breath
and were found to have a re-accumulation of fluid in your left
lung. A drain was placed by the Interventional Pulmonologists.
The drain came out and your subsequent films have been stable.
You have follow-up scheduled and you will need a chest xray
prior to your appointment.
You were seen by Physical Therapy and they recommend you be
discharged to rehab once medically cleared. Please note the
following discharge instructions:
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
* Pneumonia is a serious complication. 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.
Followup Instructions:
___
|
10570063-DS-8 | 10,570,063 | 22,761,576 | DS | 8 | 2144-08-19 00:00:00 | 2144-08-20 14:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin / hydrochlorothiazide
Attending: ___
Chief Complaint:
Unsteady gait, increased falls, urinary retention
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ of parkinsons, hyperlipidemia, type2DM, gout, HTN, BPH,
gallstones, MR,depression who is presenting with frequent falls,
of note he was recently discharged ___ fall, pt fell
while climbing stairs and broke 2 ribs, with subsequent effusion
and chest tube placement.
Pt went to his PCP on day of admission because his sister
notices he had fallen 5 times in the past 10 days. He states he
has become more unsteady on his feet and is unsure if he has hit
his head. He c/o of right knee pain.
No chest pain, SOB, fever, cough, dysuria, vomiting, nausea.
In the ED, initial vital signs were: T 97.0 P58 BP 144/71 R 18
O2 97%sat on RA
- Exam notable for: Alert with confusion easily and hematuria
through the foley
- Labs notable for K 7.3, recheck 4.4, UA with 182 RBC, 14WBC
UA:
Leuk Sm
Bld Lg
Nitr Neg
Prot 100
Glu Neg
Ket Tr
RBC >182
WBC 14
- Studies performed include CXR negative, knee xray with no
effusion, CT C-spine negative for fracture but possible MM and
osteopenia, CT head with no acute intracranial process.
- Of note, pt was initially unable to give a urine specimen. Per
PCP, pt has been having difficulty with urinary retention
recently. Straight cath was attempted x2, but this was a
difficult placement. He notably developed hematuria after this.
- Patient was given
PO/NG Atorvastatin
PO/NG Carbidopa-Levodopa (___)
PO Finasteride
PO/NG Atorvastatin 10 mg
PO/NG Carbidopa-Levodopa (___) 3 TAB
PO Finasteride 5 mg
PO/NG Pramipexole .25 mg
PO/NG Allopurinol ___ mg
PO/NG Atenolol 50 mg
PO/NG Carbidopa-Levodopa (___) 3 TAB
PO/NG Escitalopram Oxalate 10 mg
PO/NG Lisinopril 20 mg
PO Omeprazole 40 mg
- Vitals on transfer:
80; 130/68; 18; 99% RA
Past Medical History:
___ disease, hyperlipidemia, type II diabetes, gout,
hypertension, BPH, gallstones, mitral regurgitation
Social History:
___
Family History:
NC
Physical Exam:
Admission physical exam:
GENERAL: AOx3, NAD, disheveled, distraught
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: Unsteady gait, tremor, dysmetria, ___ strength in
all extremities
Foley in with frank hematuria
Discharge physical exam:
GENERAL: AOx3, NAD, in good spirits
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: slow gait, moves with walker, ___ strength in all
extremities
Foley in with frank hematuria
Pertinent Results:
Admission labs:
___ 04:10PM BLOOD WBC-7.1 RBC-4.82 Hgb-13.7 Hct-41.5 MCV-86
MCH-28.4 MCHC-33.0 RDW-13.2 RDWSD-41.0 Plt ___
___ 04:10PM BLOOD Neuts-64.7 ___ Monos-8.3 Eos-0.8*
Baso-0.3 Im ___ AbsNeut-4.58 AbsLymp-1.81 AbsMono-0.59
AbsEos-0.06 AbsBaso-0.02
___ 04:10PM BLOOD Plt ___
___ 07:33AM BLOOD ___ PTT-32.6 ___
___ 04:10PM BLOOD Glucose-105* UreaN-17 Creat-0.9 Na-133
K-7.3* Cl-99 HCO3-21* AnGap-20
___ 07:33AM BLOOD ALT-<5 AST-13 LD(LDH)-175 AlkPhos-107
TotBili-0.9
___ 04:10PM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0
___ 07:33AM BLOOD TotProt-6.7 Albumin-4.3 Globuln-2.4
Calcium-9.3 Phos-3.7 Mg-2.1
___ 07:33AM BLOOD VitB12-261
___ 07:33AM BLOOD TSH-1.6
___ 07:33AM BLOOD Free T4-1.3
___ 01:43PM BLOOD PSA-3.3
___ 07:33AM BLOOD PEP-NO SPECIFI ___ FreeLam-19.2
Fr K/L-0.77
___ 07:33AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge labs:
___ 08:36AM BLOOD WBC-7.5 RBC-5.02 Hgb-14.3 Hct-42.7
MCV-85# MCH-28.5 MCHC-33.5 RDW-12.9 RDWSD-39.9 Plt ___
___ 08:36AM BLOOD Neuts-70.2 ___ Monos-7.7 Eos-1.5
Baso-0.1 Im ___ AbsNeut-5.28 AbsLymp-1.52 AbsMono-0.58
AbsEos-0.11 AbsBaso-0.01
___ 08:36AM BLOOD Plt ___
___ 08:36AM BLOOD Glucose-144* UreaN-22* Creat-0.8 Na-142
K-4.0 Cl-105 HCO3-20* AnGap-21*
___ 08:36AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9
Radiology:
___ CHEST X RAY
FINDINGS:
The cardiomediastinal silhouette is stable, reflective of a
tortuous thoracic aorta. The cardiac silhouette is normal in
size. The hila are unremarkable. The lungs are clear without
focal consolidation. Left lateral pleural thickening overlying
healed left lateral rib fractures is unchanged. There is no
pulmonary vascular congestion or pulmonary edema. There is no
pneumothorax or pleural effusion.
IMPRESSION:No acute cardiopulmonary process.
___ KNEE X RAY
FINDINGS:
There is no fracture or focal osseous abnormality. Degenerative
changes are noted with medial and lateral joint space narrowing
and lateral
chondrocalcinosis. Tricompartmental degenerative spurring is
also seen.
There is no suprapatellar effusion. Atherosclerotic
calcifications are
identified.
IMPRESSION: No fracture.
___ CT HEAD W/O CONTRAST
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline
shift, or
acute major vascular territorial infarct. Periventricular white
matter
hypodensities are likely sequela of chronic small vessel
disease. Gray-white matter differentiation is preserved.
Ventricles and sulci are age appropriate. Mucosal thickening
noted within the maxillary sinuses. Included paranasal sinuses
and mastoids are otherwise clear. Skull and extracranial soft
tissues are unremarkable.
IMPRESSION: No acute intracranial process
___ SKELETAL SURVEY
FINDINGS:
Small lesion seen on cervical spine CT are not definitely seen
on today's
exam. There are no lytic or sclerotic worrisome lesions.
Left rib fractures are stable since ___ chest
radiograph. There are degenerative changes spine. Arterial
calcifications.
IMPRESSION: No radiographic evidence of lytic or sclerotic
worrisome lesions.
Micro
Urine culture no growth
RPR negative
Brief Hospital Course:
Mr. ___ is a ___ with history of ___ disease,
dyslipidemia, type2DM, gout, hypertension, BPH, gallstones,
mitral regurgitation, depression who presented with worsening
gait, altered mental status, urinary retention (with hematuria
following Foley catheter insertion), and progressive decline of
overall function. Infectious and metabolic work-up unrevealing.
Improvement in mental status and gait throughout hospital stay.
Dr. ___ neurologist) was in contact and assisted
with management, with no changes in ___ disease
medications advised. Question of depression contributing to
recent decline. Symptoms ultimately attributed to depression,
progressive ___ disease, with possible contribution from
urinary retention. With respect to urinary retention, patient
had a foley placed that was traumatic and associated with gross
hematuria. Throughout his stay, gross hematuria resolved. Per
urology recommendations, patient will be discharged with a foley
catheter and will follow up with his urologist Dr. ___
an official voiding trial. With respect to his dysphagia, speech
and swallow consulted, with video swallow test completed and
diet recommendations below.
ACTIVE ISSUES
# Worsening cognitive decline and gait instability with falls in
the setting of ___ disease
History of known ___ disease, followed by Dr. ___
Dr. ___ in outpatient neurology clinic. Since ___, when his
wife died of ovarian cancer, he has had significant decline. He
has been diagnosed with depression since then and treated with
low dose escitalopram without improvement. Per HCP ___
(sister-in-law) and primary care physician ___ has
been severely unsteady, falling frequently and losing his
balance almost everyday. They also notice that he falls asleep
in the middle of conversations, with increased forgetfulness
with short-term and long-term memory loss. He recently was
admitted to ___. Even at the
facility, he was falling frequently and having decline in
function. Physical exam notable for masked facial features and
some cogwheel rigidity. Labs notable for UA with 14 WBC, small
leukocyte esterase, and negative nitrite, with urine culture
negative. Noncontrast head CT negative for intracranial process,
and cervical spine CT negative for fracture. CXR reassuring
against infection or fractures. He was without neck stiffness,
headaches, or photophobia and remained afebrile and
hemodyanmically stable. Without prodrome
to falls to suggest ACS or arrhythmia, orthostatic vital signs
negative, telemetry without arrhythmia, and EKG reviewed and
reassuring. Metabolic causes investigated, include borderline
B12 at 261 (MMA pending at discharge), repleted with IM B12 and
initiation of PO B12 advised; TSH within normal limits and RPR
nonreactive. Niacin level <20, but in discussion with the
pathology resident, this level is used to exclude toxicity
rather than to evaluate for deficiency. By the time of
discharge, his balance and cognitive function had improved,
though he continued to suffer from short- and long-term memory
loss, remaining AOX3. In discussion with his outpatient
neurologists, symptoms attributed to progressive ___
disease, depression, and urinary retention. He was evaluated by
physical therapy and is being discharged to rehabilitation.
After rehabilitation, he may benefit from placement in a memory
unit, with which his primary care physician and HCP are in
agreement. Trial of melatonin initiated for improved regulation
of sleep-wake cycles.
# Oropharyngeal dysphagia
Evaluated by speech and swallow therapy and also had a video
swallow study, demonstrating oropharyngeal dysphagia, with
recommendations as below.
# Urinary retention/hematuria
He follows with urologist Dr. ___ has worked him up
extensively for his microscopic hematuria. On arrival, he had
urinary retention, not uncommon in ___ disease; he was
without back pain, saddle anesthesia, or focal weakness to
suggest spine/cauda pathology. He underwent traumatic Foley
placement, and 1L urine drained with frank hematuria with clots.
By day 2, gross hematuria had resolved. Urology consulted and
recommended that Foley catheter be left in place for ___ days,
with follow-up with his urologist for formal voiding trial with
urodynamic studies.
# Possible bone lucencies:
He was found incidentally on cervical spine CT to have possible
bone lucencies. SPEP/UPEP and SIFE/UIFE were reassuring. PSA was
within normal limits and below his prior baseline. Bone scan was
negative.
CHRONIC ISSUES
# Gout: Continued allopurinol.
# Depression: Continued escitalopram.
# Hypertension: Continued lisinopril and atenolol.
# Hyperlipidemia: Continued atorvastatin.
# BPH: Continued finasteride.
Transitional issues:
- Follow up with psychiatrist Dr. ___ ongoing treatment of
depression. Neurology believes his depression may be
contributing to his symptoms.
- Follow up with urologist Dr. ___ formal voiding trial
and ongoing work-up of hematuria.
- Follow up with neurologist Dr. ___ disease
management.
- Follow up pending MMA and consider further IM B12 repletion as
needed.
- Patient would benefit from memory unit after acute
rehabilitation.
- Speech and swallow evaluation below:
Solids: Soft solids
Liquids: Thin liquids with small single sips, cue to "hold in
mouth" and "swallow all at once" if accepting mild risk of
aspiration OR nectar thick liquids without need for
strategies/cuing.
Aspiration precautions:
-Small bites and sips, one at a time
-With Liquids small sip, "hold in mouth" and "Swallow all at
once."
-Double swallow with liquids if larger sip
-Feed fully upright
-Only initiate PO if alert, awake, responsive
-Cough/throat clear every ___ sips to clear any material
that may be in the laryngeal vestibule
Meds whole or crushed in applesauce. SLP service will continue
to follow during inpatient stay for review of strategies,
recommend continued SLP services upon discharge for review of
strategies/monitoring of diet tolerance.
New medications:
Melatonin 3mg QHS
Vitamin B12
Changed medications:
None
Stopped medications:
None
Code: DNR/DNI confirmed
Contact: HCP ___, sister in-law ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pramipexole 0.25 mg PO QHS
2. Omeprazole 40 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Carbidopa-Levodopa (___) 3 TAB PO BID
7. Carbidopa-Levodopa (___) 2 TAB PO BID
8. Atenolol 50 mg PO EVERY OTHER DAY
9. Allopurinol ___ mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Meladox (melatonin) 3 mg oral QHS
3. Carbidopa-Levodopa (___) 3 TAB PO BID
___, 1600
4. Allopurinol ___ mg PO DAILY
5. Atenolol 50 mg PO EVERY OTHER DAY
6. Atorvastatin 10 mg PO QPM
7. Carbidopa-Levodopa (___) 2 TAB PO BID
___, ___
8. Escitalopram Oxalate 10 mg PO DAILY
9. Finasteride 5 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Pramipexole 0.25 mg PO QHS
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
------------------
Altered mental status
Urinary retention
Hematuria
Dysphagia
Secondary diagnosis
___ disease
Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) with supervision
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because of worsening gait and increased
confusion. You also had urinary retention.
What happened to you during your hospital stay?
- We did extensive testing which showed absence of any infection
- We contacted your outpatient neurologist who recommended no
changes in your current medications
- You had a foley catheter placed for the urinary retention
- Speech and swallow team evaluated you and made changes to your
diet
What should you do when you leave the hospital?
- You will be discharged to a rehab where you will get stronger
- You should adhere to the following diet to prevent aspiration:
---Solids: Soft solids
---Liquids: Thin liquids with small single sips, cue to "hold in
mouth" and "swallow all at once" if accepting mild risk of
aspiration OR nectar thick liquids.
---Aspiration precautions:
-Small bites and sips, one at a time
-With Liquids small sip, "hold in mouth" and "Swallow all
at once."
-Double swallow with liquids if larger sip
-Feed fully upright
---Meds whole or crushed in applesauce
It was a pleasure caring for you here at ___. We are wishing
you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10570315-DS-4 | 10,570,315 | 25,165,954 | DS | 4 | 2198-08-27 00:00:00 | 2198-08-27 12:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness, CHB
Major Surgical or Invasive Procedure:
s/p dual chamber pacemaker implant
History of Present Illness:
___ PMH HTN, hypothyroidism, severe aortic stenosis who
underwent placement of a 23 mm LOTUS valve in the aortic
position on ___. Post-procedure the patient was noted to
have
new left bundle branch block but with no evidence of high
degree
AV block. She felt well and discharged home on ___ monitor
showed today a few episodes of complete heart block with
episodes
of up to 6sec pause. She was called and asked to come to the ED
by EP.
Pt reports that she was feeling unwell since discharge. She
notes feeling lightheaded and "just not right" when moving
around like walking to the bathroom and performing ADLs. No
chest pain or discomfort. ROS otherwise negative.
Past Medical History:
Severe aortic stenosis
Hypertension
Hypothyroidism
History of breast cancer with radiation
bacterial meningitis in ___
Social History:
___
Family History:
Mother had a stroke with residual. Father committed suicide at
___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.6 F, BP: 122/66mmHg supine, HR 72bpm, RR 16/min,
O2: 98% on RA.
Gen: A&OX3, NAD
NECK: Supple. JVP normal. NO carotid bruit.
CV: RR. normal S1,S2. Soft systolic murmur.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: Soft, NT, ND. +BS
Lower EXT: WWP. NO edema. Palpable distal pulses.
___: Several episodes of complete heart block lasting up to
6sec
ECG: NSR, Prolonged PR (332ms), LBBB
pre-TAVR ECG: NSR. PR at upper limit of normal. Normal axis.
Good RWP. NO RBBB, no LBBB
DISCHARGE PHYSICAL EXAMINATION
VS: 98.1, 130/68, 98, 18, 96% RA
Tele: v-paced, occ PVCs, HR ___, after atenolol ___
Gen: ___ yr old woman in NAD.
Neck/JVD: No JVD
Heart: S1S2 baseline reg I-II/VI systolic murmur
Chest: Right chest dressing intact over implant site, mild
surrounding bruising without swelling or evidence of hematoma,
no blood on dressing. Minimally tender.
Lungs: Clear to auscultation, no wheezing, rales or rhonchi
Abd: soft, non-tender, BS +
PV: Radial pulses: 2+ b/l. ___: 2+ bilaterally. No edema.
Extremities are warm and well perfused
Skin: Warm, dry and intact
Neuro: Alert and oriented x 3
Pertinent Results:
___ 04:20PM GLUCOSE-112* UREA N-26* CREAT-1.2* SODIUM-135
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
___ 04:20PM WBC-11.6* RBC-3.36* HGB-10.2* HCT-30.8*
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.5 RDWSD-45.9
___ 04:20PM NEUTS-74.0* LYMPHS-12.8* MONOS-11.6 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-8.57*# AbsLymp-1.49 AbsMono-1.35*
AbsEos-0.09 AbsBaso-0.04
___ 04:20PM PLT COUNT-177
___ 05:25AM BLOOD WBC-8.9 RBC-3.10* Hgb-9.7* Hct-28.5*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.5 RDWSD-44.7 Plt ___
___ 05:25AM BLOOD Glucose-87 UreaN-26* Creat-1.2* Na-132*
K-4.1 Cl-97 HCO3-24 AnGap-15
___ 05:25AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
___ 07:58PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 07:58PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.0 Leuks-SM
___ 07:58PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-3
___ 07:58PM URINE CastHy-15*
___ 07:58PM URINE AmorphX-RARE Uric AX-OCC
Brief Hospital Course:
Ms. ___ is an ___ yr old woman with a PMH of HTN,
hypothyroidism, severe aortic stenosis who underwent placement
of a 23 mm LOTUS valve in the aortic
position on ___. Post-procedure the patient was noted to
have
new left bundle branch block but with no evidence of high
degree
AV block. She felt well and discharged home on ___ monitor
the next day
showed today a few episodes of complete heart block with
episodes
of up to 6sec pause. She was called and asked to come to the ED
by EP.
Pt reports that she was feeling unwell since discharge. She was
re-admitted to the hospital and monitored on telemetry. She
continued to have episodes of CHB, that occurred mainly with
activity, so she remained on BR She remained hemodynamically,
stable. On ___, she underwent a dual chamber pacemaker implant.
On ___ she was restarted on atenolol and evaluated by physical
therapy. She was discharged home with services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Aspirin 81 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
9. Amoxicillin ___ mg PO PREOP
10. Calcitriol 0.25 mcg PO DAILY
11. ___ Adult 50+
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tab ORAL DAILY
12. Potassium Chloride 20 mEq PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Potassium Chloride 20 mEq PO BID
Hold for K >
9. Amoxicillin ___ mg PO PREOP
10. Multivitamins 1 TAB PO DAILY
11. ___ Adult 50+
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tab ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CHB post TAVR s/p dual chamber pacemaker implant
Severe AS s/p pacemaker implant
CKD stage III
Hypertension
E coli UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for a pacemaker implantation
to treat your abnormal heart rhythm. This abnormal rhythm
started after your TAVR procedure. Originally, your abnormal
rhythm was stable, and you were sent home with remote
monitoring. However, shortly after your return home, you became
symptomatic and developed a dangerous heart rhythm. You had a
pacemaker placed in order to prevent your heart from beating too
slowly.
Instructions regarding the care of the implant site have been
reviewed and are included in your discharge packet.
Please follow up in the device clinic next week as scheduled.
Followup Instructions:
___
|
10570398-DS-6 | 10,570,398 | 23,322,892 | DS | 6 | 2188-06-30 00:00:00 | 2188-06-30 14:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / lovastatin / furosemide
Attending: ___.
Chief Complaint:
fevers, rigors
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p AVR (25mm tissue) and CABGx2 on ___. His
post-operative course was unremarkable; he was discharged to
rehab on POD 6 to improve his overall strength. He was
readmitted briefly from ___ for orthostatic hypotension
when
working with ___. He was most recently seen in Dr. ___
clinic on ___ and has continued to do well since. He reports
continuing to gain strength daily, eating, drinking, ambulating
and overall feeling well.
Last night he felt subjectively warm followed by rigors for
about
a minute which self-resolved. His wife checked his temperature,
it was 99. Upon recheck of his temperature overnight it was
102.3 then 102.6. He comes in for evaluation. He feels well
currently and denies any present complaints.
Past Medical History:
Severe Aortic stenosis
Hypertension
Hyperlipidemia
Polymyalgia rheumatica on chronic steroids
Recent nose bleeds requiring cauterization (aspirin since d/c'd)
Thrombocytopenia
GERD
Right sided sciatica
Gout
Hard of hearing (right sided hearing aid)
Carpal tunnel syndrome bilaterally (wearing splints at night)
Arthritis
Past Surgical History:
AVR (tissue valve), CABGx2 ___
Right shoulder surgery for a "separation"
Social History:
___
Family History:
Father died at age ___ from unknown causes, might have had a
stroke. Mother with "cardiac disease", dying in her ___ from a
"giant embolism"
Physical Exam:
99.4 98.6 70 113/52 18 97%RA
NAD, AAOx3
well-healed midline sternal incision, no sternal click
RRR, soft systolic murmur
unlabored respirations, clear to auscultuation
abdomen soft, NTND
ext no edema, well-healed vein harvest site
Pertinent Results:
___ 08:20AM BLOOD WBC-4.2 RBC-4.15* Hgb-11.4* Hct-35.0*
MCV-84 MCH-27.5 MCHC-32.5 RDW-17.0* Plt ___
___ 05:41AM BLOOD WBC-7.1 RBC-4.16* Hgb-11.5* Hct-34.5*
MCV-83 MCH-27.6 MCHC-33.2 RDW-17.2* Plt ___
___ 08:20AM BLOOD Plt ___
___ 05:41AM BLOOD Plt ___
___ 05:41AM BLOOD ___ PTT-32.3 ___
___ 08:20AM BLOOD Glucose-114* UreaN-23* Creat-1.1 Na-140
K-3.6 Cl-105 HCO3-25 AnGap-14
___ 05:41AM BLOOD Glucose-128* UreaN-24* Creat-1.1 Na-134
K-3.9 Cl-99 HCO3-24 AnGap-15
___ 08:20AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
.
TEE
Conclusions
The left atrium is normal in size. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. A 25mm bioprosthetic
aortic valve prosthesis is present. The prosthesis is well
seated and not rocking. No masses or vegetations are seen on the
aortic valve. The aortic root is thickened. No aortic valve
abscess is seen. Trivial amount of paravalvular leak. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild to moderate (___) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, there is no significant change.
IMPRESSION: No evidence of endocarditis. Normally functioning
25mm tissue bioprosthetic valve. Mild-moderate mitral
regurgitation.
Brief Hospital Course:
Mr. ___ was admitted for further fever work-up. Sternotomy
wound is wee healed. Urine culture was negative. Chest X-ray
was unremarkable. Blood cultures are pending at the time of
discharge. He remained afebrile throughout the hospital course.
TEE was performed to rule out endocarditis, and it did. He
will follow-up with his PCP on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Aspirin 81 mg PO DAILY
3. DiphenhydrAMINE 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Allopurinol ___ mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Lorazepam 1 mg PO HS
9. Metoprolol Tartrate 12.5 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 20 mg PO DAILY
12. PredniSONE 6 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. DiphenhydrAMINE 25 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Furosemide 20 mg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Pravastatin 20 mg PO DAILY
11. PredniSONE 6 mg PO DAILY
12. Lorazepam 1 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
PMH:
aortic stenosis s/p AVR
coronary artery disease s/p CABG
PMH: Hypertension, Hyperlipidemia, Polymyalgia rheumatica on
chronic steroids, Recent nose bleeds requiring cauterization
(aspirin since d/c'd), Thrombocytopenia, GERD, Right sided
sciatica, Gout, Hard of hearing (right sided hearing aid),
Carpal tunnel syndrome bilaterally (wearing splints at night),
Arthritis, Right shoulder surgery for a "separation"
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, steady gait
Sternal Incision - well healed
Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10570455-DS-3 | 10,570,455 | 26,071,429 | DS | 3 | 2179-03-16 00:00:00 | 2179-03-16 11:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
chest pain at rest
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times two (LIMA to LAD, SVG to
PLV) ___
History of Present Illness:
___ year old male who originally presented to his PCP's office in
___ with complaints of chest pain. He underwent a stress ___
on ___ which was found to be abnormal. He was scheduled for
outpatient catheterization but presented to ___ with
rest chest pain.
He was transferred to ___ for further evaluation and a
cardiac catheterization. He was found to have left main and
three vessel disease. Cardiac surgery consulted to evaluate for
surgical revascularization.
Past Medical History:
CAD
Hypertension
OSA (does not use CPAP)
Hyperlipidemia
Hypothyroidism
Past Surgical History:
Partial Hip replacement
Herniorrhaphy
Left rotator cuff surgery
Social History:
___
Family History:
Family History:Premature coronary artery disease- Father had
CAD/CABG in his ___
Physical Exam:
Pulse:60 Resp:12 O2 sat:99/RA
B/P Right:142/59 Left:150/62
Height:6' Weight:95.3 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no murmur ascultated
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Dsg in place and appropriate Left: 1+
DP Right: dopp Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
No carotid bruits heard
Pertinent Results:
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ TEE (Complete)
Done ___ at 11:19:24 AM PRELIMINARY
Referring Physician ___
___ of Cardiothoracic Surg
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 72
BP (mm Hg): / Wgt (lb): 200
HR (bpm): BSA (m2): 2.13 m2
Indication: Coronary artery disease. Aortic valve disease.
Coronary artery disease. Left ventricular function. Mitral valve
disease.
Diagnosis: R06.02, I34.0, I36.8
___ Information
Date/Time: ___ at 11:19 ___ MD: ___,
MD
___ Type: TEE (Complete)
3D imaging. Sonographer: ___, MD
Doppler: Full Doppler and color Doppler ___ Location: ___
Lab
Contrast: None Tech Quality: Adequate
Tape #: Machine: ___
Echocardiographic Measurements
Results
Measurements
Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.43 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 63 ml/beat
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 2.2 cm <= 3.4 cm
Aorta - Abdominal: 2.0 cm <= 2.0 cm
Aortic Valve - Peak Gradient: 8 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 4 mm Hg
Aortic Valve - LVOT VTI: 20
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *2.4 cm2 >= 3.0 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Moderate ___. No spontaneous echo
contrast or thrombus in the body of the ___. All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Normal LV cavity size. Low normal LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma in ascending aorta. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of mitral valve chordae.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
___. A TEE was performed in the location listed above. I
certify I was present in compliance with ___ regulations. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
Suboptimal image quality - poor echo windows.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Basal InferoseptalBasal AnteroseptalBasal Anterior
Basal InferiorBasal InferolateralBasal Anterolateral Mid
InferoseptalMid AnteroseptalMid Anterior
Mid InferiorMid InferolateralMid Anterolateral Septal
ApexAnterior Apex
Inferior ApexLateral Apex Apex
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The right ventricular cavity is mildly dilated with normal free
wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. There are simple atheroma
in the aortic root. There are simple atheroma in the ascending
aorta. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no pericardial effusion.
POST CPB:
1. Preserved bi-ventricular systolic function.
2. Unchanged valvular structure and function.
3. No other change
.
___ 05:43AM BLOOD WBC-6.0# RBC-2.92* Hgb-9.0* Hct-28.1*
MCV-96 MCH-30.8 MCHC-32.0 RDW-13.0 RDWSD-45.7 Plt ___
___ 05:49AM BLOOD WBC-9.7 RBC-3.30* Hgb-9.9* Hct-31.1*
MCV-94 MCH-30.0 MCHC-31.8* RDW-13.0 RDWSD-44.7 Plt ___
___ 01:36PM BLOOD ___-19.6*# RBC-4.34* Hgb-13.2* Hct-39.6*
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.6 RDWSD-41.7 Plt ___
___ 01:54AM BLOOD ___ PTT-25.3 ___
___ 05:43AM BLOOD Glucose-93 UreaN-19 Creat-1.0 Na-142
K-3.9 Cl-102 HCO3-35* AnGap-9
___ 05:49AM BLOOD Glucose-114* UreaN-21* Creat-1.1 Na-138
K-3.6 Cl-100 HCO3-27 AnGap-15
___ 12:00PM BLOOD ALT-35 AST-26 CK(CPK)-58 AlkPhos-58
Amylase-82 TotBili-0.3
___ 05:43AM BLOOD Mg-2.3
Brief Hospital Course:
Mr. ___ presented to ___ with chest pain, which was
relieved with nitroglycerin. He was transferred to ___, where
a catheterization revealed multi-vessel coronary artery disease.
He underwent a pre-operative work-up and on ___ underwent
bypass surgery. Please see the operative note for details. He
tolerated the procedure well and transferred in critical but
stable condition to the surgical intensive care unit. Later that
evening he extubated without incident. On the following day his
chest tubes were removed and he was started on Lopressor and
Lasix. He transferred to the step-down floor on post-operative
day two.
Chest tubes and pacing wires were discontinued without
complication. The ___ was evaluated by the physical therapy
service for assistance with strength and mobility. Oxygen
saturation remained in the high ___ with activity- it is
recommended that the ___ follow-up with PCP ___
?undiagnosed COPD and CPAP compliance. By the time of discharge
on POD 5 the ___ was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
___ was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO QPM
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Furosemide 40 mg PO BID Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth q3h Disp #*40
Tablet Refills:*0
4. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
5. Potassium Chloride 20 mEq PO BID Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
8. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10570463-DS-3 | 10,570,463 | 20,466,910 | DS | 3 | 2164-07-28 00:00:00 | 2164-07-29 10:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of asthma and remote Hodgkin's
(early ___) presenting with progressive shortness of breath
and
chest tightness.
Patient notes that about a month ago, house nearby was
demolished, and increasing dust in the air. He developed cough,
as well as rhinorrhea and significant congestion. Presented to
PCP office and told he had sinusitis 2 weeks ago and treated
with
Augmentin for 7 days with improvement in sinus tenderness and
congestion. However, today patient describes being unable to
catch his breath and noted some chest tightness. This has been
worse with exertion, and feels better when lying down. Went to
___ office today, and noted to be slightly hypoxic (92% down
from
normal baseline) with wheezing and diaphorectic. Was tachy to
104
and wheezing/using accessory muscles to breath. Had been using
an
old inhaler at home q1h without improvement.
Patient denies any fevers or chills. Notes cough productive of
clear sputum. Patient denies any recent surgeries or traumas,
immobilization or recent cancers. Of note, Hodgkin's was
diagnosed in ___ and has not produced any complications since
then (aside from resulting hypothyroidism). Patient does have a
history of asthma as well as significant smoking history (30
pack
years), no formal diagnosis of COPD.
In the ED, initial vitals were: 96.9 ___ 28 97% RA
was as low as 88% on RA
peak flow pre tx 60, peak flow post tx 220
- Exam notable for:
Coarse breath sounds with prolonged expiratory wheeze
bilaterally.
- Labs notable for:
BMP: 143/4.9 / ___ < 102
CBC: 13.6 > 16.9/51.9* < 288
Trop < 0.01
VBG 7.35 / ___
Lactate 1.4
UA negative
UCx, BCx pending
- Imaging was notable for:
IMPRESSION: CXR
No acute intrathoracic process.
- Patient was given:
Albuterol neb x 2, ipratropium Neb x 3, 125mg methylpred
- Transfer vitals: 98.1 88 150/90 18 98% 2L NC
Upon arrival to the floor, patient reports feeling much better.
He currently is not having SOB and only mild chest discomfort
that feels like it is from his cough/difficulty taking deep
breaths. He feels no fevers/chills. Notes some mild loose stools
when he was taking augmentin but this has resolved.
Past Medical History:
Per OMR:
HYPOTHYROIDISM
- Following Hodgkins radiation therapy
SEXUAL DYSFUNCTION
- Following inguinal surgery
*S/P SPLENECTOMY ___
- With exploratory lapaorotomy for Hodgkins
HYPERLIPIDEMIA ___
THERAPEUTIC PHLEBOTOMY
- On testosterone, managed by urology
HEARING LOSS
SLEEP APNEA
ANXIETY
SKIN CANCERS
Basal Cell skin cancer
HEMOPTYSIS
H/O ASTHMA ___
- Allergic, cats, feathers; patient believes this has resolved
H/O HODGKIN'S DISEASE ___
- S/P radiation
H/O PALPITATIONS ___
- Told of pvc's after holter several years ago
H/O TESTICULAR PAIN ___
- Varococeil repair ___, persistant pain
H/O INCISIONAL HERNIA
H/O COLONIC ADENOMA
H/O PPD POSITIVE
- S/p INH per pulmonary note in OMR
H/O DEPRESSION
Social History:
___
Family History:
FAMILY HISTORY:
Patient notes mother who passed away from complications of COPD
and paternal grandparent who had COPD. Also notes family history
of cardiac disease in old age.
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: 98.5 134/78 93 1893% 2L on admit
GENERAL: Patient appears well, w NC in place, in NAD
HEENT: MMM, no scleral icterus. No maxillary sinus tenderness.
NECK: No significant LAD, no JVP elevation
CARDIAC: slightly tachycardic, normal rhythm, normal s1 and s2,
no m/r/g
LUNGS: Diffuse mild wheezing, both inspiratory and expiratory,
with some diminished sounds at the bases
ABDOMEN: Soft, nontender, nondistended
EXTREMITIES: WWP, no ___ edema
NEUROLOGIC: A&Ox3, moving all extremities with purpose, PERRL
SKIN: No rashes or ulcers
On Discharge,
Pox 90-92% on Room air, including ambulation
He appeared extremely well, ambulating with ease
Lung exam notable for only scattered wheezes.
Pertinent Results:
___ 12:45PM BLOOD WBC-13.6* RBC-5.70 Hgb-16.9 Hct-51.9*
MCV-91 MCH-29.6 MCHC-32.6 RDW-14.2 RDWSD-47.7* Plt ___
___ 06:40AM BLOOD WBC-20.7* RBC-5.52 Hgb-16.3 Hct-49.5
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.1 RDWSD-46.6* Plt ___
___ 12:45PM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-143
K-4.9 Cl-105 HCO3-26 AnGap-12
___ 06:40AM BLOOD Glucose-160* UreaN-12 Creat-0.7 Na-143
K-4.1 Cl-105 HCO3-22 AnGap-16
___ 06:40AM BLOOD Calcium-9.6 Phos-2.7 Mg-2.1
___ 12:54PM BLOOD O2 Sat-94
CXR
PA and lateral views of the chest provided. The lungs are clear
bilaterally. There is no focal consolidation, effusion, or
pneumothorax. There are no signs of congestion or edema. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
Brief Hospital Course:
___ male with history of asthma remote Hodgkin's presenting with
progressive shortness of breath concerning for asthma vs. COPD
exacerbation.
#SOB / cough / hypoxemia
#h/o asthma / possible COPD
Patient presenting with several days of worsening
dyspnea/hypoxia. Given extensive smoking history, may have COPD,
but also w history of asthma and recent dust exposure. Sinusitis
appears to be improved, but with ongoing rhinorrhea and cough.
- Patient had dramatic improvement in symptoms with treatment
with prednisone, duonebs and azithromycin. He had mild hypoxia
(90-92%) at rest and with ambulation. His baseline oxygen
saturation appears to be around 95%, suggesting some mild
underlying COPD. He had PFTs done in ___, and PCP can
consider repeat after this present flare has been treated to see
if in fact there is underlying COPD. He was discharged on
ipratropium/albtuerol every 8 hours; if he is back to baseline,
PCP to adjust treatment for maintenance at ___.
#Chest tightness
Likely ___ cough/reactive airway disease per above. EKG in ED
was without ischemic changes and first cardiac enzymes were
negative
- Trend additional cardiac enzymes
- resolved by the time patient arrived on medical floor.
#tobacco use
Patient would be interested in trying to quit, has tried in past
but relapsed
I recommended that he continue nicotine patch, and gave him
information on use of chantix, which he reviewed and will
discuss with PCP at ___.
#hypothyroidism
- continue synthroid
#HLD
- continue lipitor
#Depression
- continue sertraline
#Primary prevention
- continue aspirin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Sertraline 100 mg PO DAILY
5. Testosterone Cypionate 50 mg IM WEEKLY
6. TraZODone 50-100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
This is your rescue inhaler.
2. Azithromycin 250 mg PO DAILY Duration: 3 Doses
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q8H
use this every 8 hours until you see Dr ___.
4. Nicotine Patch 14 mg/day TD DAILY
5. PredniSONE 40 mg PO DAILY Duration: 3 Days
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Sertraline 100 mg PO DAILY
10. Testosterone Cypionate 50 mg IM WEEKLY
11. TraZODone 50-100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Wheezing, shortness of breath due to either asthma or COPD
(emphysema) flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with difficulty breathing, and this may have
been triggered by exposure to smoke/building dust from a
demolition near your home. You have improved with antibiotics
and breathing treatments. I have sent a prescription for
combivent inhaler that you should use three times a day until
you see Dr ___. The combivent includes albuterol. However,
if you develop acute shortness of breath or wheezing in between
combivent, you may use the individual albuterol inhaler. I have
sent over prescriptions for 3 additional days of prednisone and
3 days of antibiotics (azithromycin) to your pharmacy ___
___, ___
You have a followup with Dr ___ week, and which point
you should discuss repeating pulmonary function tests in the
future. It is important that you continue to abstain from
smoking, and use of nicotine patches can be helpful in that
regard. You can also discuss with him use of chantix
Followup Instructions:
___
|
10570524-DS-21 | 10,570,524 | 29,254,955 | DS | 21 | 2175-03-30 00:00:00 | 2175-03-31 16:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / adhesive tape
Attending: ___
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
From admitting H&P:
"Ms. ___ is a ___ female, history of SVT, sinus
bradycardia, MVP, dementia, osteopenia, ___, hearing loss, who
presents with concern for seizure vs. questionable syncopal
episode, also with SVT.
Per Atrius records review, patient follows with Dr. ___.
Was initially diagnosed with SVT in ___. ___ showed
infrequent SVT at that time. Had previously discussed various
treatment options including observation and Valsalva maneuver
given symptoms were infrequent, versus beta-blockade however
this was previously limited by her low normal blood pressure and
sinus
bradycardia, versus RFA. Had agreed upon conservative management
including observation and Valsalva maneuvers.
She had also previously seen her PCP, last visit ___,
reporting palpitations and dizziness. Had MRI which showed no
evidence of acute process. Thought to potentially have BPPV, was
given meclizine, however she never took this and found exercise
to be helpful.
Family reports that on day of presentation, patient was sitting
in chair and lost consciousness suddenly. Had approximately
7-second episode of all 4 extremity jerking movements. She was
subsequently noted to be catatonic and nonresponsive for about 5
minutes. Subsequently had episode of urinary incontinence, she
is not incontinent at baseline per daughter. She abruptly woke
up at her approximate mental baseline (AAO x1). Was subsequently
brought here for further evaluation. Per family, patient also
recently had URI with sore throat and slightly elevated heart
rates on ___ for which she was seen at ___
urgent care and given fluids. She still having intermittent sore
throat, nonproductive cough, also with rhinorrhea.
In the ED initial vitals were:
T 98.4 HR 160 BP 94/79, RR 16, O2 96%RA
EKG: Narrow complex, regular, HR 155, normal axis, no acute
ischemic changes
Patient subsequently converted to sinus with vagal maneuvers.
She then returned to ___ with heart rate 145, for which she
received adenosine 6 mg IV. With adenosine, she converted to A
fib with heart rates in the 80-90s, which subsequently converted
back to prior SVT with heart rate in the 140-150s. This then
spontaneously converted to sinus without intervention. She was
asymptomatic during the entirety of the above course.
In discussion with Atrius cardiologist, given her new atrial
fibrillation, she was given Eliquis in the ED.
Labs/studies notable for:
- WBC 3.6, Hb 12.9, PLT 116
- Na 132, K 4.7, bicarb 17, BUN 16, Cr 1.0, glucose 174
- INR 1.2
- Lactate 2.8 --> 1.9
- Troponin <0.01
- AST 62, ALT 24, ALP 47, T. bili 0.3
- Flu negative
CXR: No signs of pneumonia.
Patient was given:
___ 12:01 IV Adenosine 6 mg
___ 14:58 PO Metoprolol Tartrate 25 mg
___ 14:58 PO/NG Apixaban 2.5 mg
___ 17:15 PO Benzonatate ___ m
Vitals on transfer: T 98.2 HR 52, BP 115/57, RR 22, O2 96%RA
Subjective: History obtained from both patient and daughter
(limited from patient as mainly responds yes to ROS questions).
Daughter also provides information that patient had a fall this
morning, unclear if this was witnessed, per daughter she did not
think her mother had head strike. At present, patient denies any
shortness of breath, palpitations, chest pain, lightheadedness.
Still is having some intermittent sore throat and also some
rhinorrhea. Otherwise no fevers, chills, abdominal pain, nausea,
vomiting, or any changes in bowel habits."
Past Medical History:
- SVT
- MVP
- Mild-moderate MR
- Mild AS
- Dementia (AAO x 1 baseline)
- Osteopenia
- SCC
- Hearing loss
Social History:
___
Family History:
Non-contributory
Physical Exam:
At admission:
VS: T 98.4 BP 120/60 HR 64, RR 18 O2 96%RA
General: Comfortable, in NAD
HEENT: NC/AT, PRL, EOMI
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Regular rate and rhythm, ___ systolic murmur heard across
precordium
Abdomen: Soft, NT/ND, normoactive bowel sounds. No evidence of
organomegaly.
Extremities: 2+ peripheral pulses, no C/C/E. No TTP on trauma
exam.
Neuro: CN II-XII intact. No focal neurological deficits. Motor
strength ___ in all 4 extremities symmetric. Sensation intact.
AAO x1 only to person.
At discharge:
Vitals: 24 HR Data (last updated ___ @ 820)
Temp: 98.1 (Tm 98.4), BP: 122/78 (122-149/72-91), HR: 66
(51-72), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA
I/O= Last 24 hours Total cumulative -1840ml
IN: Total 120ml, PO Amt 120ml
OUT: Total 1960ml, Urine Amt 1960ml
Weight on admission: 55.5kg
Telemetry: sinus bradycardia with intermittent SVT, likely AT
General: seated upright in bed, appears well. No acute distress
HEENT: EEG leads in place. No scleral icterus. EOMI. Oral mucosa
pink and moist
Lungs: Decreased breath sounds throughout, but otherwise CTA in
all lung fields posteriorly. No respiratory distress or
accessory
muscle usage
CV: RRR. Grade III/VI systolic murmur present at all posts,
loudest at LUSB with some radiation both to the neck and the
axilla. Radial pulses 2+
Abdomen: Bowel sounds present throughout. Soft, NT, ND
Ext: Warm, well-perfused. No pitting edema.
Neuro: A&O to person. Not oriented to time or place. Moves all
extremities appropriately. No facial asymmetry.
Pertinent Results:
ADMISSION LABS:
___ 11:03AM BLOOD WBC-3.6* RBC-3.97 Hgb-12.9 Hct-40.0
MCV-101* MCH-32.5* MCHC-32.3 RDW-13.2 RDWSD-49.1* Plt ___
___ 11:03AM BLOOD Glucose-174* UreaN-16 Creat-1.0 Na-132*
K-4.7 Cl-100 HCO3-17* AnGap-15
___ 11:03AM BLOOD ALT-24 AST-62* AlkPhos-47 TotBili-0.3
___ 11:03AM BLOOD cTropnT-<0.01
___ 11:03AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.9 Mg-1.8
___ 12:15PM BLOOD Lactate-2.8*
INTERIM LABS:
___ 05:00PM BLOOD Lactate-1.9
DISCHARGE LABS:
___ 05:37AM BLOOD WBC-3.5* RBC-3.63* Hgb-11.8 Hct-36.3
MCV-100* MCH-32.5* MCHC-32.5 RDW-13.1 RDWSD-48.2* Plt ___
___ 05:37AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-140
K-4.1 Cl-104 HCO3-24 AnGap-12
___ 05:37AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
EEG: This telemetry captured no pushbutton activations. It
showed a
slow and disorganized background throughout, indicative of a
widespread but probably mild encephalopathy, as on the previous
recording. There were no areas of prominent focal slowing, and
there were no epileptiform features or electrographic seizures.
TTE ___: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic function
(LVEF 69%). Mild mitral regurgitation with normal valve
morphology. No structural cardiac cause of syncope identified.
Abnormal continuous flow best in the suprasternal notch view c/w
a patent ductus arteriosus.
CT HEAD WITHOUT CONTRAST:
1. No evidence of acute intracranial abnormality.
2. Chronic age-related changes, including global parenchymal
atrophy and sequela of chronic small vessel ischemic disease.
3. Mild paranasal sinus disease
CT C-SPINE WITHOUT CONTRAST:
1. No evidence of acute fracture or traumatic malalignment.
2. Mild retrolisthesis of C4-C5, likely chronic and secondary to
degenerative change.
3. Moderate multilevel degenerative changes as described above,
most notably at C3-C4 and C4-C5.
CHEST XRAY:
AP upright and lateral views of the chest provided. Coarsened
lung markings may reflect chronic lung disease. There is no
consolidation to suggest pneumonia. No large effusion or
pneumothorax. No signs of pneumonia. Cardiomediastinal
silhouette appears normal side from aortic knob calcifications.
Bony structures are intact.
Brief Hospital Course:
TRANSITIONAL ISSUES:
[] ___ services for med adherence and vital sign checks at ___
[] goals of care discussion with PCP to determine utility of
continuing Eliquis
[] if recurrent syncopal episodes or symptomatic of SVT,
consider outpatient cardiac monitoring to evaluate for
tachyarrhythmia burden
[] CBC at first follow-up to monitor for resolution of mild
leukopenia and thrombocytopenia this admission
[] Monitor for resolution of cough, likely viral URI (CXR
normal)
============================
Ms. ___ is a ___ female, history of prior SVT, sinus
bradycardia, dementia, osteopenia, SCC, presenting with concern
for seizure activity vs. syncope, also with SVT.
#SVT:
The patient has a known history of SVT with documentation as far
back as ___. She follows with Dr. ___ in cardiology.
She previously had a Holter monitor which showed infrequent SVT.
Per chart review, the patient reported increasing symptoms of
her SVT in ___, so a repeat Holter study was
recommended, but the patient declined. She presented to the
hospital this time following a syncopal episode with shaking of
the extremities after losing consciousness and a subsequent
episode of urinary incontinence. In the ED, she was noted to be
in SVT with heart rates in the 160s. Vagal maneuvers were
initially successful, but the patient went back into SVT shortly
after. She was given adenosine and initially reverted to sinus
rhythm, but then went back into SVT again. She subsequently
converted back to sinus rhythm spontaneously. She was given 25mg
metoprolol in the ED but became bradycardic with rates in the
___. On the floor, she was monitored with constant telemetry and
noted to have sinus rhythm with asymptomatic paroxysmal SVT that
spontaneously reverted to NSR. She was given 12.5mg metoprolol
succinate while hospitalized for rate control which she
tolerated well.
#Atrial fibrillation:
Noted in the ED to be in SVT, which on further review, appeared
most consistent with atrial fibrillation. The patient has a
CHADSVASc score of 3, so felt to be high risk enough to warrant
anticoagulation. Due to recent fall, anticoagulation was held
until CT head and neck could be performed. These studies showed
no evidence of acute injury or hemorrhage, so the patient was
started on lower dose apixaban for stroke prevention due to her
age >___ and weight <60kg. The topic of anticoagulation was
approached with the patient's family. It was explained that
while this reduces her risk of stroke, it may be removed in the
future if not consistent with her goals of care. Risks of
anticoagulation, including bleeding, ICH, and GI bleeds were
discussed with family prior to discharge. The primary care
physician should have ___ discussion with the patient and her
family in the outpatient setting regarding goals of care and
risks/benefits of continuing anticoagulation.
#?Convulsive syncope vs. seizure:
Due to reported jerking movements of extremities and urinary
incontinence after loss of consciousness, the patient was
monitored with 24hr EEG. Seizure less likely given lack of true
postictal period and no history of seizures. EEG demonstrated
diffuse slowing consistent with dementia, but no rhythmic
discharges to suggest seizure. Echocardiogram showed flow
pattern consistent with PDA, with no intervention or further
workup pursued given the patient's age and lack of symptoms or
sequelae related to PDA. Given known tachyarrhythmia without
other significant findings to explain loss of consciousness, her
episode is most consistent with convulsive syncope.
#Thrombocytopnia
#Leukopenia:
Noted to have low WBC count of 3.6 at admission and platelets of
103 from baseline ~150. Prior records indicate that her WBC
counts have previously ranged from 4.3-4.7. Her counts remained
persistently low during the hospitalization. This is likely
multifactorial, but is likely related to acute viral URI on
chronic illness. Malignancy could be considered if not
resolving. The patient reported a cough and rhinorrhea
consistent with URI, but had no findings on lab work or physical
exam to suggest more severe infection. UA without signs of overt
infection and patient without symptoms of UTI. She remained
afebrile throughout her hospital stay.
#Hyponatremia:
On arrival, serum Na 132. Likely hypovolemic hyponatremia, as
the patient also had a slightly elevated lactate at admission
and both of these lab abnormalities resolved with increased PO
fluid intake.
#URI:
History of recent cold like symptoms including nasal congestion,
sore throat and cough. Chest x-ray without evidence of
pneumonia. Influenza negative. Remainder of infectious workup
negative. Given guaifenesin and benzonatate for symptomatic
relief.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QTUES
2. Saccharomyces boulardii 250 mg oral BID
3. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) 1 drop
4. Ascorbic Acid Dose is Unknown PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
3. GuaiFENesin ER 600 mg PO Q12H
RX *guaifenesin 200 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
4. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
5. Alendronate Sodium 70 mg PO QTUES
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
7. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) 1 drop
8. Multivitamins 1 TAB PO DAILY
9. Saccharomyces boulardii 250 mg oral BID
10. HELD- Ascorbic Acid Dose is Unknown PO DAILY This
medication was held. Do not restart Ascorbic Acid until you see
your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Convulsive syncope
Supraventricular tachycardia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you fainted
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were noted to have an abnormal heart rhythm where your
heart was beating very quickly
- Your symptoms were somewhat concerning for a possible seizure,
so we monitored your brain activity to evaluate for evidence of
seizures. This showed activity consistent with dementia, but no
seizure activity was seen. The shaking movements seen after you
lost consciousness are consistent with a normal fainting
response, called convulsive syncope.
- You were started on a medication called metoprolol to help
keep the heart rates in a normal range.
- Because you go in and out of your abnormal heart rhythm, you
are at increased risk for stroke. You were started on a blood
thinner called apixaban to decreased your risk of stroke.
- You reported a cough. Your symptoms were most consistent with
a viral illness. We gave you cough medicine to help treat your
symptoms.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Seek medical attention if you have new or concerning symptoms
or you develop chest pain, shortness of breath, fainting,
swelling in your legs, or abdominal distention.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10570689-DS-7 | 10,570,689 | 28,048,281 | DS | 7 | 2128-02-04 00:00:00 | 2128-02-05 13:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ hx of GBM s/p resection completed RT/temodar ___ sent in
from ___ clinic for admission due to positional headache,
with clinic ___ demonstrated 12mm MLS per report. No other new
neuro symptoms. No f/c, vomiting, abd pain,weakness. She reports
that in the morning when she gets up or turns her head to the
right especially she notes pounding in different areas of the
head; all over the head, or one area (left or right, front or
back at a time). When she lays down or is still the pounding
goes
away. Has chronic left visual field defect but otherwise no
visual changes. one episode of emesis in AM last week but none
since. Has irritable bowel, chronic, but no new
diarrhea/constipation/abd pain. No fevers. Symptoms have been
stable for about a week now. She uses fioricet with good effect
needing it every 8 hours at this point but no other pain
meds.Endorses keeping up with PO intake. She was seen in clinic
today as above. Per call in referral note from Dr.
___, pt admitted for IV steroids and MRI for
further characterization of brain lesion.
In the ED, L lateral hemianopia unchanged. T 98.5 BP 101/43 HR
66, RR 18 99% RA. Chem unremarkable, CBC with WBC 2.6 ANC 1610
and plts 110, Hct 35. Otherwise UA and chem unremarkable. Given
4mg po dexamethasone.
Spoke w/ radiologist on the phone, there is no report on the CT
read but per their review 8mm midline shift (compared to 5mm on
prior) with significant amount of right sided edema. No e/o
hemorrhage.
On arrival to the floor denies headache or symptoms currently.
REVIEW OF SYSTEMS: Per HPI otherwise full 10 point ROS neg
except for dry cough which is chronic, and IBS symptoms
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ Vision problems started
Saw PCP
___ examination was normal
___ Headaches started
___ Brain MRI showed right temporal mass
___
___: glioblastoma
___ Resection of residual tumor by Dr. ___: glioblastoma
___ - ___ IMRT/TMZ
___ Head CT showed 12 right-to-left shift
___ Brain MRI planned
PAST MEDICAL HISTORY:
1. Right temporal glioblastoma
2. Irritable bowel syndrome
3. Appendectomy ___
4. Tonsilectomy ___
5. Tubal ligation ___
Social History:
___
Family History:
Of her four siblings, one brother had a coronary
bypass at age ___ and many of the siblings had colon polyps. Her
mother died at ___ with lung, breast and colon cancer. Her father
died at ___ with mesothelioma, he also had coronary bypass, and
tissue heart valve.
Pertinent Results:
ADMISSION LABS:
WBC: 2.6*. RBC: 3.87*. HGB: 11.6. HCT: 35.5. MCV: 92. RDW: 13.8.
Plt Count: 110*.
Neuts%: 61.8. Lymphs: 23.5. MONOS: 10.8. Eos: 2.7. BASOS: 0.8.
Na: 138. K: 4.5 (HEMOLYSIS FALSELY ELEVATES K.). Cl: 99. CO2:
31.
BUN: 9. Creat: 0.8
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-2.4* RBC-3.65* Hgb-11.1* Hct-34.0
MCV-93 MCH-30.4 MCHC-32.6 RDW-13.7 RDWSD-46.5* Plt Ct-96*
___ 06:40AM BLOOD Creat-0.7 Na-142 K-3.8
___ 06:40AM BLOOD VitB12-333 Folate-14.0
IMAGING:
CT head
FINDINGS:
Postoperative changes are identified as on the prior study.
Compared to the prior study there is considerable increase in
edema in the right frontoparietal occipital lobe with mass
effect on the right lateral ventricle and midline shift of
approximately 15 mm. There is no dilatation of the left
temporal horn to suggest subfalcine herniation, however. There
is mild medial displacement of the right uncus identified but no
evidence of uncal herniation. There is no hemorrhage.
IMPRESSION:
Increase edema and mass effect at the site of previously noted
lesion in right frontoparietal lobes. No hemorrhage.
Brain MRI
IMPRESSION:
1. Change in configuration and interval increase in size and
peripheral contrast enhancement of the dominant right
temporoparietal resection cavity with marked increased
surrounding edema resulting in right to left subfalcine
herniation and mild right uncal herniation.
2. Two additional small satellite lesions, one in the medial
right temporal lobe and the other in the high right parietal
lobe, as described above. Mild nodular enhancement of the right
occipital horn epididymal lining. These findings are most
consistent with progressive disease, although radiation necrosis
remains within the differential, but is less likely.
Head CT ___
IMPRESSION:
1. Status postsurgical changes related to craniotomy and mass
resection as
described.
2. Grossly stable extensive edema of the right frontal and
parietal occipital
lobes.
3. Grossly stable mass effect on right lateral ventricle and
right uncus and midline shift, with grossly unchanged
configuration of ambient cistern.
Brief Hospital Course:
___ with right temporal lobe glioblastoma s/p near-total
resection, presenting with positional headaches and NCHCT
showing
significant cerebral edema w/ midline shift.
#Cerebral edema - ___ underlying disease as well as radiation
effect. Significant edema on L leading to midline shift as well
as slight uncal herniation. Currently alert, only focal deficit
is prior visual field cut.
- she was started on dexamethasone 4mg q6 with improvement in
headaches and unsteadiness. decreased dex to q8 and repeat head
CT stable w/ early herniation resolved
- cont prn fioricet
- she will remain on dexamethasone every 8 hours and f/u w/ Dr
___/ repeat MRI in one week
# GBM - s/p resection x 2, XRT and temodar completed ___. MRI
today concerning for progressive disease in resection cavity w/
satellite lesions vs radiation necrosis. Per Dr ___
likely latter, if progression would be very soon after treatment
w/ poor prognosis. treating radiation effects w/ steroids as
above.
# Leukopenia
# Thrombocytopenia - new since ___. No fevers or bleeding.
folate/b12 normal
likely ___ temodar and/or combined RT effect. stable to slowly
improving
# Anxiety - stable, continue sertraline, klonipin
# Prophy - start atovaquone pcp ppx given increasing steroids,
likely will be on dex for weeks to months.
- cont PPI while on steroids
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN head ache
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. Sertraline 200 mg PO DAILY
6. Dexamethasone 4 mg PO Q12H
7. Omeprazole 40 mg PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. ClonazePAM 0.5 mg PO BID
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN head ache
2. ClonazePAM 0.5 mg PO BID
3. Dexamethasone 4 mg PO Q8H
take at ___ and ___
RX *dexamethasone 4 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Senna 8.6 mg PO BID
8. Sertraline 200 mg PO DAILY
9. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*1
10. Acetaminophen ___ mg PO Q6H:PRN pain
total daily tylenol not to exceed 4000mg
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Cerebral Edema
Glioblastoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___, it was a pleasure caring for you during your
stay at ___. You were admitted with headaches and found to
have swelling in the brain requiring increased dose of steroids.
Your symptoms have improved but we will need to wean down more
slowly. Please continue dexamethasone as prescribed until your
follow-up next week.
Followup Instructions:
___
|
10570689-DS-8 | 10,570,689 | 22,393,568 | DS | 8 | 2128-04-06 00:00:00 | 2128-04-06 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
nausea, vomiting, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old right-handed woman, right
temporal GBM s/p resection in ___, s/p chemoradiation and
temozolamide w/ progression, currently on trial study, who was
admitted to ICU immediately
upon arrival to floor from ED for unresponsiveness. On ___ she
presented
to ___ with worsening of basleine headaches
and vomiting.
Her exam was notable for intact MS, CN (except left
hemianopia),no weakness on motor exam, coordination intact, LT
decreased on Right foot, reflexes 2+ symmetric, and able to walk
unaided.
She was sent to the ED for admission for symptom control and
further eval.
Per report her nausea and vomiting usually only lasts minutes to
an hour and resolves with oral anti-emetics at home. Also at
baseline has headaches, usually
bifrontal with radiation to top of her head, pressure like in\
quality, described as "migraines", which sometimes are
associated with these episodes.
On morning prior to presentation, while driving into neuro-onc\
clinic appointment, patient developed acute-on-chronic headache
(similar in quality) and intractable vomiting/nausea, which has
been constant. She has produced mostly brown/bilious, non-bloody
vomit with some whole food contents. Denied any coffee ground
emesis, abd pain, diarrhea, melena, or BRBPR. Does state that
headache and nausea seems to be worsened with any movement of
her head. Endorses neck stiffness, which tends to occur with her
headaches. No fever, chills, difficulty breathing. No sick
contacts or people at home with similar symptoms.
ED team differential at that time was med effect (Known effect
of
Trial Drug ACP 196), worsening tumor burden vs. infection, and
she was treated with IVF, Ativan/reglan/ compazine prn nausea,
repeat NCHCT.
At 22:20, She then triggered for SBP ___, which on recheck and
cuff change was 110, fingerstick 94, repeat EKG stable. She had
1 episode of emesis.
They attributed BP reading to likely cuff error. NCHCT showed
stable shift, she was started on decadron 4 mg TID (takes 8mg in
am and pm at home)
At 2230, she then triggered for hypotension to 60's systolic,
but was "less responsive than prior", but "arousable, [and] BP
on recheck up to 90-100's systolic, patient rigoring", so was
given IVF, and repeat labs were checked.
ED then consulted neurosurgery for finding of new hyperdensities
in previously resected CT Brain (done at ~ 9 pm; previously felt
to be stable) to "to help determine clinical significance and
whether or not intervention or neurosurgical admission may be
indicated". Radiology preliminary read was discussed at 00:30 am
- New foci of high density likely ___ post treatment changes,
but could not rule out hemorrhage; stable subfalcine herniation
On Neurosurgery exam, patient was lethargic, not cooperative
with exam, arouse to persistent voice and noxious; oriented to
name only; ___ 6-> 4 b/l, symmetric face, decreased bulk,
normal ___ symmetrically antigravity with equal and brisk
withdrawal to noxious. NSGY reviewed case, and recommended
repeat NCHCT in am and she was admitted to oncology.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ Vision problems started
Saw PCP
___ examination was normal
___ Headaches started
___ Brain MRI showed right temporal mass
___
___: glioblastoma
___ Resection of residual tumor by Dr. ___: glioblastoma
TREATMENT SUMMARY
___ - ___ IMRT/Temozolamide
___ Head CT showed 12 right-to-left shift
___ Brain MRI showed progression
___ DFCI ___ consent presented
___ DFCI ___ consent signed
___ C1D1 DFCI ___ with ACP-196
___ C1D8 DFCI ___ with ACP-196
___ C1D15 DFCI ___ with ACP-196
PAST MEDICAL HISTORY:
1. Right temporal glioblastoma
2. Irritable bowel syndrome
3. Appendectomy ___
4. Tonsilectomy ___
5. Tubal ligation ___
Social History:
___
Family History:
Of her four siblings, one brother had a coronary
bypass at age ___ and many of the siblings had colon polyps. Her
mother died at ___ with lung, breast and colon cancer. Her father
died at ___ with mesothelioma, he also had coronary bypass, and
tissue heart valve.
Physical Exam:
NEURO EXAM in ED:
Tmax: 99.8 BP: 109/65 HR: 65 R:18 O2 Sats: 100% RA
Gen: Ill-appearing female, lying on stretcher.
HEENT: Pupils: ___
Neck: Supple.
Lungs: No respiratory distress.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, difficult to arouse, but alerts to
voice with effort. Not cooperative with exam, flat affect.
Orientation: Oriented to name.
Language: Significant hypophonia. No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 6mm to 4mm
bilaterally.
V, VII: Face symmetric at rest
VIII: Hearing intact to voice.
Motor: Decreased bulk, normal tone bilaterally. No abnormal
movements, tremors. Moves all extremities antigravity, withdraws
to noxious.
DISCHARGE EXAM:
General: sleepy but arouses to voice or stimulus and follows
simple commands inc hand grip and wiggles toes. NAD.
HEENT: Healed Surgical Scar on R scalp
Neck: Supple
Pulmonary: CTAB anteriorly nonlabored
Cardiac: RRR
Abdomen: soft, NT/ND, +BS
Extremities: no edema
Skin: no rashes or lesions noted.
GU: foley in place, clear yellow urine
Neuro: ___, EOMI face symmetric, moves all extremities
spontaneously, sensation grossly intact to light touch. gait and
coordination not assessed
Pertinent Results:
ADMISSION LABS:
wbc 4.8 hgb 7.4 plt 76
N:80.6 L:10.7 M:7.3 E:0.2 Bas:0.2 ___: 1.0 Absneut: 3.84
Abslymp: 0.51 Absmono: 0.35 Abseos: 0.01 Absbaso: 0.01
Ca: 6.7 Mg: 1.1 P: 2.2
138 ___ AGap=13
3.0 20 0.4
ALT: 22 AP: 46 Tbili: 0.3 Alb: 3.6
AST: 56
Lactate:2.0
___: 9.7 PTT: 22.6 INR: 0.9
TSH:1.2
IMAGING:
CT head ___
FINDINGS:
The patient is status post resection of a right glioblastoma
multiforme. Foci of high density in the resection cavity in the
right parietal lobe are new since the CT of ___, and could
represent acute hemorrhage or post treatment changes.
Subfalcine herniation which shift of the normally midline
structures to the left by 12 mm is stable ___. There
is no downward herniation. Mass effect on the right lateral
ventricle and third ventricles months changed.
The patient is status post right craniotomy. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear.
IMPRESSION:
1. Foci of high density in the resection cavity are new since
___ and
could represent post treatment changes, but foci of acute
hemorrhage cannot be excluded. Further evaluation could be
performed with MRI.
2. Stable midline shift.
Head CT ___
FINDINGS:
Dental amalgam streak artifact limits study.
The patient is status post resection of a right glioblastoma
multiforme. Foci of high density in the resection cavity in the
right parietal lobe are unchanged since the prior CT performed 8
hours prior. Subfalcine herniation with shift of the normally
midline structures to the left by 12 mm is also stable. The
basilar cisterns are preserved. Mass effect on the right
lateral ventricle and third ventricles is changed.
The patient is status post right craniotomy. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Stable foci of high density in the resection bed which may
represent
treatment related effects or stable blood products.
3. Stable subfalcine herniation since the prior CT performed 8
hours prior.
4. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
Brief Hospital Course:
The patient was admitted to the oncology floor w/ noted
worsening of mental status in comparison to ED report and prior
neuro-surgery exam. Pt was unresponsive to sternal rub,
transferred immediately to ICU and sent for stat repeat NCHCT.
Upon Admission to ICU, admitting team with concern for decreased
movement in L side. Neurology was consulted for AMS and ? Left
sided weakness. Neurology exam notable for lethargy but arousal
to sternal rub, did not answer questions or follow commands,
pupils 2 mm -> 1.5 b/l, with decreased withdrawal to noxious
most
prominent in LLE, then LUE compared to R hemibody.
Patient was seen ___ mins afterwards by neurosurgery. At that
time, patient had a fixed R dilated pupil (5mm), unable to be
aroused, weak withdrawal of R hemibody to noxious, and no
withdrawal of L hemibody to noxious.
She was given Mannitol 50 G and Dexamethasone 10 mg, for
presumed elevated intracranial pressure w/ herniation.
When primary team was attempting to place IJ, patient vomited,
and was seen shaking. It was unclear if shaking was due to
seizure. Patient was given 1 mg Ativan and loaded with keppra
per neurology recommendations. The patient was intubated for
airway protection. While in ICU she was also found to have
worsening acute hyponatremia and received 3% hypertonic saline.
After further discussion with her husband and family as well as
Dr ___ of care changed to comfort measures only as
there was concern she was experiencing progressive disease and
no further medical treatments available and she also could be
experiencing adverse effects from study drug. Code status
changed to DNR/DNI. She was extubated on ___ and post extubation
she has been minimally interactive, able to speak few words.
Continues to experience nausea and occasional vomiting which was
treated with ongoing IV antiemetics including Zofran, Compazine
and Ativan. She was also given IV morphine for headache
although and at time of discharge reports is only mild. She was
transferred back to oncology floor and verbalized to husband
wish for hospice services and family in agreement. She will be
transferred to inpatient Seasons Hospice in ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN head ache
2. Prochlorperazine 5 mg PO Q6H:PRN nausea
3. Sertraline 200 mg PO DAILY
4. Ranitidine 150 mg PO BID
5. Bisacodyl ___AILY:PRN Constipation
6. Calcium Carbonate 500 mg PO QID:PRN Dyspepsia
7. Multivitamins 1 TAB PO DAILY
8. Simethicone 120 mg PO QID:PRN Flatulence
9. Senna 8.6 mg PO DAILY:PRN Constipation
10. Docusate Sodium 100 mg PO BID:PRN Constipation
11. Ibuprofen 400 mg PO Q12H:PRN Pain
12. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY:PRN Constipation
13. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic TID:PRN
Dry Eyes
14. Venlafaxine 50 mg PO BID
15. Restasis 1 drop Other BID
16. ClonazePAM 0.5-1 mg PO Q8H:PRN Anxiety
17. ACP 196 Study Med 200 mg PO BID
Discharge Medications:
1. LORazepam 0.5 mg IV Q4H:PRN nausea, vomiting
2. Morphine Sulfate ___ mg IV Q1H:PRN Pain
3. Ondansetron ___ mg IV Q8H:PRN nausea
4. Prochlorperazine 10 mg IV Q6H:PRN Nausea
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN head ache
Do not exceed 6 tablets/day
6. Senna 8.6 mg PO DAILY:PRN Constipation
7. Restasis 1 drop Other BID
8. Ranitidine 150 mg PO BID
9. Prochlorperazine 5 mg PO Q6H:PRN nausea
10. Docusate Sodium 100 mg PO BID:PRN Constipation
11. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic TID:PRN
Dry Eyes
12. ClonazePAM 0.5-1 mg PO Q8H:PRN Anxiety
13. Calcium Carbonate 500 mg PO QID:PRN Dyspepsia
14. Bisacodyl ___AILY:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Glioblastoma
Intractable nausea, vomiting
Headache
Elevated intracranial pressure
Possible seizure
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:
You were admitted with worsening headache, nausea, vomiting and
somnolence. Due to concern for hemorrhage and increased
pressure in the brain you underwent head CT and were intubated
for airway protection and received steroids and mannitol to
reduce the pressure. It was also possible you had a seizure and
you received seizure medications. After further discussion
based on your wishes the goals were changed to comfort measures
and you will be discharged to hospice.
Followup Instructions:
___
|
10571299-DS-11 | 10,571,299 | 21,988,342 | DS | 11 | 2177-09-18 00:00:00 | 2177-09-19 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Clindamycin / Evista / bee stings / Tegaderm
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with B-cell lymphoma admitted from the ED with
fevers.
Patient reports feeling generally fatigued since she received C2
R-CHOP. This morning, she felt particularly warm, and noted her
temperature to be 102.5. She has an associated episode of
feeling
very cold on ___, but no significant rigors or night sweats
She also reports increasing SOB over the last several days, but
denies cough or chest pain. No headache or changes to her
vision.
She has had mild ST and rhinitis. She denies abdominal pain,
nausea, vomiting, or diarrhea. She does have poor appetite. No
dysuria. No new rashes or joint pain. No mucosal sores or
lesions. Due to her fever, she presented to the ED.
In the ED, initial VS were pain 0, T 99.2, HR 128, BP 158/70, RR
22, O2 97%RA. Exam was unremarkable. Initial labs were notable
for Na 127, HCT 26.5, WBC 8.5 (ANC 7310), nl UA and lactate 0.8.
CXR was indicative of a lingular pneumonia. Patient was given 1g
IV meropenem and 2L NS prior to admission to ___ for further
management. VS prior to transfer were T 99.3 HR 100 BP 128/60 HR
19 O2 100%RA.
On arrival to the floor, patient has no acute complaints.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ - Developed a left inguinal lymph node
- ___: Primary care physician, ___ sent the
patient for CT abdomen and pelvis done at ___. There is a left
inguinal lymph node measuring 2.1 cm in maximum dimension. The
remainder of the CT abdomen and pelvis was without
lymphadenopathy, the spleen was normal size, and there were no
concerning liver lesions. Note is made of a heavy
atherosclerotic calcification.
- ___: She was referred for biopsy, which was performed in
Interventional Radiology. B-cell non-Hodgkin lymphoma, that
physiologically appears like follicular lymphoma; however, flow
cytometry shows that the cells are CD10 negative. Also, in the
follicles, there are areas of increased proliferation which is
not totally consistent with follicular lymphoma. Preliminary
cytogenetics show a subtle translocation of chromosomes 3 & 14,
fusing BCL6 and IgH.
- ___: Initial Oncology consultation ___ with Dr
___.
- ___: Open resection of left inguinal lymph node
- ___: PET CT scan showed there was no FDG-avid disease in
the chest, abdomen or pelvis, there was some low-level FDG
activity in the left inguinal region felt to be postsurgical in
nature.
- ___: The patient saw Dr. ___ at the
___. Plan favored R-CHOP chemotherapy versus admission
to
hospital for dose adjusted R-EPOCH.
-___: The patient had a Port-A-Cath placed an
echocardiogram performed the same day at ___.
The echocardiogram interpreted by Dr. ___ and
she notes in the right atrium, an ill-defined density, possibly
consistent with a mass, measuring 2.1 x 2.1 cm located near the
lateral wall of the right atrium. In fact, the remainder of the
echocardiogram shows moderate pulmonary hypertension, moderate
mitral regurgitation and mild regional left ventricular
dysfunction with a normal global ejection fraction. Further
imaging like cardiac MRI or even a TEE was recommended.
- ___: She had a cardiac MRI which revealed what looks like
a
prominent
Eustachian valve in the RA, normal variant. Thus,she was
cleared
to proceed with chemotherapy; we will plan a repeat echo after
3
cycles.
- ___: She commenced with treatment
TREATMENT SUMMARY:
___: C1D1 R-CHOP
___: C1 D8 IVF
___ C2 D1 R-CHOP w/ neulasta support
___: C2 D8 IVF
PAST MEDICAL HISTORY:
-Asthma possibly COPD
-Hypertension,
-Glaucoma
-Raynauds
-Melanoma right arm, she has had a
s/p right axillary lymph node dissection and also had a small
melanoma
in-situ in the the vulva
Social History:
___
Family History:
Mother died of ovarian cancer. The patient
cared for her. The patient has been tested and is BRCA1 and 2
negative. Her father died of an MI. Her brother had melanoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.0 HR 116 BP 134/75 RR 24 SAT 95% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: Anicteric sclerae, PERLL, OP clear, no LAD
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes3.
DISCHARGE EXAM:
==================
VS: 99.2 ___ 96% RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: MMM oropharynx clear, no thrush
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
SKIN: No significant rashes
Pertinent Results:
LABS RESULTS:
================
___ 10:11PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:01PM LACTATE-0.8
___ 09:00PM GLUCOSE-117* UREA N-21* CREAT-0.8 SODIUM-127*
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-22 ANION GAP-16
___ 09:00PM estGFR-Using this
___ 09:00PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-77 TOT
BILI-0.5 DIR BILI-0.2 INDIR BIL-0.3
___ 09:00PM LIPASE-43
___ 09:00PM ALBUMIN-3.4* CALCIUM-9.4 PHOSPHATE-3.2
MAGNESIUM-1.6
___ 09:00PM WBC-8.5# RBC-3.00* HGB-9.3* HCT-26.5* MCV-88
MCH-31.0 MCHC-35.1 RDW-13.2 RDWSD-40.6
___ 09:00PM NEUTS-80* BANDS-6* LYMPHS-5* MONOS-7 EOS-0
BASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-7.31* AbsLymp-0.43*
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00*
___ 09:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL
___ 09:00PM PLT SMR-NORMAL PLT COUNT-342#
___ 09:00PM ___ PTT-29.8 ___
IMAGING RESULTS:
===================
CXR ___
Right-sided Port-A-Cath tip terminates at the junction of the
SVC and right atrium. Cardiac, mediastinal and hilar contours
are normal. Lungs
demonstrate marked hyperinflation with severe upper lobe
predominant
emphysema. New consolidative opacity in the lingula is
compatible with
pneumonia. Scarring within the lung apices is re- demonstrated.
No pleural effusion or pneumothorax is present. There is no
pulmonary edema. No acute osseous abnormality is visualized.
MICROBIOLOGY:
================
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
URINE NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
Brief Hospital Course:
This is a ___ with B-cell lymphoma on R-CHOP ___, who was
admitted w/ fever to ___. She was found to have L lingular
PNA. She doesn't have neutropenia. She received one dose of IV
___ and vancomycin from treatment of HCAP and then transitioned
to levofloxacin 750 daily total of 8 days (last day= ___.
During hospitalization she was found to have mild hyponatremia
which improved with IVF. Her fever resolved and her shortness of
breath improved to baseline. On the day of discharge the patient
was feeling well with mild SOB which is her baseline.
TRNASITIONAL ISSUES:
- The patient was started on PO levofloxacin 750mg for treatment
of HCAP last day would be ___
- would require CXR in 1 month to confirm radiographic
resolusion of pna
- has baseline anemia and Hb on discharge was 8.5. would require
a CBC in 1 week.
- has mild hyponatremia which improved with IVF; follow up a
chem7 in 1 week.
CODE: full
CONTACT: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety/insomnia
2. amLODIPine 5 mg PO BID
3. Combivent Respimat (ipratropium-albuterol) ___
mcg/actuation inhalation Q6H:PRN SOB/Cough
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Lisinopril 20 mg PO BID
6. LORazepam 0.5 mg PO Q4H:PRN allergic symptoms
7. Ondansetron 8 mg PO Q8H:PRN nasuea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
10. Vitamin D 1000 UNIT PO EVERY OTHER DAY
11. Nicotine Patch 21 mg TD DAILY
Discharge Medications:
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety/insomnia
2. amLODIPine 5 mg PO BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Lisinopril 20 mg PO BID
5. LORazepam 0.5 mg PO Q4H:PRN allergic symptoms
6. Nicotine Patch 21 mg TD DAILY
7. Ondansetron 8 mg PO Q8H:PRN nasuea
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
10. Vitamin D 1000 UNIT PO EVERY OTHER DAY
11. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 250 mg 3 tablet(s) by mouth daily
Disp #*18 Tablet Refills:*0
12. Ipratropium-Albuterol Inhalation Spray
(ipratropium-albuterol) ___ mcg/actuation INHALATION Q6H:PRN
SOB/Cough
Discharge Disposition:
Home
Discharge Diagnosis:
health care associated pneumonia
follicular lymphoma on chemotherapy
hypertension
Asthma
Glucoma
Anxiety disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at the ___.
You were admitted because of pneumonia which manifested as fever
and shortness of breath. During you admission you underwent
blood tests and were started on antibiotics (namely
Levofloxacin). We recommend that you continue levofloxacin for a
total of 8 days (end date: ___.
Please take you medications as prescribed and follow up with you
appointments as listed below.
Again, it was a pleasure taking care of you at the ___. We
wish you all the best.
Your ___ team.
Followup Instructions:
___
|
10571311-DS-27 | 10,571,311 | 25,105,998 | DS | 27 | 2159-09-20 00:00:00 | 2159-09-21 10:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
EtOH withdrawel, anxiety, numbness/tingling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of EtOH abuse and anxiety who presents with AMS.
Patient extremely anxious on presentation to the ED and
initially states that he has numbness and tingling in his hands
and ___ area x7 months but is acutely worse today. Patient
also states that he has been drinking significant quantities of
EtOH however was sober for 9 months. He claims that he relapsed
the previous ___ and has been drinking vodka (states small
bottles, cannot quantify) since. His last drink was ___ night
at an unknown time. Denies use of other drugs/illicits. No
falls, trauma. Currently denies any SI/HI.
Patient states that he drinks because he becomes anxious with
his family. He also states that he is always anxious but it is
much worse today since he stopped drinking. He is frustrated by
a "sensation" in his hands and arms and lips. He states that it
is the same as normal, but more pronounced today. He also
complains of numbness/tingling of his lips, again a symptom he
reports with anxiety. Patient states he has always been anxious
and prior to moving to the ___ from ___, he lived in a psych
hospital in ___. He states that he does not have a
psychiatrist in ___.
Review of OMR shows that patient has had previous ED
presentations as well as PCP presentation for similar
complaints. PCP note dated ___ states "left hand and
___ area felt paralyzed. This resolved and then he wanted
to go home" symptoms which are similar to his current
complaints.
Initial vitals in ED notable for afebrile 97.6, BP 120/96; HR
93, RR 10, 94%RA. Patient was given 1mg IV lorazepam x2, 5mg PO
diazepam, 1L NS, unclear amount of ___ and 1gm IV
Ceftriaxone. Labs notable for WBC 8.3. Hgb 18.2, Plt 203, K5.6,
Lactate 4.3, Lipase 65, EtOH 136, tox screen otherwise negative.
CXR and CT CAP without evidence of acute pathology.
At time of transfer, vitals 98.2, BP 139/97, HR 108, RR 18
95%RA.
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.
Past Medical History:
1. Depression (prior hospitalization in ___ in ___ prior
suicide attempt where he jumped off a roof; therapist - ___
___ ___
2. Alcohol abuse (per OMR, prior DTs and completed 4-months of
an alcohol treatment program, pt denies any history of
hallucinations). Of note appears to binge for <14 days at a
time, not constantly drinking.
3. (?) Essential tremor (prescribed Propanolol)
4. Tobacco abuse.
Social History:
___
Family History:
Father with depression and sister completed suicide.
Physical Exam:
ADMISSION PE:
Vitals: 98.1; 160/88; 108; 50; 96RA
General: Alert, oriented, sitting cross-legged in bed, rocking
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
mild Tongue fasciculations
Neck: Supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, normal gait. Mild essential tremor
bilaterally.
DISCHARGE PE:
VS: 98.1; 126/61; 63; 18; 96RA; Pain ___
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilat. otherwise no w/r/r
HEART: RRR, no MRG
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 01:28AM BLOOD WBC-8.3 RBC-5.94 Hgb-18.2* Hct-51.1
MCV-86# MCH-30.6 MCHC-35.6* RDW-14.4 Plt ___
___ 01:28AM BLOOD Neuts-30.9* Lymphs-62.8* Monos-4.6
Eos-1.3 Baso-0.4
___ 01:28AM BLOOD ___ PTT-31.5 ___
___ 01:28AM BLOOD Glucose-121* UreaN-14 Creat-1.1 Na-143
K-5.6* Cl-107 HCO3-20* AnGap-22*
___ 01:28AM BLOOD AST-37 AlkPhos-71 TotBili-1.1
___ 01:28AM BLOOD Albumin-4.9 Calcium-8.5 Phos-3.7 Mg-2.2
___ 04:39AM BLOOD D-Dimer-668*
___ 01:28AM BLOOD Osmolal-337*
___ 01:28AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:40AM BLOOD Lactate-4.3*
DISCHARGE LABS:
___ 05:25AM BLOOD WBC-6.0 RBC-5.08 Hgb-15.2 Hct-43.5 MCV-86
MCH-29.8 MCHC-34.8 RDW-15.1 Plt ___
MICRO: Blood Cx NGTD
STUDIES/IMAGING: CXR: Low lung volumes. Otherwise no acute
cardiopulmonary abnormality.
CT CAP:
Prelim Read:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No acute abdominopelvic findings.
3. Hepatic hemangioma.
4. Hepatic steatosis.
5. Mild interval increase in size of 3 renal hypodensities, as
above, not fully characterize but likely representing cysts.
Brief Hospital Course:
___ with hx of EtOH abuse and anxiety who presents to ED with
reported AMS admitted for hand/lip tingling and EtOH withdrawel.
# EtOH Withdrawel - pateint with hx of admission for
phenobarbitol protocol as well as possible baseline
anxiety/psych d/o. Review of chart suggestive of patient having
seizures in past, but patient cannot confirm. Required Valium x
2 this admission. Started patient on Thiamine/folate this
admission. Observed for ___ since last EtOH drink. Of note,
unclear if patient truly drinks chronicly and is at risk for
withdrawel. Per discussion with patient, states that currently
binges for ___ days and then stops drinking for extended periods
of time. Currently scoring <10. Also, if last drink ___,
approaching 72 hour window for detox.
# Anxiety - patient with apparent hx of anxiety which appears to
be exacerbated when he withdraws from EtOH. Does not follow with
psychiatrist. Treated withdrawel which improved symptoms.
Encouraged f/u with psychiatrist.
# Arm ___ tingling - Patient has dx of
essential tremor for which he was prescribed propranolol. No
longer taking. However, review of chart shows multiple
admissions for numbness/tingling which appears to resolve with
resolution of his anxiety and benzos. Physyical exam reassuring
with normal strength, sensation. Calcium WNL. Must also consider
EtOH neuropathy, but MCV WNL. Symptomaticlly improved this
admission.
# Elevated Lactate - likely due to dehydration. No obvious
source of infection. Possible to have chronic elevations in
alcoholics. Considered ethylene gylcol intoxication given
patient's elevated serum osmolality, however no osmolal gap when
corrected for serum EtOH. Patient denied ingestion other than
EtOH. Received 1g CTX in ED for unclear infection but was
without symptoms of infection for duration of hospitalization.
After some IVF on medicine floor, trended down to 1.3. Resolved.
TRANSITIONAL:
- continue to encourage patient to seek outpatient psych f/u
- SW provided pt with contact number for psych programs and EtOH
cessation programs
Medications on Admission:
None
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diangosis:
- EtOH Withdrawel
- Anxiety
Secondary Diagnosis:
- EtOH neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitaliation. You
were admitted for alcohol intoxication and arm/hand tingling. We
gave you medications to treat your mild alcohol withdrawel. We
also gave you IV fluids. We feel that the numbness and tingling
that you feel in your arms may be related to your drinking and
recomend that you avoid drinking in the future if possible. You
should continue to take your medications as prescribed.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10571504-DS-8 | 10,571,504 | 21,061,121 | DS | 8 | 2176-08-29 00:00:00 | 2176-09-05 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma:
Stab wounds Left scapula, bilateral elbow, left hand
Major Surgical or Invasive Procedure:
___: wash-out and suturing of lacerations elbows, left hand
History of Present Illness:
This patient is a ___ year old male who was stabbed multiple
places with glass chance or from outside hospital for
question vascular deficit to the right hand. Patient was
noted to have a decreased ulnar pulse and decreased
sensation to his fourth and fifth digit. Patient did have a
tourniquet placed to stop persistent bleeding by EMS when
first brought to the outside hospital
Timing: Sudden Onset
Severity: Wound pain
Moderate
Duration: Hours
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION: ___
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
GU/Flank: Back nontender no other lacerations
Extr/Back: No edema
Skin: 4 cm superficial wound extending from scapula towards
the axilla multiple small lacerations to fourth and fifth
digit on the left 2 small lacerations to the right upper arm
decreased right ulnar pulse, with intact pulses in other
extremities
Neuro: Speech fluent, Motor 5/ 5 in all extremities,
sensory without focal deficit, 2+ deep tendon reflexes
bilaterally, downgoing toes
Psych: Normal mentation, Normal mood
Supplements
Physical examination upon discharge: ___
t=98.7, hr 72, bp=148/72, rr=16, 100 room air
General: NAD
HEENT: full cervical ROM
CV: ns1, s2, -s3 ,-s4, no murmurs
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: no calf tenderness bil., no pedal edema bil., sutures
elbows bil., ___ left metacarpal sutures, ___ left carpal suture
SKIN: Sutures left scapula
NEURO: alert and oriented x 3, speech clear, no tremors.
Pertinent Results:
___ 06:07AM BLOOD WBC-12.2* RBC-4.92 Hgb-15.2 Hct-42.2
MCV-86 MCH-31.0 MCHC-36.0* RDW-12.4 Plt ___
___ 06:07AM BLOOD Plt ___
___ 06:07AM BLOOD ___ PTT-28.0 ___
___ 06:07AM BLOOD ___ 06:07AM BLOOD UreaN-10 Creat-1.0
___ 06:07AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:08AM BLOOD Glucose-104 Lactate-2.8* Na-145 K-4.0
Cl-101 calHCO3-26
___: chest x-ray:
IMPRESSION: No acute intrathoracic process. Healed right
clavicular
fracture.
___: CTA upper extremity:
IMPRESSION:
1. Patent and normal caliber right upper extremity arteries.
Evaluation the venous structures is slightly limited due to poor
opacification in the arterial phase; however, there is no
evidence of acute vascular injury in the soft tissues.
2. No acute osseous injury.
Brief Hospital Course:
___ year old gentleman admitted to the acute care service after
stabbing injury to left scapula, bilateral elbows, and left
hand. The patient was transferred from an outside hospital after
concern for a decreased pulse and decreased sensation to his
right. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent wash-out and suturing of
lacerations. The vascular service was consulted because of
concern for a vascular injury because of the patient's
presentation. To evaluate for a vascular injury, the patient
underwent a cat scan angiogram. The brachial, radial, and ulnar
vessels were of normal caliber and contour without evidence of
occlusion or active extravasation to suggest vascular injury.
The patient's pain was controlled with tylenol. The patients
vital signs were monitored. The patient was seen by the social
worker upon admission to the hospital. The patient was
discharged home on HD # 2 in stable condition. A follow-up
appointment was made with the acute care service for removal of
the sutures.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: stab wounds
left scapula, bilateral elbow, Left hand
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 you were stabbed in the
left shoulder, left hand and elbows. You were suturing in you
elbow. Your vital signs have been stable and you are preparing
for discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Please watch for and report:
* any yellow/green drainage from elbow wounds
* increased pain left shoulder
* increased redness from left shoulder wound/yellow or greeen
drainage from wound
* numbness/tingling left ___ finger
* increased pain left ___ finger
* inability to move left fifth finger
Followup Instructions:
___
|
10571791-DS-4 | 10,571,791 | 24,996,968 | DS | 4 | 2152-11-29 00:00:00 | 2152-11-29 16:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillin V / Lipitor
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: ___
_
________________________________________________________________
PCP: Dr. ___
.
_
________________________________________________________________
HPI:
___ w/ history of pancreatic mass with atypical cells ___ years
ago who is referred in for abnormal chest x-ray, concerning for
metastasis. Per ED report pt's family reports she minimizes her
symptoms and that she has been unable to sleep for several days
___ pain. She reports a dry cough x weeks since ___, along
with epigastric and lower abdominal pain x weeks as well which
she attributes to the coughing. She reports shortness of breath
when laying flat which resolves immediately with sitting up. No
shortness of breath on exertion. She reports abdominal
distention. Her lower abdominal pain is improved with standing
or bringing her knees close, worse with lying flat. She denies
fever, chills, chest pain, n/v/d/c. She reportedly told EMS she
had head pressure, but she denies that here as well as denying
vision changes. Her family reports she is confused per baseline
and not safe for home.
Upon arrival she scoffs at the claim that she was confused
although she does repeat herself and ask the same questions
repeatedly. She reports feeling dehydrated.
.
In ER: (Triage Vitals:
0 |98.0 |117 |180/60 |18 |97% RA )
Meds Given:
Fluids given: !L NS
Radiology Studies: none
consults called.None
.
PAIN SCALE: ___
REVIEW OF SYSTEMS:
All other systems negative except as noted above
Past Medical History:
HTN
H/o pancreatic mass
Social History:
___
Family History:
Multiple family members with pancreatic cancer.
Physical Exam:
Vitals: T 97.8 P ___ BP 149/62 RR 18 SaO2 96% on RA
GEN: Dishelleved appearing female
HEENT: ncat anicteric MMM, poor dentition
NECK: supple
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, mildly distended, no rebound or guarding
EXTR:2+ dpp b/l
DERM: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, forgetful, ? defiant
Pertinent Results:
___ 03:24PM COMMENTS-GREEN TOP
___ 03:24PM LACTATE-1.6
___ 03:15PM GLUCOSE-111* UREA N-29* CREAT-1.2* SODIUM-136
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-22 ANION GAP-20
___ 03:15PM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-85 TOT
BILI-0.4
___ 03:55PM PLT COUNT-422*
___ 03:55PM NEUTS-76.8* LYMPHS-14.9* MONOS-6.8 EOS-0.6*
BASOS-0.5 IM ___ AbsNeut-8.74* AbsLymp-1.70 AbsMono-0.78
AbsEos-0.07 AbsBaso-0.06
___ 03:55PM WBC-11.4* RBC-4.69 HGB-13.5 HCT-42.7 MCV-91
MCH-28.8 MCHC-31.6* RDW-13.4 RDWSD-44.5
___ 03:55PM CALCIUM-10.8*
___ 03:55PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-96 TOT
BILI-0.4
___ 03:55PM estGFR-Using this
___ 03:55PM GLUCOSE-114*
___ 03:15PM PLT COUNT-341
___ 03:15PM PLT COUNT-341
___ 03:15PM NEUTS-78.4* LYMPHS-13.6* MONOS-6.4 EOS-0.8*
BASOS-0.4 IM ___ AbsNeut-7.29* AbsLymp-1.26 AbsMono-0.59
AbsEos-0.07 AbsBaso-0.04
___ 03:15PM WBC-9.3 RBC-4.68 HGB-13.5 HCT-42.1 MCV-90
MCH-28.8 MCHC-32.1 RDW-13.2 RDWSD-43.4
___ 03:15PM ALBUMIN-3.8 CALCIUM-10.6* PHOSPHATE-3.3
MAGNESIUM-2.0
___ 03:15PM LIPASE-33
___ 03:15PM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-85 TOT
BILI-0.4
___ 03:15PM GLUCOSE-111* UREA N-29* CREAT-1.2* SODIUM-136
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-22 ANION GAP-20
___ 03:24PM LACTATE-1.6
___ 03:24PM COMMENTS-GREEN TOP
=====================================
MRCP ___
. 10 x 8 mm hypoenhancing pancreatic body mass, likely a ductal
adenocarcinoma, causing moderate upstream dilation of the main
pancreatic
duct, with contact upon the anterior aspect of the splenic
artery without
encasement or narrowing. No lymphadenopathy or distal
intra-abdominal
metastasis detected.
2. Segment VIII FNH or transient hepatic intensity difference,
and segment VI
hemangioma. No concerning hepatic mass.
3. Gallbladder adenomyomatosis.
4. Extensive atherosclerotic plaques throughout the infrarenal
abdominal
aorta.
CT TORSO:
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. Moderate atherosclerotic plaque is noted.
The heart,
pericardium, and great vessels are within normal limits. No
pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pneumothorax. There is a small left
nonhemorrhagic pleural
effusion
LUNGS/AIRWAYS: There are innumerable pulmonary nodules with the
largest mass
in the lingula measuring 1.9 x 3.2 cm. The airways are patent
to the level of
the segmental bronchi bilaterally. There is bronchial wall
thickening, likely
reflecting small airways disease.
BASE OF NECK: There is an 8 mm hypodense nodule in the left
lobe of the
thyroid.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is a 7 mm hypodensity in segment 4 of the liver which is
too small to
characterize (09:21). There is a wedge-shaped area of hypo
enhancement in the
right lobe along the falciform ligament which is incompletely
characterized
(09:24) There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is decompressed.
PANCREAS: There is a 2.4 x 3.6 x 2.8 cm hypodense mass in the
body of the
pancreas. There is distal pancreatic atrophy and duct
dilatation. The mass
encases the common hepatic artery causing narrowing and abuts
the celiac axis.
The mass causes attenuation of the SMV and portal confluence and
occludes the
splenic vein. The SMA is patent.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions. Note is made of a 13 mm accessory
spleen.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal. There
is a moderate
to large amount of ascites.
PELVIS: The urinary bladder and distal ureters are unremarkable.
Ascites
tracks into the pelvis.
REPRODUCTIVE ORGANS: Hypodensity is seen within the uterus in
the region of
the endometrial canal measuring 8 x 17 mm. The adnexa are
unremarkable.
LYMPH NODES: Lymphadenopathy including celiac axis lymph nodes
measuring 1 x
1.8 cm and portacaval lymph nodes measuring 1.5 x 1.8 cm are
noted. There is
nodularity in the amount as well as peritoneal thickening and
nodularity
suspicious for peritoneal carcinomatosis.
VASCULAR: There is no abdominal aortic aneurysm. Extensive
atherosclerotic
disease is noted. Severe stenosis of the right superior femoral
arteries is
noted.
BONES AND SOFT TISSUES: There are sclerotic lesions in L3 and in
the left
sacrum along the SI joint. The abdominal and pelvic wall is
within normal
limits.
IMPRESSION:
1. Mass in the pancreatic body suspicious for adenocarcinoma,
increased in
size compared to MR from ___ with splenic vein
occlusion and
narrowing of the SMV and PV confluence.
2. Widespread metastases including lung, peritoneal
carcinomatosis, mesenteric
lymphadenopathy and likely bone and liver mets.
3. Moderate to large ascites
4. No evidence of pulmonary embolism
5. Small left pleural effusion
Brief Hospital Course:
The patient is an ___ year old female with h/o HTN, h/o
pancreatic mass for which she declined further w/u who presents
with persistent cough, abdominal pain and lethargy.
METABOLIC ENCEPHALOPATHY
COUGH
METASTATIC PANCREATIC CANCER TO LUNG, LIVER, ABDOMEN
ASCITES
CT Torso ultimately found her metastatic disease which is the
likely cause of above. There was no evidence of PNA or PE. She
did not seem encephalopathic the day after admission and her
family felt she was at her baseline.
I discussed her condition at length with the patient and family.
She was very clear and reasonable in her wishes to decline any
further work up or treatment. She was interested in palliative
care. Therapeutic paracentesis was discussed but she declined
this. She will consider this going forward. She was agreeable
to low dose Lasix for which this was started at 10mg daily. Her
lisinopril was stopped. She otherwise felt well on discharge.
Palliative care follow up was arranged
CKD stage III:
This remained stable. Her lisinopril was stopped on discharge
in favor of Lasix
HTN, benign: stable. Lisinopril stopped per above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H cough
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled four
times a day Disp #*1 Inhaler Refills:*0
2. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
3. Furosemide 10 mg PO DAILY
please have your kidney and electrolytes tested on next follow
up
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
4. Outpatient Lab Work
on next follow up. please have your kidney and electrolytes
tested
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic pancreatic cancer to lung, liver, abdomen
Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were found to have pancreatic cancer which has spread to
throughout your body, as well as fluid in your abdomen. This is
the likely cause of your symptoms. Please follow up closely
with your PCP and the palliative care clinic to help with your
symptoms. Please take all medications as prescribed
Followup Instructions:
___
|
10572440-DS-7 | 10,572,440 | 28,780,865 | DS | 7 | 2180-06-24 00:00:00 | 2180-06-24 10:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
PCN, lexapro, lorazepam, sertraline,sulfa / Sulfa (Sulfonamide
Antibiotics) / Penicillins / Ativan / Lexapro / sertraline
Attending: ___.
Chief Complaint:
L open distal radius/ulna fracture
Major Surgical or Invasive Procedure:
L distal radius/ulna I&D and ORIF L radius
History of Present Illness:
___ with pmhx significant for severe basilar artery stenosis,
dementia with cognitive impairment, who presents from ___
___ with an open left distal ulnar fracture and closed
distal radius fracture s/p fall. Patient is a poor historian ___
dementia.
She states that she was ambulating at home today and tripped
over her scooter. She typically uses a wheelchair for
ambulation.
Past Medical History:
- Basilar artery stenosis
- Depression with psychotic features
- Dementia
- HTN
- HLD
- Gout
- Acute angle glaucoma/macular degenation
- Hard of hearing
- Hypothyroidism
- Cholelithiasis
- Osteoarthritis of the R knee
- Constipation
- Pancreatic Cyst
- Cataracts
Social History:
___
Family History:
non contributory
Physical Exam:
Gen: NAD
Left upper extremity:
- Skin intact, splint in place L forearm, fingers edematous with
ecchymosis.
- Full, painless AROM/PROM of shoulder, elbow, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2s cap refill, fingers WWP
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 an open fracture of her L distal radius and ulna and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for I&D of the L distal
radius and ulna and ORIF of the L distal radius fracture, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics 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 patient was initially agitated and
delirious but improved to her baseline with avoidance of opiate
pain medications and recommendations from a geriatric consult.
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
nonweightbearing in the left upper extremity, and will be
discharged on Aspirin 325mg daily for 14 days 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. Pravastatin 20 mg PO QPM
2. Venlafaxine XR 75 mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NS BID congestion
6. Levothyroxine Sodium 100 mcg PO DAILY
7. OLANZapine 5 mg PO DAILY
8. Ursodiol 300 mg PO BID
9. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NS BID congestion
3. Levothyroxine Sodium 100 mcg PO DAILY
4. OLANZapine 5 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 20 mg PO QPM
7. Ursodiol 300 mg PO BID
8. Venlafaxine XR 75 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 650 mg PO 5X/DAY Pain
11. Aspirin 325 mg PO DAILY Duration: 14 Days
12. Docusate Sodium 100 mg PO BID
13. Senna 17.2 mg PO BID:PRN constipation
14. TraMADol 50 mg PO BID
15. TraMADol 50 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L open distal radius/ulna fracture
Discharge Condition:
Mental Status: Confused - sometimes. (baseline dementia)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
- ___ 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:
- Nonweightbearing in the left upper extremity. Remain in splint
until follow-up.
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 ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 2 weeks after the
procedure.
WOUND CARE:
- ___ may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Left upper extremity: Non weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Splint and ace wrap on L forearm/hand to remain in place until
follow-up.
Care: Monitor for increased swelling, elevate forearm above
heart as much as possible to decrease swelling, monitor for any
s/s of infection.
Followup Instructions:
___
|
10572526-DS-7 | 10,572,526 | 21,962,447 | DS | 7 | 2188-10-23 00:00:00 | 2188-10-24 06:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toradol / tramadol / Penicillins / Versed / Erythromycin Base /
Egg / trazodone
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMHx of cholecystitis (sp ERCP and sphincterotomy
in ___ and sp cholecystectomy in ___, PAF (on Warfarin),
chronic lung disease (BOOP vs. COPD), ?Adrenal insufficiency,
presenting from ___ with a 7d hx of RUQ
abdominal pain.
Pt was recently admitted to ___ (___)
for SOB and weight gain. She was diagnosed with diastolic CHF
exacerbation, bronchitis and COPD exacerbation. She was
discharged with an increased dose of lasix (20mg --> 60mg), and
new medications including: lisinopril, doxycycline, and a
prednisone taper (completed on ___. She was referred to
rehab for conditioning. Pt was doing well in rehab until ___,
when she developed fever and night sweats. She was started on
levofloxacin for presumed PNA (completed on ___ and her fever
resolved.
Approximately one week prior to presentation, pt began to
experience pain in RUQ. Pain was dull, achy, intermittent,
___, pleuritic and worse with movement. Pt reports sx
associated with intermittent nausea, chills/sweats.
Per pt, she was not given diltiazem, metoprolol and prazosin at
the rehab for the past 3d bc of BPs within low range. ___
RN staff, pt refused metoprolol x 2d but received all other
medication. Also, per rehab, pt's INR was noted to be 3.1 on
___ ___ontinued to receive coumadin and INR was not
repeated.
She reports recurrence of subjective fever 1d PTA. She also
reports stable dyspnea on exertion. She denies fevers, CP, SOB,
dysuria, hematuria, vomiting, cough.
At OSH, a RUQ US was performed and showed linear hyperechoic
densities in the CBD, suggestive of retained stones and pt was
transferred to ___ for furhter evaluation.
On EMS arrival pt found in rapid a fib rhythm (150s) w/ SBPs
70-90s. Pt received Diltiazem 20mg IV and HR on arrival down to
110-115, afib and SBP up to ___. In the ED, VS: T 98, P
___, BP 103/78, R 18, O2 Sat 100% on RA
Labs were notable for: INR 5.4, PTT 59.9, WBC 10.4, Hct 45.1,
lactate 2, Cr 1, UA negative
The pt underwent a CT abdomen w/o contrast, which shwoed no
evidence of gallstones or other findgins to explain pain. She
also underwent RUQ US, which showed no stone in the biliary
tree. Chronic extra-hepatic biliary dilatation to 1.1 cm,
unchanged from U/S of ___ and may be related to prior CCY. EKG
showed afib with wide complexes and tachycardia.
She received dilaudid 1mg IV x 4.
Vitals prior to transfer: T 98.9, P 97, BP 112/67, R 14, O2 Sat
97%
Currently, pt complains of minimal RUQ pain.
Past Medical History:
Atrial Fibrillation (sp cardioversion, on Coumadin)
Fibromyalgia
LBBB
CHF eith preserved EF
Thalamic infarct in ___ (no residual deficits)
Phlebitis in RLE (age ___
Ischemia of RUE finger/shoulder (arterial embolisms vs. DVTs)
Hypercoagulable state (previously thought to be Protein C
deficiency but level was 90% of normal, per record)
HTN
HLD
PUD - h/o GI bleeding
Migraine headaches
Fibromyalgia
Nephrolithiasis
? BOOP vs. COPD
? Adrenal insufficiency
PSHx:
s/p c-section x ___
s/p L4/5 discectomy ___ years ago (patient fell on her)
s/p removal of a histiocytoma of L lower shin
Social History:
___
Family History:
Grandfather paraplegic; possibly ___ clotting dz
Brother; CVAs following CABG.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.4, 102/54, 89, 16, 93% RA
GENERAL - elderly woman, NAD
HEENT - MMM, sclera anicteric, PERRL, EOMI (constricted)
NECK - supple, no thyromegaly, no JVD
LUNGS - Rhonchi diffusely most at R base. Diminished air
movement, resp unlabored, no accessory muscle use
HEART - Irregular, no MRG
ABDOMEN - NABS, TTP in RUQ (mild); no guarding or rebound
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); well-healed excision scar on lower anterior L shin
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VSS
GENERAL - elderly woman, NAD
HEENT - MMM, sclera anicteric
NECK - supple, no JVD
LUNGS - CTAB
HEART - Irregular, no MRG
ABDOMEN - NABS, TTP in RUQ (no tenderness with deep pressure
using stethoscope, only when palpating with hands); no guarding
or rebound
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); well-healed excision scar on lower anterior L shin
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 09:45PM BLOOD WBC-10.8 RBC-5.82*# Hgb-14.1 Hct-45.1
MCV-78*# MCH-24.2*# MCHC-31.2 RDW-17.3* Plt ___
___ 09:45PM BLOOD Neuts-73.1* Lymphs-17.7* Monos-6.1
Eos-2.6 Baso-0.5
___ 09:45PM BLOOD ___ PTT-59.9* ___
___ 09:45PM BLOOD Glucose-130* UreaN-15 Creat-1.0 Na-138
K-3.3 Cl-99 HCO3-27 AnGap-15
___ 09:45PM BLOOD ALT-14 AST-19 CK(CPK)-40 AlkPhos-139*
TotBili-0.3
___ 09:45PM BLOOD Lipase-30
___ 09:45PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:45PM BLOOD Albumin-3.5
___ 01:20PM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
___ 10:12PM BLOOD Lactate-2.0
___ 12:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 12:50AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
RELEVANT LABS:
___ 09:45PM BLOOD ___ PTT-59.9* ___
___ 01:20PM BLOOD ___ PTT-58.5* ___
___ 05:50AM BLOOD ___ PTT-60.2* ___
___ 09:45PM BLOOD Lipase-30
___ 01:20PM BLOOD Lipase-29
___ 03:50PM BLOOD Lipase-37
___ 01:20PM BLOOD Cortsol-4.6
___ 05:50AM BLOOD Cortsol-2.0
___ 03:50PM BLOOD Cortsol-2.8
___ 05:09PM BLOOD Cortsol-26.1 (1 hr after Cosyntropyn
250mg IV)
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-11.4* RBC-4.88 Hgb-12.1 Hct-39.8
MCV-82 MCH-24.7* MCHC-30.3* RDW-18.2* Plt ___
___ 07:50AM BLOOD ___ PTT-38.0* ___
___ 07:50AM BLOOD Glucose-76 UreaN-14 Creat-1.0 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
___ 06:10AM BLOOD ALT-11 AST-16 AlkPhos-113* TotBili-0.3
___ 07:50AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.6
MICRO:
BLOOD CULTURES ___: PENDING
IMAGING:
RUQ US ___:
IMPRESSION: No definite intrahepatic biliary ductal dilatation.
Chronic
extra-hepatic biliary ductal dilatation, which may be related to
patient's
history of cholecystectomy, unchanged from prior ultrasound of
___. No
evidence of choledocholithiasis.
CT ABD PELVIS WO CONTRAST ___:
IMPRESSION:
1. No CT findings to explain patient's abdominal pain.
2. No radiopaque retained gallstone seen.
CXR ___:
FINDINGS: As compared to the previous radiograph, the size of
the cardiac
silhouette has increased. There is no evidence of pneumonia in
the lung
parenchyma but scarring has developed at the apical aspect of
the middle lobe and the bases of the middle lobe. The scarring
is better appreciated on the frontal than on the lateral
radiograph. No pneumonia, no pulmonary edema. Mildly enlarged
cardiac silhouette without fluid overload. Mild tortuosity of
the thoracic aorta.
EKG ___:
Atrial fibrillation with rapid ventricular response rate of 114
beats per
minute. Left bundle-branch block. Compared to the previous
tracing of ___ sinus rhythm is no longer appreciated and the
ventricular rate is faster.
EKG ___:
Atrial fibrillation with rapid ventricular response rate of 107
beats per
minute. Left bundle-branch block. Possible inferior wall
myocardial
infarction of indeterminate age. Compared to the previous
tracing of ___ the inferior Q waves are new.
Brief Hospital Course:
Ms. ___ is a ___ with a PMHx of cholecystitis (sp ERCP
and sphincterotomy in ___ and sp cholecystectomy in ___,
PAF (on Warfarin), chronic lung disease (BOOP vs. COPD),
??Adrenal insufficiency, presenting from Rehab with a 7d hx of
RUQ abdominal pain.
# RUQ Pain
The etiology of this pain was initially unclear. There was no
evidence of PNA on CXR. There was no evidence of biliary
pathology based on CT, US and low Tbili (although possible that
pt passed gallstones at Rehab). No evidence of mesenteric
ischemia (low lactate). Also no evidence of hepatitis on UA or
labs. Pancreatitis unlikely since lipase neg. Acute adrenal
insufficiency and narcotics withdrawal would have been expected
to present with diffuse abd pain. PUD also less likely. PE is
possible given hx of clotting disorder but pt was already on
therapeutic coumadin, satting well on RA. The cause of patient's
abdominal pain remains unclear.
# Afib with RVR
Pt had atrial fibrillation with RVR to the 150-170s on several
occasions. This was thought to be ___ recent discontinuation of
metoprolol by pt at the rehab center. DDx/contributing factors
included hypotension. She was treated with ASA 325mg, statin at
home dose and initially diltiazem 30mg po q6h, later increased
to 60mg po qid and metoprolol 12.5mg po bid. Coumadin was held
for a supratherapeutic INR. INR on day of discharge was down to
1.6 so she was given a dose of warfarin 3mg. She was discharged
on her home dose of 5mg daily. Metoprolol and diltiazem were
changed back to home doses upon discharge.
# Hypotension
Pt was recorded to be hypotensive at OSH and had SBP values in
the 85-100 range during the admission. Cortisol levels
low-normal. DDx for hypotension included hypovolemia ___ poor
intake in setting of nausea and increased lasix dose vs. adrenal
insufficiency. Pt underwent a cosyntropin stimulation test which
showed a normal adrenal response to ACTH.
# Hx of Fevers at Rehab
Pt was sp a treatment course of Levofloxacin for presumed PNA.
Pt had no evidence of infection during the hospitalization.
# ST Depressions on EKG
Likely rate-related changes. TnT negative. Pt was noted to have
new inferior Q-waves but TnT/CKMB values remained low. She had
no symptoms of chest pain or tightness.
# Elevated INR/Clotting disorder
INR elevation on arrival was likely iatrogenic in setting of pt
receiving Coumadin while on abx and in the setting of an already
elevated INR, per rehab nursing staff. Coumadin was held until
___ when INR was 1.6. She was discharged on home dose of
warfarin 5mg daily
# Dyspnea/Chronic Lung Disease
Pt has a hx of COPD vs. BOOP per OSH records. She was treated
with her home inhalers and complained of minimal hypoxia. She
was noted to have wheezes on lung exam on one occasion but
otherwise had a relatively benign pulmonary exam.
# Tobacco Addiction: Nicotine patch continued
# Anxiety/Depression: Ativan and fluoxetine were continued per
home dose
# ?Hypothyroidism
Pt has no known diagnosis of hypothyroidism but appears to be on
standing levothyroxine. Pt declinined levothyroxine during this
hospitalization saying that she did not need it.
TRANSITIONAL ISSUES:
- Please clarify indication for levothyroxine
- Please consider PFTs to better characterize the nature of pt's
chronic lung disease
- Please follow up final blood cultures from ___
- Please consider checking ACTH level to evaluate for
possibility of secondary adrenal insufficiency
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Fleet Enema ___AILY:PRN constipation
3. Acetaminophen 650 mg PO Q4H:PRN pain
4. Atorvastatin 10 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Diltiazem 240 mg PO DAILY
Hold for SBP < 110 and HR <55
8. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP <110 and HR < 55
9. Fluoxetine 10 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Prazosin 1 mg PO BID
Hold for SBP <110
13. Furosemide 60 mg PO DAILY
Hold for SBP < 110
14. Lisinopril 2.5 mg PO DAILY
Hold for SBP < 110
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
nebulizer every 4 hours: prn SOB
17. Senna 1 TAB PO DAILY
18. Prochlorperazine 10 mg PO Q8H:PRN nausea
19. Lorazepam 1 mg PO TID
20. Morphine SR (MS ___ 15 mg PO Q12H
hold for sedation and rr<10
21. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
22. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Fleet Enema ___AILY:PRN constipation
6. Fluoxetine 10 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Lorazepam 1 mg PO TID
RX *lorazepam 1 mg 1 tab by mouth Three times per day Disp #*90
Tablet Refills:*0
10. Morphine SR (MS ___ 15 mg PO Q12H
hold for sedation and rr<10
RX *morphine 15 mg 1 tablet(s) by mouth two times per day Disp
#*40 Tablet Refills:*0
11. Nicotine Patch 14 mg TD DAILY
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours Disp #*30
Tablet Refills:*0
14. Senna 1 TAB PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
nebulizer every 4 hours: prn SOB
17. Diltiazem 240 mg PO DAILY
Hold for SBP < 110 and HR <55
18. Metoprolol Succinate XL 25 mg PO DAILY
HOLD for SBP<100, HR<55
19. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Abdominal Pain
Secondary: Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted for abdominal pain. You were also found to have a fast
heart rate. Your INR was elevated and we held your Coumadin your
INR went into the goal range. We restarted your medication to
regulate your heart rate and it improved; however, we used lower
doses since your blood pressure was low. It is not clear what is
causing your abdominal pain, but we ruled out all of the
potentially dangerous possibilities. We wish you well!
Followup Instructions:
___
|
10572581-DS-16 | 10,572,581 | 23,707,889 | DS | 16 | 2132-10-06 00:00:00 | 2132-10-07 19:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Melena, Hct drop
Major Surgical or Invasive Procedure:
Endoscopy ___
Capsule endoscopy ___
History of Present Illness:
___ with history of CAD, s/p CABG in ___, with recent admission
in ___ for NSTEMI s/p DES to the OM1 graft, also found to be
in new a.fib during this admission (not cardioverted) discharged
on aspirin/plavix/rivoroxaban who now presents with
lethargy/fatigue and 15 pt Hct drop over last 2 weeks in setting
of dark stools. He notes that since his discharge he has had
worsening fatigue and increased crampy pain in his legs with
exertion (bilaterally, oppsed to his baseline left leg pain).
He's also had decreased appetite and overall energy. He denies
any abdominal pain, and notes that his stools are well formed
without diarrhea, nausea, or vomiting. He went to his scheduled
vascular appointment today where he was found to be pale, and
noted to have a Hct drop and subsequently referred to the ED.
.
In the ED, VS were 97.9 92 98/51 16 96%ra. Rectal showed dark
G+ stool. Hct 19.7 from 34.8 at last discharge. Retic count is
8.7. Lactate was 1.0. INR 1.3. Electrolytes unremarkable.
EKG showed NSR, no signs of ischemia. 2 PIVs were placed and he
was bolused with protonix and started on ggt. He received 1 L
NS. He was crossed for 2 U PRBC and the first unit was hannging
on transfer. GI was consulted who recommended continuing these
interventions with plan to make NPO after midnight and do EGD in
the AM.
On arrival to the MICU, VS 98.1 72 116/58 13 99% RA. He
feels well and is denying CP, SOB, abd pain, n/v/d.
Past Medical History:
CABG ___
NSTEMI ___, DES to OM1 graft
Dyslipidemia
hypertension
GERD
PVD
Social History:
___
Family History:
brother had sudden death at age ___, unknown cause
No other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAM:
.
Vitals: 98.1 72 116/58 13 99% RA
General: Pale, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
throughout precordium
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace edema. Well healed
scars on medial right thigh
Discharge:
Vitals- 97.7-98.3, 98-120/49-58, 68-90, 94-96% RA
General- Well appearing elderly male in NAD
HEENT- EOMI, PERRL, MMM, oropharynx clear
Neck- supple, JVP 5cm, no LAD
CV- RRR, normal S1/S2, grade III/VI crescendo murmur heard
throughout precordium, radiating to left axilla.
Lungs- Clear to auscultation bilaterally. No w/c/r
Abdomen- +BS, soft, NT, ND, no hepatosplenomegaly
Ext- warm, well perfused, 2+ ___ pulses, no edema
Pertinent Results:
ADMISSION LABS:
___ 05:42PM BLOOD WBC-9.4 RBC-2.08*# Hgb-6.0*# Hct-19.7*#
MCV-95 MCH-28.9 MCHC-30.4* RDW-18.9* Plt ___
___ 05:42PM BLOOD ___ PTT-34.7 ___
___ 05:42PM BLOOD Ret Aut-8.7*
___ 05:42PM BLOOD Glucose-123* UreaN-25* Creat-1.0 Na-138
K-4.3 Cl-102 HCO3-24 AnGap-16
___ 05:42PM BLOOD LD(LDH)-218 TotBili-0.4 DirBili-0.1
IndBili-0.3
___ 05:42PM BLOOD Iron-39*
___ 03:53AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.3
___ 05:42PM BLOOD calTIBC-345 ___ Ferritn-27* TRF-265
___ 08:11PM BLOOD Lactate-1.0
Discharge labs:
___ 07:45AM BLOOD WBC-7.0 RBC-3.25* Hgb-9.9* Hct-32.0*
MCV-98 MCH-30.3 MCHC-30.9* RDW-17.3* Plt ___
___ 03:50PM BLOOD Hct-32.6*
___ 07:30AM BLOOD WBC-7.4 RBC-3.37* Hgb-10.2* Hct-32.8*
MCV-97 MCH-30.3 MCHC-31.1 RDW-17.6* Plt ___
___ 05:42PM BLOOD Ret Aut-8.7*
___ 05:42PM BLOOD calTIBC-345 ___ Ferritn-27* TRF-265
CXR ___: Cardiac size is top normal, accentuated by the
projection. Bibasilar opacities, larger on the right side, are
consistent with likely small pleural effusions and
consolidations. There is mild-to-moderate interstitial edema.
There is no pneumothorax. Sternal wires are aligned. Followup is
recommended to exclude the development of TRALI.
CXR ___:
IMPRESSION: Substantial interval improvement of post CABG
pulmonary vascular congestion and left-sided pleural effusion.
EGD ___:
Mucosa suggestive of ___ esophagus
No blood or bleeding. No abnormality to accound for GI bleeding
Polyp in the second part of the duodenum
Otherwise normal EGD to third part of the duodenum
ECGStudy Date of ___ 5:16:08 ___
Sinus rhythm. Inferior Q waves with T wave inversions. T wave
inversions in
leads V5-V6. Consider inferior myocardial infarction with
lateral involvement. Since the previous tracing of ___
minimal change.
Brief Hospital Course:
___ yom with CAD, s/p NSTEMI with DES placed ___, recent
diagnosis of a. fib, discharged on ___ on
aspirin/plavix/rivaroxaban now presenting with significant Hct
drop in setting of GI bleed, initially admitted to MICU.
# GI bleed with Hct drop: Hct 19.7 on admission. Given dark
stools without signs of bright red blood, most likely represents
an upper GI bleed in setting of starting aspirin, plavix,
rivaroxaban. He was maintained on protonix ggt and changed to
PO PPI once EGD showed no active bleed. It did however show
barrets esophagus which will need outpt followup. He remained
hemodynamically stable in the MICU s/p 3 U PRBC with Hct
stabilizing in the low ___. His aspirin/plavix were continued
(though changed to lower dose aspirin) givne recent DES.
Rivaroxaban was held given low daily stroke risk with afib and
discharge plan for this was to continue to hold it. Lisinopril
was held given bleed and was restarted at discharge. Metoprolol
was restarted at a low dose and was restarted on discharge.
# SOB: Pt developed acute SOB on morning of ___. CXR showed
concern for volume overload vs. TRALI in setting of blood
transfusion. Received lasix 40mg x1, with significant
improvement in respiratory status .
# Recent NSTEMI: S/p DES in OM1 graft, discharged on
aspirin/plavix. Both were continued given the high risk of
in-stent thrombosis, though aspirin was initially changed to
81mg in-house and changed to 81 mg on discharge. Metoprolol was
continued at lower dose given GI bleed and was changed back to
home dose on discharge. Lisinopril was initially held and
changed back to home dose on discharge. He was continued on
home atorvastatin
# Atrial fibrillation: New onset during recent admission for
NSTEMI. CHADS of 2. No cardioversion performed. He was
maintained on rate control with metoprolol and started
rivaroxaban on that admission. On this admission, he remained
NSR on EKG and tele. Overall has very low daily risk of CVA off
of anticoagulation (~5% yearly risk) so held rivaroxaban with
plan for continued holding on d/c and follow up with PCP/
cardiologist. We also lowered aspirin to 81mg daily per
consultation with cardiology. We continued lower dose
metoprolol given GIB in the MICU and was changed back to home
dose at discharge.
# Thrombocytosis: Pt with Plt of 628 on admission, have been
trending down. Likely represents inflammatory state in setting
of bleed.
# PVD: On cilostazol as outpt for PVD for symptomatic treatment.
This was held while in the MICU and while on the floor. We
continued to hold this at discharge, with consideration of
restarting as an outpatient.
# GERD: Maintained on protonix ggt and then changed to BID PPI
# Transitional Issues
-Pt is full code
-Needs outpt follow up for ___ esophagus
-Restarting cilostazole per PCP.
-Follow up capsule report per GI
Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid ().
7. rivaroxaban 15 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol succinate 100 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*
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# Acute blood loss anemia
# Gastrointestinal bleed
Secondary diagnosis:
# Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission.
You were admitted because of fatigue and dark stools concerning
for a gastrointestinal bleed.
You had an endoscopy, looking at the upper portion of your GI
tract, which did not show any source of a bleed.
You were given blood transfusions, and your blood levels
remained stable prior to discharge.
We did a capsule endoscopy which was pending at the time of your
discharge.
The following changes were made to your medication regimen:
- STOP cilostazol, discuss restarting this medication with your
primary care doctor
- STOP rivaroxaban
- CHANGE Aspirin to 81mg daily asa dosing
Followup Instructions:
___
|
10572718-DS-25 | 10,572,718 | 27,649,879 | DS | 25 | 2128-08-09 00:00:00 | 2128-08-18 15:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Lower extremity weakness, fatigue, and tremulousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with large B Cell Lymphoma involving T3-T4 dx'd in ___,
treated with radiotherapy alone and without recurrence, CHB s/p
___ pacemaker, HTN, rheumatoid arthritis, CKD (baseline Cr
1.3-1.4), CHF (most recent EF 45% in our system, ___, NIDDM
(Hgb 5.8 on ___, paroxysmal Afib previously on Eliquis,
presenting with acute lower extremity weakness with worsening
fatigue over the last several days.
Patient reports that her legs became weak when she was stepping
out of a cab on her way to her oncology appointment today. She
did not notice any weakness this AM, and denies any history of
similar symptoms, including when she had multiple spinal
procedures in ___ for spinal lymphoma. She reports some
shakiness in her arms. she has had weakness in her legs ___ to
pain and muscle spasms in her thighs for a while since she
started moving again after being immobilized from a cold in
___. Then the weakness in her thighs became full body
weakness in the past week or so, however, she says that the
weakness waxes and wanes and 4 days ago she was able to walk
around outside in her yard and in her house. She denies any
back pain, bowel/bladder incontinence, tingling, or numbness. No
fevers/chills, dyspnea, cough, dysuria, urinary retention,
abdominal pain, or diarrhea. Denies loss of consciousness. she
has been sleeping more upright ___ to pain in her upper back
near her hardware, she is up ___ pounds from her dry weight. She
denies missing her home furosemide or committing any dietary
indiscretions.
Of note, she lives alone and reports adequate functioning at
home, but is concerned that she may not be managing her
medications adequately. She recently ran out of Eliquis due to
delay in refill and has been unable to fill prescription given
lack of ride.
In the ED:
Initial vital signs were notable for:
0 98.5 64 141/61 18 99% RA
Exam notable for:
Alert, conversant, not in distress
RRR
Clear lungs
Spine markedly kyphotic with subcutaneous metal implants noted,
but no tenderness to palpation of cervical-sacral spine
Rectal tone intact
CNII-XII intact, motor strength ___ in upper and lower
extremities, bilateral patellar reflexes 3+, down-going Babinski
Labs were notable for:
UA bland
Bun 65/Cr 1.4
LDH 284
Uric acid 7.2
Total protein 6.0
IgG 477, IgA 32
WBC 6.3, no bands, Abs neutr 4500
CT chest w/o contrast and CT head w/o contrast did not show
acute events.
Past Medical History:
1. History of complete heart block status post dual-chamber
pacemaker in ___, concurrently with AV conduction.
2. Systolic dysfunction with an EF of 50-55% by last echo ___.
3. Hypertension.
4. Lower extremity edema.
5. Moderate mitral regurgitation.
6. Pt with history of lymphoma of the spine (T3-T4 mass). Bone
marrow aspirate and biopsy for staging was negative, as were her
staging PET and CT scans. s/p T1-8 fusion, radiation therapy in
___ she did not receive chemotherapy because of her CHF and
concern she could not tolerate it. Has been in remission since
this time.
7. Rheumatoid arthritis: methotrexate and rituxin
8. *S/P COMPRESSION FRACTURES - lower cervical upper
thoracic-confirmed by bone scan ___ - had been on evista prior.
Fosamax and Darvocet started around ___. had lymphoma found there
later as well. fosamax stopped ___
Social History:
___
Family History:
Unspecified heart condition in her father, which began in his
___ and lead to death at ___. No other family history of heart
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.9 PO 149/65 L Lying 65 20 100 Ra
GENERAL: Alert and interactive. In no acute distress. Kyphotic
posture sitting up in bed.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD. JVP @ 9 cm.
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.
BACK: Hardware underneath skin protruding in upper back, No
spinous process tenderness or tenderness to hardware. No CVA
tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 tested and intact. ___ strength b/l grip
strength, flexion and extension @ elbow joint, ___ strength b/l
plantar flexion and dorsiflexion. 4+/5 strength RLE @ hip
flexion, ___ strength LLE @ hip flexion. Normal sensation. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 97.6 PO151 / 64 R Sitting60___%RA
GENERAL: Alert and interactive. In no acute distress. Kyphotic
posture sitting up in bed.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD. JVP @ 9 cm.
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.
BACK: Hardware underneath skin protruding in upper back, No
spinous process tenderness or tenderness to hardware. No CVA
tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 tested and intact. ___ strength b/l grip
strength, flexion and extension @ elbow joint, ___ strength b/l
plantar flexion and dorsiflexion. 4+/5 strength RLE @ hip
flexion, ___ strength LLE @ hip flexion. Normal sensation. AOx3.
Pertinent Results:
Admission labs:
___ 10:19AM BLOOD WBC-5.2 RBC-3.93 Hgb-11.8 Hct-36.3 MCV-92
MCH-30.0 MCHC-32.5 RDW-14.0 RDWSD-47.7* Plt ___
___ 10:19AM BLOOD Neuts-51.6 ___ Monos-14.5*
Eos-4.8 Baso-1.0 Im ___ AbsNeut-2.66 AbsLymp-1.42
AbsMono-0.75 AbsEos-0.25 AbsBaso-0.05
___ 01:47PM BLOOD ___ PTT-28.3 ___
___ 10:19AM BLOOD Glucose-109* Na-142 K-4.6 Cl-107 HCO3-19*
AnGap-16
___ 10:19AM BLOOD UreaN-65* Creat-1.3*
___ 10:19AM BLOOD ALT-28 AST-27 CK(CPK)-86 AlkPhos-49
TotBili-0.3
___ 10:19AM BLOOD LD(LDH)-284*
___ 01:47PM BLOOD proBNP-1262*
___ 10:19AM BLOOD TotProt-6.0* Albumin-4.2 Globuln-1.8*
Calcium-9.2 Phos-3.0 Mg-2.5
___ 10:19AM BLOOD UricAcd-7.2*
___ 01:47PM BLOOD TSH-0.89
___ 10:19AM BLOOD RheuFac-<10 ___
___ 10:19AM BLOOD PEP-HYPOGAMMAG IgG-477* IgA-32* IgM-43
IFE-NO MONOCLO
___ 03:03PM URINE Color-Straw Appear-Clear Sp ___
___ 03:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:03PM URINE Hours-RANDOM
Discharge labs:
___ 06:50AM BLOOD WBC-6.6 RBC-3.46* Hgb-10.6* Hct-32.9*
MCV-95 MCH-30.6 MCHC-32.2 RDW-14.2 RDWSD-49.3* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-29.6 ___
___ 06:50AM BLOOD Glucose-84 UreaN-53* Creat-1.3* Na-146
K-5.2 Cl-113* HCO3-21* AnGap-12
___ 06:50AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.4
Microbiology:
___ 3:03 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Imaging studies:
EXAMINATION: CT CHEST W/O CONTRAST ___
INDICATION: ___ year old woman with weakness, hx of lymphoma
involvement of
thoracic spine// evaluate for pneumonia or pulmonary edema, as
well T-spine
fracture/hardware migration
TECHNIQUE: Multidetector helical scanning of the chest was
performed without
intravenous contrast agent and reconstructed as contiguous 5 mm
and 1.25 mm
thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 32.0 cm; CTDIvol = 18.0 mGy (Body)
DLP = 575.1
mGy-cm. Total DLP (Body) = 575 mGy-cm.
COMPARISON: Chest CTA dated ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The thyroid is not clearly
delineated.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Mediastinal lymph nodes are not enlarged.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is moderately enlarged and there is no
coronary arterial
calcification. Pacemaker leads are again seen. There is no
pericardial
effusion.
VESSELS: Vascular configuration is conventional. Aortic
caliber is normal.
Atherosclerotic calcifications are seen in the thoracic and
abdominal aorta.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: There is a focus of rounded opacification
in the left
lower lobe abutting the pleura, best seen on the coronal the
view (601:72),
which could represent atelectasis and/or scarring. Although
less likely, an
underlying mass lesion cannot be excluded. This area head
demonstrated more
significant atelectasis on the prior and was not well assessed
at that time.
There is no emphysema. There are multiple sub 5 mm ground-glass
and solid
nodules in the bilateral upper and right lower lobes (4: 51, 52,
68, 74, 97).
These are grossly unchanged compared to prior. There is a
punctate granuloma
in the right upper lobe (04:53). A 9 mm calcification is again
seen in the
left lower lobe (4:122). Chronic scarring and fissural
thickening is again
seen in the azygos lobe. Bibasilar atelectasis is present.
AIRWAYS: The airways are patent to the subsegmental level
bilaterally.
PLEURA: There is no pleural effusion.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic
lesion.
Multilevel degenerative changes are severe. Spinal hardware and
compression
deformities of T3 and T4 are unchanged. Severe kyphosis is
again
demonstrated. Mild retrolisthesis of T11 on T12 is similar to
prior. Mild
anterolisthesis of C3 on C4 and C6 on C7 is present. A
Schmorl's node is
again seen at the inferior endplate of T11.
UPPER ABDOMEN: This study is not tailored for evaluation of the
abdomen.
Allowing for this, the partially visualized upper abdomen
demonstrates a left
upper pole renal cyst measuring 2.4 cm (03:44).
IMPRESSION:
1. No acute pulmonary abnormality.
2. Rounded focus of opacification in the left lower lobe could
represent
atelectasis and/or scarring. Although less likely, an
underlying mass lesion
cannot be excluded. Consider ___ imaging if clinically
indicated.
3. Bilateral millimetric pulmonary nodules are grossly unchanged
compared to
___.
4. Severe cardiomegaly, unchanged.
5. Severe kyphosis and degenerative disease, as described above.
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD ___
INDICATION: ___ year old woman with lower extremity weakness//
?evidence of
acute infarct
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast. Coronal and sagittal reformations as well as bone
algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy
(Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
Periventricular and subcortical white matter hypoattenuation is
nonspecific,
but likely the sequela of chronic microvascular infarction.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable apart from bilateral lens
replacements.
Dense atherosclerotic calcifications of the cavernous carotid
arteries are
noted bilaterally.
IMPRESSION:
1. No acute intracranial abnormality. Please note that MRI
would be more
sensitive for detection of acute infarction.
2. Mild age-appropriate atrophy and chronic small vessel
ischemic changes.
TTE ___:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal cavity size. There
is normal regional left ventricular systolic function.
Inferolateral wall contractility is delayed/dyssynchronous. The
visually estimated left ventricular ejection fraction is >=55%.
There is no resting left ventricular outflow tract gradient.
Tissue Doppler suggests an increased left ventricular filling
pressure (PCWP greater than 18mmHg). There is Grade II diastolic
dysfunction. Mildly dilated right ventricular cavity with mild
global free wall hypokinesis. There is abnormal septal motion
c/w conduction abnormality/ paced rhythm. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. There is a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) are moderately thickened. There is
no aortic valve stenosis. There is mild [1+] aortic
regurgitation. The mitral leaflets are mildly thickened with no
mitral valve prolapse. There is mild [1+] mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is mild to moderate [___] tricuspid regurgitation. Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be UNDERestimated. There is moderate pulmonary artery systolic
hypertension. The end-diastolic PR velocity is elevated
suggesting pulmonary artery diastolic hypertension. There is a
trivial pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness and cavity
size with normal regional/global systolic dysfunction. Increased
PCWP. Grade II diastolic dysfunction. Mild aoertic
regurgitation. At least mild to moderate tricuspid
regurgitation. At least moderate pulmonary artery systolic
hypertension. Pulmonary artery diastolic hypertension.
Brief Hospital Course:
___ woman with large B Cell Lymphoma involving T3-T4 dx'd in
___, s/p radiotherapy with no recurrence, complete heart block
s/p ___ pacemaker, HTN, rheumatoid arthritis, CKD
(baseline Cr 1.3-1.4), chronic diastolic CHF (most recent EF
<55%), NIDDM (A1C 5.8 on ___, paroxysmal Afib on Eliquis,
who presented from ___ clinic with subacute lower extremity
weakness, fatigue, and tremulousness. Evaluation included CT
head and chest that did not show any acute intracranial or
intrathoracic abnormality. UA was negative. Laboratory
evaluation was significant for mild stable metabolic acidosis
with bicarb of 21, mild chronically elevated LDH at 284, stable
creatinine at 1.3, proBNP of 1262 (without known baseline). Her
TSH was normal and rheumatoid factor and ___ were negative.
Workup also included immunoglobulins C3 and C4 which were only
notable for a mildly decreased IgG and IgA at 477 and 32
respectively. The patient improved on her own within 24 hours of
admission and was seen by physical therapy who recommended home
with physical therapy. She was discharged with home ___ & OT
after her clinical improvement. All of her home medications were
continued during admission.
Transitional issues:
======================
- Patient with mild anemia without evidence of bleeding prior to
discharge H&H 10.6 and 30.9 respectively, possibly secondary to
dilution and phlebotomy. Please repeat in 1 week.
- Patient with mildly decreased IgG and IgA at 477 and 32
respectively. Given recent severe illness please consider
repeating these labs and workup for common variable immune
deficiency.
- Aldolase pending on discharge, please ___.
- Incidental finding of rounded focus of opacification in the
left lower lobe on CT chest could represent atelectasis and/or
scarring. Although less likely, an underlying mass lesion cannot
be excluded. Consider ___ imaging if clinically indicated.
- Patient with difficulty reading given macular degeneration.
Please continue to monitor for accurate medication management.
#CODE: DNR/DNI
#CONTACT: ___ (cousin, HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Polyethylene Glycol 17 g PO BID
5. Rituximab 10 mg IV 2X/YEAR
6. Lisinopril 2.5 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
2. Apixaban 2.5 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Polyethylene Glycol 17 g PO BID
8. Rituximab 10 mg IV 2X/YEAR
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Weakness, transient
fatigue
SECONDARY:
Chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you here at ___
___.
WHY YOU WERE ADMITTED:
You were admitted because you felt weak and shaky.
WHAT HAPPENED WHILE YOU WERE HERE:
Please send blood test to look for reasons why you would be weak
or shaky. All of the lab tests that were sent were normal. We
also did an ultrasound of your heart that looked stable. Most
likely, this happened because you missed your medications and
did not eat or drink before your appointment. There are a
couple of labs that we want your primary care physician to
___ on they are listed below.
WHAT YOU SHOULD DO WHEN YOU LEAVE:
- ___ with your primary care doctor at the appointment
listed below. You will likely have repeat blood work at this
time.
- We have set up home physical therapy for you. They will visit
you and provide exercises for you to do at home.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10573007-DS-8 | 10,573,007 | 24,553,354 | DS | 8 | 2127-12-20 00:00:00 | 2127-12-20 18:40:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right upper quadrant pain and right lower quadrant pain
Major Surgical or Invasive Procedure:
___ - Percutaneous liver biopsy of concerning metastatic
nodules
History of Present Illness:
Mr ___ is a ___ year old male with a history of rectal
cancer with metastases to the liver who recently underwent
surgery for resection of these metastases. He is also on
___ therapy for his metastases. He is presenting for acute
onset of abdominal pain.
Mr ___ was administered ___ 2 weeks prior. Usually,
during the first week after chemo, he feels fatigued and
nauseous. However, he noted that this time, these symptoms
persisted beyond the first week. He had a few episodes of
emesis during this period.
On the day prior to admission, he was back in the clinic for the
next round of ___. Immediately when the infusion began, he
had sudden, acute, robust pain in the right upper and lower
quadrant associated with nausea and emesis. The symptoms
improved upon cessation of chemotherapy. He was sent to the ED
for evaluation of these symptoms.
In the ED, a CT scan revealed a perihepatic fluid collection and
2 potential sites of new metastases including in the left lobe
of the liver and in the adrenal. Labs were significant for
neutropenia. His UA was also noted to be positive. General
surgery consultation suggested initiation of antibiotics and
recommendation for interventional radiology to see the patient
given the fluid collection. His pain and nausea had resolved at
this point. He was admitted to ___ on the ___ service
for further evaluation.
Past Medical History:
PMH:
-colon cancer
-depression
-anxiety
-kidney stones.
PSH:
-Low anterior resection
Oncologic History:
- ___: Regular screening colonoscopy reveals an
infiltrative, partially-obstructing, large mass at 22 cm
proximal to the anus in the distal sigmoid, partially
circumferential,measuring 2 cm in length. Additionally, a
penduculated 3 cm polyp was noted at 18 cm in the rectum, and an
unusual thickened fold was noted at 80 cm in the likely splenic
flexure. Pathology of these lesions demonstrates superficial
fragments of tubulovillous adenoma with high-grade dysplasia at
22 cm, filiform serrate adenoma with foci of high-grade
dysplasia at 18 cm, and fragments of hyperplastic polyp with
features suggestive of sessile serrated adenoma/polyp at the
splenic flexure.
- ___: Undergoes low anterior resection with total
mesorectalexicison. Pathology reveals 7.0 cm rectal
adenocarcinoma, partially mucinous, low grade, invading through
the muscularis propria into the subserosal/perirectal adipose
tissue but not extending to the serosal surface, no
lymphovascular invasion, perineural invasion present, 4 of 24
lymph nodes involved by metastatic adenocarcinoma, with three
discontinuous extramural deposits, resection margins negative.
Pre-surgical CEA reportedly 53. Staging studies showed multiple
small pulmonary micronodules, as well as several subcentimeter
hypodensities within the liver;hemangiomas/cysts. The final
staging was pT3, pN2a, cM0, StageIIIB.
- ___: CEA 11.8.
- ___: Undergoes 12 cycles of modified FOLFOX6
adjuvant chemotherapy, administered by Dr. ___ at
___ ___. This was complicated by mild
neuropathy in his feet, which required holding oxaliplatin on
cycle 6, and subsequent dose-reduction of oxaliplatin (to 50
mg/m2) for further cycles.
- ___: CEA 1.9
- ___: CEA 1.3
- ___: CT torso demonstrates a new 2.4 cm lesion in the
right lobe of the liver, suspicious for a metastatic focus.
Stable very small bilateral pulmonary nodules identified on
chest CT.
- ___: CEA 6.0
- ___: Undergoes laser lithotripsy of left ureteral stone
and placement of left ureteral double-J stent.
- ___: Undergoes right hepatic lobectomy by Dr. ___,
with pathology demonstrating metastatic adenocarcinoma,
moderately to poorly-differentiated, consistent with colonic
primary.
- ___: Initial medical oncology evaluation at ___.
Social History:
___
Family History:
Family history is notable for diabetes in his mother and COPD in
his father.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
====================================
Physical exam:
VS: HR 110, temp 99, RR 12, O2 sat 98% RA BP 120/70
Gen: Caucasian male, relatively cheerful disposition, in no
apparent distress
HEENT: Anicteric
Cardiac: Tachycardic, regular rhythm, no appreciable murmurs
Pulm: clear bilaterally
Abd: abdominal scar from prior liver surgery evident on right
abdomen, bowel sounds normal and active, abdomen slightly
distended with no shifting dullness or fluid wave, left abdomen
soft and nontender, right abdomen tender with guarding
Ext: no edema noted
PHYSICAL EXAM ON DISCHARGE
====================================
VS: t98.0 bp111/51 p65 rr22 97% RA
Gen: no apparent distress
HEENT: Anicteric
Cardiac: regular rate and rhythm, no appreciable murmurs
Pulm: clear bilaterally
Abd: abdominal scar from prior liver surgery, + BS, slightly
distended, non-tender on palpation ("just a little sore")
Ext: no edema noted
Pertinent Results:
ADMISSION LABS
=========================================
___ 09:32AM BLOOD WBC-4.0 RBC-4.86 Hgb-13.9* Hct-43.4
MCV-89 MCH-28.7 MCHC-32.2 RDW-16.6* Plt ___
___ 09:32AM BLOOD Neuts-22* Bands-0 Lymphs-56* Monos-16*
Eos-3 Baso-2 Atyps-1* ___ Myelos-0
___ 09:32AM BLOOD Plt Smr-LOW Plt ___
___ 09:32AM BLOOD UreaN-11 Creat-1.1 Na-141 K-4.0 Cl-106
HCO3-29 AnGap-10
___ 09:32AM BLOOD ALT-22 AST-24 AlkPhos-73 TotBili-0.5
___ 03:25PM BLOOD Lipase-75*
___ 09:32AM BLOOD TotProt-6.7 Albumin-4.1 Globuln-2.6
Calcium-9.7 Phos-2.7 Mg-2.1
DISCHARGE LABS
=========================================
___ 06:01AM BLOOD WBC-2.4*# RBC-4.50* Hgb-12.1* Hct-40.2
MCV-89 MCH-27.0 MCHC-30.2* RDW-17.2* Plt Ct-94*
___ 06:01AM BLOOD Neuts-25* Bands-0 Lymphs-53* Monos-20*
Eos-2 Baso-0 ___ Myelos-0
___ 06:01AM BLOOD Plt Smr-NORMAL Plt Ct-94*
___ 06:01AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-138
K-4.2 Cl-108 HCO3-25 AnGap-9
___ 06:30AM BLOOD ALT-25 AST-26 LD(LDH)-209 AlkPhos-64
TotBili-0.7
___ 06:01AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.0
EKG
=========================================
___: Ectopic atrial tachycardia. Left axis deviation. Left
anterior fascicular block. Non-specific repolarization
abnormalities. Compared to the previous tracing of ___ there
is no significant change.
MICROBIOLOGY
=========================================
___ Blood culture (x2): pending
___ URINE CULTURE (Final ___: <10,000 organisms/ml.
RADIOLOGY
=========================================
US ABD, SINGLE LIMIT (___):
1. 6.7 x 3.4 x 4.5 cm hypoechoic collection along the resection
margin that has a very thick irregular hyperechoic rim and
likely represents either post-surgical change or a necrotic
metastasis.
2. Solid hypoechoic lesions adjacent to the resection margin and
within the left lobe of the liver, that are consistent with
liver metastases.
CT ABD & PELVIS WITH CONTRAST (___):
1. 6.1 x 3 cm hypodense focus in the right lobe of the liver at
the margin of the prior resection may be postoperative change,
however abscess or disease progression with possible necrosis is
not excluded.
2. 1.4 cm hypodensity in the left lobe of the liver was not
definitely present previously and may be a new focus of
metastasis.
3. Worsening retroperitoneal lymphadenopathy.
4. New 1.7 cm left adrenal nodule, worrisome for metastasis.
Brief Hospital Course:
___ old male with rectal adenocarcinoma (s/p rectal mass
excision and FOLFOX6) recently found to have metastasized to the
liver (now s/p resection and ___ therapy) who presents with
right-sided abdominal pain after receiving chemotherapy.
# Abdominal pain:
Pain is likely related to chemotherapy infusion, given timing of
patient's symptoms (i.e. severe burning pain and nausea right
after the medication was given) and short duration (resolved
within 24 hours). Fluid collection noted on ultrasound was
thought to be related to post-surgical change. ___ performed
liver biopsy of the left lobe, which they thought to be new
metastasis, and have sent for biopsy and touch prep cytology.
# Neutropenia:
In setting of ___. Patient did not spike fevers while on
service. At the beginning of admission, urine and blood
cultures were sent, and the patient was started empirically on
vancomycin and zosyn. Because the patient did not have fevers
as an inpatient and WBC count increased from 0.7 (___) -> 1.1
(___) -> 2.4 (___), antibiotics were discontinued. The urine
culture returned negative, although the blood cultures are still
pending.
# Rectal adenocarcinoma with liver metastases:
CT scan from ___ revealed worsening retroperitoneal LAD, and
potential new metastatic nodules (1.7 cm left adrenal and 1.4 cm
left liver lobe). After U/S of the abdomen on ___ was
concerning for a solid mass (likely metastasis of primary
cancer) in the left lobe of the liver, ___ performed a biopsy,
which has been sent for tissue and cytology. These results
ought to be followed up with outpatient provider.
TRANSITIONAL CARE ISSUES
====================================================
- Reconsider chemo regimen moving forward considering patient's
likely disease progression on ___, and potential reaction to
chemo
- Discussion of prognosis and goals of care with primary
oncologist
- Follow-up tissue and cytology from liver biopsy
- Follow-up blood cultures that are currently pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Acetaminophen 650 mg PO Q8H
3. Famotidine 20 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. Metoprolol Tartrate 25 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Mild oxaliplatin reaction
- Metastatic rectal adenocarcinoma
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 the oncology service with
abdominal pain and a mild reaction after oxaliplatin
chemotherapy which improved. Imaging demonstrated some
concerning nodules in your liver and a biopsy was performed to
clarify if this relates to your cancer. You will follow-up with
Drs. ___ in clinic to discuss further
chemotherapy.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
Followup Instructions:
___
|
10573256-DS-17 | 10,573,256 | 29,088,728 | DS | 17 | 2170-06-08 00:00:00 | 2170-06-09 14:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Avocado / cantalope / Banana
Attending: ___.
Chief Complaint:
Dizziness, palpitations, and malaise, with hyponatremia at ___'s
office.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ F with hx of DM, HTN, anxiety p/w few days
of weakness, dizziness, worsening palpitations, and general
malaise. Went to see ___ yesterday and labs were notable for a
sodium of 120 and patient was sent to the ED. Reports that she
has had occasional palpitations that lasts for a few seconds to
30 minutes since the beginning of this ___. It occurs on
average once every other day and accompanied with a feeling of
"despair, like if something bad was going to happen." Never has
chest pain, weakness, or syncope with these episodes. Since last
week, her palpitations has worsen in terms of duration and
frequency. She has been very stressed and anxious lately because
she is attempting to get her husband into a nursing facility
since her husband has dementia and multiple medical problems.
States that it has been difficult being his caretaker especially
because he can 'sometimes be aggressive and often demands sex'.
She is also sad about his deterioration. She has had a decrease
in appetite recently and has not been eating or sleeping too
well. Last meal was yesterday morning.
Patient notes a productive cough (whitish sputum), headache, and
shortness of breath. She has a history of chronic cough for
about ___ years that tends to worsen with climate change (usually
worse coming into ___ and at the end of ___). Cough often
occurs at night. Her headache and shortness of breath was
transient and has completely resolved. She usually gets SOB with
walking briskly, or when she talks too fast, but not with
walking at a regular pace, which she does daily as she has no
car. She lays flat to sleep, and uses ___ pillows at night, but
the second is for her back. She has dizziness when getting up
from a sitting position. Currently denies fever, nausea,
vomiting, dysuria, suprapubic pain, bloody stools,
lightheadedness, sob, dizziness.
Per PCP, HCTZ dose was recently increased from 12.5mg to 25mg.
But, patient was confused on how to take the medication and took
both doses (total of 37.5mg).
In the ED, initial vitals 98.2 116 145/58 16 99% RA. Labs
notable for FENa of 0.1%; UA positive. Lactate 4.5 trended down
to 2.6 with IVF. Na of 120, and was 125 three hours later with
fluids. She received CTX and 2L NS.
Vitals prior to transfer: 97.7 83 112/59 17 98% RA. On arrival
to the floor vitals are 138/60, 99, 18, 99% RA. Currently,
reports feeling much better and less anxious. Denies chest pain,
palpitations, dysuria, headache, sob, dizziness. +urinary
frequency.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. +
occasional constipation.
Past Medical History:
-HTN
-diabetes
-hyperlipidemia
-hypothyroidism
-osteoporosis
-asthma
-lower back pain after a fall ___ years ago
-hx of treated H.pylori
-hx of cataracts
Social History:
___
Family History:
She has four children, two of whom have diabetes as well. Her
mother died at ___ of unknown reason. Her father died at ___
years old. She has three sisters and a healthy brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7, 138/60, 99, 18, 99% RA
GENERAL - pleasant female NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, L ptosis (chronic for several
years), sclerae anicteric, slightly dried mucous membranes, OP
clear
NECK - supple, no thyromegaly, no JVD
LUNGS - mild crackles at LL base otherwise CTA bilat, no wheezes
or rhonchi, 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 rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS - T 97.7, Tm 98.2, HR 66 (66-99), BP 125/77 (122-157/60-77),
RR 16 (___), O2Sat 96% RA (96-99%), BG 185
GENERAL - well-appearing woman in NAD, comfortable and
conversant
HEENT - NC/AT, PERRLA, EOMI, anicteric sclera, left ptosis, MMM,
OP clear and without lesions, pink mucous membranes,
nonerythematous.
NECK - supple, no carotid bruits, no LAD.
LUNGS - Crackles in the left lung base, no other adventitious
sounds, with good aeration throughout, and good respiratory
effort with equal expansion; respirations unlabored, with no
accessory muscle use.
HEART - RRR, no m/r/g, nl S1/S2
ABDOMEN - +BS, soft, nontender, nondistended, no masses, no
rebound/guarding
EXTREMITIES - warm and well perfused, with capillary refill <1s,
no edema appreciated
SKIN - no rashes or lesions noted
NEURO - awake, A&Ox3, CNs II-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 11:48AM BLOOD UreaN-6 Creat-0.6 Na-120* K-4.2 Cl-81*
HCO3-23 AnGap-20
___ 11:48AM BLOOD Glucose-230*
___ 02:05AM BLOOD Glucose-187* UreaN-9 Creat-0.6 Na-125*
K-4.0 Cl-83* HCO3-27 AnGap-19
___ 02:05AM BLOOD WBC-6.9 RBC-4.60 Hgb-13.4 Hct-38.1 MCV-83
MCH-29.2 MCHC-35.3* RDW-12.3 Plt ___
___ 02:05AM BLOOD Neuts-58.8 ___ Monos-8.5 Eos-1.7
Baso-1.2
___ 02:05AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.8
___ 04:05AM BLOOD Lactate-4.7*
___ 02:45AM URINE Color-Straw Appear-Clear Sp ___
___ 02:45AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 02:45AM URINE RBC-<1 WBC-33* Bacteri-MOD Yeast-NONE
Epi-1
___ 03:47AM URINE Hours-RANDOM UreaN-466 Creat-67 Na-14
K-27 Cl-19 Uric Ac-15.3
___ 03:47AM URINE Osmolal-354
PERTINENT LABS:
___ 06:58AM BLOOD Lactate-2.6*
___ 08:13PM BLOOD Lactate-1.5
___ 11:48AM BLOOD UreaN-6 Creat-0.6 Na-120* K-4.2 Cl-81*
HCO3-23 AnGap-20
___ 02:05AM BLOOD Glucose-187* UreaN-9 Creat-0.6 Na-125*
K-4.0 Cl-83* HCO3-27 AnGap-19
___ 03:30PM BLOOD Na-130* K-4.0 Cl-92*
___ 07:45AM BLOOD Glucose-197* UreaN-13 Creat-0.4 Na-132*
K-4.4 Cl-97 HCO3-25 AnGap-14
MICROBIOLOGY:
___ 3:48 am URINE Site: NOT SPECIFIED CHEM# ___
___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
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-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 4:03 am BLOOD CULTURE: PENDING
___ 2:05 am BLOOD CULTURE: PENDING
STUDIES:
___ EKG
Sinus tachycardia. Otherwise, within normal limits. No previous
tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
118 158 82 ___ CHEST (PA & LAT)
Compared with Chest radiograph from ___
PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear without
confluent
consolidation. There is no pulmonary edema or pleural
effusions. Cardiomediastinal and hilar contours are within
normal limits. There is no pneumothorax. IMPRESSION: No acute
cardiopulmonary process. No pneumonia.
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-4.4 RBC-4.23 Hgb-12.2 Hct-35.7*
MCV-84 MCH-29.0 MCHC-34.3 RDW-12.7 Plt ___
___ 07:45AM BLOOD Glucose-197* UreaN-13 Creat-0.4 Na-132*
K-4.4 Cl-97 HCO3-25 AnGap-14
___ 07:45AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of DMII, HTN,
HL, and anxiety, who presented with dizziness, palpitations,
increased weakness and found to have hyponatremia and a UTI.
ACUTE CARE:
# Hypovolemic hyponatremia: Ms. ___ presented to her PCP's
office for routine BP check, with the above complaints, and labs
performed there revealed hyponatremia (Na 120). In the ED, FENa
was 0.1, and her clinical presentation of dizziness worse with
standing, recent poor po intake, and taking an extra 12.5mg of
her HCTZ medication supported the diagnosis of hypovolemic
hyponatremia. She was given normal saline to correct her volume
status as well as her hyponatremia, and her electrolytes
corrected, from a sodium of 120 --> 125 --> 130 --> 132.
Medications and dosages of all of patient's medications were
reviewed with patient prior to discharge. She was also
encouraged to maintain healthy dietary habits and eat regularly.
# Uncomplicated UTI: Her UA was suggestive of a UTI in the ED,
with 33 WBCs, positive nitrite, and moderate bacteria, and she
endorsed symptoms of increased frequency without dysuria. She
was started on ceftriaxone in the ED and was continued on
ceftriaxone. She was transitioned to PO ciprofloxacin for her
last dose, which will complete her 3 day course of antibiotics.
Urine culture grew E. coli sensitive to ceftriaxone and
ciprofloxacin; resistant to bactrim and ampicillin. She remained
afebrile throughout her hospitalization with no CVA tenderness
on exam. Blood cultures with no growth to date. She was
discharged with prescription for her last dose of cipro.
# Lactic acidosis: Her lactic acid was 4.7 when the patient
arrived to the ED. On repeat labs it was trending down, to 2.6,
then 1.5, reaching normal levels within 24 hours. The etiology
is unclear, as she did not appear in shock from hypoperfusion,
Cr. and blood pressures were normal, and she was afebrile and
looked clinically well. She is on metformin for DMII, which can
cause lactic acidosis as a side effect, but this has been a
long-standing medication.
# palpitations/anxiety: palpitations are transient, with no
other symptoms to suggest cardiac cause. EKG with no ischemic
changes. ECHO stress normal in ___, with normal ejection
fraction. Likely a result of her stressful home situation as
timing of her palpitations correlates with husband's worsening
behavior. Social work was consulted and support was provided.
# Dizziness: These symptoms seem to occur with standing most
often in the last few days. This is most likely a result of her
UTI and hypovolemic status as it resolved after IVF.
# Social concerns: Patient is the sole caretaker of her husband
who has multiple medical issues as well as Alzheimer's dementia,
and aggressive/sexual behavior. She was concerned about who
would care for him while she is in the hospital, and her
granddaughter and nephew stayed with him during the day and
overnight while she was here. Her husband currently goes to a
senior program during the day, but Ms. ___ is looking for a
SNF to care for him full time. This is an ongoing process and is
not completely worked out; currently Mr. ___ has a social
worker looking for placement. Per granddaughter, this situation
has been a source of stress and anxiety, often leading to Ms.
___ neglecting her own care and leading to
anxiety/palpitations. This likely played a role in this recent
hospitalization, as Ms. ___ was not eating or sleeping well.
She will be continuing the process of seeking out a nursing home
facility for her husband, which will hopefully alleviate some of
the stress caused by her current living situation. In the
meantime, her nephew will stay with her husband and she will
stay with a friend while these plans are finalized. Our social
worker was in contact with her to help her resolve some of the
above acute issues, such as finding a caretaker for her husband
while she was at the hospital.
CHRONIC CARE:
#Asthma: No wheezes on exam or other signs to suggest an
exacerbation. She suffers from a chronic cough that is worse
cough at night. Her home medications of fluticasone daily and
albuterol prn were continued while in the hospital.
#DMII: On metformin and januvia, with a HbA1c 8.3 on ___.
Fingersticks were checked and she was kept on a humalog sliding
scale. Her sugars ranged from 178-290. She was discharged on her
home medications.
#HTN: HCTZ was held while in the hospital, in the setting of
hypovolemia hyponatremia. Atenolol and losartan were continued.
She was discharged home with instructions to continue all her
hypertensive medications.
#Hyperlipidimia: She was continued on home simvastatin. Her last
LDL was 40 on ___.
#Osteoporosis: Continued on calcium and vitamin D. She takes
alendronate on ___.
#Hypothyroidism: TSH 3.1 on ___. Continued with
levothyroxine
TRANSITIONAL CARE:
#PENDING STUDIES AT TIME OF DISCHARGE:
- blood cultures from ___
#ISSUES TO DISCUSS AT ___:
- PCP: please ___ with a chemistry panel to ensure
resolution of hyponatremia
- Patient discharged with one more day of antibiotic (cipro) for
UTI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSAT
2. Tizanidine 30 mg PO QHS:PRN back pain
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
5. Aspirin 81 mg PO DAILY
6. Atenolol 100 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Vitamin D 400 UNIT PO BID
11. Calcium Carbonate 600 mg PO BID
12. Loratadine *NF* 10 mg Oral PRN allergies
13. Losartan Potassium 100 mg PO DAILY
14. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q4-6h: PRN wheezing
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Hydrochlorothiazide 25 mg PO DAILY
17. Benzonatate 200 mg PO TID:PRN cough
Discharge Medications:
1. Alendronate Sodium 70 mg PO QSAT
2. Aspirin 81 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Calcium Carbonate 600 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Vitamin D 400 UNIT PO BID
11. Benzonatate 200 mg PO TID:PRN cough
12. Hydrochlorothiazide 25 mg PO DAILY
13. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
14. Loratadine *NF* 10 mg Oral PRN allergies
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q4-6h: PRN wheezing
17. Tizanidine 30 mg PO QHS:PRN back pain
18. Ciprofloxacin HCl 250 mg PO Q12H
RX *ciprofloxacin 250 mg 1 tablet(s) by mouth dos veces al dia
Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Hypovolemic Hyponatremia
-Urinary tract infection
Secondary:
-Anxiety
-Asthma
-Diabetes
-Hypertension
-Hypothyroidism
-Osteoporosis
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 during your stay at ___
___. You were hospitalized at the
hospital because of dehydration and an infection in your urinary
tract. You were treated with fluids and antibiotics.
Please make sure you continue to keep hydrated by drinking
plenty of fluids and not skipping meals.
Please continue to take your antibiotic (ciprofloxacin) for one
more day. Make sure you attend your appointment with Dr. ___
___ week (see below).
Followup Instructions:
___
|
10573359-DS-13 | 10,573,359 | 24,411,676 | DS | 13 | 2177-06-08 00:00:00 | 2177-06-08 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
___
Attending: ___.
Chief Complaint:
feeding tube dislodged
Major Surgical or Invasive Procedure:
___
Exchange of a gastrojejunostomy tube for a new 22 ___ MIC G-J
tube
History of Present Illness:
___ well known to the thoracic surgery service s/p lap to
open repair giant PEH, gastrostomy on ___ c/b leaking GT
converted to G-J tube, which migrated into the rectus muscle,
significant excoriation of skin, requiring fistula appliance
around G-J tube to maintain tube position and protect skin,
discharged to rehab on ___. She returns with her G-J tube
fallen out. She also notes that she feels significantly weaker
than when she was discharged which her son believes is due to
the
rehab dropping her TF to 10/hr d/t the leakage. The appliance
was also removed causing increased leakage and allowing the tube
to migrate out once again. She denies any abdominal pain except
at the site of the G-J tube. No f/c/ns. She does have some
occasional nausea and spits up when she attempts to take PO. No
CP/SOB.
Past Medical History:
Aortic Stenosis,
Aortic Regurgitation
Moderate Mitral Stenosis
Coronary Artery Disease
Hypertension
Dyslipidemia
Carotid Disease
Gallstones
Hiatal Hernia
Thyroid Nodule, FNA biopsy negative
Past Surgical History:
s/p Right ankle surgery
s/p Appendectomy
s/p Tonsillectomy
s/p Cataract surgery
Social History:
___
Family History:
Father died at ___ and Mother died at ___ of heart related issues.
Physical Exam:
Vitals:97.7 66 114/51 18 100% 2L NC
Gen: chronically ill appearing, deconditioned
CV: RRR
Abd: Soft, mild excoriation around GJT site, mild erythema at
site, mild tenderness at GJ tube site.
Ext: no c/c/e
Pertinent Results:
___ CXR :
PICC line terminating in the superior vena cava. No evidence of
acute
disease
___
Successful exchange of a gastrojejunostomy tube for a new 22
___ MIC
Preliminary Reportgastrojejunostomy tube. The tube is ready to
use.
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
___ 19:10 5.1 3.30* 10.7* 33.6* 102* 32.4* 31.8 16.0*
364
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:02 177*1 23* 0.7 148* 4.5 110* 34* 9
Source: Line-PICC
___ 06:32 171*1 26* 0.6 149* 4.4 110* 31 12
Source: Line-picc
___ 19:30 188*1 31* 0.7 150* 5.0 110* 36* 9
___ 07:05 162*1 38* 0.7 152*2 3.4 107 38* 10
___ 19:10 139*1 38* 0.7 151*3 3.2* 103 36* 15
Brief Hospital Course:
Mrs. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and admitted to the hospital for further
management of her feeding tube and correction of her
hypernatremia. She remained NPO and was treated with IV fluids
and her Lasix was also held. Her G tube site continued to drain
stomach contents and was pouched as her skin had patchy areas of
erythema and a yeast like appearance.
She was taken to Interventional Radiology on ___ for
replacement of the G J tube after 2 failed bedside trials. The
tube was appropriately placed and her tube feedings were resumed
with Vital 1.5 at 40 cc/hr over 24 hrs. She was also receiving
tap water flushes of 150 cc/hr every 6 hrs. Her gastrocutaneous
continues to drain from arounf the G J tube insertion site and
the area is pouched to protect her skin. Octreotide was started
a few weeks ago in an attempt to decrease the amount of drainage
and will continue.
The Cardiology service followed her closely during her last
admission and recommended starting Amiodarone as soon as she can
take orally to keep her in NSR. She has been in NSR this
admission and her Lovenox continues. Her lasix was held due to
her dehydration on admission but should be resumed tomorrow as
her EF is 30%. Her heart rate should be < 70 therefore her
metoprolol can be increased if needed.
She needs aggressive ___ as she was very independent prior to
her last admission and needs to regain her strength and
mobility. She was discharged to rehab on ___. She will need
to follow up with Dr. ___ in 2 weeks. Please send a
record of her G tube and pouch output with her. See pouch
instructions below.
Pouch applied to protect the skin.
Procedure:
Cleanse area with warm water
Patted dry
Applied a small piece of pink hytape to top edge of bumper so
that it will lay flat
Applied a ___ " ___ moldable wafer with ___ of an
adapt ring along lower edge.
Applied pink hytape in an "X" on the inside and outside of a
___ high output pouch # ___
Cut an opening thru this tape and brought the GJ tube thru
Attached the wafer and pouch
Applied more pink high tape to secure tube.
She did not have a large amount ___ tube drainage today but has
a history of large amount and so a pouch applied.
Please monitor amount and type ___ tube drainage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
2. Miconazole Powder 2% 1 Appl TP TID to groins and buttock
3. Ondansetron 4 mg IV Q8H:PRN nausea
4. Metoprolol Tartrate 12.5 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Heparin 5000 UNIT SC BID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
8. Aspirin ___AILY
9. Docusate Sodium (Liquid) 100 mg PO DAILY:PRN constipation
10. Furosemide 40 mg IV BID
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
12. Lorazepam 0.5 mg PO HS:PRN anxiety
13. Micro-Guard (miconazole nitrate) 2 % TOPICAL DAILY
14. Octreotide Acetate 100 mcg SC Q8H
15. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain
16. Pantoprazole 40 mg IV Q12H
17. Paroxetine 40 mg PO DAILY
18. Enoxaparin Sodium 70 mg SC Q 12 HRS
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Aspirin ___AILY
3. Enoxaparin Sodium 70 mg SC Q 12 HRS
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Metoprolol Tartrate 12.5 mg PO BID
use suspension and give via J tube
5. Micro-Guard (miconazole nitrate) 2 % TOPICAL DAILY
6. Octreotide Acetate 100 mcg SC Q8H
7. Ondansetron 4 mg IV Q8H:PRN nausea
8. Paroxetine 40 mg PO DAILY
use suspension and give via J tube
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
10. Docusate Sodium (Liquid) 100 mg PO DAILY:PRN constipation
11. Furosemide 40 mg IV BID
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
13. Lidocaine 5% Patch 1 PTCH TD QPM
14. Lorazepam 0.5 mg PO HS:PRN anxiety
15. Miconazole Powder 2% 1 Appl TP TID to groins and buttock
16. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain
17. Pantoprazole 40 mg IV Q12H
18. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
G-J tube malpositioned
Gastrocutaneous fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were re admitted to the hospital for replacement of your
feeding tube which was done successfully and now your J tube
feedings have resumed.
* You still need to let your stomach heal therefore you cannot
eat, only occasional sips of water.
* You will need to see Dr. ___ in a few weeks to
evaluate the healing process and hopefully the gastric drainage
will decrease.
* Work with Physical Therapy to help increase your mobilty and
endurance.
* If you have any problems with the tube, fevers, increased
abdominal pain or any other symptoms that concern you call Dr.
___ at ___.
Followup Instructions:
___
|
10573563-DS-9 | 10,573,563 | 22,037,326 | DS | 9 | 2131-03-01 00:00:00 | 2131-03-01 17:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of atrial fibrillation, CAD s/p MI, HFpEF, and
stroke who is presenting here to the ED after a fall. The
patient tripped while trying to remove her shirt, +headstrike,
-LOC. She complained of right-sided chest pain that worsened
with deep inspiration and hip pain. She denied any
lightheadedness and/or dizziness, SOB or palpitations before
falling.
Past Medical History:
1. Hypertension.
2. Dynamical left ventricular obstruction caused by hyperdynamic
ventricle, symmetric left ventricular hypertrophy, and systolic
anterior motion of mitral valve leaflets.
3. Diabetes
4. S/p MI in ___, unclear if intervention
5. ?Cirrhosis from fatty liver disease
5. Osteoporosis
6. Cholecystectomy.
7. Hysterectomy.
Social History:
___
Family History:
Denies family history of CAD.
Physical Exam:
Admission Physical Exam
VS - 98.3 95 140/98 16 98% RA
Gen - NAD
HEENT - PERRL, no blood from ears, nares, or mouth, no C-spine
ttp
CV - RRR
Pulm - non-labored breathing, no resp distress, ttp over R chest
wall and R upper back, vertical abrasion over R upper back
Abd - soft, non distended, contender
MSK & extremities/skin - no leg swelling observed b/l, no
visible bony deformities of any extremity, b/l palpable ___ and
DP pulses, mild ttp over T and L spine, pelvis stable
Discharge Physical Exam:
VS: 97.6 PO 125 / 65 70 18 95 Ra
GEN: NAD
HEENT: PERRL, EOMI. Nares patent, mucus membranes pink/moist.
CV: RRR
PULM: Clear to auscultation bilaterally. Tender to palpation
right ribs.
ABD: Soft, non-tender, non-distended.
Ext: Warm and dry. Scant edema bilateral lower extremities.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 05:30AM BLOOD WBC-5.7 RBC-4.20 Hgb-11.9 Hct-36.7 MCV-87
MCH-28.3 MCHC-32.4 RDW-14.4 RDWSD-45.3 Plt ___
___ 04:45PM BLOOD WBC-10.9* RBC-4.52 Hgb-12.7 Hct-39.9
MCV-88 MCH-28.1 MCHC-31.8* RDW-14.4 RDWSD-46.3 Plt ___
___ 05:30AM BLOOD Glucose-110* UreaN-19 Creat-0.7 Na-141
K-3.8 Cl-102 HCO3-27 AnGap-12
___ 04:45PM BLOOD Glucose-110* UreaN-16 Creat-0.7 Na-139
K-4.4 Cl-99 HCO3-25 AnGap-15
___ CT Head:
No acute intracranial process, no hemorrhage.
Global volume loss, probable sequela of chronic small vessel
disease and
chronic right parietal and insular encephalomalacia.
___ CT C-Spine:
1. No acute fracture traumatic malalignment.
2. Multilevel degenerative changes, as described above not
substantially
changed from prior study.
___ CT Torso:
1. Posterior right tenth and eleventh rib fractures.
2. Diffuse osteopenia throughout the axial and appendicular
skeleton.
3. Pulmonary artery enlargement suggesting pulmonary
hypertension.
___ Hip Xray:
No fracture or dislocation.
___ 7:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
The patient presented to the ED complaining of right sided chest
pain and bilateral hip pain. Vital signs were stable. CT head
showed no evidence of intracranial bleed or traumatic injury. CT
C spine showed no evidence of fracture or misalignment. Pelvis x
rays ruled out hip fracture or dislocation. CT chest showed
posterior right tenth and eleventh rib fractures.
The patient was admitted to the Trauma service on ___ for
pain control given her rib fractures. She initially required IV
pain medication, then transitioned to tramadol and Tylenol with
adequate pain control. Her hematocrit and vital signs remained
stable. She was evaluated by ___ and OT who recommended discharge
home with 24 hour supervision and walker. Her family agreed and
was willing to assist in providing care.
At the time of discharge, the patient was doing well, had normal
vital signs, tolerated a regular diet and ambulated without
difficulty. She was discharged home with ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO QPM
2. Betamethasone Dipro 0.05% Oint 1 Appl TP QID
3. Furosemide 20 mg PO EVERY OTHER DAY
4. Furosemide 40 mg PO EVERY OTHER DAY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Apixaban 2.5 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Senna 8.6 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
do not exceed 4000 mg/24 hours.
2. Lidocaine 5% Patch 1 PTCH TD QAM rib fx's
RX *lidocaine 5 % apply to rib area 12 hours on 12 hours off
Disp #*30 Patch Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
Take lowest effective dose.
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*36 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. Betamethasone Dipro 0.05% Oint 1 Appl TP QID
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
11. Docusate Sodium 100 mg PO BID
12. Furosemide 20 mg PO EVERY OTHER DAY
13. Furosemide 40 mg PO EVERY OTHER DAY
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Metoprolol Succinate XL 200 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Mechanical Fall
Posterior right tenth and eleventh rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a fall. You sustained right
sided rib fractures. You have worked with Physical therapy and
are cleared for home with 24 hour supervision.
* Your injury caused 2 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10573705-DS-7 | 10,573,705 | 24,727,195 | DS | 7 | 2156-01-25 00:00:00 | 2156-05-02 06:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
acute onset vertigo and nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman w/ HTN,
HLD, GERD, and long history of smoking who is presenting to ED
with acute onset vertigo and nausea. LKW was ___ at 2am. He
states that his symptoms started this morning when he woke up
around 7am. He tried to stand up from the bed and noticed that
the room was spinning. He stood up and walked to the bathroom,
but felt that his gait was unstable and he had to hold on to the
wall for stabilization. He then took his blood pressure
medications (does not recall the name or the dose) and went back
to sleep. He awoke again around 11am this morning, and noted
that
his symptoms recurred when he moved his head and tried to get up
from the bed. Because his symptoms persisted, he called his son
who brought him to the ED. Within an hour of the presentation to
the ED, his symptoms improved, and they recur only when he turns
his head to either side, last few minutes then stop. These
symptoms are associated w/ nausea, which is why he has not had
appetite today and did not eat or drink anything. He continues
to
endorse some unsteadiness in his gait, which is most prominent
when he first stands up and directly associated w/ the symptoms
of vertigo.
He denies headache, neck pain or stiffness. There is no
dyarthria. He denies any changes in vision. No tinnitus. No
changes in hearing. No rashes. There is no focal weakness or
sensory changes. Denies dysphagia. Denies bowel or bladder
incontinence or retention.
Past Medical History:
HTN
HLD
GERD
Smoker - 1+PPD
Social History:
___
Family History:
No h/o strokes, seizures.
No h/o bleeding or clotting disorders.
Physical Exam:
Admission PHYSICAL EXAMINATION
Vitals: T: 97.8 BP: 121/79 HR: 71 R: 18 O2Sats: 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx, poor dentition
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty w/ ___ interpreter. Per
interpreter, his language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: There is a very mild facial asymmetry w/ mild nasolabial
fold flattening on the R side, but activates symmetrically.
VIII: Hearing intact to finger-rub bilaterally. ___
maneuver positive on the L w/ couple beats of rotatory nystagmus
and vertigo
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Cautious initiation. Somewhat broad-based, cautious
steps,
but able to ambulate without assist. Romberg absent.
Discharge PHYSICAL EXAMINATION
Vital signs:
24 HR Data (last updated ___ @ 1720)
Temp: 97.7 (Tm 98.3), BP: 125/78 (117-133/70-78), HR: 68
(63-72), RR: 18 (___), O2 sat: 99% (95-99), O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, poor dentition
Pulmonary: breathing comfortably on RA, no increased WOB
Cardiac: warm, well-perfused
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, hospital (does not know
name), and date. Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial asymmetry.
VIII: Hearing intact to finger-rub bilaterally
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE 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
-Reflexes: Deferred.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF .
-Gait: Deferred.
Pertinent Results:
___ 04:30AM BLOOD WBC-6.2 RBC-4.91 Hgb-14.8 Hct-43.7 MCV-89
MCH-30.1 MCHC-33.9 RDW-12.4 RDWSD-40.1 Plt ___
___ 04:30AM BLOOD ___ PTT-30.1 ___
___ 04:30AM BLOOD Glucose-106* UreaN-23* Creat-0.8 Na-142
K-3.8 Cl-103 HCO3-27 AnGap-12
___ 02:21PM BLOOD ALT-23 AST-19 AlkPhos-70 TotBili-0.4
___ 02:21PM BLOOD %HbA1c-6.1* eAG-128*
___ 02:21PM BLOOD Triglyc-146 HDL-50 CHOL/HD-3.5 LDLcalc-98
CTA Head/Neck ___:
IMPRESSION:
1. 5 mm round hyperdense lesion in the subcortical right insula,
which may
represent blood products or mineralization. 2 mm linear
hyperdensity along
the right anterior pons is consistent with calcification. No
edema or mass
effect.
2. 3 x 3.3 x 4.1 cm heterogenous mass with internal within the
left carotid
space, likely a globus vagale paraganglioma. The mass displaces
the internal
carotid artery laterally without narrowing, and displaces the
internal jugular
vein posteriorly.
3. Otherwise no appreciable atherosclerosis and no stenosis in
the cervical
carotid or vertebral artery.
4. Normal CTA of the head.
5. The included upper lungs demonstrate emphysema and mild
centrilobular micro
nodularity suggestive of small airways disease.
MRI Soft tissue neck w ___ cont ___: IMPRESSION:
1. 5 mm right subcortical insular and 2 mm right ventral pontine
foci of
susceptibility artifact, corresponding to hyperdensities on the
preceding CT.
Diagnostic considerations include mineralization secondary to
prior
inflammation, versus cavernous malformations. The 5 mm lesion
does not
demonstrate classic features of a cavernous malformation on T1
or T2 weighted
images. No associated edema to indicate recent hemorrhage. No
contrast
enhancement.
2. Unremarkable MRA of the circle of ___.
3. 3 x 3.3 x 4.1 cm T2 heterogeneously enhancing mass with
multiple small
maternal flow void in the upper left carotid space, most likely
a glomus
vagale paraganglioma. The lesion displaces the internal carotid
artery
laterally and the internal jugular vein posteriorly.
MRI brain
IMPRESSION:
1. 5 mm right subcortical insular and 2 mm right ventral pontine
foci of
susceptibility artifact, corresponding to hyperdensities on the
preceding CT.
Diagnostic considerations include mineralization secondary to
prior
inflammation, versus cavernous malformations. The 5 mm lesion
does not
demonstrate classic features of a cavernous malformation on T1
or T2 weighted
images. No associated edema to indicate recent hemorrhage. No
contrast
enhancement.
2. Unremarkable MRA of the circle of ___.
3. 3 x 3.3 x 4.1 cm T2 heterogeneously enhancing mass with
multiple small
maternal flow void in the upper left carotid space, most likely
a glomus
vagale paraganglioma. The lesion displaces the internal carotid
artery
laterally and the internal jugular vein posteriorly.
CT Chest ___:
IMPRESSION:
1. No definite CT evidence of primary or metastatic disease
within the chest,
abdomen, or pelvis.
2. 3.2 cm bilobed fluid attenuating lesion with calcification or
stone within
the right hepatic lobe adjacent to the gall bladder fundus.
This is likely a
gallbladder fold or adenomyomatosis, possibly complicated cyst
or sequela to
prior infectious/inflammatory process. No concerning features
are seen.
CT Abd/pelvis w cont ___:
IMPRESSION:
1. No definite CT evidence of primary or metastatic disease
within the chest, abdomen, or pelvis.
2. 3.2 cm bilobed fluid attenuating lesion with calcification or
stone within the right hepatic lobe adjacent to the gall bladder
fundus. This is likely a gallbladder fold or adenomyomatosis,
possibly complicated cyst or sequela to prior
infectious/inflammatory process. No concerning features are
seen.
Brief Hospital Course:
Mr. ___ is a ___ gentleman w/ HTN,
HLD, GERD, and long history of smoking who presented to ED with
acute onset vertigo and nausea. Found to have mass in the left
carotid space inferior to the level of the jugular foramen
measuring approximately 3.7 x 2.4 x 4.3 and small hemorrhage in
right insula and right ventral pontine.
#Intraparemchymal hemorrhage
On imaging there was a 5 mm right subcortical insular and 2 mm
right ventral pontine foci of susceptibility artifact,
corresponding to hyperdensities on the preceding CT.
Diagnostic considerations include mineralization secondary to
prior
inflammation, versus cavernous malformations. The 5 mm lesion
does not
demonstrate classic features of a cavernous malformation on T1
or T2 weighted
images. No associated edema to indicate recent hemorrhage. These
remained stable. These were felt to no represent metastasis d/t
lack of enhancement on MRI, though this cannot be fully
excluded. He was discharged with strict return precautions. Plan
to get repeat MRI in 3 months.
#Glomus vagale paraganglioma
On imaging there was 3 x 3.3 x 4.1 cm T2 heterogeneously
enhancing mass with multiple small maternal flow void in the
upper left carotid space, most likely a glomus
vagale paraganglioma. The lesion displaces the internal carotid
artery
laterally and the internal jugular vein posteriorly. ENT was
consulted during admission and will follow up as an outpatient
for biopsy. Given that paraganglioma can have secretory
properties urine metanephrines and serum catecholamine were sent
and pending at time of discharge. He also had CT torso which was
negative for evidence of primary malignancy
#Hypertension - no changes made to medications
Transitional Issues:
=====================
[]f/u results of Vanillylmandelic Acid, 24hr urine
Metanephrines, serum catecholamines
[]Follow up with ENT for possible embolization and surgical
resection
[]Further smoking cessation counseling
[]f/u with neurology
[]Repeat MRI head w/ and w/o in 3 months
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No. If
no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Omeprazole 20 mg PO DAILY
4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==================
#intraparenchymal hemorrhage
Secondary Diagnosis
====================
#Glomus Vagale Paraganglioma
#Hypertension
#HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of vertigo/dizziness
resulting from an ACUTE HEMORRHAGIC STROKE, a condition where
there is bleeding in the brain. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-High blood pressure
- Neck mass, likely paraganglioma
We are changing your medications as follows:
No changes to your medications.
Please take your other medications as prescribed.
You were also found to have a mass in your neck compressing some
of the blood vessels. It is suspected to be a tumor called
glomus vagale paraganglioma.
Please follow up with Otolaryngology (ENT/Ear Nose Throat)
doctor to discuss possible surgical removal of the mass. An
appointment has been made for you; see below.
Please follow-up with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, 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:
___
|
10574269-DS-19 | 10,574,269 | 23,244,208 | DS | 19 | 2180-11-25 00:00:00 | 2180-11-25 17:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with a history of DM2,
peripheral vascular disease s/p R BKA, CAD s/p CABG, old CVA,
presenting after a witnessed seizure at his nursing home.
The patient reports that he has been having nausea, vomiting,
and
diarrhea several times per day for around 3 days. He attributes
this to an increase in his Victoza dose, as he has had a similar
reaction to this medication in the past. The vomiting was at
first non-bilious and non-bloody, but reportedly eventually
became coffee-ground in appearance. On the day of presentation,
he had a witnessed seizure in his nursing home bed that lasted
30
seconds after he was discovered before abating on its own.
He was transferred to ___, where labs showed Hgb 12 and Cr
1.5. UA was not concerning for infection there. ___ showed
large chronic left PCA territory infarct of the occipital lobe
and small chronic right putaminal lacunar infarct without acute
hemorrhage, acute infarction, edema, mass, mass effect, or
fracture. He had an episode of vomiting in the ___ which
tested occult positive, so he was given 80 mg IV Protonix and IV
zofran. He was transferred to ___ for neurology evaluation and
EEG.
In the ___ ___, initial VS were: T 98.9 HR 109 BP 111/70 RR 20
O2 sat 99% RA
Exam notable for:
Neuro-intact
R BKA with 7 cm linear wound over the posterior distal right
thigh, granulation tissue present, no surrounding cellulitis,
erythema, drainage, discharge.
Small hemostatic laceration and abrasion over the anterior left
tongue.
ECG: Sinus tachycardia, normal axis and intervals, no ischemic
ST
changes
Labs showed leukocytosis to 11.5, Hgb 11.3, INR 1.2, Mg 1.5,
chemistry with Cr 1.9 of unclear chronicity. CXR showed no acute
pulmonary process.
Neurology was consulted and recommended holding bupropion and
correcting electrolyte abnormalities, without further imaging or
workup until medically stabilized.
Patient received IV zofran and 500 cc NS prior to transfer to
the
floor.
On arrival to the floor, patient endorses the history above,
though he does not remember the seizure event. He denies any
prior history of seizures. His nausea is improved and he has not
vomited since arrival to ___. He denies fevers, chills, chest
pain, cough, abdominal pain, melena, and hematochezia. He does
report that he had a recent hospitalization at ___ for
a
soft tissue infection, and that he also had brown emesis during
that admission. Review of these records shows an EGD on
___
to first part of duodenum without any blood or bleeding source.
Past Medical History:
DM2
Peripheral vascular disease
S/P R BKA
CAD s/p CABG
CVA
Social History:
___
Family History:
Father with colon cancer. Mother with alcohol abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.4 BP 109 / 61 HR 102 RR 20 O2 sat 98%Ra
GENERAL: Lying in bed, alert and conversant, no distress
HEENT: AT/NC, anicteric sclera, dry mucous membranes
NECK: supple, no LAD, no JVD
CV: RRR, normal S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: S/P R BKA with bandage on posterior leg. No
cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, CNII-XII intact, motor strength ___ in bilateral
upper and left lower extremity.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: T-97.6 BP- 103/58 P- 71 RR- 18 SpO2: 96% RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: Normocephalic, atraumatic. Pupils equal and reactive to
light. Extraocular movements grossly intact, however
finger-following test abnormal from h/o R homonymous hemianopia.
Anicteric sclera. No oral lesions noted, including tongue
lesion.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, nontender, nondistended, no hepatomegaly, no
splenomegaly. Hypoactive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema. R BKA noted
with no drainage, erythema or swelling noted. 2 x 3 cm wound
PULSES: 2+ ___ pulse on L, 2+ DP pulses on L.
NEURO: A&Ox3, sensory and motor function grossly intact
SKIN: No significant rashes.
Pertinent Results:
Admission Labs:
===============
___ 09:35PM WBC-8.0 RBC-2.94* HGB-8.5* HCT-27.0* MCV-92
MCH-28.9 MCHC-31.5* RDW-13.7 RDWSD-46.1
___ 09:35PM PLT COUNT-302
___ 03:00PM WBC-8.6 RBC-3.09* HGB-8.9* HCT-27.9* MCV-90
MCH-28.8 MCHC-31.9* RDW-13.7 RDWSD-45.1
___ 03:00PM PLT COUNT-337
___ 05:50AM GLUCOSE-177* UREA N-39* CREAT-2.1* SODIUM-143
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
___ 05:50AM ALT(SGPT)-23 AST(SGOT)-17 LD(LDH)-145 ALK
PHOS-95 TOT BILI-0.4
___ 05:50AM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-2.2
___ 05:50AM WBC-10.2* RBC-3.54* HGB-10.5* HCT-31.5*
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.4 RDWSD-44.4
___ 05:50AM PLT COUNT-381
___ 11:13PM GLUCOSE-240* UREA N-37* CREAT-1.9* SODIUM-140
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 11:13PM estGFR-Using this
___ 11:13PM CK(CPK)-84
___ 11:13PM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-1.5*
___ 11:13PM WBC-11.5* RBC-3.83* HGB-11.3* HCT-34.2*
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.5 RDWSD-44.0
___ 11:13PM NEUTS-82.7* LYMPHS-8.8* MONOS-7.9 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-9.48* AbsLymp-1.01* AbsMono-0.91*
AbsEos-0.00* AbsBaso-0.04
___ 11:13PM PLT COUNT-421*
___ 11:13PM ___ PTT-25.4 ___
DISCHARGE LABS:
___ 05:10AM BLOOD WBC-6.9 RBC-3.28* Hgb-9.6* Hct-29.8*
MCV-91 MCH-29.3 MCHC-32.2 RDW-12.9 RDWSD-43.0 Plt ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD Glucose-176* UreaN-34* Creat-1.4* Na-139
K-4.5 Cl-102 HCO3-23 AnGap-14
___ 05:10AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
___ 04:36AM BLOOD calTIBC-226* Ferritn-228 TRF-174*
___ 04:36AM BLOOD Triglyc-91 HDL-36* CHOL/HD-2.4 LDLcalc-31
IMAGING:
CXR ___
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with hematemesis// eval for aspiration or
pneumomediastinum
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: None
FINDINGS:
Lungs are fully expanded and clear. No pleural abnormalities.
Heart size is
normal. Cardiomediastinal and hilar silhouettes are normal. No
evidence of
pneumomediastinum. Median sternotomy wires and mediastinal
clips are noted.
Larger surgical clips project over the left thorax on the
frontal view.
IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
MRI/MRA Head/Neck ___
Final Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with past medical history of CVA,
here with
seizure concerning for evolving or new infarct/TIA. Evaluate
for infarct flow
limiting lesions.
TECHNIQUE: Three dimensional time of flight MR arteriography
was performed
through the brain with maximum intensity projection
reconstructions.
Dynamic MRA of the neck was performed during administration
intravenous
contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR,
T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented
images were
generated. This report is based on interpretation of all of
these images. The
examination was performed using a 1.5T MRI.
COMPARISON: Head CT from outside hospital dated ___.
FINDINGS:
MRI BRAIN:
Encephalomalacia involving the left occipital lobe is
demonstrated, consistent
reported history of previous left PCA stroke. Multiple foci of
subcortical
and confluent periventricular T2/FLAIR hyperintensities are
present
bilaterally, nonspecific but could represent sequela of chronic
microangiopathy. Hyperintensity in the the thinned cortex
suggests air
necrosis.
A low signal focus on gradient echo is demonstrated in the left
putamen,
concordant with focal calcifications seen on previous CT.
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. The ventricles and sulci are slightly prominent,
could reflect
age-associated involutional changes.
MRA BRAIN:
Irregular segmental narrowing is demonstrated in the middle
cerebral arteries
bilaterally, most notably involving the horizontal segments but
also seen in
the Sylvian and cortical segments. There is severe stenosis of
the left
posterior cerebral artery and marked narrowing of the P1 segment
of the right
posterior cerebral artery. Narrowing of the right superior
cerebellar artery
and right vertebral artery distal to the origin of the
posterior-inferior
cerebellar artery are also demonstrated. There is no evidence
of aneurysm.
MRA NECK:
Focal narrowing is present at the origin of the left internal
carotid artery
(45% NASCET). Otherwise, the common, internal and external
carotid arteries
demonstrate no other significant narrowing. There is no
evidence of right
internal carotid artery stenosis by NASCET criteria. As noted
above, there is
narrowing of the right vertebral artery distal to the origin of
the
posterior-inferior cerebellar artery. Otherwise, the origins of
the great
vessels, subclavian and vertebral arteries appear normal
bilaterally.
IMPRESSION:
1. Irregular segmental narrowing of multiple intracranial
vessels, including
bilateral middle cerebral arteries, posterior cerebral arteries,
and right
vertebral and superior cerebral arteries. No aneurysm.
2. 45% focal narrowing at the origin of the left internal
carotid artery by
NASCET.
3. Left occipital lobe encephalomalacia without evidence of
acute infarction
or hemorrhage.
EEG:
Brief Hospital Course:
Assessment:
Mr. ___ is a ___ man with a history of DM2,
peripheral vascular disease s/p R BKA, CAD s/p CABG, old CVA,
presenting after a witnessed seizure at his nursing home and 3
days of n/v with reported coffee-ground emesis.
#Seizure
Had witnessed seizure at the nursing home described as
generalized tonic clonic activity. No prior history of seizure
activity and does not take any anti-epileptic drugs. In our
emergency room, a non-contrast head CT was negative for acute
intracranial pathology. He was found to be hypomagnesemic in the
setting of nausea/vomiting with the remainder of his
electrolytes being normal. He chronically takes bupropion at
home which has the well known side effect of decreasing seizure
threshold. His urine and serum tox screens were negative. His
blood glucose was well controlled while in house. He had an
MRI/MRA of his head/neck which showed his known CVA but no other
evidence of acute infarct. He had an EEG which showed no focal
seizure activity while he was inpatient. As such, we feel that
the seizures were likely the result of hypomagnesemia in the
setting of bupropion use and prior CVA. He was discharged
without buproprion, and with neurology follow up. Notably, for
his old stroke, he had a TTE which showed a small PFO of
undetermined significance, and he was monitored on telemetry
without any signs of atrial fibrillation. To rule out paroxysmal
atrial fibrillation, the patient was discharged with ___ of
Hearts monitor which will be worn for two weeks. Results should
be reviewed at neurology follow up, and if there is any sign of
atrial fibrillation the patient should be considered for
anticoagulation.
#Normocytic anemia
#Coffee-ground emesis, resolved
The patient was reported to have had coffee ground emesis and
hematemesis prior to admission. There were no witnessed episodes
in house. We started the patient pantoprazole 40 mg PO daily on
admission but he will not need to continue this on discharge. He
was hemoconcentrated on admission which was likely the result of
dehydration ___ nausea and vomiting. His hemoglobin decreased to
~9 after IV hydration which per record review is likely his
baseline. He likely suffers from a combination of iron
deficiency anemia as well anemia of chronic disease. He did not
require blood transfusions during this admission. Please obtain
a CBC at his first follow up to ensure anemia is stable.
#N/V, resolved
3-day h/o nausea and vomiting prior to admission, no episodes of
emesis while in house. Pt reports he has experienced this
before from home Victoza, particularly when uptitrating dose
which he has been doing recently. Given the season and
that he resides in a community-living setting, there was
initially concern for GI viruses such as norovirus however he
did not have any episodes of nausea/vomiting here so we did not
pursue an infectious work up. He also had a normal white count.
. Transaminases not concerning for hepatic/cholestatic process.
His blood and urine cultures were negative during this
hospitalization.
___ on CKD,
Discharge creat from ___ ___ (admission for soft tissue
infection) was 1.6, on admission was 2.1, then decreased with IV
fluids and increased PO intake. Should have Chem-7 in one week
to ensure normalization of creatinine.
#RLE BKA wound
Wound on right leg stump, pt reports ___ malfitting prosthesis.
Does not appear infected, approximately 2 cm x 3 cm, no purulent
drainage. Our wound care nurses saw the patient while in house
and suggested Cover with Xerform gauze, top with ABD pad, Secure
with Kling and ACE wrap, and Change dressing daily
CHRONIC ISSUES:
===============
#DM2:
Continued home insulin and held his home glyburide while in
house. We restarted this on discharge.
#CAD s/p CABG
We continued home aspirin, metoprolol, and statin at their
normal doses
Transitional Issues:
=====================
[]45% focal narrowing at the origin of the left internal carotid
artery by
NASCET: Please follow with ultrasound of carotid arteries to
monitor for progression
[]Discontinued Bupropion due to lower seizure threshold, may
need alternative antidepressant
[]Normocytic anemia may need iron supplementation in the
outpatient setting: Please draw CBC at first follow up
[]Check chem7 to ensure normalization of creatinine to baseline
in 1 week
[]Discharged with ___ of hearts: Please follow up results and
consider anticoagulation for stroke prevention if any evidence
of atrial fibrillation.
[]Small Patent foramen ovale on echocardiogram, will refer to
cardiology for follow up on decision of anticoagulation vs PFO
closure
[]Had low fasting glucose at 51, decreased dose of lantus to 18
units ___ need uptitration
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Thiamine 100 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. GlyBURIDE 5 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Phosphorus 325 mg PO PRN taken PRN w/ furosemide for ___ edema
7. coenzyme Q10 10 mg oral DAILY
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Aspirin 81 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Furosemide 40 mg PO PRN ___ edema
14. DHA Algal-900 (docosahexanoic acid) 300 mg oral DAILY
15. escitalopram oxalate 20 mg oral DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. MethylPHENIDATE (Ritalin) 10 mg PO BID
18. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. coenzyme Q10 10 mg oral DAILY
5. DHA Algal-900 (docosahexanoic acid) 300 mg oral DAILY
6. Escitalopram Oxalate 20 mg oral DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 40 mg PO PRN ___ edema
10. GlyBURIDE 5 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. MethylPHENIDATE (Ritalin) 10 mg PO BID
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Phosphorus 325 mg PO PRN taken PRN w/ furosemide for ___
edema
17. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
1) Seizures
2) Acute kidney injury
3) patent foramen ovale
Secondary Diagnosis
====================
1) Diabetes Mellitus Type 2
2) CAD S/p CABG
3) PVD s/p right BKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
-You were admitted because of vomiting and a seizure
What was done for me while I was in the hospital?
-We gave you medication for the nausea
-We gave you fluids in your IV
-We did an MRI which showed your old stroke but nothing else
bad
-We did an EEG, which showed that you were not still having
seizure
What should I do when I leave the hospital?
-Please take all of your medications as prescribed
-Please do not take bupropion as it may have contributed to your
seizure
-Wear your heart monitor until you see neurology
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10574334-DS-7 | 10,574,334 | 26,983,493 | DS | 7 | 2188-05-31 00:00:00 | 2188-05-31 14:52:00 |
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 open both bone forearm fracture
Major Surgical or Invasive Procedure:
___: L forearm I&D, ORIF
History of Present Illness:
___ LHD s/p MVC with a L distal forearm open fracture. She had a
front on collision. No headstrike, unclear LOC; no neck pain,
headache, or visual changes. No other injuries. First presented
to ___. CT head/cspine/torso was performed
and negative for acute process. XR of the left wrist
demonstrated an open distal radius fracture. Received tetanus
vaccination, ancef and gentamicin prior to transfer to ___.
Mild tingling in the fingers of the L hand.
Past Medical History:
CVA ___ year ago, depression, HTN, HLD, h/o alcoholism
Social History:
___
Family History:
Non-contributory
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Splint in place, clean, dry, and intact
Left upper extremity fires EPL/IO/OP/flexors
Left upper extremity SILT in median, radial, ulnar and axillary
distributions
Left upper extremity radial pulse 2+ with distal digits warm and
well perfused
Pertinent Results:
L wrist xray ___:
3 views of the left wrist were obtained fluoroscopically,
demonstrating fixation plates and associated screws transfixing
distal radius ulna fractures, now in much improved near
anatomic alignment. Please refer to full operative note for
further details.
___ 05:10AM BLOOD WBC-10.9* RBC-2.94* Hgb-9.1* Hct-28.4*
MCV-97 MCH-31.0 MCHC-32.0 RDW-14.2 RDWSD-50.4* Plt ___
___ 05:10AM BLOOD WBC-11.4* RBC-2.80* Hgb-8.6* Hct-27.8*
MCV-99* MCH-30.7 MCHC-30.9* RDW-14.2 RDWSD-51.9* Plt ___
___ 05:10AM BLOOD WBC-11.9* RBC-2.87* Hgb-8.8* Hct-28.8*
MCV-100* MCH-30.7 MCHC-30.6* RDW-14.3 RDWSD-52.2* Plt ___
___ 05:10AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-138
K-4.1 Cl-107 HCO3-23 AnGap-12
___ 05:25AM BLOOD Glucose-104* UreaN-13 Creat-0.7 Na-137
K-4.2 Cl-106 HCO3-21* AnGap-14
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L open both bone forearm fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for irrigation and debridement, open
reduction and internal fixation L forearm, 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 ___ and OT who determined that discharge to home was
appropriate. The patient was found to have an oxygen requirement
while in the hospital. She required ___ to maintain O2
saturations above 90%. The patient has a history of COPD and has
apparently been non-compliant with her home medication.
Medicine was consulted who recommended a chest xray and an EKG,
both of which did not demonstrate any acute pathology. They
recommended home O2 as well as advair and albuterol. The
patient's insurance would not cover the advair for home, and the
patient was recommended to follow up with her primary doctor
concerning her new medications and her new O2 at home. The PCP
was contacted and made aware of these new developments in her
care. 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 upper extremity in the operative
splint, 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. Metoprolol Succinate XL 100 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Citalopram 40 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Acetaminophen 1000 mg PO TID
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs by mouth Every
4 hours Disp #*1 Inhaler Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily
Disp #*60 Capsule Refills:*0
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
inhalation by mouth Twice daily Disp #*2 Disk Refills:*0
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp
#*90 Tablet Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth Twice daily
Disp #*60 Capsule Refills:*0
12. Vitamin D 800 UNIT PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left grade I open both bone forearm fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB LUE in splint
HOME OXYGEN:
- You are being sent home on new home oxygen to help you breath.
It is extremely important to not smoke while on oxygen. It is
very dangerous to smoke while on oxygen and you could
potentially start a fire. Please do not smoke while on oxygen.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily for 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
Physical Therapy:
Activity: Activity: Activity as tolerated Activity: Ambulate
twice daily if patient able
Left upper extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake
Treatments Frequency:
Site: LUE
Description: Splint and ace wrap to LUE, ecchymosis/bruising to
L fingers, moderate edema to L fingers
Care: Monitor site for any increased swelling, monitor for s/s
of infection
Followup Instructions:
___
|
10574803-DS-16 | 10,574,803 | 21,769,290 | DS | 16 | 2143-09-14 00:00:00 | 2143-09-14 17:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ yo ___ woman with metastatic
NSCLC (squamous) progressed through ___ line treatment and
complicated by right sided pleural effusion, sp TPC placement
___ who is admitted from the ED with increasing shortness of
breath in the context of presumed pleural space infection.
Interview conducted with aid of over the phone interpreter, but
was limited due to difficulty in translation. Remainder of
history obtained from record review.
Patient reports she has been feeling generally more unwell over
the last several days. This has primarily manifested as
increased dyspnea on exertion, as she becomes winded with
walking to and from the bathroom. She also seems to have noted
some leg swelling. She has a very problematic chronic cough that
seems to have increased over the last few weeks. She denies
frank fevers or chills. Appetite is poor, but no N/V/D.
Of note, since last ___ she has had much less drainage from
her tunneled pleural catheter. TPA/DNAse was administered on
___ with improvement in drainage, but pleural fluid culture
at that time grew Moraxella catarrhalis and she had erythema
along the tract. She was started on Augmentin, and was asked to
increase the frequency of her drainage to daily, but it is
unclear if she has been compliant.
In the ED, initial VS were T 97.3, HR 108, BP 125/66, RR 30, O2
94%3LNC. Initial labs notable for Na 132, K 6.3 (hemolyzed,
repeat 4.6), HCO3 27, Cr 0.5, WBC 8.1 (72%N), HCT 34.0, PLT 358,
trop negative x1, lactate 4.1. CXR showed white out of right
hemithorax and progression of left basilar opacity. Patient
could not lie flat for CT. Pleural studies were sent, and are
pending. IP was consulted who recommended continuous drainage of
right TPC following TPA instillation. TPA was instilled and
dwelled x1 hour, then hooked up to water seal. Patient was given
ceftriaxone, azithromycin, flagyl, ibuprofen, benzonate, and
IVF. VS prior to transfer were T 97.8, pain 5, HR 105, BP
102/55, RR 18, O2 97% 3LNC.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was attempted but limited
due to difficulty with using the over the phone translation
service.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: Patient had persistent right shoulder pain.
-___: CT scan showed a right middle lobe mass with
obliteration of the majority of segmental bronchi. There was
prominent mediastinal and right hilar lymphadenopathy. There
was
a 2.1 x 1.7 cm sclerotic lesion nearly replacing the entirety of
T2 vertebral body with prominent anterior paravertebral soft
tissue thickening.
-___: Bronchoscopy was performed. Pathology of the level
7 lymph node was positive for malignant cells. This was
consistent with non-small cell carcinoma favoring
squamous(positive for P63 and CK ___, negative for TTF-1).
-___: MRI of the head was negative for intracranial
disease.
-___: PET scan showed right middle lobe mass consistent
with a bronchogenic carcinoma. FDG avid metastases in the right
hilum, mediastinum, and supraclavicular fossa. Osseous
metastases
in T2 left hilum.
-___: MR ___ showed complete replacement/involvement of
the T2 vertebral body by tumor with paravertebral and epidural
extension, more so on the right than the left, resulting in mild
canal narrowing (with preserved CSF space) and complete
obliteration of the right T2 neural foramen. Possible early
involvement of the lateral aspect of the T3 vertebral body by
direct extension of the para-vertebral portion of this
metastasis.
-___: Completed 30Gy in 10 fractions to the T1-4
spine and right SCV
-___: C1D1 ___
-___: Admitted for diffuse rash. She was treated with
anti-histamines. She was seen by derm who felt this was likely
secondary to Taxol.
-___: C1D1 ___
-___: C5 D1 Gemcitabine/Carboplatin 20% dose reduced
- On ___ she was started on Nivolumab.
- ___ CT shows disease progression in the right middle lobe
lesion.
- ___ - Patient was started on clinical trial ___ with
Nivolumab + Urelumab
-___. Patient had disease progression, came off ___.
- Radiation therapy to the lung mass ___ to ___.
- ___: C1D1 Gemcitabine
- ___: disease progression on CT scan. Stopped chemotherapy.
- ___: s/p R pleurx
- ___ and ___: Pleural fluid growing Moraxella
Catarrhalis
PAST MEDICAL HISTORY:
- Metastatic NSCLC (squamous, dx ___
- HTN
Social History:
___
Family History:
No known family history of cancer.
Physical Exam:
ADMISSION PHSYICAL:
=======================
T 97.8 BP 126/71 HR 109 RR 20, O2 96%4LNC
GENERAL: Pleasant woman sitting up in bedside chair on her
computer, but coughing profusely throughout exam
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Tachycardic rate and regular rhythm, no murmurs,
rubs, or gallops
RESPIRATORY: Between coughing fits no significant respiratory
distress, decreased breathsounds throughout entire right lung
field. Right TPC draining dark red serosanguinous fluid
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding
MUSKULOSKELATAL: Warm, well perfused extremities with 1+
bilateral edema
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: Erythema and induration spreading several centimeters
around ___ insertion site - area is marked
DISCHARGE PHYSICAL:
=======================
Pertinent Results:
ADMISSION LABS:
========================
___ 11:00AM BLOOD Neuts-71.6* Lymphs-14.3* Monos-11.8
Eos-0.5* Baso-0.7 Im ___ AbsNeut-5.82 AbsLymp-1.16*
AbsMono-0.96* AbsEos-0.04 AbsBaso-0.06
___ 11:00AM BLOOD WBC-8.1 RBC-4.18 Hgb-10.0* Hct-34.0
MCV-81* MCH-23.9* MCHC-29.4* RDW-16.0* RDWSD-47.8* Plt ___
___ 06:51PM BLOOD ___ PTT-32.2 ___
___ 11:00AM BLOOD Glucose-164* UreaN-11 Creat-0.5 Na-132*
K-6.3* Cl-89* HCO3-27 AnGap-16
___ 11:00AM BLOOD cTropnT-<0.01
___ 03:20PM BLOOD CRP-79.2*
___ 11:26AM BLOOD ___ pO2-59* pCO2-60* pH-7.35
calTCO2-35* Base XS-4
MICRO:
====================
___ 11:23 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ (___) ON
___ @
2:40PM.
MORAXELLA CATARRHALIS. SPARSE GROWTH.
ERYTHROMYCIN , TETRACYCLINE , AND SULFA X TRIMETH test
result
performed by ___.
CEFTRIAXONE MIC = 0.25 MCG/ML Susceptibility results
were obtained
by a procedure that has not been standardized for this
organism
Results may not be reliable and must be interpreted
with caution.
CIPROFLOXACIN MIC = 0.032 MCG/ML Susceptibility results
were
obtained by a procedure that has not been standardized
for this
organism Results may not be reliable and must be
interpreted with
caution.
CEFTRIAXONE AND CIPROFLOXACIN test result performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORAXELLA CATARRHALIS
|
ERYTHROMYCIN---------- S
TETRACYCLINE---------- S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Blood culture- Negative
MRSA Screen- Negative
Urine Culture- Negative
CYTOLOGY:
======================
Pleural fluid Cytology: Negative for Malignant Cells
STUDIES:
=======================
___ CXR
IMPRESSION:
There is complete opacification the right hemithorax, unchanged.
Small left pleural effusion is slightly increased in volume.
Interstitial edema is slightly worsened. Cardiomediastinal
silhouette is stable. Right-sided Port-A-Cath tip projects to
the ___. Right-sided chest tube is unchanged. No pneumothorax
is seen.
Lower Extremity Ultrasound ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Ms. ___ is a ___ yo ___ woman with metastatic
NSCLC (squamous) progressed through ___ line treatment and
complicated by right sided pleural effusion, sp TPC placement
___ who is admitted from the ED with increasing shortness of
breath and found to have severe sepsis and empyema s/p
intra-pleural tPA and braod spectrum antibiotics.
# Severe sepsis:
# Pleural space infection
# Metastatic non-small cell lung cancer
The patient presented with sepsis due to infected pleural fluid.
She was seen by IP who recommended continuous drainage of TPC -
low continuous wall suction. She was started on broad spectrum
antibiotics which were discontinued once decision was made to
transition care to ___. Her chest tube was clamped in
transition to ___ facility and can be drained intermittently
for comfort.
#Dyspnea:
Likely related to volume overload and interstitial edema,
including her plueral effusions. The patient was started on
morphine infusion at 0.5mg/hr with dose increased to 1mg/hr for
comfort. Bolus dosing of 1mg Q30ms was also ordered and was
given as needed for dyspnea. A foley was placed for patient
comfort. Lasix was discussed but it was ultimately determined
that this would not help with comfort. The patient has a chest
tube/pleurex which can be drained intermittently for comfort.
#Oral secretions
___ be related to to her pulmonary edema/overload. Managed with
hyocscyamine PRN, reasonable to try glycopyrolate.
#Goals of care - After discussion with the patient, her family,
oncology and palliative care the patient was transitioned to
___ focused care on ___ with management of symptoms as
above. The patient will be transferred to ___
for ongoing hospice care.
Transitional issues:
-- Patient discharged on Hospice
-- Consider intermittent drainage of pleural fluid via pleurex
cathter for management of dyspnea
Code status: DNR/DNI
HCP: Husband
___ on ___:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Benzonatate 100 mg PO TID:PRN cough
4. Guaifenesin-CODEINE Phosphate 10 mL PO HS:PRN cough
5. Gabapentin 300 mg PO QHS
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Morphine Sulfate ___ 7.5 mg PO Q6H:PRN Pain - Moderate
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. GuaiFENesin ___ mL PO TID:PRN cough
11. Ibuprofen 200 mg PO Q8H:PRN Pain - Moderate
12. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
Discharge Medications:
1. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
2. Haloperidol 0.5 mg IV Q6H:PRN nausea
3. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
4. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
5. Hyoscyamine 0.125 mg SL Q6H:PRN secretions
6. LORazepam 0.25 mg IV Q2H:PRN anxiety, nausea
7. Morphine Sulfate 1 mg/hr IV DRIP INFUSION
Allow bolus: Yes Bolus: 1 mg<br>Q30MIN:PRN
8. GuaiFENesin ___ mL PO TID:PRN cough
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic Squamous Cell Lung CA
Sepsis due to empyema
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:
Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted with an infection in the fluid
surrounding your lung. After discussions with your oncologist,
and the palliative care team a decision was made to focus your
care on comfort. You will be discharged to a hospice house for
ongoing care.
Your ___ Care team
Followup Instructions:
___
|
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